Ambulance Driver Files A Day in the Life | Kelly Grayson
…is still the same.
In past months, I’ve had a couple of readers (oddly enough, both named Kate and both fellow bloggers), suggest that I post about the unique signs and symptoms that women experience in a heart attack.
Women, strange and wondrous creatures that they are, often present with atypical symptoms when suffering a heart attack. Perhaps it’s the innate orneriness of the gender that makes them prone to flouting all the conventional wisdom concerning heart attacks, or perhaps it’s because God granted them the higher pain threshold necessary to squeeze a watermelon through an opening the size of a lemon…
…but the point remains that, quite often, the gentle gender quite often just doesn’t feel pain like the men. Now normally, when women start behaving unexpectedly, we men have been conditioned to purchase cards, chocolate and flowers and grovel for forgiveness. However, when that unexpected behavior happens to be heart attack symptoms, it behooves us to recognize the signs, lest the cards and flowers be chosen from an entirely different section of FTD’s inventory.
I have a few caveats, though. First, this is not a scholarly article. I get paid to do those. You want specific journal references and hard data, any of this stuff can be found in a Medline or Google search. Secondly, this post is for laypeople. I’ll eschew the use of technical terms for the most part, and some of the pathophysiology will be rather simplified. Still, some of the newer EMTs or students may find the explanations useful. Thirdly, I’ll not delve into the treatment of myocardial infarction. That’s another post entirely.
A myocardial infarction occurs when the blood supply is interrupted to the heart muscle. This blood is supplied via the coronary arteries that arise at the base of the aorta. These arteries fill with blood when the heart relaxes after each contraction, relying on back pressure in the aorta to fill them with richly oxygenated blood.
Now, as we approach our golden years, these two arteries (right and left) and their branches often tend to get filled with plaque, a condition known as atherosclerosis. This may severely compromise the blood flow through these vessels, or inhibit their ability to dilate and allow greater blood flow in response to greater oxygen demand.
Normally, this atherosclerosis is mostly due to entirely preventable factors such as obesity, high cholesterol and smoking, but some segments of the population seem genetically predisposed to it, just as others seem to be able to eat three bowls of lard a day and never have a total cholesterol higher than 160.
If you’re part of the latter group, call your Mama tonight and thank her for the good genes.
Now, when the oxygen demand of the heart exceeds what these narrowed arteries can supply, the heart muscle shifts into anaerobic metabolism. Simply put, the heart muscle needs more oxygen than the narrowed arteries can supply, and thus shifts into a less efficient form of metabolism that not only supplies less total energy, but also tend to produce some nasty byproducts.
Lactic acid, chief among the nasty byproducts, is the primary cause of the discomfort we feel during cardiac events. The same “burn” you feel in your skeletal muscles after a strenuous workout produces the classic cardiac chest pain commonly referred to as angina pectoris.
Now, a number of things can produce such a condition. Strenuous exercise and stress are two of the most common culprits, but pretty much anything that stimulates your heart to work harder than its arteries can supply oxygenated blood can do it.
Drug use can do it as well, and quite often users of methamphetamine or cocaine can experience Prinzmetal’s angina or a variant, caused by excessive heart rates and spasm of those coronary arteries. Occasionally, this vasospastic angina can be severe enough and prolonged enough to cause significant damage to the heart muscle – for all intents and purposes, a myocardial infarction, even though the patient does not have atherosclerosis.
The problem is, this cardiac chest pain is not always well recognized. You see, cardiac pain is organ pain. Our organs, while richly supplied with nerve endings, are typically only sparsely supplied with sensory nerves. The richer an area is supplied with sensory nerves, the more acutely we can feel sensation there. Your fingertips, for example: richly supplied with sensory nerves. That’s why a paper cut hurts more than a similar boo boo in another location.
Our skeletal muscles, skin, and the linings of our body cavities are richly supplied with these nerve endings, and when we suffer an insult to one of these areas, we can usually distinguish the source of the pain rather quickly. It’s somatic pain, and quite often, the patient can point to the area in question with one finger and say, “It hurts right there, like someone stabbing me with an ice pick.”
Not so with organ pain. The lack of these sensory nerve endings doesn’t necessarily make us feel the hurt any less acutely, but it often does pose problems for the brain in interpreting exactly from where these woochie signals are coming. Many times, the patient suffering from organ pain can only vaguely wave their hand at the area in question and say, “It aches somewhere around there.”
And those are most often the words they’ll use. Ache. Pressure. Tightness. Heaviness.
When that vague hand gesture is waved around the chest, those words take on a special meaning to health care providers. They mean the problem is serious. Not that we’ll discount words like sharp or stabbing, because they occasionally occur with a heart attack too, but they just don’t typically elicit the same degree of concern. By the same token, just because they say ache doesn’t mean they aren’t experiencing Godawful discomfort.
Adding to the vague nature of cardiac pain is the fact that several organs often share the same sensory nerves. Frequently, the brain will misinterpret the signals entirely, and the patient will report the pain perhaps a foot away from the organ in question. This is known as referred pain. The gall bladder, for example, shares sensory nerves with the right shoulder. Patients with gallbladder problems quite often complain of right shoulder pain, and have very little stomach pain.
The inferior wall of your heart shares sensory nerves with your diaphragm (no, not the contraceptive device), and quite often an infarction in this part of the heart is mistaken for gas or indigestion. Many are the patients who have told me, “If I could just burp, I’d feel better,” who turned out to be having an inferior wall myocardial infarction. There are documented, albeit rare, cases of patients having myocardial infarctions whose only presenting complaint was hiccups.
[And now, every hypochondriac who reads this blog will grab their keys and head to the ER next time they have hiccups.]
But these vague symptoms, coupled with plain old, ugly, denial, often has patients suffering through a heart attack at home alone, without ever seeking medical care.
Funny how it is that so many people will rush to the ER demanding Vicodin for their hangnail, yet so many others of a certain generation will tough out a heart attack at home with Maalox and Tums.
Now, how can we tell you’ve had a heart attack in the past? Simple. It leaves evidence on your 12-lead EKG. When the paramedic, nurse or respiratory therapist attaches that sophisticated voltmeter to your heart, it can tell by the shape of the waveforms whether you’ve had a heart attack before.
Not only that, it can tell whether you’re having a heart attack now, versus having already had one way back when. The waveforms are different for an acute process as compared to an old one.
The machine isn’t foolproof, however. It is just a fancy voltmeter, after all. It misses things. Almost every machine on the market uses the same proprietary algorithm to interpret the meaning of all those squiggly lines. When it does notice the infarction, it can usually tell you chapter and verse about it.
Unfortunately, it also fails to notice a significant number of real infarctions. That’s when you need a real, live trained medical provider who knows how to interpret those squiggly lines when the machine can’t decide.
To backstop that, we draw blood to test the levels of certain cardiac enzymes that are released when the myocardium is damaged. These enzymes vary in their sensitivity and their specificity to heart muscle. Simply put, some levels rise faster than others, and others can be elevated by something other than a heart attack.
So, our fallback position is usually the patient’s chief complaint. What brought them to the ER in the first place? When the EKG and the labs are ambiguous, the patient’s symptoms are usually the deciding factor in whether the complaint is treated like a heart attack.
This conundrum is the bane of emergency physicians everywhere. Is it a cardiac event, or is it a gastrointestinal problem? Many patients are admitted overnight to rule out a heart attack, only to discover that if they really had just burped, all their symptoms would have disappeared.
Conversely, some patients go home with a prescription for Pepcid or Zantac, only to be brought back by the paramedics three hours later, in full cardiac arrest.
Been there, done that.
So what’s the difference between angina and a heart attack, you ask? Well, angina differs from an actual myocardial infarction not by degree of severity of pain, but by precipitating factors. There is precious little evidence that correlates the severity of one’s pain to the severity of the cardiac problem.
Mainly, angina occurs during physical activity, and is relieved by rest and administration of nitroglycerin or other antianginal drugs.
Nitroglycerin is by far the most commonly used drug for emergency treatment of angina, but there are a number of drugs available for regular, daily use. Mainly, these drugs result in the production of nitric oxide, which relaxes smooth muscle. This smooth muscle relaxant effectively dilates the coronary arteries, thus allowing increased blood flow and increased oxygen supply. This nitric oxide also tends to have interesting effects on other parts of the body.
Like the goober.
This pleasant, but not wholly unexpected, side effect is what induced the good folks at Pfizer to market their promising new angina medication to an entirely new market. When a large portion of your study group reports, “Nope, chest still hurts like hell, but interestingly enough I’ve been able to strike sparks with my wanger since I’ve been taking it…”
Well, it doesn’t take a marketing genius to recognize the potential there.
Still, angina is reversible. The patient stops whatever they were doing, pops a pill under their tongue, and presently the pain resolves. Either make the coronary arteries bigger and allow more blood flow, or calm down until the heart can make do with the available supply.
It’s still a problem, and it’s still a big red warning sign. But it’s not a heart attack.
Heart attacks don’t go away with rest and nitroglycerin. The treatment is much more involved. Often you find patients who have chronic angina, who notice a change in the character, severity or frequency of their pain, a condition known as unstable angina.
Usually it’s reversible too, using a little more involved and aggressive treatment plan. Occasionally, it heralds an actual myocardial infarction that, with prompt and aggressive treatment, we’re able to circumvent before any significant damage occurs.
Now, what exactly does a heart attack feel like? Most people describe it as a heavy weight, tightness or pressure in the center of the chest. It may radiate into the jaws, shoulders or arms. It’s often accompanied by nausea, difficulty breathing or severe weakness. Victims often break out in a cold sweat.
But only two out of three patients actually has any chest pain.
That’s one in three that has a gen-yoo-wine heart attack, without any pain at all. Thirty three and a third percent.
Next time you’re in the ER feeling deathly ill, look to your right, then your left. Are both those guys moaning and clutching their chests? If they are, you’re probably having a heart attack and don’t even know it.
Emergency health care providers have known for quite some time that certain demographics tend to experience unusual or very subtle symptoms when they have a heart attack; usually women, diabetics, or the elderly.
And if you’re an old diabetic woman, watch out!
Women, in my estimation, have a higher pain threshold than men. There may be a more physiologically sound explanation for it, but in my experience, men in general are wimps when it comes to pain.
Elderly patients sense pain less acutely than do healthy adults or children, due to age-related decline in their nervous system function. Plus, they’re from a generation raised to be much more stoic than the kids we’re raising today.
Diabetics tend to suffer peripheral nerve neuropathies, a common complication of their disease. They don’t sense pain well.
But the incidence of those subtle or unusual symptoms isn’t limited to those three demographics. Indeed, it extends across the patient spectrum. It can happen with anyone.
While many healthcare workers believe in the myth of the silent myocardial infarction, in which someone supposedly has a heart attack with absolutely no symptoms, it really is just a myth. There are always symptoms.
They just tend to be mistaken for something else, like a stomach virus, or food poisoning, or the flu. Until of course, the day comes when Ambulance Driver attaches the sophisticated voltmeter to your chest, looks at the readout and purses his lips thoughtfully, and says, “Are you sure you’ve never had a heart attack?”
Then you know what it actually was.
This brings us to the culmination of our little treatise on chest pain. Some symptoms show up often enough in those unusual cases that they, alone or in combination, can be classified as anginal equivalents.
In other words, they’re as good an indicator as chest pain that you may be having a heart attack. They occur most often in women, but they can happen to anybody.
If you have significant risk factors for heart disease, such as smoking, hypertension, obesity or high cholesterol, or familial risk factors, and you exper
ience a sudden onset (key phrase here) of one or a combination of these symptoms:
- Extreme weakness
- Severe nausea
- Difficulty breathing
Get thee to a hospital immediately, preferably in an ambulance.
Seriously, you could be having a heart attack.
I invite your questions in the comments section. I’ll answer whatever I can.