34. The Pulse

January 24, 2021


It was my last week before my scheduled 3-week vacation. I was doing what I loved the most: Hospitalist care. I got to the hospital about 10 minutes late, or 10 minutes after I used to get there. That was Jax’s fault, he had decided to go earlier with me in the subway but he takes too long with his breakfast.

‘I have my ritual, Lisa.’ He said. ‘The world is not gonna end if we get there not late, but just a bit less early.’

‘Fine.’ I sighed while getting in the next train.

Walking into Brooklyn Hospital 6:20am I noticed Jax was right. I was still early as I liked. At my floor I went to get my admissions for the day and there was only one: Kate Sato. Oddly I thought her name sounded familiar. Going through her chart I was able to get some info. A japanese woman, 30 years old. Wait, MD. She was a general surgery resident also at Brooklyn Hospital.

She had been admitted overnight, while she was on call. Dr. Sato started to feel lightheaded in the OR, so she stepped aside from the surgery she was operating in. No more than 2 minutes passed until she collapsed on the ground. Nothing that worrisome so far. The truth is, you would be surprised at how many doctors experience at least 1 vasovagal syncope during a surgery. Yep, I’m included in that list: vascular surgery rotation, myiasis debridement, 5 minutes and I was blacked out.

Kate’s problem was that when she fell, the other doctors in the room assessed her and couldn’t find her pulse. Worried, the physician in charge, Sergei, started the protocol. Her airway and breathing were okay, but he just couldn’t feel her pulse. He then put a stethoscope on Kate’s precordium and thankfully heard her heart beating. About 3 minutes later she recovered her consciousness with no post-event confusion.

Well, it still looked like a vasovagal syncope to me. Her pulse was probably just hard to find. I couldn’t see why exactly she was admitted after that, so I went to find out.

‘Good morning, Dr. Sato.’ I said as I entered the room. ‘It’s a pleasure to meet you. I am Lisa Diaz, the Internal Medicine resident.’

‘Hi, Lisa! You can call me Kate.’ She smiled. ‘So, let’s get this over with. Shoot.’

‘Alright.’ I smiled back. ‘You know how this works. Tell me what happened.’

‘Very well. I was in the OR assisting in a colectomy. The surgery had some complications so we were operating for about 3 hours when I started feeling lightheaded. I asked to be excused for a moment and then I remember waking up with everyone staring at me.’ She laughed. ‘I was feeling fine when I woke, a bit weak but fine. So Sergei reached for my wrist with a frightened face and told me I had no pulse. I checked for myself and who’d thought I really have no pulse.’ She extended her hands to me.

There was still a lot to ask but I went for it and checked. It was true, I couldn’t feel her left radial pulse at all. Her right I wasn’t sure, maybe there was a very weak one. I nodded for her to proceed.

‘So everybody was bothered by this. And I was still a little weakened so they decided to admit me and call vascular surgery. I think they’re supposed to come here today.’

‘I see. What about now, how are you feeling?’

‘I’m super now. 100%.’

‘Good. And yesterday, during surgery, did you feel anything else before passing out? A funny smell, vertigo, pain, anything at all?’

‘I don’t think so. Nothing out of the ordinary.’

‘What would you call ordinary?’

‘Oh, long days in the OR can be tiring. Body eventually aches, especially my arm.’ She pointed to her left arm.

A picture was beginning to form in my mind. She was really sounding like a vascular patient with claudication. But somethings didn’t add up: it was an upper limb claudication for starters, she was a young woman with no medical history and no risk factors for vascular disease. Her family history was also clean, and nothing else came up in her review of systems. So I proceeded to her physical exam.

I thoroughly assessed, or tried to, all of her pulses. Her left brachial and radial pulses were indeed absent, and the right side was definitely there, although diminished. The lower body pulses were apparently preserved. She was somewhat hypertensive, and given her condition, I decided to measure her blood pressure in both arms, and I found a 15 mmHg difference between them. At that point, I was convinced she had systemic vasculitis. It fit just right. 

When I turned to leave Kate’s room I ran into Lucy standing at the door.

‘Morning, Lisa.’ She said calmly walking me out of the room. ‘I came to check on Dr. Sato as well. But watching your history and exam, I think you already have something for me.’ She smiled.

‘I do.’ I turned to her. ‘I think she has systemic vasculitis. It’s what can explain her presentation at this age.’

‘That’s right, Lisa, but you can be more specific. Be less afraid of getting it wrong.’

I smiled. ‘Fine. Takayasu. I think she has Takayasu Arteritis.’

‘That sounds more like a resident of mine.’ Dr. Collins winked. ‘So pulseless disease. How does that fit with her symptoms?’ She raised one eyebrow.

‘Well…’ I stuttered. ‘She doesn’t have a pulse! Her upper limbs have discrepancies in blood pressure and she has left arm claudication.’

‘And the syncope?’ She pushed.

No good answer came to mind.

‘Remember: this is a large vessel vasculitis.’ She continued. ‘It affects the aorta and its branches.’

Then it hit me. ‘She could have had subclavian steal syndrome.’

‘Exactly. An occlusion in the subclavian artery, proximal to the vertebral artery origin, can cause flow reversal in that vertebral. It’s possible that led to arterial insufficiency in the brain. Discuss it with vascular surgery, who is also on this case. Then we’ll take the next steps. Dr. Sato will need imaging, maybe an MR angiography.’


‘Now comes the hardest part.’ She sighed.


‘Telling Sato. That’s always the hardest part. No one wants to be sick, especially doctors.’

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