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the south shall rise again! (or something) - Sing a Song of Sixpence
Pocket full of rye
the south shall rise again! (or something)
Brief ED post, no need for editing - nothing gross:

The next chart in the rack is Duncan Weisner, an 18 year old with chest pain. He's got no medical history, no relevant family history, no real risk factors. I don't know what's going on but I figure before I go into the room that he's not dying of a heart attack.

In the room there is a chunky young guy clutching his chest.  He's hooked up to a monitor which shows an extremely normal heart rhythm. The nurses have put the EKG on the counter and it could not be more normal.  Duncan has an equally out of shape friend with him who limps painfully around the bed, holding a half eaten bag of Doritos and winces visibly as he sits down.

"What's going on, Mr. Weisner?" I ask.
"I think I'm having a heart attack," he gasps. He does look miserable but I'm not convinced he is having a heart attack.
"Well, tell me the story of your pain. When did this start?"
"Cooper and me," he gestures towards his friend, "we're trying to get in shape. We're going to join the army so we want to get in shape." City X donates a lot of young men and women to the armed forces. It is the only way out for many people - and there is possibly a smaller likelihood of being shot in a foreign country than there is on the streets of City X. I see a lot of vets in my ED and a lot of very sad parents but I don't think I've ever seen people attempting to get into the army before.
"It's great that you're trying to get into shape. When did the pain start?"
"Well we rented this DVD that was supposed to be like basic training and, shit man, that shit is hard core. We were running and doing crunches and stuff. We must have done like, a million crunches and a million push ups and a million squats. Maybe more. But we're going to get in shape!"
"Did the pain start when you were exercising?"
"Nah. We both finished and then we had a couple of 40s. We deserved them after that shit. And when I woke up this morning I was having a heart attack."
"Hmm," I say, and do a physical exam.

Mr. Weisner needs to lose about 50 lbs but his heart has a regular rate and rhythm with no murmurs, rubs, or gallops; his lungs are clear. He's got mild diffuse tenderness in his quadraceps , hamstrings, gastrocs, deltoids, biceps, triceps and impressive tenderness along both sides of his anterior chest wall. I diagnose him with acute inflammation of his pectoral muscles from doing way too many push-ups. He is mortified. Cooper  teases him. I mention that Cooper is limping and perhaps shouldn't throw stones. Mr. Weisner laughs uproariously and Cooper retreats into his bag of Doritos.

"So what motivated you to join the army now?"  I'm killing time while I finish up my charting. This guy was brought back as an emergent patient and I need to get him out quickly to free up the monitored bed for someone who might actually be having a heart attack. The question agitates my patient.
"This country is a bunch of pansies who don't know how to fight. We're willing to go and kill a bunch of Arabs, but we won't stand up for our own people!" This confuses me.
"Do you mean the situation in Afghanistan?"
"No! They're just another bunch of towel heads. I don't even know what the fuck we're doing there, that Osama guy has moved on by now. I'm talking about America. America is being attacked and nobody is doing nothing."
"Um," I say.
"Yeah, we used to have a cold war and everybody was all nuts about it but now we have a hot war and nobody cares."
"Ah," I say.
"See?" Cooper says, heatedly, "She doesn't care either!" He turns addresses me directly, "I don't know what is wrong with you people!"  I'm not sure what part of being a short, four-eyed, overeducated female he means by "you people," but regardless, I've been called worse.
"Lady," says Mr. Weisner, grabbing my wrist and then remembering who I am and releasing it as if he had been burned, "I mean doctor. Doctor, the Russians invaded Georgia. My grandma is from Georgia. Don't you care?!"

I discharge Mr. Weisner with a prescription for Ibuprofen and orders to ramp up more slowly on his exercise plan.

and, yes, this is a compilation of multiple patients. This seems to be a common misperception.

Tags: , ,

31 ellucidations or expositions or put your $0.02 here!
From: tlatoani Date: October 28th, 2008 09:50 pm (UTC) (Link)
spiral_fire From: spiral_fire Date: October 28th, 2008 09:56 pm (UTC) (Link)
Darwin is calling!
figent_figary From: figent_figary Date: October 28th, 2008 10:08 pm (UTC) (Link)
Oh yes. And more than once or twice. It is part of the liberal media conspiracy to keep it out of the press.
From: tlatoani Date: October 29th, 2008 12:22 am (UTC) (Link)
The ignorance, it burns...
phawkwood From: phawkwood Date: October 29th, 2008 03:43 pm (UTC) (Link)
Like white hot needles it is!!! Curse it! curse it!!
figent_figary From: figent_figary Date: October 29th, 2008 11:23 pm (UTC) (Link)
Hey, take care of yourself. Two of our best 'medics died this month and one last month. Not only do I miss them personally, but we really need you guys!
phawkwood From: phawkwood Date: October 29th, 2008 11:55 pm (UTC) (Link)
I do.

I'm sorry to hear about that, I don't think I'd caught those passing on the grapevine. Too much of that kind of thing going around.
spiral_fire From: spiral_fire Date: October 29th, 2008 02:18 am (UTC) (Link)
I shared this story with my friend who said, " they'll be so disappointed when the "brain doctors" refuse to give them bullets with their rifles...
but each will wear the special badge that reads, "gunning for Darwin '09"
theweaselking From: theweaselking Date: October 28th, 2008 09:57 pm (UTC) (Link)
I'm glad to see you posting again!

So, what, in our compilated patient, is the source of the "heart attack" chest pain? Strained pecs from pushups and abuse of a weight machine?
figent_figary From: figent_figary Date: October 28th, 2008 10:00 pm (UTC) (Link)
yup. Just an acute overuse injury. I actually see this quite a bit. Mr. Weisner was straight forward but when it is a fat 50 something smoker whose dad died of a heart attack at 45 who has suddenly decided to get in shape it's a lot less easy to blow them off.
decafdyke From: decafdyke Date: October 29th, 2008 12:17 am (UTC) (Link)


it sounds ridiculous when it's not happening to you, but i have done silly things at the gym that led to a combination of chest pain and tightness the next day, and it was kinda scary.
figent_figary From: figent_figary Date: October 29th, 2008 02:01 pm (UTC) (Link)

Re: yeah

I've also seen really impressive abdominal wall tenderness that mimics peritonitis from doing too many sit ups. We almost sent one guy to surgery before we figured out what was going on.
inhumandecency From: inhumandecency Date: October 29th, 2008 04:29 pm (UTC) (Link)

Re: yeah

Especially since once you have the core symptoms, it's not hard for your brain to start making up twinges in your shoulder, sweating, irregular heart rate... I've also seen one website that lists "feeling of impending doom" as a symptom of a heart attack.
figent_figary From: figent_figary Date: October 29th, 2008 11:22 pm (UTC) (Link)

Re: yeah

But it totally is!
When a patient says "I think I'm going to die" they probably are. I take it really seriously.
inhumandecency From: inhumandecency Date: October 29th, 2008 11:28 pm (UTC) (Link)

Re: yeah

So you find that it's more diagnostic than the physical symptoms alone? My early training was in a panic disorder lab, where we learned that a feeling of impending doom is mostly a symptom of *thinking* you're having a heart attack.

I can't imagine what I'd do if I was a doctor for someone with panic disorder and CHD.
figent_figary From: figent_figary Date: October 30th, 2008 03:57 pm (UTC) (Link)

Re: yeah

Well...not *more* diagnostic. It all fits into a package - physical symptoms, physical exam findings, lab and xray findings, and 'gut feeling.'

When I get a little old lady in who "just doesn't feel right" and has made arrangements for her neighbor to take care of her dog in case she doesn't come back from the hospital I get scared. When someone who has had a couple of serious illnesses before tells me that he "thinks this is the last one" I get scared. When someone comes in with vague symptoms and a nonspecific exam but real underlying disease and states "I think something is really wrong." I get scared.

But this is something we're taught in medical school. Patients know when they are really sick and patients know when they are going to die. We're taught to ask about a feeling of impending doom. We're not taught that a FOID is due to thinking you are having a heart attack.

Have I ever seen any data? No. Do I have lots of anecdotes? Sure. But I'm conditioned to remember that one time I explained a complex procedure to an old guy and he said "I just don't think that will be necessary, Doc." and died and to discount the 8000 times that I saw people who felt totally great and then died.

Taking care of people with hypocondriasis or panic disorder or bad fibromyalgia and also real disease is maddening. They end up getting very over-worked because nobody wants to be the one to miss something just because the person has cried wolf before or has chronic pain. And then what we do to them is not benign and not without side effects and a cascade of badness happens.

Residents are the most superstitious group of educated people in america. I think ED docs aren't far behind. I think there could be some really interesting research here although it would be painful to set up.
inhumandecency From: inhumandecency Date: October 30th, 2008 05:52 pm (UTC) (Link)

Re: yeah

It's one of those things that's hard to research because no one can bring themselves to take any chances. You could see whether patients' beliefs about whether they'll survive a procedure predict whether they will, independently of health. But it gets epistemologically complicated because optimistic people do tend to be more resilient physically as well as emotionally. Could a patient's beliefs both predict and influence their survival? Actually, Judy and I are meeting with some cancer people today to discuss a trial of a positive emotions intervention for people with stage IV pancreatic cancer, so we might get to find out.

In the case of panic disorder, a lot of people visit several cardiologists before they're referred for psychological evaluation, so often you do know whether it's plausible that they're having an actual physical crisis. It probably also helps that panic disorder tends to emerge when you're pretty young. Still, I find the differences in outlook between psychological and medical practitioners very interesting!
From: (Anonymous) Date: October 30th, 2008 06:35 pm (UTC) (Link)

Re: yeah

I'm a caregiver for my Mom who has schizophrenia and also cancer, plus a lot of other "little diagnoses" like irritable bowel, arthritis, etc. She has more than twenty meds at any one time. We've made a lot of visits to the ED, and I spend a lot of time with doctors in general. It's maddening to try to untangle symptoms and feelings and such. In our case, the mental illness seems to cause some very frustrating sensory integration deficits, so that sometimes she's in a lot of pain and it's nothing, and other times she feels nothing and she could literally have a broken bone. I think that "gut feeling" is really worth listening to. There was one time recently that Mom was in to the doctor with vague symptoms, and she was on the fence about admitting her. I said to her, "I just have a bad feeling about this one. I don't want to take her home like this," and so she was sent over to the hospital, and it was found that she was indeed quite sick. To be fair, some of my other bad feelings have been wrong. There's just no way to be right every time. Sometimes I think that talking to patients and asking a lot of questions can get in the way of a diagnosis. Some people come in with their own idea of what's wrong, and they can be very persuasive. Mom is terrible about this. I spend a lot of time trying to diplomatically tell doctors to please ignore what Mom is saying and do a careful exam. I go along in part as a reality check, otherwise she would spend all of her time in MRI. In taking care of Mom, I always listen to what she says, but I also draw on my experience working with animals in veterinary hospitals, and I look at her behavior, how she's acting, etc. If she says she's in horrible pain, but she hops out of bed, has a normal breakfast, and doesn't seem slowed down by it, I'm not going to freak out like I would if I came in and found her looking gray and dehydrated with no energy, saying she everything is fine. Even so, I'm still wrong quite often.
From: ellameena Date: October 30th, 2008 06:36 pm (UTC) (Link)

Re: yeah

That was me.
From: (Anonymous) Date: October 29th, 2008 05:54 pm (UTC) (Link)


Thanks so much for the post today - it's terrific to have you posting again. I have to admit, I laughed until my sides hurt with the Georgia thing. I love how U.S.-centric our population can be sometimes. Kudos to you for not busting a gut and laughing in their (sweaty) faces. I couldn't have done it myself, LOL. :)
shekkara From: shekkara Date: October 29th, 2008 12:06 am (UTC) (Link)
OMG. So funny! You know this would make a really good stand-up comedy routine, but sadly half the US wouldn't get it.
From: ellameena Date: October 29th, 2008 06:57 pm (UTC) (Link)
Is this a joke? People really believe that Russia invaded Georgia, U.S.?
figent_figary From: figent_figary Date: October 29th, 2008 10:02 pm (UTC) (Link)
It was funny but not a joke. A bunch of my patients have been confused about this. You have to remember, the literacy level in City X is about 42% and the vast majority of people in the city do not have a high school education. I first heard about South Ossetia from the BBC followed by NPR. My patients (to grossly generalize a diverse population) get their news, if they get news, from Fox or someone down the street who saw something on Fox.
From: ellameena Date: October 29th, 2008 10:18 pm (UTC) (Link)
Well, I know not everyone is a fan of FOX, but I think this misunderstanding is way too egregious to blame on them. I think anyone who bothered to follow the news at all would get straightened out on this particular misunderstanding quite quickly. Still and all, it's astonishing that anyone over the age of six could believe such a thing! I don't suppose you tried to correct them on the facts?
figent_figary From: figent_figary Date: October 29th, 2008 11:19 pm (UTC) (Link)
Yeah, that was poorly worded. I apologize.

I was actually using "Fox" as an imprecise and unclear (unless you had a crystal ball into my mind) short hand for "poor quality television news" regardless of the station or political slant.

I would agree, everyone reading this blog and everyone I hang out with as a friend and all of my co-workers know that the Georgia that Russia invaded has lousy barbecue and a notable lack of any part of of the devastation that followed Sherman's March to the Sea. My patients, however, are a different story. This type of ignorance, even though it is easy to laugh at, reflects a deep lack of knowledge and lack of education in the population with whom I work.

Most of my patients could not name all the states in the nation or locate most of the states on a blank map. Many of them are completely illiterate and innumerate - they can can sing the alphabet but not recognize letters (and these are adults we're discussing) not write their full first and last name or can write their name and are proud of that fact but can not write anything else. Most of them can not read simple medication instructions and by simple I mean "take 1 pill in the morning" and not "400mg qid/300bid PO on alternate days."

Only 42% of the City X can read at or above a 6th grade level. I don't think many/most of my patients follow any news (but this is speculation on my part) and, in large part this is due to the fact that international news is neither interesting nor relevant to many of them.

I do try to correct my patients' lack of knowledge regardless if they think that the flu shot prevents the "stomach flu" or that they can't get pregnant if they have sex standing up or that the Russians invaded America. The last point is easier than the first two since there is a "Brooklyn" in the state where I practice so I can draw the comparison between Georgia here and Georgia there and Brooklyn here vs. Brooklyn, NY. Some of my patients are embarrassed, some are amused, some are relieved, and some flat out don't believe me.

Of course, patients aren't the only ones with a painful lack of knowledge. I've had residents -residents who went to college and medical school in the United States- not know that Côte d'Ivoire was a country (and then couldn't figure out what language was spoken there (dude, the name is in French!) and couldn't guess the continent even when I told them that two of its neighbors were Mali and Guinea), think that Rhode Island is an island, and think that Panama is a part of Mexico.

As a nation, we're pretty appallingly ignorant about geography:

I'm enough of a geek to think this is fun:
and enough of an egotist to be shocked and horrified that I couldn't get all 195 the first time.
uplinktruck From: uplinktruck Date: October 30th, 2008 03:33 pm (UTC) (Link)
My Lady, first I must point out that I am in the television business. Fox is one of many people that hire my services and equipment.

But I can tell you that on a day to day average their quality is equal to CBS or ABC. Fox far exceeds NBC and CNN. And I say this because I sit and watch all of them assemble their facts and out their stories together.

At Fox, they are under strict orders to get ALL sides of the stories they cover. Failing this they had better have a concrete explanation as to why they did not. (IE: The other side refused to speak on the matter, etc.)

Fox puts all sides of an argument up in all political matters. They get spokespeople from both parties and let them plead their case in a a free debate format.

No other network places that requirement on their producers, editors and talent.

What I've discovered in talking with people that make these statements about Fox news is they never remember the person speaking for their side of the argument. They only remember that fox put on Newt Gingrich. For some reason they never remember that Molly Ivans was the one debating Newt. (Just an example, I don't know if those two have ever done head to head battle on Fox.)

This applies to the straight news portion of Fox's programing and most of the commentary, but not all of it. When you get to the editorial side of the outlet, I freely admit Fox is heavily conservative.

Just sayin', ya know?

Edits: Jeeze I'm a lousy typist when I get too much blood in my caffeine stream...

Edited at 2008-10-30 03:37 pm (UTC)
figent_figary From: figent_figary Date: October 30th, 2008 03:41 pm (UTC) (Link)
My apologies.

I batted out a quick reply and didn't bother to think, first. That always gets me into trouble.

I've got to admit, I don't have cable. I don't have a TV. When I did have a TV I never had time to watch it. I can't recall the last time I saw a TV news show so I was speaking out entirely out of some usually non-verbal part of my anatomy. Thanks for telling me about Fox's stringent requirements for news, that is a great thing to know and a good thing to remember when I'm about to start maligning groups for "unfair" coverage.

Mea culpa. Thank you for pointing out my error.
uplinktruck From: uplinktruck Date: October 30th, 2008 03:06 pm (UTC) (Link)
It is not a joke. I've heard it before. Even been asked on job sites why we aren't covering it more and if the Russian's are in Atlanta yet.
From: ellameena Date: October 30th, 2008 06:25 pm (UTC) (Link)
*head desk*
shadowriderhope From: shadowriderhope Date: November 6th, 2008 02:11 am (UTC) (Link)
Owie. :( That's frightening. But glad to see you posting!
From: scotty011 Date: October 6th, 2010 08:22 am (UTC) (Link)
These posts are fantastic figent_figary.

As an eager ED doctor from Australia your entries have continually reminded me why I'm doing all this study!

Thanks so much and keep posting!

31 ellucidations or expositions or put your $0.02 here!