Among the adventures for your primary care physicians is managing the complaint of abdominal pain. And while it is very different if you’re 2 or 12 or 20 or 50 or 80, the problems range from nothing to dangerous. But unlike the complaint of chest pain, dropping over dead from it is essentially never the case, so there is time to assess the situation.

The abdomen is full of organs and they all behave differently, and you may be able to zero in on what the problem might be with a few tips. Here are some thoughts on what organs act like when they are hurting:

Appendicitis. The appendix is a little worm-shaped finger-sized blind loop of intestine that hangs down off the beginning of the colon, and is famously present in the lower right abdomen, or the “right lower quadrant” (RLQ). In the condition of acute appendicitis there is an obstruction at the pore where it attaches to the colon there, with poop material, etc., and it begins to swell. Eventually it will pop (“perforate”), and this is bad because rupture of any part of the colon spills the germs that live there (as part of normal bowel “flora”) out into the abdominal cavity, and if this is allowed to fester for some days the infection in the belly cavity gets large and out of control and threatening. Yet while it seems like at least a quarter of the appendicitis cases we see are perforated, I cannot recall any cases where the person died from it, but it is possible. Hence, it is worth getting evaluated for, if the pain is down on that side of the belly.

The condition is unusual in the elderly and littler kids, but I have seen it in all ages. The peak age is young teenagers. A typical story is waking up with pain around the belly button and loss of appetite. By noon the pain seems to localize in the RLQ, and that night there is a general surgeon in your life. Appendectomy is a minor procedure taking less than an hour usually, and nowadays is done with a fiberoptic tool.

It is difficult to tell who has appendicitis by examination, and years back we had to “sell” a surgeon on the idea that he or she needed to see the patient in the emergency department, and things like abnormal labs, fever, and the exam itself are unreliable. Hence, they used to train surgeons to find that at surgery only half of patients actually had appendicitis, to make sure they were operating aggressively enough.

Even though we don’t feel good about CT scan radiation dose, if you’ve got an appendicitis story we’re breaking out the scanner. An ultrasound can sometimes be useful but is not as good. There aren’t many cases that hide from the scanner, so a normal study is pretty reassuring. Generally, with appendicitis you’re getting worse by the hour, so if things seem to be improving you can consider waiting. If you’re on to day two I’d worry less, but I’ve seen lower grade cases develop slowly like that. But remember, if there’s an infection thing like that in your belly, you should be able to push on it and find tenderness, and any time you can find something like that in the abdomen you’d better be careful. Tenderness (i.e., hurts to push on) is a key warning sign in abdominal pain complaints of any kind. And there is the term “rebound tenderness”, where shaking the belly cavity and moving things around in there will make an inflamed thing hurt. If there’s rebound, you’re getting worse.

Barbers used to do minor surgeries, and hung bloody rags outside to dry, and after this practice ended they just made those whirly red signs to mimic the rags. Their scalpels were used by surgeons of a later day. But yes, barbers used to do appendectomies.

Other conditions: Upper abdominal pain

Pain in the upper abdomen is common and there are several organs up there that can hurt for one reason or another. There is the stomach, the gall bladder, the early loops of the small bowel (the duodenum), and very importantly, the pancreas, and it can be hard to tell them apart based on the hurt, and whether it’s tender there or not to push on. They all cause nausea and vomiting, and can affect and be affected by eating. They all hurt through to the back (except the small bowel maybe). For bad enough complaints, a series of labs, an ultrasound, or even a CAT scan can tell you what’s wrong usually. And you can run up a large bill quickly for belly pain evaluations and come up with a bunch of you know what.

Do I have a stomach ulcer? The stomach is in the upper mid-abdomen region called the “mid-epigastrium”, and deep-hurt, organ-type pain in this location, often felt radiating through to the back, may signal the stomach is hurting. Ulcers develop gradually, so the complaint is typically weeks of discomfort, usually worse when the stomach is empty, like in the middle of the night, when there is nothing but acid gnawing away at the stomach lining. The pain at times becomes intolerable, and vomiting is not unusual. Food often makes things feel better, presumably by diluting the acidic juices.

The stomach manufactures acid to a very low pH (high acid is low pH), and in so doing injures the stomach itself, and also the first part of the small bowel it empties into (the duodenum). Furthermore, the reflux of its contents injures the esophagus, resulting in the zillion-dollar antacid business. And we don’t eat a lot of rough foods like we used to, so all this acid seems increasingly unnecessary. Since the advent of acid suppressors like histamine blockers (Zantac, Pepcid, Tagamet) and proton pump inhibitors (Prilosec, Nexium, Prevacid, others), we just don’t see stomach ulcers like we used to. However, with the introduction of the over-the-counter (OTC) anti-inflammatories like ibuprofen and naproxen, we still see ulcers, and these medications are now the main cause. Alcohol and especially cigarettes are famous causers for stomach ulcers as well.

Upper GI Bleeding

Another consequence of stomach or duodenal ulcer is bleeding and hemorrhage from the organ, a life-threatening situation. There are big arteries up there and when there is bleeding it is typically massive. Blood is cathartic, so before long it is coming out the bottom of you. And after traveling through the digestive system it is metabolized to black, and the term for the black, tarry, unbelievably foul-smelling “end-product” is “melena” (pronounced MELL-ena). Many times people have no idea the black stuff is blood, and may report “black diarrhea”. But it is the drop in circulating blood volume that makes people collapse or feel weak or dizzy especially on standing, and this is what brings them to the medical system. It is the low blood pressure, fast heart rates, and loss of color that leads us to suspect that the condition of “upper GI” (for gastro-intestinal) bleeding is occurring. Resuscitation with IV fluid is critical, and often more “intensive care” is needed for stabilization. If the circulatory system loses pressure it can be very hard to get it back, presenting a potentially fatal situation. And these are very frequent emergencies.

Passing “bright red blood” from below, is scary, right? Well, it is in fact less often dangerous when compared to upper GI hemorrhage and melena. Bleeding from “below” that is red is usually from the colon, which doesn’t bleed like the stomach and duodenum do.

The forceful nature of vomiting can tear esophageal tissue a little bit and scare people, especially young people, but without melena or signs of blood loss (low blood pressure, fast heart rates, poor color), these red pukes rarely add up to something serious. Reassuring people is another story however.

Early in my career, in the early 80s, fiberoptic tools were just being invented. Now, you name the area of the body, and there’s a scope for it. Besides looking at and biopsying tissue, they also can be used to stop bleeding and open obstructions. They are very helpful managing intestinal bleeding and have revolutionized care immensely. And they have allowed for the gastroenterologists of the world to live in very large homes.

The Pancreas

This digestive organ resides on the left side of the upper abdomen, but the hurt generated when there’s something wrong can be anywhere in the upper abdomen and generally toward the midline. It can even hurt on the right of the upper abdomen, the area typically reserved for the gallbladder, so it’s hard to tell. The pancreas is a vital organ, and when something’s wrong with it, it stops you in your tracks. The pain is intolerable, and there is often vomiting, and one knows this is more than your average bellyache. The most common cause of pain in the organ is injury caused by alcoholism. Occasionally medications and high fat levels in the bloodstream can injure and inflame the organs, the condition of “pancreatitis”.

The leaf-shaped pancreas coalesces into a single duct that connects with the bile duct coming down from the liver, and they form one duct that empties into the upper part of the small intestine, so stones and sludge from the gallbladder can get loose and travel down the piping and plug up the pancreas duct. The resulting backup injures the pancreas and this can be life-threatening (“gallstone pancreatitis”). And the bile backup turns you yellow.

They say there are three rules of surgery: eat when you can, sleep when you have to, and don’t ever mess with the pancreas. It is a flimsy, fragile organ and is profoundly unforgiving. Recovery can be long, with incapacitation and starvation, since eating flares it all up again. Once they start, these problems can recur.

Haunting ERs everywhere: then patient with chronic pancreatitis. They rarely deviate from the profile of 30s to 40s, former drunks and usually drug addicts, from bad childhoods, now broken down to chronically depressed chronic pain patients. They orbit into the ER every so often with “a flare-up”, and there’s usually not enough narcotics in the box to give them relief, and they’re always wide awake and hoping, usually pleading, for more. Their labs are unreliable, and yes you can see abnormalities on CT scans, but then where are you? Usually you have validated their ghastly plight, that this little organ can make you so miserable. Even when we can’t find anything wrong with it.

As with all chronic pain patients. antipsychotics with a little narcotic is usually the key to the temporary relief we hope to provide. And bet on this: these people haven’t paid any bills recently.

The Gallbladder

The liver sits in the right UPPER quadrant of the abdomen (RUQ). Beneath it, hanging on some ductwork emerging out of the bottom of the liver is the gallbladder. This small pouch of an organ a few inches long stores bile. This residue of metabolism (bile) is dumped into the small intestine where it aids in digestion of fats in the diet. It is also responsible for the color of poop. The “gall” (bile) can sludge and form stones, and these can cause intermittent pain and lead to surgical removal for relief.

The stomach itself secretes a hormone called CCK (cholecystokinin, or “make the gallbladder move”), which finds it’s way through the blood to the gallbladder and makes it contract, and this all happens when you eat. If there are stones in the gallbladder, a right upper abdominal pain may follow a meal an hour or so later. The hurt is bad but tolerable, and people put up with it for years. But a diseased, stone-filled gallbladder can get swollen, infected, rupture even, and good luck surviving all that. And this is not to mention the possibility of sending one of those stones down the duct system and injuring the pancreas.

It’s a small industry regarding the gallbladder in the management of belly pain complaints. Usually with classic symptoms and an ultrasound that shows stones, the local surgeon can remove it with a few cool tools of the modern era and you’re home tomorrow with a small scar. But what if the tests are normal? Well, they’ll often take it out anyway, and then what if the pain doesn’t go away? Is this just some sort of chronic pain? Are narcotics involved, or psychiatric behavior? Welcome to my shift.

The Colon

The colon starts in the Right Lower Quadrant, where the appendix is. It goes from there up toward the RUQ (the ascending colon), then goes across the upper abdomen behind the stomach (the transverse colon), turns downward there on the left side of the abdomen (the descending colon), makes an ess heading back toward the sacrum (the sigmoid colon), then goes straight down as the rectum (a word that means straight), and then the anal structures form the exit.

The rectum is usually empty, and when it’s not you can tell gas vs liquid vs solid, and you knew that. There is an involuntary muscle there which relaxes when any of these substances come in contact with it, and then only the voluntary external sphincter allows for fecal continence. And you knew that also.

Constipation: The job description for the colon is to remove water and “form” stool. Low food intake, dehydration, and narcotics along with other medications can result in drying and stool retention, what we call constipation. If firm stool makes it into the rectum and down to where the relaxation tissue is (a toothy looking structure called the dentate line), stool and stool liquid leak out, and this is called stool “impaction”. Often the only help is to manually disimpact the colon with the (gloved) finger. Soap suds enema, delivered with the long hose and quart of soapy water inserted a few feet up into the descending colon, is the best treatment, and nurses love you for ordering this. But constipation and impaction are awful for the sufferers, and we do well to help out. Cathartic agents (things you can drink that clean you out) like Magnesium Citrate bottles, available over the counter, are reliable relievers of constipating conditions.

The ER is famous for poop stories, and the most notorious top 100 are all from narcotic withdrawal. And without question, with narcotics being the reliable personality destroyers that they are, it makes sense that these people become “full of sh–”, which they generally are figuratively to have fooled themselves into this catastrophic addiction. When they get overmedicated or even frankly overdosed, and are rescued with the narcotic reverser naloxone, they wake up in a pile of…themselves. That is, if they wake up at all.

Diverticulitis:  The colon has 3 bands of longitudinal muscles with areas where the colon is “bare” between them, and over the years as much as 1/3 of people develop small balloon pouches we call diverticuli. And while they may never cause problems, they famously get infections in them and cause an acute abdominal pain from the condition called diverticulitis. This almost always involves the descending and sigmoid colon, and so is a left-sided abdominal pain complaint unfolding gradually over several days. It is treated with antibiotics, and is usually diagnosed by CT scan. And like appendicitis, these things can rupture (though rarely), they can obstruct the bowel, and can bleed profusely (often when they are not inflamed as in acute diverticulitis). I have been surprised in my career how common diverticular disease actually is in our society. But as opposed to appendicitis, there is no rush to go to the hospital before one ruptures. Still, if you’re hurting and tender over there, you should check into it. When a diverticulum does rupture, the surgical repair is much more than an appendectomy, often resulting in temporary colostomy.

Crohn’s disease and Ulcerative colitis: This pair of conditions involve inflammation of the bowel as the result of auto-immunity. In Crohn’s disease any part of the bowel from the esophagus to the rectum can be involved, and in Ulcerative colitis it is the colon that is under attack. In both cases there is lots of abdominal cramping and diarrhea over months, and periods of bloody diarrhea. The diagnosis is made by biopsy and the care is necessarily delivered by the specialist in the field, the “gastroenterologist”. They are treatable conditions, and may remit for years. The typical age of onset is people in their 20s and 30s.

GLUTEN Problems

Gluten refers to the starchy wheat particles in the diet, and some people can’t break them down, resulting in chronic vague abdominal discomfort, bloating and cramping, a condition called “Gluten-Sensitive Enteropathy”. Sufferers usually don’t know they have it, and can take a long time to make a connection between the stuff they’re eating and their symptoms. Hence most take a long time to get diagnosed. Some are born with the problem, others develop it in adulthood, often after serious illness. There is usually wasting and anemia and the malaise that goes with all that, as they seek medical attention and are routinely misdiagnosed until eventually a solid practitioner gets to the bottom of it. Total avoidance of gluten basically cures the problem.

GERD

Gastroesophageal reflux disease (GERD). GERD treatment is a zillion dollar industry. There is a large, well-controlled muscle (the pyloris, a word that means fire) at the end of the stomach that allows the stomach to be the reservoir we need it to be so we don’t have to eat all day long. After a meal, the pyloris will open briefly every 20 minutes or so, and the stomach (a muscle) will contract and squish a small amount of foodstuff into the small bowel, and then it closes up again. Holding back things at the esophagus end of the stomach is a relatively much smaller muscle, the lower esophageal sphincter (LES). It predictably loses the battle against the pyloris, and as a result, food, now acidified, refluxes into the esophagus. This may range from a little “heartburn” to full-blown GERD, where there is damage to the esophagus resulting in scarring and eventually narrowing. Over time, there can be enough scar buildup, often without even noticing it has gone on, that food gets hung up there requiring a trip to the ER. The gastroenterologist is called in, and a fiberoptic tool used to clear the thing. I have worked most of the Thanksgivings of my adult life, and I believe on every one of them somebody came in with “esophageal impaction”.

In the late 80s, the new class of acid stoppers mentioned earlier (proton pump inhibitors like prolosec, Nexium) came on the market and are great at turning off the acid, and while the reflux disease continues the injury is not nearly as bad, and the long-term consequences less. So with much of these symptoms, people should feel free to medicate themselves with these drugs, previously very expensive and now affordable, and safe in the long term.

Nausea, vomiting and diarrhea, and dehydration:

Microbes attack the intestine on regular occasion as we inoculate ourselves after coming in contact with other people. When it’s a virus there is sudden onset of nausea, vomiting, and lots of watery diarrhea. Among the most reliable epidemics of the calendar year are the intestinal viruses of late summer, propagated by mosquitoes. Each germ seems to have its own personality, with some causing more nausea and vomiting and some being more of a diarrhea result. Some invade and enter the bloodstream bringing fever and the “achy” feeling, referred to as “myalgias and arthralgias”, or muscle and joint aches. A common effect of this class of viruses is “inner ear dizziness”, a vertigo, room-spinning, head-movement-induced nausea condition that can take two or three weeks to clear. Sometimes the germs get into the nervous system causing the non-dangerous form of meningitis called “aseptic” (viral meningitis).

Dehydration: A lot of people who come to the hospital complain that they think they’re “dehydrated”, with no real sense of what that means. Certainly humans have an ability to run a little wet or dry, and you can usually tell by the darkness of your urine. But look at dehydration like this: there are three degrees of dehydration: 5%, 10%, and the max, 15% dehydrated. So, from hot summer days to intestinal viruses, you may dry out. For 5% dehydrated, maybe you’re a little lightheaded and dry-mouthed, and your heart runs a little. In 10% dehydrated you’re quite flat and need to be laying down mostly, along with having dry membranes, and dizziness on standing resulting from decreased blood volume. But when we test you with this amount of dehydration, your labs are fairly normal, and while a little IV fluid helps, you’re handling the situation, and eventually the stomach will settle and you can start drinking again, and wouldn’t have died. But as you get more like 15% dehydrated, the blood pressure might be in the 70s, the heart rate in the 130s or higher, and lab testing will show that the kidneys are failing, and electrolytes like potassium and sodium are rising to dangerous levels. IV fluid “resuscitation” is probably essential for survival in these situations. So, often it is the most excellent RN who manages IV access for the life-saving of it all. While I mouse click a bunch of notes and orders and other nonsense.

And lastly, the rear end: The most common of rear end problems are hemorrhoids, fissures, and infections. Hemorrhoids are hemorrhages into the skin of the anus itself, which is a tender and soft mucous membrane. They are managed acutely with lots of soapy water soaking and a variety of salves with limited benefit. They generally must run a course of 3 or 4 weeks, when the clot solidifies and resorbs to some degree. Fissures are slits in the anal muscle from trauma and are associated with a wicked spasm after bowel movements lasting an hour. The best treatment is to aggressively apply “Calmoseptine”, a relative of the zinc oxide the surfers and lifeguards use.

And then there are infections. Pain, redness and swelling or abscess formation in the outskirts of the anus are the typical and unmistakable complaints and findings. They may require a surgeon to slice and drain them open, a painful experience. In fistula formation, a tunnel has dissected from the rectum around the anal muscles and emerging a short distance away. They drain a foul smelling combo of poop juice and infection. Again, a surgeon can “work on” these things for you, and thank goodness for that.

From the head and neck, to the extremities and fingers and toes, there are lots of things to think about, and I will make some attempt to address at least the more common situations people get themselves into, and some basic concepts as to what to do and when. It is quite the industry, accounting for a significant percentage of the conditions that constitute a minor and sometimes major injury. On the other hand, we see a lot of stuff that probably don’t need medical attention, but never forget, we’re here for what YOU think is an emergency, not what WE think is an emergency. If it’s nothing it’s nothing.

LACERATIONS: Here’s a brief anatomy lesson: The skin is a dead layer (epidermis) on top of a live layer (dermis), and at the bottom of the dermis is a tough, white and shiny layer of tissue called the superficial fascia. The blood vessels and nerves travel through here to innervate and supply life-giving blood to this very circulated and active tissue. Below this is a layer of fat that looks like little globs of tannish tissue. Below that is the “deep fascia”, the bottom layer of the skin. And under that, in most places, is muscle.

To lacerate into the dermis at all generally hits a small blood vessel and you bleed. But it is when you have violated the superficial fascia that it all sags open (“gaps”), and the fat is visible, and you’re best off getting it sutured together, so it will heal faster, and with a more narrow scar. If you cut into the fat far enough you have gotten all the way through the skin and exposed the muscular layer, where things become dangerous in a hurry, and pretty much everyone would agree that you’re going to need to go to the hospital. And with hand injuries especially, they can be disabling and can require sophisticated intervention.

All wounds heal by scarring, which takes a year or more, so the wound is purple and somewhat wide until the process is finally over, leaving, ideally, a thin white line. In areas where there is constant movement (by the mouth, front of the knee), the scar will usually end up wider, and less cosmetically good.

Pretty simple, right? Sewing up a cut is about the first thing they’ll allow a young doctor in training or a medical student to do. But there are a number of things to be alert to. Was a tendon involved? A nerve? Is there anything in the wound, like a rock or a piece of wood? What about a bite, like a dog or a cat or (Gasp!) a human? So we explore all wounds for foreign bodies, aggressively irrigate bite wounds and antibiotic them, and always be alert to signs of deep involvement with tendons and nerves, where you should be able to tell if something isn’t working.

It’s important to note that there was no suturing in cave man days, so wounds will all eventually heal together with scarring. Therefore it depends a little on the lacerated, the location, the age of the patient. Can I duct tape this? Well, if you sew the wound, it’ll be about 7% healed when the stitches come out, so anything that is cleaned and held together long enough to start the healing process will work, so duct tape instead of stitches is a reasonable concept. In fact my last duct-taping I needed for myself was 3 days ago.

Stitches themselves become a foreign body problem after a few weeks, so we have them removed by then. The face, such a fast healer, will leave stitch mark scars (“tram track lines”) if left in that long so they are recommended to be removed within 5 days, and no later.

What about glue? I don’t like it, and I’m sure if done right, especially for small wounds in non-cosmetic places, the result is good. But for me, if there is deep enough of a wound to violate the superficial fascia, I like to sew them. Staples work well, but are often hard to “install” properly, and I reserve them for scalp wounds. And you may notice that essentially all surgical wounds now are stapled together. Stapling definitely “bunches” the edges of the wounds as they “staple”, and this allows for good healing.

There are fancy stitches like mattressing and running stitches, and if your doctor went to a good training program you may see this. Most wounds can be sewn with “simple, interrupted” stitches, for sure. But here’s an interesting issue: tissue fibers run in the direction of underlying muscle, so when a sharp object cuts across them, they retract a little, and pull in the dead layer some. If simply sutured, often the dead layers on either side of the wound are pulled together, and they will not stick together, and may fall apart when the stitches are removed. With a mattress stitch, you turn the needle around when the initial harpooning is done, going back in near where the needle came out, and then back out the other side where the needle went in to start with, when you tie the knot (now on just one side of the wound), it nicely everts the edges, putting dermis to dermis which is what you want. When the stitch comes out, it flattens out no problem.

But wait doctor, my little brat child has a laceration on his FACE! Don’t I need a plastic surgeon? Usually the answer is no. Hey, if you cut yourself you’re going to make a scar and that’s all there is to that. Plastic surgeons do face lifts and boob jobs. Calling in a “specialist” sounds good and all of that, but who sews up all the cuts in the community? Right, your local ER guy. But there are times when you need that help, and you can imagine the deep gashes of trauma, and it’s not a good thing. But your ER doctor should tell you when there is something more than he feels comfortable with. Otherwise, it’s a good idea to massage wounds that are in cosmetic areas of the face, to keep the edges even and flat, and this can be very helpful at improving the cosmetic outcome. Rub it for a minute or two several times a day when you think of it, and for weeks or a few months even.

A few more thoughts. Every dog that ever bit a kid’s face (a favorite place for animals to attack each other) never bit a kid before. So I don’t like old dogs and new humans. And while I’m not a dog people type, I sure see how much they mean to their owners. But dog bites to kids faces… makes me want to blame somebody. Antibiotics for bites is routine. But only about 5 or 10% of dog bite become infected, while 80% of cat bites do. So remember: the solution to pollution is dilution, so copious flushing of all bites is a great idea.

A human bite is a rare event. You may know they’re a bad thing and they are, but it is usually a punch to the mouth, and a laceration of a knuckle by a tooth that constitutes a “human bite”. There are university hospitals that admit people for IV antibiotics for any such injury. But they can be really bad, especially on top of the hand, where there is not as good of circulation as in other places.

Tetanus? Most of us will go our entire careers and never see a case of tetanus. That’s because we vaccinate against it with an effective vaccine. And something like 80% of the 25 or 30 cases reported in the US each year are in people over 50 who’ve never even had their first vaccination. And there are less and less of those people out there. And 25 or 30 cases is an absolutely teen weeny amount. So if the question is about whether you need a tetanus shot or not, probably not.

We did have a case of tetanus at a local hospital a long time ago, and it illustrates the germ pretty well. Tetanus lives in soil, so wounds out-doors involving moist earth, and allowed to fester long enough for the germs to produce the toxin that make muscles go into spasm (“tetany”) is the scenario. This lady was around 50 and had cut her foot on something in a manure pile, and she said that when her dogs barked that her back would stiffen up so bad she couldn’t stand it. You may have heard of the term “lockjaw”, an old name for this infection. If you kill the germs with antibiotics, that’s usually it. But support of breathing may be needed until then, which is the main concern.

One last thing regarding lacerations (or “lacs” as we call them). How long can I wait to get it fixed? It varies. But as healing begins, they won’t always stick together if you try to sew them up,(dehiscence), and the rate of wound infection goes up after 6 hours or so. Any fixing after that is questionable. On the face you can go up to 24 hours, and we’ll still sew them, because of cosmetic concerns and because the face, with so much blood supply, will do OK usually. But we are wise to “freshen up” the wound by scrubbing hard enough to make it bleed some. Still, don’t wait if you can help it. (A common scenario is waking up with a wound after a wild night on the town generally involving alcohol.)

Orthopedic injuries;

Like lacerations, there are lots of options as far as what to injure, and for the most part you can always wait a few days or even longer for an orthopedist to tell you what happened and how to deal with it, as opposed to a clock ticking like in lacerations. A broken bone will start to heal at a few weeks, so you can’t wait forever, but getting your ankle x-rayed in the middle of the night doesn’t make much sense. Here are a few of the more famously injured orthopedic structures.

Hands and fingers, and forearms and wrists constitute the lion’s share of such injuries. Bent fingers and bent forearms are worth going to the hospital about because “reductions” of deformities is generally done and recommended., rather than waiting. Especially wrists and forearms. Kids are great at such injury. No one will ever argue with bringing in a kid for evaluation. If there’s one thing we’ll drag an orthopedist into the ER for, it’s bent forearms.

Elbows, especially in kids, break badly sometimes and require operative repair. So if there is much swelling and pain with movement of the elbow, especially in the growing child, going to the ER is always the right thing to do, even in the middle of the night. Nerves and arteries are in there and can be entrapped, and this is bad.

The shoulder is a very mobile joint, allowing you to raise your arm in class for example. But “stability” of the joint is sacrificed, since the only thing holding the joint together is muscle. So there are a lot of ways to “strain” these muscles, and tendinitis (where something gets overused and worn raw) is very common here. More significant injuries and cause the shoulder to come apart, where the top or the humerus comes away from the shoulder blade completely. In such dislocation usually there is a deformity and drastically reduced range of motion, and an ER visit for this is recommended.

When collarbones break, like with any bone, the pain is huge. They often shatter and splinter, but for the most part heal without much intervention over a period of weeks. No treatment for them other than a sling. They are almost never repaired. In shoulder “separation”, there is injury to the only ligament of the shoulder, the one holding together to end of the collarbone and a knob on top of the shoulder blade. This is where a lump will develop with injury, usually when you land directly on the outside of the upper arm, like on the turf from a fall or a tackle in a sport. If the ligament tears completely the collarbone will wing up an inch or so, making this obvious. Can you touch the other shoulder? You probably don’t have much of an injury. If the collarbone is sticking up a lot, a visit to the bone doctor in the coming days is typically recommended, but like with collarbones, they usually just let them heal rather than offer surgical repair.

Hips: Anyone can fall hard enough to break their hip, and when it happens there is little doubt, because you can’t walk, and the leg injured will often shorten and rotate externally, making a quick diagnosis pretty simple. There are lots of repair options. Beware this: the growing child will often injure the head of the femur, which is only held on by the weak growth plate at that end of the bone. So for limping kids you need to be careful, and seeing an orthopedist is a good idea. If this cap of the bone has “slipped” off the top of the femur, there is a limited time for repair to be done before a disastrous outcome results, making it a famous emergency medicine worry.

Knees: The knee joint is a hinge, so again it is only ligaments and tendons holding them together. So with the femur on one side and the tibia on the other, these are two huge bones and they won’t break unless with major trauma, in which case a gross deformity occurs. (The word “gross” simply means all that is visible to the naked eye.) So injuries are usually internal, such as with ligament tearing.

The knee is a huge joint, and when something big happens to it, it swells and that’s how you know you need to see a bone doctor about it. Usually something “pops” in the knee when something tears, and if it’s the internal criss-cross ligaments (the “cruciates”), the joint swells almost right away, a sign of internal bleeding.

The knee joint has a little gasket type structure that sits on the bearing surfaces of the tibia, and we often “pinch” this with rotational injuries. The joint will often swell overnight, mildly a lot of times, but it becomes hard to extend the joint all the way, and it hurts to walk on it. It will improve with more limited activity for weeks, and can recur in the future with overuse.

Ankles: Remember, ligaments are tough structures that hold joints together, attaching to all the bones involved. When the range of motion (ROM) of the joint is exceeded by enough force, they tear and generally make a “pop” of a noise, and hemorrhage locally, and may swell immediately. The most classic probably is the ankle sprain. There are ligaments on the outside that tear with rollover injuries like landing on someone’s foot playing basketball, and there is a big triangular ligament on the inside of the ankle, and it’s harder to tear (but stepping in a hole is one option). So as the scarring process heals the injured ligament, walking and so forth is very difficult. Healing to normal generally takes months, and in severe injuries, half of a year recovering is typical. And yes, x-rays should be done, because often the fibula on the outside 0f the ankle, a thing bone, will break, and require casting for proper healing.

We used to splint and even cast ankle sprains but found out that the joint does poorly so now, just 3-4 days in, you should be bearing weight on a sprained ankle. And it will only allow so much, but there are a lot of reflexes in this joint, and it can literally have trouble finding the floor with too much immobilization. Wearing air splints and gel splints is helpful, and allows for weight bearing during the healing process. And a good dose of Aleve (2) or ibuprofen (800mg) can do wonders for a bad ankle, or any orthopedic injury for that matter.

Feet and toes: People drop things on their toes, step in holes, or put too much force turning and running, and the foot can sprain and of course fracture bones. While not debilitating like knee and ankle in juries, if there’s much swelling an x-ray is worthwhile.

One last description as far as fractures are concerned. Bones are hard, and they break, and this is fracture, plain and simple. So we can describe what happened when we look at the x-ray, as the various types of fracture, and there are many. They can be angulated, or displaced, or just crack and lay in good position. If there are several pieces, that’s comminuted. Through the skin, that’s compound of course. Long bones tend to fracture in a spiral. A piece of a tip can break off, and that’s “avulsion”. If there’s a cancer in the bone, that’s a pathologic fracture. Not rocket science, right? Well, orthopedists are definitely the carpenters of medicine, and their tool box includes saws and drills and screws and plates and hammers (occasionally), and orthopedists like to look at themselves as the tradesman of medicine, and they all seem to love what they do, and their residencies are very competitive to get into.

There are two basic ways this happens. One is where a clot is formed elsewhere in the body like in the heart or the carotid arteries, and travels to the brain circulation where it hits a small enough blood vessel and can’t go further, and causes the injury. These are called embolic (to travel), and are relatively small injuries that are generally complete when you see such a patient, and the hunt begins for the source. The other is where a big blood vessel has developed a large cholesterol buildup, which for some reason pops open like a piece of popcorn, aggregates blood to it, and a large area of brain tissue dies because it has lost its arterial supply. This is called “thrombotic” (a thrombus is a clot within a blood vessel. It is these latter big strokes that often give the warning spell we call the TIA.

TIA stands for transient ischemic attack, and “ischemic (i-SCHEME-ic is the pronunciation). It’s real simple. We think these cholesterol plaques grow very slowly but at some point rupture, and blood begins to stick to them. This may cause what looks like a stroke to last only about 20 or 30 minutes, and then there is a return to normal. And while it’s good to return to normal, one must definitely go to the hospital and be evaluated.

Embolic strokes are often minor and recovery nearly complete. Thrombotic strokes are big and usually bad, and while there is always some improvement as the brain recruits new tissue to do the work of the injured tissue (called “plasticity”), it’s not like the factory model. Consequently we do all we can to prevent them, and we have tricks to reverse them when we can. So, if there are signs of stroke, there is a big push to get people to the hospital, and for hospitals to recognize these patients at the door, and get them medication if they are candidates.

If you wake up with stroke symptoms, which is often the case, we usually cannot argue to give clot dissolvers, which are dangerous, because the three hour window is not known. But it’s always good to go to the hospital if you have symptoms like that, because a whole lot of things could be wrong,

Of course, preventing strokes is important. It starts with having aspirin in your diet, where even just a regular old 325 mg over the counter aspirin will reduce your chance of heart attack and stroke both by over 50%. Cholesterol-lowering drugs also reduce the likelihood of both of these terrible medical conditions. Know your family history, and properly treat blood pressure problems, and diabetic conditions. But, bang for the buck, taker that aspirin every day.

Other neurologic conditions

Dizziness is a common complaint in ERs and primary care offices. We separate them into three distinct categories: “True dizziness”, where there is a balance problem bad enough to have to hold on to something, “vertigo”, where there is room spinning and motion sickness, and “lightheadedness”, which is everything else when there is no imbalance and no room spinning. These are all very common reasons people go to a hospital.

True dizziness is what we’re looking for, because there is usually something wrong. A simple test is to see how one does with their eyes closed (Romberg’s test). A lot of times the eyes and the ability to fixate on something can cover some amount of imbalance, and it’s not hard to tell when someone is off balance. Scans and further studies are generally recommended, and it is often a functional problem where nothing is seen on a scan. And good luck fixing the dizzy patient.

In vertigo, the problem is eye movement related. Do you recognize that the eyes are on opposite sides of the head, and where one moves out, the other must move in to follow it. This coordination is done in the brain, and is assisted by a canal system in the inner ear called “the labyrinth”. As you move or turn your head, the fluid in this tiny canal system moves, and moves the nerves in there, and the brain directs the eyes to move conjugately. In motion like in a car or on an amusement park ride, this can set off a search pattern, and as the eyes dance back and forth the room appears to spin. It is a big symptom that can be incapacitating, and is surprisingly common. Being real drunken also does this, and the dancing eye pattern is something a cop will look for when he pulls you over and is suspicious of DUI.

The most common cause of vertigo in the general population is infection of this inner ear canal system with virus, like when an intestinal virus is going around, and respiratory viruses do it as well. Most of the time people aren’t otherwise sick, but they wake up one morning and when the sit up or turn their head, the room “spins” and they develop nausea. We see this every year when certain epidemics come through town, so some germs are much better at it than others. The spells generally calm down after a few days, but can happen intermittently for 3 weeks, with days of being normal in between. The treatment involves any nerve quieting medications, like antihistamines (meclizine, or “Antivert” is the most common Rx), and benadryl would work. In bad cases we use a famous brain slower called “Valium”, from psychiatry. The condition can be so bad that people can’t walk or can’t open their eyes.

And then there is everything else, “lightheadedness”. The brain is exquisitely sensitive to everything in the blood stream, so anything that’s out of balance, the brain knows it. There is no frank imbalance like in true dizziness, and no vertigo symptoms which are so peculiar. Just, swimmy-headed feeling. You can take a bunch of deep breaths and hyperventilate yourself, and get very lightheaded and numb all over, and even pass out, because by blowing off so much carbon dioxide you can change the chemistry of the blood stream enough to affect the brain’s function, because it’s an electrical organ. Hyperventilation, subtly, from too much adrenaline and stress and nervousness is by far the most common cause of being lightheaded. Things like blood sugar (low or high), and medications, and being dehydrated are other examples.

Numbness is a common complaint, and if it’s from nervousness it should be symmetric on both sides of the body, and start in the periphery, like in the hands and feet and face. If numbness is more one sided, it gets a little more interesting. If it involves several areas of the body and there fore several nerve distributions, we figure it’s a brain symptom. But in the absence of movement problems, trouble talking or walking, or visual complaints, it’s usually the brain malfunctioning from stress, adrenaline, or behavioral difficulties. If numbness is in an extremity, and follows a single nerve supply distribution, it is probably entrapped somewhere. And with all lacerations, we have to wonder if you may have cut a nerve somewhere, and there are ways of telling.

There is also something we call “pseudoneurological” symptoms, where psychiatry is the problem. This is perhaps the dramatic and weird patient with “the weak and dizzies”, or a sense of numbness or neurologic-sounding symptoms, often limited to sensation but not showing the hard core “deficits” we find on neurologic examination. They’re the hard work of the job.

One more thing. If you can close your eyes and jump up and down on one foot, you’re probably OK. To do this maneuver you must first hear the common, understand it, understand that you are to follow it, and have enough strength and coordination to do it physically.

Seizures: The brain is an electrical organ, and if one area of the brain goes wild and generates a lot of electricity, it can cause the whole brain to “turn on”, and this is seizure. All of the muscles contract, and while the flexors and extensors fight it out, there is a mixture of tonic contraction, and back and fotth movement we call clonus. So a true, full-blown seizure is this unconscious, fall to the ground, chew your tongue experience with “tonic and clonic” movements lasting 2-5 minutes, and in some cases longer. There is some amount of air movement that goes on, so people don’t die of them, unless they are unwitnessed and go on one after the next (status epilepticus). When it’s over a person generally wakes up a few minutes later with no recollection of the incident. It is followed ny 2-6 hours of being groggy and out of it, and people usually sleep. A seizure is called “ictus”, and the recovery “post ictus”, or being “post-ictal”.

Some people just have a seizure every once in a while, and this is epilepsy. Brain injuries like previous trauma or stroke or brain infection can leave injured tissue that can ‘spark” these spells every so often. In all these cases there are medications that prevent them or reduce them significantly.

Our main concern in an ER is two things: was it really a seizure or not, or was it just a pass out spell. And if it was real, then we must inform patients that it is illegal to drive a care for 3 months until you are seizure-free under the care of a neurologist.

But you can’t believe how many phony seizures there are out there (“pseudoseizure”), and many of the mind confabulations are are in people with actual seizure disorders. But when witnessed by people who have ever seen seizures, they just don’t look right, or involve too much symmetrical bouncing around like an athletic act would be, or lots of eyelid fluttering, a famous sign of behavioral conditions, and also crying is a dead giveaway. Often there are months of increasing spells of apparent seizure activity, medications have not helped, and diagnostic studies are normal. And so often, there is the accomplice, the very concerned family member or loved one for whom the performance is being executed, from the subconscious mind of the sufferer. There is no fun for anyone involved. Look for histories of sexual abuse, identity maldevelopment, a history of psychiatric intervention, or other dysfunction.

Passing Out (Syncope)

In school I embarrassed myself by pronouncing the word syncope as it appears, or “sin-cope”. It’s “SIN-ko-pee”. Or being syncopal, or having a syncopal episode. You wouldn’t believe how much of it we see. They say half of people pass out once in their life, and there are some that do it recurrently. There is sudden, often instantaneous loss of consciousness with a fall to the floor, and return to noral alertness happens in anywhere from a few seconds to a few minutes. Usually people around thought you were dying. And people of all ages do it. So we sort through them a lot.

The most common and famous cause of syncope is abrupt imbalance of the automatic parts of the nervous system that control heart rate and blood distribution. You take for granted that the two systems that do this are in a balance, and when they go out of balance even briefly down you go. The two systems in a tug of war for blood supply are the adrenaline side, wanting blood to flow to the muscles and for the heart to race in order to assist this, and a vegetative side that holds blood to the core, especially around an impressive latticework of blood vessels around the digestive system. When you eat, this latticework engorges, and nutrients are absorbed and sent up to the liver for management and packaging. In simple syncope, this system goes off, slows the heart, and engorges the vessels of the digestive system. With the brain at the top of the body requiring a steady flood of blood for proper function, this “perfusion pressure” drops, and the thing winks out, and down you go. Once flat, blood will re-flow, and you wake up. During this time blood pressure is barely noticeable, in the 50s or 60s. Soon, the adrenaline receptors in the circulation will notice what’s happened, and a big adrenaline surge will follow. So, often no only do people wake up, but will be nervous and shaky and pale, and this will all take a half an hour or so to play out. And of course that’s an eternity.

Again the question: what happened? Was it a seizure? Was it an abnormal heart rhythm? Did you pass out” Ultimately, what we’re looking for, as far as danger is concerned, is, is there any reason to think your heart was in a potentially fatal rhythm? This is very hard to say, and very unusual. Was it during exercise? Was there any chest pain? Is this the third time in a week in someone who’s never passed out before? Were you exercising? In anything weird, we’re recommending a monitoring device which most hospitals offer for home use, and cardiologists have tests they do.

A typical pass out spell goes like this. Usually a person can feel their abdominal vessels engorge, and describe a “queasy” feeling. They recognize that they need to sit down before they fall down, and then ultimately end up on the floor. The triggers are many. Usually people haven’t eaten or drank all day. The sight of blood and the smell of food can trigger it. Coughing can trigger them, as can laughing really hard. Breath holding can do it. Squeezing your eyeballs can do it. A very big cause is going to the bathroom, especially bearing down as if the have a baby or pass stool or urine (Valsalva’s maneuver), and I’m amazed at how often this happens.

After a period of observation in an ER, often with an EKG check or lab studies, and cardiac monitoring, we send most people home with apparent simple syncope. It is a spell often named after the big nerves of the torso that come directly from the brain, the “Vagus” nerves, that manage the blood flow to the bowels mentioned above, and they send a nerve to the heart and cause it to slow. So terms like “vagal spells”, or vaso (blood vessel) vagal syncope is a term, as is vagaling down also.

Unfortunately that’s not all that’s showing. And this is not to blame the food industry either. But tell me, what percentage of the people you know make any real attempt to stay in good shape? It’s not easy, and that’s obvious. But do you wish to stay healthy or not? A lot of people don’t make it an agenda piece for themselves. Because of an ever-expanding waistline, we now figure that the rising prevalence of type 2 diabetes will make future generations drop their life expectancy for perhaps the first time since we evolved this way.

I’ll say this, it is hard to watch people struggle with their weight. They become much less beautiful, their physical performance becomes less impressive, and they’re less fun. They look older, age faster, and are much less healthy for the long haul, mentally and physically, which is a drag on everything including and especially themselves. And most have tried dietary manipulation with varying degrees of success, almost always temporary. There is exasperation, and behavioral problems like depression. All because of capitalism’s success at feeding them right into the grave. A battle lost.

Calorie Accountants

If you just plain don’t eat, you get skinny. Like in prison camps. So it stands to reason that if a person does some version of this, like “going on a diet”, that over time you will weigh less, and it’s true. But be sure of this: if you are counting calories, and picking food favorites as if to control your weight, you are completely on the wrong track.

Poor weight management, like poor conditioning, is a failure of the mind. Because if this “mind” really wanted to improve its body, for the good of the self, let alone for the sake of other humans who might enjoy and be inspired by such behavior, then it would not have let this happen. But instead, there was bullshit and cobwebs and lies, and as if below its very nose, the beauty of youth has morphed into this poor form.

Mistreatment of the digestive system is the single most common crime of the self. This mistreatment, of not only the self but the body as well, to repeatedly employ this set of organs for the pure and simple serving and satiation of the self and it’s culinary fascination, is top. Ahead of drugging, emotioning, laziness, or antisocialing, as far as indulgences that are reliably self-defeating.

We were given the big reservoir, the stomach, to take in a load of food at once, and then over hours these organs all get to working and involving, and they are wired to get everything they can out of this food ingestion, and store the energy molecules for future use. During our long evolution, coming up with something to eat was what you did all day long, because it was hard to get and secure and save. Needless to say, that’s not the case anymore. And since it all feels so good and tastes and looks so good, we go quickly from “starving” to satiated, a fantastic modern age journey. Who could blame us?

“Experimenting” with prolonged periods of not eating

Thus, I have favored people approaching it as a mind exercise, because the mind is the problem, not the mirror or the clothes or the lab testing. It’s you. So I tell people they should experiment with prolonged periods of not eating. Simple, right?

When you wake up in the morning, your body has spent several hours completing the “processing” of meals from the day before, and all the packaging by the liver and activities at the “storage facilities” (fat tissue for lipids, muscular tissue for sugars) are winding down, what do you do? Eat. Yuk. I mean, here’s the body ready to do work, and now you’re going to re-direct everything into a vegetative mode. Again.

When you eat a meal, the stomach stores the food, delivering it gradually to the small intestine in small dumps every 20 minutes or so. As this call of duty falls on the very active small intestine the impressive latticework of arteries and veins engorges, to whisk off the nutrients to the liver for manipulation. The liver, you may know, is perhaps the bloodiest organ of them all, and so for hours there is this engorgement and energy expenditure as the metabolic work that is necessary to manage this latest fill-up takes place. The body’s vegetative nervous system is running this show, so the heart slows, and the mind drags, and the couch looks very enticing. So you jump in your car and head to “work”.

Ever hear that breakfast is the “most important” meal? Yeah, me too, in magazines and from fat people. But never from medical people. To me this is among the most cruel of all the urban myths. Keeping up “the fast” is just such a beautiful thing to me. Or maybe a small intake of food, but really any amount of eating gets that whole ball rolling. And while it might be OK for thin, wiry, in-shape people like me, it is where I recommend people start when they are wanting to improve their weight and “shape” issues, this “prolonged period of not eating”.

So I tell them to try this. Pick a few days of the week, or even just one to start, and experiment with not eating all day. At first you will be hungry, and please don’t say you’re “starving” like so many do. Just don’t use that word. It shows that hunger has its hold on you. But you’re fat, not starving. And a snack is OK somewhere in there. But what I want you to feel is that as the hours go by, that hunger reflex fades, and rarely comes back like it did. Feel the mind sharpen. Fell the musculature thrive with all the blood flow and perfusion it needs, without having to play the tug of war game with the digestive system and its big latticework of vessels. Then try to make it to nighttime. Tomorrow, go ahead and eat like you like to so much. Two such days a week not only will guarantee weight loss, but will hopefully serve to re-introduce you to yourself, especially the sharper mind. And only you can treat yourself to this experiment, and see how it makes you feel. And how many days of the week you might want to try it.

Add to this some wise foodstuff selections, like fruits and vegetables, and you can expect to become a much more impressive creature almost immediately. And by shocking the self into this, you can really feel like you’re doing something, other than some little trick of still eating too frequently, but with prettier looking food.

The Role of Exercise

It is among the urban myths that you can lose weight by exercising. At least a lot of weight. Your body is chewing up lots of energy by just living, and by the work of the heart and kidneys and brain and muscles. So as caloric intake drops, these parts of the body are more than adequate at burning up the excess for you.

But to be beautiful, of course exercising and conditioning is plain flat essential. To what degree you can do it, well we’re all different, and some people are so out of shape they can barely walk. But surely, walk a little, then run walk, and whatever, and gradually you can pull off some regimen. But you have to want to, and a lot of people can’t and won’t. What has to happen though is an entirely different approach to your relationship with food.

I want to tell you something that really worked for me: quadriceps strengthening. The quads, the front thigh muscles, are extensors, and they are thin and long and age poorly. This causes us to lose stride, and get winded with minor exertion. I bought a quad strengthener when I was forty and my knees were starting to bother me. I could see the thigh atrophy in the shower. I bought the machine, put it in the basement, and hit it a few times a week. I’ve rebuilt them, and I can’t believe how much not only my leg strength improved, but my ability to run and jump and climb stairs and play basketball and seemingly never get winded. It’s like my whole muscular system toned up. I’ve added chin-ups and pull-ups, and it’s really been fun for me. Full disclosure: I have no investments in quad strengthening benches.

So there’s your recipe. Start with a day, or ideally two, of the week, and make them the days of experimenting with prolonged periods of not eating. Explore the self as it reverts to that lean nifty creature we all are deep inside. On the other days, be wise with what you eat, but not overly so, because it just doesn’t matter nearly as much as how often you eat. And buy a quad strengthener.

Once you get to the weight you’ve decided on, use the PPNE’s to maintain it, by weighing yourself frequently, and expecting it to rise and need to be smacked down again. But especially, be impressed that your mind works better. Consider strength training and your very own exercise routine, not only to make the shirts fit better, but to improve your esteem. And remember, you got fat because you ignored and denied it was happening, which is a self-cruelty that only you can explain to you.

Just about everyone gets a headache now and then. A little of your favorite remedy and that’s that, right? Well guess what, for a lot of people headaches get so bad as to become incapacitating, and it surprised me to find out how often we see people in the ER with the chief complaint of headache. And not surprisingly there are a lot of urban myths surrounding them. Is this a migraine? Do I have a brain tumor or a cerebral hemorrhage? Is it my blood pressure doing this? Can you just shoot me?

So, in addition to trying to provide relief, we must wade through the layers of nonsense regarding cause, as well as trying to come up with something for people who live with frequent or even daily headache, and the disability and lost productivity and decreased quality of life that comes with them. Fortunately, I have all the answers.

An awake and alert nervous system sends out abundant stimulation to the muscles of the body, ideally “lighting up” these orthopedic stalwarts of our existence. They burn up the local stores of our main energy source, glucose, generating CO2 and H2O that the heart and lungs must irrigate and ventilate. If the oxygen delivery lags behind, we generate other byproducts of this muscle activity that must be “re-set” at some point, making us breathe heavy with a racing heart after we stop what we’re doing, for several minutes.

At night, we re-manufacture these nervous system chemicals, called neurotransmitters, that do the stimulating, during restorative sleep patterns. If you stay up all night you might notice how poorly all of this works the next day, and that you seem to get winded with even minor exertion. That’s because there is so little nerve output that only a portion of the muscle gets activated, and in working overtime generates this debt noted earlier.

I’m convinced that this physiologic shortcoming is at the basis of the 95 or so percent of headaches, that are from a hurt in the muscles of the upper back and neck, all working in unison to stand up, and hold our head up. And with the muscles of the spine especially, we’re talking about a tough, powerful, heavily worked and relied upon group of muscles, that hold us up against gravity, in that genius of an “ess” curve, bending in at the neck, backwards for the thorax, inward as the low back’s lumbar region, and then again curving backward as the fused sacrum, or “tail” bone. Headache and backache are the maladies of this reality, when it is not functioning ideally for whatever reason.

When you lay down at night and drift off to sleep, there is a period of hours when the brain continues to generate signals (and we can see them if we have the your head wired, like in a sleep lab). Then, at 3 or 4 in the morning, there is a total shut-off for 20 minutes or so, during which there appears to be no electrical activity in the brain. Then there is a rise of activity to where dreams are generated, what you know as REM (Rapid Eye Movement”) sleep, for several minutes, and then from there to more wakefulness, such that you’re barely asleep. This period of relative wakefulness is accompanied with a “major position change”, where you roll over or something like that. Without this nifty unconscious maneuver you would get bed sores, from laying in one place so still for so long. So thence, sleep comes in these 20 or so minute groupings.

Then, ideally, you pull this off 4 or 5 more times, and wake “fully restored”. Probably, it is during this “off” period early in the pattern that the brain manufactures new neurotransmitters depleted during the day, like the ones to muscles and other commonly utilized parts of the anatomy. During REM, the brain is maybe dumping or re-filing thought activities from the frontal lobes, the bull(crap) of our “minds”. My impression is that people who suffer headache are usually too alert or over -alerted to properly turn the mind off enough for it to slip into these restorative patterns.

Sleep quality, and the ability to perform well at turning yourself off, is probably some kind of gift. For many of us, from environmental factors to inherited traits, something is wagging the dog, and affecting the ability of this important brain function to happen smoothly and consistently. Others will tell you they’ve never had a headache their whole life. They’re the good sleepers.

Hence: headache-prone behavior is caffeine and cigarettes and high-stress lifestyles and realities and poor physical conditioning, and headache-free behavior more like people of even mood, with the intellect to avoid frustrating social realms, eat few pharmaceuticals and no nicotine, and are in good physical condition and shape.

“Normal” people get runs of headaches, lasting a few days to a few weeks. Why would that be? We know people go through episodes for a few months where their brain is alerted of over-juiced for one reason or another, and they will show poor night-time restoration and feel it as the “tension” of tired, sore, fatigued muscles. Other than riding it out and recognizing it and marveling at it and trying to gain self-reflection, , and find the right over-the-counter remedy that works for you, there isn’t much you can do. But it’s a zillion dollar industry, and swirls in urban myth, and the “art” of medicine.

Here’s mine: Bayer aspirin is magic, and a gram is the dose (three 325’s is 975 mg, or about a gram). Preventive for hangovers when taken late, like 3 a.m. Consider a mild caffeine dose (soft drink chug) for these circumstances. During the day, Excedrin or another caffeine idea tab seems reliable. They usually have some Tylenol (acetaminophen) and aspirin in them, and two extra strength tabs is the dose. You will feel the caffeine. Can you see its role, caffeine that is, in tension headache treatment, by pepping up the nervous system, to send out more electricity to the skeletal system and body? Tylenol and ibuprofen and naproxen alone, good luck with them but I don’t see them as good headache medicines for some reason. Not for me anyway.

Occasionally a headache is bad enough that a trip to the hospital is needed for relief, or perhaps diagnostic worries. I myself have been that bad on too numerous occasions, but have I have never considered an ER visit (well, maybe.) But in all of my headaches I have somehow managed to turn off into a restorative pattern, and wake up with it gone, even just an hour later. Such “power” naps are not as hard as you might think, because eventually you would just collapse into one. Get comfortable, turn of the lights, and think about your favorite things.

The treatment for headaches in the emergency department is to “achieve” sleep, with a combination of narcotic, nausea medicine, hydration (interestingly always a big help). In people who are really suffering, a dose of major tranquilizer, like the ones we treat schizophrenics with, can really be helpful. They happen to be magic for managing these acute headaches, if that tells you anything.

“Migraine” Headache

In the head, only the following can hurt, since the brain itself has no sensation at all: the scalp structures and skull, the membranes that surround the nervous system, and the blood vessels. What we have just discussed above is the skeletal source of that common malady of “tension” headache. When the membranes are the source of the headache pain, the reason is usually infection (meningitis) and bleeding (cerebral hemorrhage), and these are the famous catastrophes. And lastly, blood vessels have sensation, and when pain is originating from them, this is what we call “migraine headache”.

Migraine headache has been associated with severity (they’re actually not consistently that severe), and I like the old saying, “If it’s my headache, it’s a migraine headache”. People are funny that way. Like, this ain’t no regular headache. It’s a migraine! But there is no test that tells you that what you’re feeling is a migraine, despite the sufferer’s insistence or the diagnoser’s assurance. They are among the urban myths, which is to say they exist, but at a far rarer frequency than the world thinks. But as a rule of thumb, any headache that is limited to one side of the head should be considered suspicious for the migraine phenomenon. And the treatment for them is different from the treatment of other headaches, and so getting the diagnosis right is important. Especially for people suffering headache several days of the month.

But what are they? Here are the theories. Arteries have muscle in them, so they can spasm, and this is what we think starts the process of true migraine headaches. Maybe a few inches of the vessel, a twisty spasm, set off by who knows what. After what is probably 20 minutes or so of spasm, starving down-stream tissues release chemistries that make the vessel relax, and it is the resulting flailing and bulging of the artery that leads to the pain and “throbbing” with each heartbeat of this one-sided headache. This pain, often localizable with one finger, goes on for 2-8 hours and sometimes longer, and then usually that’s it. To experience one a month is a lot, and most true migraine sufferers only get a few a year. I honestly think I’ve only seen 30 or 50 “real” migraines, out of literally ten thousand or more headaches that I have seen over all these years. Usually a heavy duty pain shot gives long enough relief that patients can be released to weather the remainder of it at home.

During the spasm phase at the beginning, most migraine people have no symptoms, so the fairly sudden-onset of one-sided throbbing pain, would be a typical “common” migraine. If, during the early phase (of spasm) there is an “aura” or a sense that one is coming, this is “classic” migraine. And there are cases where the spasm can interrupt blood flow enough to an area of the brain that stroke-like symptoms appear, such as numbness or slurred speech, or (often) trouble with vision loss. When the spasm phase switches over to dilation, the re-establishment of blood flow resolves this, and the throbbing arrives as the neurologic feature subsides. This is what is referred to as the “complicated” migraine. “Complicated” by a neurologic complaint or finding. They say there is a real if slight risk of stroke with complicated migraine but I have never seen this.

Treating frequent headache is among the great challenges of primary care. It gets to where they don’t really resemble the typical sort of migraine, and becomes the mild to moderate misery of chronic daily headache. Any number of blood-vessel acting medications are out there, some to try to abort the headache during aura, others used for prevention, and all a patient and their doctor can hope for is to stumble on the right one at the right dose with the least side effects that can allow a person to function.

Dangerous causes of headache

Are you worried something is dangerously wrong, like a brain tumor or a cerebral hemorrhage, or even meningitis? Well, there are warning signs of these that are pretty consistent, and when there’s anything weird accompanying the headache, like sudden onset, a fainting spell, high fevers, stroke-looking signs, a trip to your local emergency department is a good idea.

Bleeds: There is absolutely no room in the head for anything besides the brain, so when there is a blood vessel rupture, either spontaneously or from trauma, all hell breaks loose. The pressure generated from hemorrhage makes all the local nerves stop working, resulting in “neurologic features” that accompany what is generally a sudden-onset of headache. Famously, cerebral hemorrhages (“bleeds”) result in stroke-like symptoms, like confusion and disorientation, visual loss, trouble talking or making sense, and arm or leg weaknesses. Falling. Imbalance. It should not be subtle. Always be concerned about sudden onset of terrible headache, especially with anything neurologic.

Where do spontaneous hemorrhages come from? The brain has a huge amount of blood supply, and its many branchings can leave weaknesses where small, berry-sized bubbles can form, called berry aneurysms. And these can rupture at arterial pressure in people of any age. And if they bleed just a little, a fairly terrible headache can result and improve in a few hours as the blood washes away in the brain’s circulating fluid system, where these hemorrhages bleed into. But most people don’t seem to get this warning of a small bleed, and when a big bleed comes, neurologic disaster results. So for any “thunderclap” headache, where there is sudden onset of “the worst headache of your life”, lasting however long, this could be one of these bleeds and going to the ER about it is a good idea. Your local ER doc should be able to order the right study to figure this out.

A CT scan may not show a small bleed, especially if several hours have lapsed. So the only way of knowing a small one might have happened is by doing a “spinal tap” where fluid in the bottom of the nervous system is checked for red blood cells. Either way, new imaging studies can generally find these weak spots, and with moderate danger, a neurosurgeon can clip an aneurysm, while everyone holds their breath. This is world-class medicine of course.

High Blood Pressure and Headaches

I do not consider high blood pressure to be a cause of either awful tension headaches or the migraine syndrome, although a lot of patients do. But outrageously high blood pressure is a problem of course, and in rare and very extreme case causes a neurologic injury to the brain with stroke-like findings, but without hemorrhage.

But yes, high blood pressure is a cause of a type of cerebral hemorrhage, and they are often catastrophic. As opposed to being on the top and outskirts of the brain like in aneurysm bleeds described above, these are penetrating bleeds, often into to deep areas of the brain where the results can be catastrophic. The pressure they generate, especially after a few days of inflammation that accompany such injury, results in unfortunate neurologic outcomes. And these are usually people on in years more, and who have longstanding multiple medical problems.

Trauma

The Good Lord put the delicate brain in a hard box, the bony cranium, to protect it. But with enough force, things tear and rip and bleed. Veins and arteries both can do it, but we see a lot more where there was enough force to tear a vein. The pressure in these vessels is much lower, and the bleeding slower. But there is pressure generated all the same, and neurologic features result. So with a fall or with other traumas, headache with anything neurological is cause for an emergency room visit.

Maybe you’re heard of the “dura”, the tough, leathery lining of the central nervous system, surrounding the brain and down the spinal cord to the bottom. There are three linings of the brain and spinal cord. The outer is the dura mater (“tough mother”), attached to it the spidery looking “arachnoid” membrane, and below that, the fluid that bathes the nervous system, the cerebro-spinal fluid, or CSF. On the brain itself, the pia mater, or (“soft mother”), a thin and delicate membrane. Like the shrink wrap. Vein bleeds form a clot between the dura and the arachnoid (“sub-dural”), and arteries bleed below the arachnoid into the CSF, as “sub-arachnoid” hemorrhages. They’re all bad. Subdurals are usually traumatic but can be spontaneous, especially in people who take blood thinners. And remember, subarachnoid hemorrhages are usually spontaneous and caused from rupture of an aneurysm, but sometimes no aneurysm is found.

Age is important. You have the elderly, who are fragile and fall a lot, and suffer traumatic bleeds with even minor trauma (and oh, they often fall without anyone knowing.) For the most part, we scan any old person with neurologic symptoms. On the other hand you have children, who are active and wild, and also fall a lot. And while most get a “hickey” and vomit a time or two, most are hardy enough that nothing ruptures and bleeds. And with the incidence low, and the absence of neurologic features, our main effort is reassuring moms and grandmoms. And this is important because if you scan a kid, you raise their cancer risk ever so slightly. We never used to think this, and as people get older, and more people had scans as kids, we are now able to say there is risk, albeit very low, so we only scan kids with danger signals.

Meningitis

The membranes that surround the nervous system mentioned earlier, the dura, arachnoid, and the pia, are called “the meninges”. Infection of them and the cerebro-spinal fluid (CSF) is the condition of meningitis. It is a toxic, germ illness, so people are generally sick and often vomiting, and fever is the norm. When the big germs, the bacteria, are causing the infection, you get worse by the hour and the pressure generated by all this infection can be catastrophic and fatal. The neck stiffens, the pain is terrible, and if you try to bend the neck you find it to be nearly rigid. Antibiotics need to be started without delay.

We used to see meningitis a lot more than we do today, because we are now vaccinating effectively against those germs, and therefore it is extremely rare. Still, patients develop fever and headache, and their neck might just be sore from cranking out the fever and maybe some poor sleep in there, well, how can you tell if it’s meningitis? Hence there is often a “scare” in people and kids who are sick with a virus or whatever, and your astute local ER doctor might want to recommend a spinal tap to see if the fluid shows infection.

Viral meningitis, on the other hand, is very common. There is fever, aches, bad headache, and even signs of meningeal irritation on examination. Viruses are extremely tiny and can make their way into the nervous system, but the inflammation that results is minor, and there is no progression to neurologic injury. And since most people have been sick for several days, it’s easy to conclude that this is not a bacterial infection.

One last thing: encephalitis. There are a handful of viruses that can infect the brain tissue itself, like herpes viruses, and others that can be transmitted by insects during summertime. There is headache, low-grade fever, and very definite neurologic features, usually involving alertness. And since there is treatment for most of them, diagnosing needs to be prompt. Generally, this is not hard to do. The patient is clearly sick, and modern diagnostic tools will generally zero in on them (ideally in the hands of one of the more skilled local clinicians, like an internist or a neurologist.)

What about a Brain Tumor?

Unfortunately, they do happen. Most of the time the complaint is not headache, however. New onset of seizure activity, a major change in behavior, sudden confusion or loss of memory, or disorientation (forgetting what day it is or where you’re supposed to be, or what you’re usually doing), these are not good signs. They’re usually subtle at first, but then become worse and progressive, until finally there’s enough concern that a trip to the doctor is warranted, and a CT scan shows the tumor. In some cases, such lesions are only seen on MRI, but either way, as progressive conditions, eventually they will find us if we don’t find them.

Backache

As with headache, backaches are profoundly common complaints to primary care physicians, are associated with piles of urban mythology, and a zillion dollar industry. And we can all expect back pain in our lives, especially as we get older. The most common culprit, you got it, is the spasm of the spine muscles. But we must sort through everything from disc and spine disorders to kidney stones to abdominal aortic aneurysms and hemorrhages and infection, just like in evaluating headaches. Here are some basics.

The spine muscles, especially in the lower lumbar region, are small but powerful, and when you stretch and injure them they respond with a wicked and painful spasm lasting about 5 days. Getting up from the lying (on your back) position is very very difficult and painful when the muscles are in spasm, and this is the easiest way to tell that a good old muscle pull in the back is the problem.

Muscle relaxants (like cyclobenzaprine, or “Flexeril”) are generally helpful, and there are others that don’t seem to help much. And ibuprofen (e.g. Advil) and naproxen (e.g. Aleve) can be very helpful for back spasm as well, or not.

Herniated discs: The spine is a stack of round bones, and between them is a very tough structure called the “intervertebral disc”. It is made of a tough tissue called fibrocartilage, and there are three concentric rings of this making up the disc. In the center is a semi-liquid goop called the “nucleus pulposis”, and if the disc falls apart some over time, the goop can “herniate” out from the center of the disc. Along with being painful and resulting in some amount of spine muscle spasm and local inflammation from such injury, the herniated nucleus pulposis will often sit on the nerve root right there that is exiting the spinal cord, which sits directly behind the stack of bones. This nerve “entrapment” causes the characteristic radiation of the pain all the way down to the foot on the side it herniates on. Over time (months) the goop dissolves and the nerve pain goes away.

To entrap a nerve root, (the “radicule”) results is a strip of numbness or tingling down a strip of one leg, generally 3-5 inches wide, and goes to a very specific part of the foot. Such nerve entrapment (“radiculopathy”) can be diagnosed at the bedside. There are two levels that go bad generally. At the lowest bone in the lumbar chain, lumbar #5 (or “L5″), and its connection to the sacrum, (S1), there is the nerve irritation mentioned above that goes down the back and outside of the leg to the bottom of the foot, and with it there is the loss of the ankle jerk reflex, which you can normally elicit so easily by smacking the achilles tendon with something. And the other level that often herniates is the level above it (the one between lumbar 4 and lumbar 5), which sends numbness down the front of the leg and toward the big toe, and results in weakness when trying to raise the foot and/or great toe upward. These two levels account for almost all of the low back disc herniations.

It is a significant, if non-threatening, injury for this to happen to the spine, and there is often a huge pain felt in the hip, radiated from the spine. Movement is painful and difficult for what is usually 3 months or so, badly curtailing athletic and, famously, work-related activities. For the most part, if nothing is done, you recover by a year or so. I mean, it’s a significant injury to a key part of you, the spine.

What about surgery? The problem is this. If you take patient A and patient B with the same disc injuries, and you operate on patient A (slurp out the nucleus pulposis and scrape out the local inflammation), but not on patient B,and scan them both in two years, they all look the same. So why operate? Great question. Well, the nerve pain is better immediately, but you still have to heal from the injury. But don’t ever forget, a surgeon is someone who sticks a knife in you and tells you it’s going to help. It is so variable person to person that it’s hard to tell whom to treat surgically. And someone else is surely paying the bill.

Bogus back problems (often due to conscious or subconscious malingering) have spoiled the fun in caring for back troubles. Improvement followed by return of “the pain”, and the arrival of the disability mindset is the disaster of such intervention. Long-term narcotic abuse in the “dropouts” of society has destroyed too many marginal personalities to possibly estimate, and the best advice is to just tell people to go back to work. For so many “workers”, if you’re waiting for the pain to go away so you can return to work, it doesn’t happen, whereas returning to “gainful employment” results in resolution of the pain. But chronic back pain and disability is often nothing more than a sign of people with poor nurture and upbringing, and borderline IQ. Throw in a narcotic and that’s it.

Sciatica

The very word “sciatica” makes me cringe. Named for the giant peripheral nerve heading down the back of the thigh, sciatica is a complaint where “my whole leg hurts, doc”, as opposed to the thin, 3-4 inch strip of numbness seen with herniations. That big nerve, the sciatic nerve, must navigate several muscles in the pelvis to emerge down the leg, and as we get older and our pelvis lengthens and we gain weight, the stretch on the sciatic nerve “hurts”. Usually it lasts for months, but much longer in some people.

Abdominal Aortic Aneurysm

The abdominal aorta can develop aneurysm, and the result can be anything from small leaks resulting in acute back pain, to sudden rupture without previous symptoms with a fatal outcome. They present a huge pain in the back. Some people experience a burning in the months before eventual rupture, and figure they’ve strained themselves or something. But they may note that it does not change with movement and there is no radiation of the pain. But then an aneurysm may “leak” a little bit, which may cause a collapse to the floor, a notorious warning sign. When it finally ruptures, a fatal result is the case about half of the time.

So men with blood pressure problems and a history of smoking should wonder if this is the source of this pain, and there are simple diagnostic studies that will show it. Big ones can be felt famously as a “puslatile mass” in the mid abdomen. Happily, these aneurysms can be repaired now with a relatively minor surgical procedure. People at risk, such as smokers and former smokers, male sex, a history of cholesterol and blood pressure problems, and people with family history of these aneurysms, can be screened with ultrasound cheaply and effectively.

Kidney Stones

Among the all-time painful conditions in life: kidney stones. We know back muscle spasms are very painful, and that aneurysm rupture is a huge pain. Add to that the hurt of kidney stones, and you will see that we have to deal very commonly with big back pain, presenting a diagnostic dilemma. Is something terribly wrong?

We talked about how back muscles hurt with movement, and how aneurysms might be seen in certain risk groups, and that low blood pressure could mean the thing is leaking. In kidney stones it is none of these, but they tend to have a pattern. It turns out that kidney stones are very common, especially here in the Midwest. The pain is caused when a small stone (many only 3 or 4 mm round) jabs the muscular ureter, the tube that carries urine down to the bladder. This spasm, so intense of a pain that people get sweaty and vomit, lasts a few hours and stops, presenting the classic example of “colic” (severe pain followed by no pain.) Sometimes it doesn’t subside, and the kidney becomes obstructed and bulges, and this must be dealt with by a procedure performed by a urologist.

Danger: While painful, back problems are not often from a dangerous condition, but like usual, look for warning signs. Low blood pressure and collapse are probably aneurysmal. Colic pain that is one sided and may wrap around rom the flank toward the bladder is probably a kidney stone. Pain getting up from lying flat is probably a spasm. Nerve findings is probably a disc. But there are situations where if something isn’t done, disaster results. Besides aneurysm rupture, there are spinal cord compression conditions that present as back pain. There are hemorrhages along the spine that can be paralyzing, and there are infections and abscesses that can form and do the same thing. So, trouble walking, numbness of both legs, leg weakness, and very importantly, loss of control of urination or bowel movements, are the kind of warning signs indicating immediate imaging and other diagnostics need to be done. And without delay. These are all offered by most local emergency departments.

Heart attacks: Heart attacks usually unfold as what is called the “acute coronary syndrome”. The coronary arteries are the vessels that supply the heart’s muscle tissue with blood, and they develop cholesterol buildups that enlarge gradually over your lifetime. These “plaques” usually “rupture”, causing blood to clot and plug the vessel. With no other way of getting blood, the tissue supplied by this vessel dies, and that is the “heart attack”.

“Sudden death” occurs when a sliver of dying heart muscle sends out a series of chaotic electrical impulses that cause the heart to beat erratically and without coordination, and famously this can result in a total loss of actual pump activity and that’s that. You may see an “AED” sign in a gym or auditorium or elsewhere, and these are life-saving devices, and they work by resetting the heart’s electrical activity (essentially a re-boot)and it usually starts beating again.

Symptoms: There are different kinds of pains that come from different parts of the body, and this is extremely important when deciding whether to go to the hospital about it. Organs like the heart (and kidneys and lungs and the liver and spleen) hurt with what is called “visceral pain”, an awful heaviness, or an intense pressure sensation, or a bad dull ache. That is what a heart attack feels like, and it is all the opposites of the sharp and stabbing pains we experience so much of from muscles and joints and belly cramps. Those are pains that are present in an area that you can point to with one finger, whereas with the heart the hurt is regional. And there is, usually, a bothersome radiation of the discomfort into the arms, shoulders, or jaws, or all of these when the heart is what is hurting. Associated shortness of breath is also typical (“It feels like I can’t breathe”). And these are pains most people have never felt before, and they often use the term “indigestion”, all of which should warn anyone involved, from the patient to family to the emergency staff. Simply, you can’t fool around with these types of symptoms.

Coronary syndromes often have an episodic pattern of warning. Cardiac-sounding discomfort with exertion, for example, is always worrisome. Pain into the arms and shoulders, and associated shortness of breath or “difficulty breathing”. And anyone with an episode of strange chest pain lasting 15-20 minutes out of nowhere, with these features, even young people, should go to the hospital.

Here are some of the tests we do. There is the EKG, which has 12 different “leads”, or electrical pickups. Combinations of three or four of these look at the various regions of the heart, so different ones are abnormal depending on which of the heart’s three main arteries are narrowed or clotted off. There are a number of “minor” abnormalities that raise suspicions, but sometimes further testing gives an “all clear”. Often we will recommend you stay in the hospital until a heart doctor determines it is or isn’t your heart that is causing these symptoms.

There is something called a “STEMI”, where the EKG is wildly and clearly abnormal, and this is cause for immediate intervention, 24/7. At all big hospitals and universities, a staff and cardiologist is always on-call to intervene within 30 minutes of being called. They insert long catheters and using x-rays and dye they can find the blockage and open it up. And sometimes they can’t. For long blockages and diseased vessels, there is no choice but to “bypass” the vessel or vessels with vein grafts from the legs, and you probably know someone who’s had this done.

Other tests. When heart muscle is injured by interruption of blood supply, it eventually dies and falls apart, and this is called “infarction” (heart attack is not a medical term). Within a few hours the proteins that make up cardiac muscle will show up in the blood stream, and we call them cardiac “markers”. Years ago the ones we did took a few days to show up as an abnormal lab, but nowadays it’s a matter of hours. And in some cases, where there have been fairly long episodes of angina (the chest pain that comes from heart muscle starving for oxygen), low positive labs for these markers raises the suspicion for a blockage somewhere. And some are slightly abnormal and nothing is found to be wrong.

An ultrasound of the heart is a helpful study. Cheap, non-invasive, and easy to do, this test looks at the heart’s beating motion, whether there are any parts that are not moving because they have been injured by infarction, and can also tell chamber size. When the heart’s chambers enlarge, that’s bad. They lose strength, and therefore so do you. Heart ultrasounds also look at the valves and their competencies, and can diagnose fluid buildups in the heart’s surrounding membrane, the pericardium. Since ultrasound is essentially an echo phenomenon, this study is called “echocardiogram”, or simple “echo”.

Exercise testing. We do exercise testing in people who we think are OK. Maybe they’re young, their symptoms are weird or “a-typical”, but they have risk factors, and you never know. The concept is simple. We hook you up to the EKG machine and have you run on a treadmill. As your heart speeds up and needs more oxygen, the electricity starts to show it. Very often a radioactive isotope is administered and pictures taken later with a fancy camera, and if a “cold spot” shows up on the test, this could mean a narrowed artery, and an angiogram is then performed. These tests can be falsely negative and falsely positive, so we have to be on our toes that we are doing these tests on the right people. If you’re old enough and the symptoms are scary much at all, an angiogram is the desired test. They’re invasive and slightly dangerous, and a little pricey, but they tell you what you need to know.

Risk factors: Age, family history of heart attacks, and cigarette smoking are big risk factors for heart attacks, and if you’re much over thirty and this is in your family, you’re wise to go to the local ER and be evaluated. And it isn’t like you’re sweating a cancer diagnosis or something, and the consequences can be sudden death and serious loss of energy if something is wrong with the main squeezer. High cholesterol and diabetes are also the ingredients for the development of coronary artery blockages.

So, if there’s one thing to say, if there are any of these features to the symptoms go to the local ER, because there is so much that can be done to check into things further and even stop heart attacks by opening up the blood vessel with miracles of modern technological advancements.

Another worry for chest pain complaints: Blood clots in the lung.

The other big concern for chest pain complaints is blood clots in the lungs. They can be fatal, so we’re hip on them and nowadays can tell you for sure whether you have one. Usually blood clots form in the low pressure veins of the legs (all veins are of low pressure), and the can “break loose” and when they do, the anatomy takes them right through the heart and up into the lung tissue (embolization). Hence they are called “PE’s”, for “pulmonary embolus”. There they result in visceral lung pain (not usually real severe). But since they are plugging up a lung artery, the main complaint is usually marked shortness of breath. Large ones leave patients literally gasping, while smaller ones or s series of smaller ones result more in shortness of breath with exertion, or even at rest.

Risk factors for PE include long flights or drives, where blood may clot in veins due to inactivity, and another is for people with casts or splints on their legs due to orthopedic injury, for the same reason. Paralysis, weakness due to other medical problems, and stroke all raise the risk of developing leg vein clots (deep vein thrombosis, or DVT), and hospitals go to great lengths to prevent them in people admitted with these types of conditions. And there is also a subset of people out there who have a gene where their blood is prone to clotting, and we can test you for these if one develops.

Women who take birth control pills, especially if they smoke and are over 35, are at risk for DVTs and PEs. Young people can have these, so with any calf swelling (sign of leg vein clot), or trouble breathing, fast heart rates, trouble with exertion, these are very dangerous conditions and worth going to the hospital to get checked out. We can screen for both of these conditions with a simple blood test, and more definitive testing can tell us for sure if a clot has developed, or traveled to the lung.

Other Causes of Chest Pain

Chest wall pains—The thorax in all mammals is a bony/muscular box constructed to move air in and out of the lungs, and there are lots of moving parts. So injuries and other conditions can cause soreness and often a very severe sharp and stabbing pain with breathing. Visits to the ER for this account for one the most common reasons people go to the hospital. There is a lot of cartilage in the front and lower chest walls and these are often the source of this decidedly orthopedic pain (sharp, stabbing, and “right here, doc”.) Easily the most common cause of this complaint is anxiety, because adrenaline overdrives the thorax muscles to prepare for the heavy breathing needed for the famous “fight or flight” physiology of high performance. Usually there is an association with chest wall pains and painful breathing of hyperventilation, and the accompanied numbness and tingling in the periphery (face, hands, and feet). And such folks usually are acting nervous, and frightened.

Collapsed lung. Occasionally sharp and orthopedic-sounding chest pain is from pneumothorax (“air in the chest”), and these usually happen spontaneously, especially in young men with flat and broad chests. A simple x-ray tells us if one is present, and they are easily managed usually. Often this pain is felt in the shoulder, like that feeling you get when you run for a while and your chest and shoulder hurt. A pneumothorax can be dangerous, and are yet another reason to make a trip to the hospital for chest pain evaluation.

So remember, you’re never too young to have a heart attack or PE or other serious conditions, so if there is especially a reason to be safe rather than sorry, getting evaluated for chest pain is a sound concept. Especially if you’re a young male and you smoke. And you have a young family depending on you.

Upper Respiratory Conditions

With every breath, we breathe in air and God-knows-what else. So the mouth, the nose and sinuses, and the lungs themselves, have several levels of defense built in, and put up an impressive performance generally over a very long time in fighting off these “insults”. The tissues tend to heal their injuries and fight off infections.

Sinus problems: The sinuses generate a layer of mucous that coats the back or the nose and throat area, and this layer migrates back as a “layer” to the top of the esophagus, where it is swallowed and recycled. Irritation with pollens, pollutants, molds, funguses, and viruses stimulate them to generate more stuff, and the congestion becomes noticeable. We have called this “sinusitis”, and the new preferred name is “rhinosinusitis”, getting that nose word rhino in there.

The kick-up of the sinus activity will run a while and cool it, and that should be that, Decongestants, and maybe an antihistamine, usually manage the problem. But if it goes on for two or three weeks or more you begin to wonder. Sinus infection with the big germs like bacteria, where an antibiotic would be useful, I have considered unlikely, and while it depends on what you read a little, I generally favor treating the possibility with antibiotics when I see people with these symptoms. Remember, America love two things, the automobile and the antibiotic.

True sinus infection most often involves the sinuses in the cheeks, the maxillary sinuses, and also the sinuses along the sides of the nasal bridge, the ehtmoids. Did you know you had sinuses there? Generally, local pain and tenderness over these areas suggest infection, and with the maxillaries, the pain often feels like a toothache, and people go to the dentist only to find that the sinus above the tooth is infected and hurting. And the eyeball above the infected side will feel like it is popping out when you bend over. And as far as that stuff you’re blowing out of your nose is concerned, is it stretchy and thick like mucous, or runny and discolored, like pus? Infections like this are obviously common, but most can be expected to get better without significant medical intervention.

Having said that, people seek relief from these conditions, and it’s a big industry.

Sore Throats

There is the word “pharynx (FAY-rinks, say it right please), a word that means “sucker”. Like the mouth of the shark, it’s what grabs food and shoves it into the digestive system. Not surprisingly, it is often under attack by germs. When the immune system has to become involved, there is swelling and pain, and the throat gets sore and makes it painful to swallow. The term is “pharyngitis”.

You guessed it, there are two kinds of throat infection generally, viruses, and the big germs, bacteria, like strep. Most are viral, and when there is cough associated with it it’s definitely viral. But what about strep? Can you tell by looking back there?

Answer: not really. But bacterial illness is usually a more serious illness. So more than just throat soreness, when the big germs are working on you, you get “sicker”. There might be fever, and chills and laying on the couch. Headache. Stomach ache. This is an illness that’s more like strep throat.

Can you tell anything by looking back there? Here are the classics: When the uvula is red and swollen, and the soft palate is also real red, and there are dots of red on the palate above the throat (the “sunrise appearance”), and the voice is a little muffled, and the lymph nodes in front of the neck muscles are swollen and tender, then that has a good shot at being a bacterial situation (strep throat).

Mono

The Epstein-Barr virus is the germ that causes the infamous illness of acute infectious mononucleosis. It is a bug that likes humans very much, and pretty much infects all of them, gaining hold in the sinuses and upper respiratory structures. At any given time 15% of the population is shedding the virus in their respiratory secretions and saliva.

Most people get mono when they’re 2 or 3 years old, as a long fever illness with vague symptoms often generally indistinguishable from other childhood febrile illnesses. But that’s when you want to get it, as a little kid. In fact, as many as a third of people arrive in adulthood having not gotten it, and they are often stuck with a run of weeks or months of relapsing sinus and throat congestion as they mount an immune reaction to subdue the invasion, and this can take months in some people. Some get hepatitis. Eventually, the immune system wins out. A key finding with these sore throats, besides the often huge, pus-filled tonsils, is the swelling of the lymph nodes behind that muscle that forms the neck and makes football players look like they do (the sternocleidomastoid muscle). In strep throat, it’s the ones in front of the muscle swell up and get tender.

A very important class of medicine for managing all of these allergic and respiratory conditions is what you call steroids. Part of the body’s biology anyway, their effect is to tame the immune reaction. Often it’s this response itself that’s the problem, either because of long term irritation or hardcore acute invasion with germs like the flu. They really work and are prescribed a lot. It’s like managing friendly fire, the good guys shooting at you. Typical outcome of an armed anything, right? I love steroids, the anti-inflammatory variety, that is, and I would say in my career I’ve prescribed more of them than anything else by a long shot.

Pneumonia and bronchitis

Like sinuses and sore throats, viral infection of the lungs is much more common than bacterial invasion. When the latter is happening down in the lungs, that’s technically what you think of as pneumonia. But infact viruses can also cause infection down inside the lungs, but much more commonly they attach to and injure the respiratory “tree”, involving the sinuses, the throat, and the bronchial tubes. Since the Good Lord put the cough reflexes in the bronchial tubes, when you get “bronchitis”, you’re basically coughing your head off, especially at night. These are dry, non-productive coughs, and with enough trauma, you can even cough up a little blood. And some people really traumatize their bronchial apparatus with forceful coughing, maybe trying desperately to “cough something out”, and instead are prolonging their problem. It is not unusual for people to go a month with a cough in this circumstance. In smokers it can last even longer.

But then there’s pneumonia. Remember, bacteria are the big germs, and they are trying to eat you. They generate pus and recruit large amounts of the inflammatory system to react and infiltrate the area, and this accounts for the more significant, whole body symptoms. There is fever, often in high spikes followed by the traditional sweaty cool-down. There may be vomiting. In big infections breathing may be short, but this is unusual. And if the germs are overflowing into the blood stream, there is a giant chill and shake lasting half-an-hour or so, as the immune system is stoked by this real-deal threat. This chill they used to call “rigors”.

With bacterial pneumonia, you get sick quick and are getting sicker. There may be prostration and even confusion. An ambulance might be called by someone who loves you. And diagnostically, we can usually tell. People look and act sick, you can often hear the gurgling sounds in the area of infected lung with the stethoscope, and x-ray studies usually show the cloudiness of the area of infection. Antibiotics and fluids and supportive care, even hospitalization, is in order. We hope for and expect rapid improvement.

Kids get pneumonias and get over them quickly. Middle aged people can get them, and for me this has usually been during flu season. In fact, the “weakening” of a person caused by the flu often is the forerunner to bacterial complication of pneumonia, and this is why the flu can be so dangerous. Other conditions like lung cancer and look like pneumonia at first, but when there is no improvement, further testing may reveal a tumor under it all.

Influenza

Influenza is a lung virus, and causes an upper respiratory infection involving the sinuses and throat, and a really bad cough, and high fever to boot. Influenza is in the top ten causes of death every year in the US, usually from bacterial infection that follows it as pneumonia. The flu shot reduces you chance of getting it something like 60%. So if you have smoker’s lung and emphysema or COPD, or medical problems, or a lot of mileage, get the shot. It’s real safe, and not getting it can be disastrous.

In my career we have seen mostly Influenza B, which I think is a worse germ. You tend to see it around Christmas, and the later it comes, the less severe the epidemic. The Influenza A’s we’ve seen are sporadic, might come in the fall or spring, and because it is less common, it seems to be harder on younger people, who have less acquired immunity. We saw this with the H1N1 scare around 2008 or so.

Smoking and COPD

In smokers, the lungs are populated with an increased amount of immune tissue, and the mucous glands get bigger and pour out more stuff. Over years, gradually the situation plugs up more and more of the smaller airways that make up lung tissue, and eventually air movement and breathing is affected. If I gave you a stethoscope and had you listen to the lungs of smokers and non-smokers, you’d be able to tell who the smoker is. That is, if you couldn’t already tell by the bad teeth, bad skin, irritable disposition, and the fact that they look older than people their age.

At 40 or 50, or 60, it all adds up to trapped area and the inability to move enough in and out with each breath that shortness of breath results. It is harder to ventilate off the CO2 than to oxygenate yourself, but either way it breathlessness to some degree until the grave.

Thus a “chronic” condition, it is always there and will be made worse by conditions like upper respiratory viral infection, allergies and pollens, and especially, cold weather. Treatment with steroids to reduce the swelling of the airways, antibiotics (rarely helpful because bacterial infection is usually not the case), inhalers that relax airway muscle, and mucous reducers like guaifenesin (present in almost all the over-the-counter preps) is the approach. If you end up hospitalized, that is not exactly a good sign, and if this is starting to be required every several months, the end is in sight.

And for what exactly? A million tranquilized moments, that’s what. Quitting the habit is obviously very difficult. And smokers, well, they’re of an ilk. They all remind me of each other. Their main addiction is to taking breaks. I always say that “all the fun people smoke”, which is being kind. So do all the drunks and drug addicts, and the schizophrenics and most of the psychiatry patients. Hence the impression that nicotine is the “nonspecific tonic for the troubled mine. Glad I never did it.