I see chest pain all day, every day

Sometimes I feel as if my entire emergency medicine career is dedicated to one patient complaint.  And that one complaint is chest pain.  It may be that the incidence and prevalence of chest pain was the same during my medical school and residency training as it is now.   But I doubt  it.

I recall how I struggled to learn the salient questions.  ‘Where is your chest pain?  Is it heavy, dull, sharp or achy?  Is it worse with breathing?  Have you had a cough?  Have you had leg pain, or traveled a long distance?  Doe s it radiate to your back or arm?  Are you nauseated, short of breath or sweaty?’  It seems simple, but perhaps because I didn’t ask those questions all day, every day, I did not immediately become facile at the chest pain history.

Chest pain, because of the possible pathologies it represented, was a big deal.  I came of age as a physician in the time when clot-busting thrombolytics were the latest and best therapies for those with heart attacks.  We were highly attuned to the complaint of chest pain.  Drug trials were all around, as academics and pharmaceutical companies were struggling, and battling, to decide which of the many drugs on the market were best for our unfortunate patients whose chest pain was actually due to MI.

When someone had chest pain, residents wanted to see them.  Staff physicians hovered nearby to make sure we did the right things, asked the right questions, ordered the correct tests and accurately interpreted the electrocardiogram.

Fast forward.  I see chest pain all day, every day.  I’m probably better and faster than ever in my career.  But now I have so many patients with the same complaint, and with subtle differences, that I feel as if I’m going crazy.  Here’s a standard line-up on a busy day:

Bed 5:  85-year-old male with chest pain in the left arm and left shoulder, radiating to the neck.   No shortness of breath, mild nausea; sweats, but attributes it to playing golf.  Had 5 vessel bypass 10 years ago.

Bed 7:  68-year-old female with chest pain on the right, radiating to the neck.  Short of breath, no nausea, some sweats.  Left arm tingling.  Felt heart racing.  Strong family history of heart disease.  Smokes one pack per day but quit … yesterday.

Bed 8:  45-year-old male with chest pain in the mid-sternum, radiates to both arms and back, slightly short of breath, right arm tingling, profound nausea, sweats and dizzy.  Onset while lifting a horse’s leg to apply a horseshoe. Smokes 2 packs per day.  Last cigarette in triage area.

Bed 9:  29-year-old female with family history of heart disease, just traveled six hours in a car.  Pain is dull, radiates to both sides of jaw.  Was short of  breath, but isn’t now.  Was nauseated but isn’t now. Also has cough.  Used crack and meth last night.

Bed 10:  54-year-old male with severe cough.  Had angioplasty last year with stents.  Coughing severely, and has pain with cough.  But also, another “dull, achy pain” in his back and right arm.  Wife states he looks just like he did with his heart attack ten years ago.  He says he’s fine.

Bed 11:  19-year-old female with tingling all over, chest pain and hyperventilation.  Her mother insists the family has “lots of folks with blockages,” and that the patient’s uncle died at age 21 of a massive heart attack.  Patient states she is upset over her boyfriend.

Bed 19:  7-year-old male with chest pain after falling onto his bicycle.  Mother says, “there’s lots of heart problems in the family, and I’d rather be safe than sorry, doc!”

Bed 20:  30-year-old male with ankle sprain who states he waited too long in the waiting room, then called EMS complaining of chest pain, “yeah, it goes to my left arm, up my neck, makes me nauseated and short of breath.  Can I get something for my ankle?”

Anyone who works in a busy emergency department can tell you that these are standard complaints on any typical day.  The truth is, I can barely keep it straight.  When I talk with consultants, I have to have each chart and EKG in front of me, or else the subtleties of all the presentations become lost.

Furthermore, we see so much chest pain that our cardiologists are only marginally interested.  They don’t want to see the patients; they let me do the work-up and the referral unless the patient is admitted and the admitting internist or FP consults them.  (Those are real consults, apparently).  But I understand, to some extent.  The cardiologists face the same vague uncertainty as I.

Further,  physical exam and history are helpful, but only a little.  In the end, it’s cardiac markers and serial EKG’s, it’s chemical and exercise stress tests, echo-cardiograms and cardiac catheterizations that give the answers.  Who can blame cardiologists for not wanting to waste their time asking people the same questions I ask them?

So what does all of this chest pain mean?  It means people are living longer, and better, with heart disease.  This is due to diligence on the part of primary care, aggressive intervention on the part of cardiologists, widespread education campaigns by public health and incredible scientific advances by (yes, it’s true) pharmaceutical and medical device companies.

It means that individuals who would have died in the past, and in many other parts of the world, survive because we pay attention to things like chest pain.

But let me also suggest that the reason I see so much chest pain is due to the fact that we, as a people, take every emotional or social dilemma and transform it into chest pain.  Broken hearts, broken homes, stressful jobs, stressful school, legal problems, arrest, guilt, anger, frustration, fear, all of it becomes chest pain, and the chest pain filters down to younger and younger individuals until even young children, in their distress, develop chest pain; possibly having seen and heard their families do the same thing.

We twist emotion, spirit and anatomy into a knot when we use the term “heart” to describe both the center of our thoughts and feelings, as well as using it to describe an amazing, electrically driven muscle that sustains our lives.

Every human has, to one degree or another, a broken heart.  All our thumping hearts will one day thump no more.  In the meantime, between first fetal beat and last gasp, we struggle with the brokenness, the tragedy, the trouble this life brings.

What a pity we aren’t taught to address the signs and symptoms of broken hearts, even as we evaluate diseased ones.  It may be that many more people than we realize are using physical descriptions to describe problems that neither drugs nor procedures can treat.

Chest pressure, shortness of breath, nausea, sweats and neck pain are important, and must be addressed.  But until humans look inside, until doctors look past the surface, we will end up ignoring a great deal of suffering in a vain attempt to explain it all in terms of blockages and plumbing, when so much is symptomatic of loneliness, fear, guilt and lack of purpose.

Excuse  me while I order an EKG.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test

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  • medicontheedge

    “chest pain” work-ups are cash cows in my ED…

  • Rob Burnside

    I’m thinking now of the late Dr. Howard Harris, a kind and bushy-browed pediatrician who made house calls when he could. In his black bag he kept a vial of pale yellow sugar pills (he called them “homeopathic”), dispensed in paper packets to the worried moms of not-so-actually-sick children who just needed to spend a day at home. He never blew my cover, this wise and caring physician, and somehow managed to reassure my mother all the same. Now there’s the art of medicine!