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It's great to have back on the show. A veteran emergency medicine cases expert guest, Dr. David Carr.

That's great to be here. Always great to be in person with you. Always great to see you.

So we're here at EMC Studios in Toronto, and we're not going to give it away at the top here. Dave's just got a case for us that we're going to have a little discussion around. So go for it, Dave. Yeah, you know, I saw this case and it's funny. The way my mind works is I finished my shift. I saw this case. My first thoughts were, I got to tell Anton about this. And I thought, this is something I did a lot of reflection. And I thought it's a good thing to get out there. So I'm working a shift. I'm the

morning doc. It's quiet, which is a nice thing these days. And I see a patient before the nurse does.

So essentially, they're just brought into a room, not even in a gown, no bloods or anything there.

And I read the triage notes, you know, it's electronic, so I read the note before I go in.

And it says 73-year-old man, sudden onset of right flank pain at six in the morning.

And granted, this is now seven in the morning, 7.30 or something like that.

So past medical history, it says, M.I. and renal colic. He was taking aspirin was his only

medication, no real oral anticoagulants. And I looked at his vitals, you know, couldn't be more

textbook, 120 over 80, heart rate 70, that's 100%, temperature 362,

rest rate 14. So I kind of already have a sense of what's going on. And I go in the room

and I meet a really stoic guy. And I think that's really important and we'll get there afterwards.

And, you know, I kind of take this history and I said,

like, what happened? And he said, you know, I was sleeping. I was fine last night. I'm retired. I don't do that much. I'm not that active. And at 5, 5.30 in the morning, like I woke up with severe pain. And, you know, I had a kidney stone three, four years ago on the same side. So I kind of knew what the pain was.

I took a Tylenol. It wasn't really helping. And the pain's really severe. And you could tell this guy was struggling. So he came into the hospital. All right. So far, this is not a very exciting case there, Dr. Carr. I mean, so you got a guy with renal colics. So, what, you got a urine, you got some bloods, you give him an insed, maybe some morphine, send him off for the CT renal colic protocol. Yeah, 100%. Look, you know, I think we're old enough to say that we didn't train in the polkis area, but this is a good guy to Pocus. You know, he's 73, 74. I'm going to just look at Zeyorta, look at a fast. I get, you know, he's a thin guy. I get really good looks. Fast is negative. His kidney looked fine by me. I didn't see obvious hydro, but I'm not like a Pocus Jedi, but it looked okay. And I got a great view of the order, like definitive scan, like there was no aneurysm. So I'm feeling pretty confident. Like pre-test, the guy who's had Rinocholic, you know, he's not 30, but I got a good Pocus. He's had Rinocholic, says it feels exactly the same, same side, same pain, Torridal, dilated, lights, creatin, CT, goes to the next patient. Sounds perfectly reasonable. So where's the surprise here? What happened? Yeah. So scanning through the lab, so CBC lights, creatinine, normal, urine dip said trace, which was kind of like, okay, that's weird, but whatever. And, you know,

not everyone has obvious blood. And then I look at the CT. And, you know, sometimes these CT renal colics can be very elaborate and sometimes they can be very brief. No evidence of nephrolothiasis,

no evidence of hydronephrosis, no cause for patient's pain scene. All right. So now we've got to start scratching our heads a bit. So what could this patient be? So you took a look at the Pocus and there's no obvious AAA. So you've pretty much ruled that out. But there's a list of other things that I'd want to think about a dissection. This guy has had an MI in the past, so he certainly got risk factors for

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