Yes, this is best case ever, mini podcast series, and I'm your host, Dr. Anton Hellman.

So we're here at the teaching course, New York City, 2015, and it's my pleasure and honor to have on the show presenting his best case ever, Dr. Anand,

Swami Nathan, otherwise known as Swami.

There's so many great foam things that you've done.

I don't even know where to start.

Well, thanks, Anton.

You know, it's a pleasure to have you down here and teaching course has been great meeting all these people and I'm really honored to be on best cases. Awesome. So Swami, let it rip. Let's hear your best case ever. All right. So, you know, this is one of those best cases that maybe doesn't have the happiest outcome, but I think it's important to talk about. So this is a patient I saw a couple years back. It was an older gentleman about 65 years old who came in via ambulance after a syncopal episode. And he rolls in and he's altered. He can't really give much information. He's kind of moaning. It's unclear exactly what's going on. He's pale. He's diaphoretic and his family's with him. And EMS rolls in and said, yeah, this guy syncopies. We picked him up. We popped an IV in him and we brought him here.

He's got a really poor pressure.

So, you know, we try to get a cuff on him.

He's like 60, 70 palp at the best. And there's so many different things that you can have when you have this undifferentiated hypotension. And so, you know, I have, I'm talking to the wife and trying to figure out what's going on.

My team is starting the resuscitation, getting ready to intubate and giving fluids and blood and all this kind of stuff. And she says, you know, he complained of back pain and then he syncopized. And I think in emergency medicine, we love patterns. Back pain and syncope in an older patient, right away it makes me think either an an aneretic dissection or more likely a AAA. So

AAA was really high up on my list of what this could be. And so I asked her, did he have abdominal pain too? Yes, he had abdominal pain too. And I'm like, okay, we're done. This is a AAA. There's very little else that this can be. And, you know, when I talk about this case afterwards in my residents, the other things that come up is if this was a 19 year old woman, I'm thinking

actopic, but it's a 65 year old man. It's a AAA. You couldn't get a more textbook case. It was absolutely textbook. And there's no real differential nightmare here. There's no diagnostic dilemma. We know what we're dealing with. So we've got now a hypotensive guy, likely with a AAA. The good thing is we've got point of care

ultrasound, so we can figure out right away. Does this guy have a AAA that's leaking or not? We've slapped the ultrasound in his belly, and he's just got blood everywhere. I can't find the aorta, but he's got blood everywhere. I'm like, I'm done. I know exactly what this is. So the first step at this point, you know, we're putting in the large war IVs and we're getting ready to intubate. We're getting blood because we're in a trauma center, so we take out the

uncrossmatched blood and we're getting ready to intubate and we're getting blood because we're in a trauma center. So we take out the uncrossmatched blood and we're getting that

flowing into the guy. The next thing on my list of things to do was to call my consultant. The only cure for this guy is going to be in the operating room. We know that. We know this guy's got to get to the operating room fast. If he gets there fast, maybe he's got a good outcome. So we get

our vascular surgeon on the line. This is like 6.30 in the morning, which is exactly when vascular the operating room fast. If he gets there fast, maybe he's got a good outcome. So we get our

vascular surgeon on the line. This is like 6.30 in the morning, which is exactly when vascular surgeons are rounding. So it was perfect. And the guy's down in the ER within five minutes. So within five minutes, I've got the vascular surgeon, the vascular attending down there. We're resuscitating this guy. And I'm talking to him like, listen, this guy's got a triple A. He goes, well, what's the story?

I tell him the story.

He goes, okay, it sounds like a AAA.

Let's go to the OR.

So we're starting to get this guy, and I'm talking to him, I'm like, listen, this guy's got a triple A. He goes, well, what's the story? I tell him the story. He goes, okay, it sounds like a AAA. Let's go to the OR.

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