The ER and French-Fry Connection

There is a maxim in many emergency rooms about french fries: It states that anyone who arrives at the ER eating from a bag full of fries can’t be sick. This is a logical premise, since anyone well enough to stop for a meal on the way to the ER can’t be too badly off. Truly sick people generally go from bad to worse very quickly and often without warning, so it’s best to identify them ahead of time, which is why the french-fry trick comes in handy.

Maxims, of course, are not foolproof, as Mr. Shackley (not his real name) was to prove to me one night several months ago. Mr. Shackley was a tall, hefty man of 68 who looked like a middle linebacker fallen on hard times. He had a girth that rivaled that of a medium-sized sequoia. He and his neatly dressed, attentive wife had stopped for dinner at a drive-thru, and somewhere between the burger and the end of the fries, Mr. Shackley had developed very severe abdominal pain.

Mr. Shackley explained that his pain radiated from his mid-abdomen to his back, was making him feel nauseated and was giving him a numb sensation in both of his legs. His previous health problems were a heart attack several years ago and high blood pressure; the salty fries, he admitted sheepishly, were not part of the diet plan he had worked out with his regular doctor. Still clutching the white bag in one hand, he eagerly lifted up his gown so that I could examine his mammoth midsection. His size made such an examination difficult, and my probings revealed very little, but one thing that stood out were his pulses, which were noticeably diminished in his lower extremities.

The body has a large pipe, called the aorta, that comes off the heart. This pipe acts as a conduit to carry oxygenated blood from head to toe. Arteries branch from it into your arms, your legs and your head. In a person with high cholesterol and high blood pressure, the wall of the aorta will occasionally weaken, causing the aorta to balloon like a garden hose. This happens most commonly in the abdomen; here a section of the aorta can bulge out bigger and bigger until one day it springs a small leak and then explodes.

When this happens, all of the blood in your body is rapidly pumped into your abdominal cavity, where it doesn’t belong, and within minutes you’re dead. In the biz, this is called an abdominal aortic aneurysm--a triple A for short.

You only have to see one of these go bad to know that every older obese male with severe abdominal pain radiating to the back is a triple A until proven otherwise. Mr. Shackley’s blood pressure was normal to low, an ominous sign in a normally hypertensive man.

It took just one X-ray to see Mr. Shackley’s problem: The walls of his aorta were filled with a combination of calcium and cholesterol, and it was easy to see on the plain X-ray that his aorta, which should have had the diameter of a soda can, was instead as large as a basketball.

Will he be all right? his wife asked me when I returned to their room after viewing the X-ray.

Listen, I told them, Mr. Shackley has something very dangerous going on in his belly right now. If he’s going to survive, we have to get him to the operating room very quickly.

That was enough. Mr. Shackley finally relinquished his hold on the bag of fries. He was whisked off to surgery to undergo a procedure that has a survival rate, even for those who make it to the operating room before their aorta bursts, of 50%.

Frankly, my hopes for this patient were rather dim, but a month later, who should walk into my emergency room but Mr. Shackley, for--of all things--a rash underneath a skin fold of his ponderous abdomen. He had survived the surgery and had sworn off all fast food until the end of the year. He seemed unfazed by the whole experience.

That was a close call, I told him.

He agreed but waved his hand in the air dismissively. What, he asked, am I going to do about this rash?

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Steve Edelstein is an emergency room physician in Santa Barbara.