chest pain…now what

Tuesday, November 22, 2016

Bruce Arians, the Arizona Cardinal coach, had an eventful weekend and ended up batting .500 with a loss to the Vikings and a win for his heart. After returning home, he developed chest discomfort and rightfully so, made his way to the ER where tests were done to sort out the cause of the chest pain. Rightfully so, because the medical world spends lots of time, effort and money to convince people that chest pain is not normal and potentially could be deadly. Getting chest pain checked out is not something that should be delayed.

Once you get to the hospital, the science of diagnosis mixes with the art of medicine and a healthy dose of Las Vegas probability gets thrown into the mix to decide how much or how little needs to be done to make the diagnosis. If a heart diagnosis is suspected the full force of hospital technology may come raining down on the patient. It is just the suspicion of atherosclerotic heart disease (ASHD) also known as coronary artery disease (CAD) that sets events in motion.

The first step in sorting out chest pain is taking a history. It is the story of the pain that is most important: what it feels like, what brought it on, where it radiates, and whether there are other symptoms including shortness of breath, sweating or nausea. The doctor may try to find risk factors for the patient having narrowed arteries: is there a history of high blood pressure, high cholesterol, diabetes or smoking? What about family history? Or does the patient have a previous history of heart attack, stroke or peripheral artery disease.

If, after taking the history and examining the patient, the doctor thinks that the pain is not cardiac, then the story ends there. Of course, there are other killer causes of chest pain that have to be considered, including pulmonary embolus (blood clot in the lung) and aortic dissection (tearing of the main artery as it leaves the heart), but if the story is not consistent with major disaster, clinical skill allows the doctor to diagnose and treat other things that can cause chest pain, from chest wall injuries to pneumonia to reflux esophagitis.

But if there is worry that the cause of the pain comes from the heart, the next step is an EKG to look for signs of a heart attack. The heart is an electrical pump and if narrowed arteries can’t supply enough blood, that part of the heart conducts electricity differently and those changes can be seen on the EKG tracing. A heart attack means that a blood vessel is completely blocked and the next step is opening the artery either with clot busting drugs or a trip to the cath lab where a cardiologist can open the artery with a balloon and place a stent to keep the artery open.

If the EKG is normal, the next step is to look for heart muscle that is under stress; perhaps an artery not completely blocked but narrow enough not to get enough blood to meet the muscle’s needs so that it begins to ache or hurt. Blood test can measure chemicals (troponin) leaked from heart muscle cells that are irritated, but it takes at least 4-6 hour for troponin to accumulate in the blood to be detectable. Most often, people arrive in the ER within that time frame, so one troponin test begets another beyond that 4-6 hour to make certain the test remains normal.

If the EKG and troponin are normal, the worry is not yet done. Perhaps the heart artery is narrowed enough to cause pain but not narrow enough to cause damage. That might mean a patient at risk for a heart attack in the near future. The next step is imaging and stressing the heart. This testing may be done immediately but can also be safely delayed f0r 24-48 hours. And there are numerous ways to look at the heart, from a stress test on a treadmill, to chemical stress tests, to stress echocardiograms (ultrasound of the heart) and CT or MRI of the heart and finally, the gold standard, heart catheterization, the same procedure used in a heart attack but this time used to look for a narrowed artery.

Chest pain is a big deal because one only gets one heart and it has to last a lifetime. Showing up to a doctor’s office or ER complaining of chest pain will most likely get you to the front of the line. Aside from dying, that heart muscle can be electrically very irritable and puts the patient at risk for sudden death from ventricular fibrillation, a fatal heart rhythm. While Cardinal fans bemoan the loss of a football game, Coach Arians came through with a bigger win later that evening and lived to have his team play another Sunday.


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waiting to be seen

Sunday, November 15, 2015

Making the decision to visit the ER is never taken lightly. Aside from obvious injuries that need attention, think lacerations or broken bones, most other illnesses have the undercurrent of disaster. Is the chest pain a heart attack? Does my child have appendicitis? Is a tumor causing my headache? And worse yet, it’s the waiting, first in the waiting room and then finally being placed in an actual exam room, only to wait again. And then disaster strikes, but you don’t know about it.

Most hospital ERs, are staffed with doctors, nurses, lab and x-ray technicians, housekeeping and cleaning people, for the expected rush of patients that happens at different times of the day and different days of the week. Planning for the surge of patients on a weekend evening shift is no different that retail stores who prepare for Black Friday or Christmas Eve, expecting more customers. Hopefully, in the ER, the number of people working is enough to care for the number of patients walking in the door.

All that planning goes away when disaster strikes. In the Paris terrorist attacks, 129 people died (at the time of this column) and more than 350 people injured with almost 100 critically. These victims needed emergent care and many needed the services of a trauma team to provide care. But think of that number of patients. There are 13 hospitals in Paris, according to the Paris Tourism Office. Not all are capable of caring for these victims, but if each hospital took their fair share,  the “regular” emergency patients would be bumped and their wait to be seen extended. To be fair, hospitals have disaster plans and their whole staff would be mobilized to care for patients, both from the disaster and for those “routine” patients whose emergency visit was unlucky enough to happen at that same time.

People are very tolerant of waiting when a disaster happens. They see the carnage and they hear the news. Patients are less tolerant when waiting happens and they don’t know why. Many hospitals have waiting rooms that cannot see the ambulance bay and the steady stream of patients being dropped off. That said, arriving by ambulance does not necessarily let a patient jump the queue. Triage happens every time a patient gets touched, whether it is the person who walks in the ER door, or who arrives by ambulance, or who is found to be sicker than initially thought. First come, first serve is not the ER mantra.

A rush of patients doesn’t need to be the cause of the patient flow in the ER coming to a halt. It may be that the inpatient beds in the hospital are full and patients who need to be admitted from the ER have no place to go. They may be boarded in their ER bed, causing a logjam and the next patient up in the waiting room has no place to be seen. Or it may be there is one significantly ill patient that takes the time of many of the ER staff, leaving others to wait. Or it may be that a death has caused a doctor and nurse to spend time with a grieving family. Or that death caused the same doctor and nurse to take a few minutes to regroup emotionally for the next patient.

There is some sadness when hospital administration decides to use waiting times to lure patient to the ER by posting “real-time” waits on billboards or websites, or promising a patient will be seen within a certain amount of minutes. All those promises go away when a chest pain patient arrives at the door. To meet national standards of care, an EKG needs to happen within 10 minutes and if a heart attack (myocardial infarction) is happening, they need to be in the heart cath lab in less than an hour. If a stroke patient presents, they have less than 4 1/2 hours from onset of symptoms to get treatment and save their brain. Children with suspected meningitis need antibiotics immediately. A trauma patient who is in shock gets bumped to the head of the line. The waiting time listed on a website is old news if a disaster arrives before you do.

Waiting to be seen is difficult in the ER because of lack of control. There is the worry of the unknown about a headache or belly pain. There is the lack of choice as to what doctor or nurse will be providing care. And there is often a lack of information provided as to why the wait is happening in the first place. It is of little consolation to hear that somebody else is more sick or injured; there can be some perverse comfort in knowing that somebody else has it worse, but in the end, there is no joy in waiting.

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