Attack of the Heart
He is young, looks about 40 years old. Lying on the stretcher, pawing at his chest and left shoulder. Big hands and shoulders. Strong guy.
"I was out running on the beach. I started to get this pain in my side and I thought it was a stitch. I tried to run faster, take deeper breaths. I thought if I got more air the stitch would go away. It got worse. Somebody called the rescue." In my mind I could see him running my favorite stretch at the pier. No wind, gentle rolling surf, the kind of run that gives you peace of mind.
His EKG had some non-specific T-wave changes; certainly not an acute heart attack, but not normal in the strictest sense of it. His pain was convincing under the circumstances. The EMT's had put him in oxygen and given him nitro and carried him off the beach. By the time they got him to the rig the pain had gone away.
"Tell me about your health." It was a question.
"Had a physical in late July or August. Cholesterol a little high, but everything else was Ok. Doc didn't even put me on meds. She was giving me a chance to work on eating. I'm a fireman. You know, demanding, physical job. No problems there." He looked at me as if my eyes would reassure him that being able to do his job would make his symptoms insignificant. I smiled as a stray thought crossed my mind; my grandmother used to say, "if wishes were dishes, we'd all have a feast."
I did that half-smile, half-frown thing that I think makes others believe that I'm thinking about what they said. At this point I'm reluctant to be reassuring; "I'm concerned that this may be your heart. You know that your symptoms could mean a heart problem, right? Anyone in your family with heart disease when they were as young as you?"
"Not as young as me, but my dad had a heart attack when he was 52."
"That's pretty important to your risk, so we need to check you out. The nurses are going to put in an IV and draw some blood. They'll send it for heart enzymes, which show up in the blood after a heart attack. You need to let them know if you have any more pain at all, and I'll keep you posted about the tests. You're going to have a chest x-ray too, to see if there is any heart enlargement. Enlargement of the heart can be a sign of it working too hard."
He had no questions, but that didn't surprise me. In many places firemen are first responders for ambulance calls. This reason is in some communities, especially rural ones, they have volunteer rescue staffs. The firemen, already at the station, can respond to a rescue call and start basic first aid until the EMTs arrive. They know heart attack risk factors and how to do CPR; they usually arrive with oxygen and know that it's significant if chest pain is relieved by it.
About an hour and a half later I had his first enzymes back; his CPK was really high, but the heart-specific troponin was negative. CPK rises whenever any muscles have been worked hard. Apparently my friend had been doing a lot of running. The chest film had been normal. The ED doc on with me approached. "I just saw your guy with chest pain," he motioned toward the room with his head. "Go have a look; I think you'll have your answer."
Puzzled, I went to the room, where my patient was on the stretcher, his back to a seated woman with a newspaper in her hands. As if her reading had been interrupted, the paper was folded in a crumpled manner, still held between each hand by fingers with sleek, polished nails. He was crying. She was watching and looking rather neutral about the whole scene. Great gushing sobs were wracking his shoulders and his pillow case was wet. The woman spoke, "what did you expect? You've been working a million hours of overtime, totally stressing yourself out! You're never home." Her face looked tired and her voice was soft. "We've been through all this..."
"Excuse me," I addressed the woman across the sobbing man, "are you his wife?"
"For the time being," she replied.
I looked at my patient, then back at the woman. She felt like an intruder into my therapeutic space. "Would you mind excusing us for a minute?" I asked her.
After she was gone, I looked at the big guy on the stretcher. "What's going on?" I asked, as I lowered myself onto a rolling exam chair next to him, and slipped the stretcher's side rail out of view.
He sighed, one of those big shudders that come with exhausted crying. "We're getting divorced. I was out running and I got to thinking about her and the kids. I started to cry and I was running and crying. I got out of breath and had this pain...but I kept running! I couldn't run fast enough. It was stupid. Then the pain got real bad, and I was crying so hard; I had to stop. The guy who called the rescue must have thought I was nuts. I was on my knees, pounding in the sand and sobbing like a baby. It hurts," he said, as he rubbed his chest.
"It hurts now?" I asked. He nodded; "yes" was his whispered reply. The repeat EKG was normal now, completely. Another set of cardiac enzymes were close enough to due that I had them drawn again now, while he was uncomfortable. They were also normal by hour three.
I found them with his wife was sitting at the side of his bed, stroking his arm. "Will you take a few days off?" I asked. He nodded yes. "I want you to call your doctor when you get home and make an appointment for follow-up this week. I can send her a fax to let her know what happened today, that you had chest pain while you were very upset." My patient looked relieved. "You can tell her what you want about the circumstances. But you do need to see her and tell her how much stress you're under. If you were my patient in the office I'd tell you that it's time for some cholesterol medication and a stress test. Please take it easy for a few days, and don't be so hard on yourself. You've got a stressful job and a lot going on at home. Guys get killed a lot of ways, don't make yours a heart attack from stress, ok?" I left him getting dressed.
When they walked out together, she took his hand.
Laurie
A "post script," on this blog. The individual represented in this post is really a conglomerate of people that I have seen who have chest pain. Its purpose is to give the reader a glimpse into a 'slice of life' while also creating an opportunity to link my words to terms that will educate you, the reader about heart disease risk factors and tests. One of my favorite blogs is The Examining Room of Dr. Charles. Dr. Charles is a master of the "story-telling blog," and if you enjoyed this post, you should really read his!
Related Topics:
Technorati Tags: heart attack, stress, chest pain, Dr. Charles
"I was out running on the beach. I started to get this pain in my side and I thought it was a stitch. I tried to run faster, take deeper breaths. I thought if I got more air the stitch would go away. It got worse. Somebody called the rescue." In my mind I could see him running my favorite stretch at the pier. No wind, gentle rolling surf, the kind of run that gives you peace of mind.
His EKG had some non-specific T-wave changes; certainly not an acute heart attack, but not normal in the strictest sense of it. His pain was convincing under the circumstances. The EMT's had put him in oxygen and given him nitro and carried him off the beach. By the time they got him to the rig the pain had gone away.
"Tell me about your health." It was a question.
"Had a physical in late July or August. Cholesterol a little high, but everything else was Ok. Doc didn't even put me on meds. She was giving me a chance to work on eating. I'm a fireman. You know, demanding, physical job. No problems there." He looked at me as if my eyes would reassure him that being able to do his job would make his symptoms insignificant. I smiled as a stray thought crossed my mind; my grandmother used to say, "if wishes were dishes, we'd all have a feast."
I did that half-smile, half-frown thing that I think makes others believe that I'm thinking about what they said. At this point I'm reluctant to be reassuring; "I'm concerned that this may be your heart. You know that your symptoms could mean a heart problem, right? Anyone in your family with heart disease when they were as young as you?"
"Not as young as me, but my dad had a heart attack when he was 52."
"That's pretty important to your risk, so we need to check you out. The nurses are going to put in an IV and draw some blood. They'll send it for heart enzymes, which show up in the blood after a heart attack. You need to let them know if you have any more pain at all, and I'll keep you posted about the tests. You're going to have a chest x-ray too, to see if there is any heart enlargement. Enlargement of the heart can be a sign of it working too hard."
He had no questions, but that didn't surprise me. In many places firemen are first responders for ambulance calls. This reason is in some communities, especially rural ones, they have volunteer rescue staffs. The firemen, already at the station, can respond to a rescue call and start basic first aid until the EMTs arrive. They know heart attack risk factors and how to do CPR; they usually arrive with oxygen and know that it's significant if chest pain is relieved by it.
About an hour and a half later I had his first enzymes back; his CPK was really high, but the heart-specific troponin was negative. CPK rises whenever any muscles have been worked hard. Apparently my friend had been doing a lot of running. The chest film had been normal. The ED doc on with me approached. "I just saw your guy with chest pain," he motioned toward the room with his head. "Go have a look; I think you'll have your answer."
Puzzled, I went to the room, where my patient was on the stretcher, his back to a seated woman with a newspaper in her hands. As if her reading had been interrupted, the paper was folded in a crumpled manner, still held between each hand by fingers with sleek, polished nails. He was crying. She was watching and looking rather neutral about the whole scene. Great gushing sobs were wracking his shoulders and his pillow case was wet. The woman spoke, "what did you expect? You've been working a million hours of overtime, totally stressing yourself out! You're never home." Her face looked tired and her voice was soft. "We've been through all this..."
"Excuse me," I addressed the woman across the sobbing man, "are you his wife?"
"For the time being," she replied.
I looked at my patient, then back at the woman. She felt like an intruder into my therapeutic space. "Would you mind excusing us for a minute?" I asked her.
After she was gone, I looked at the big guy on the stretcher. "What's going on?" I asked, as I lowered myself onto a rolling exam chair next to him, and slipped the stretcher's side rail out of view.
He sighed, one of those big shudders that come with exhausted crying. "We're getting divorced. I was out running and I got to thinking about her and the kids. I started to cry and I was running and crying. I got out of breath and had this pain...but I kept running! I couldn't run fast enough. It was stupid. Then the pain got real bad, and I was crying so hard; I had to stop. The guy who called the rescue must have thought I was nuts. I was on my knees, pounding in the sand and sobbing like a baby. It hurts," he said, as he rubbed his chest.
"It hurts now?" I asked. He nodded; "yes" was his whispered reply. The repeat EKG was normal now, completely. Another set of cardiac enzymes were close enough to due that I had them drawn again now, while he was uncomfortable. They were also normal by hour three.
I found them with his wife was sitting at the side of his bed, stroking his arm. "Will you take a few days off?" I asked. He nodded yes. "I want you to call your doctor when you get home and make an appointment for follow-up this week. I can send her a fax to let her know what happened today, that you had chest pain while you were very upset." My patient looked relieved. "You can tell her what you want about the circumstances. But you do need to see her and tell her how much stress you're under. If you were my patient in the office I'd tell you that it's time for some cholesterol medication and a stress test. Please take it easy for a few days, and don't be so hard on yourself. You've got a stressful job and a lot going on at home. Guys get killed a lot of ways, don't make yours a heart attack from stress, ok?" I left him getting dressed.
When they walked out together, she took his hand.
Laurie
A "post script," on this blog. The individual represented in this post is really a conglomerate of people that I have seen who have chest pain. Its purpose is to give the reader a glimpse into a 'slice of life' while also creating an opportunity to link my words to terms that will educate you, the reader about heart disease risk factors and tests. One of my favorite blogs is The Examining Room of Dr. Charles. Dr. Charles is a master of the "story-telling blog," and if you enjoyed this post, you should really read his!
Related Topics:
Technorati Tags: heart attack, stress, chest pain, Dr. Charles
