Friday, September 29, 2006

TGI

Three years ago Sid was taken to A&E with chest pains. There was a flurry of White Coated Doctorly activity, and exercise ECG (negative), Blood tests (all normal), and even, after a brief interval, angiography (wide patent coronary arteries throughout). Despite all of the above he was stuck with a label of Angina and ended up on a plethora of meds, including beta blockers, aspirin, a statin and a diuretic.

The whole process took a couple of months during which he was going to and fro to the hospital, and so was not available for work. This underlined to him the severity of his condition. And yet, throughout it all he carried on smoking twenty a day.

A short while later his heart rate fell catastrophically low, leaving him faint and wibbly all the time. His beta-blockers were duly stopped and he got a lot better. He continued to get chest pains, and so, almost as an afterthought, he was referred to gastroenterologists and had a gastroscopy. This revealed inflammation throughout the stomach and oesophagus-- a common cause of chest pain. So he started more meds for this. The pain got a bit better, but his other meds all continued as before (except his aspirin, given that it causes gastric inflammation) because, after all he had had angina. Still he smoked just as before.

Two years later ( and still with a twenty a day habit) he went to see a new cardiologist. The cardiologist looked at the results, and at the patient, suggested that the pain might not be angina after all, that it would be a good idea if he stopped smoking, and that he might like to see a chest specialist. This really upset Sid, and his wife Joelene. They are convinced he has angina. After all he was told so years ago, and the lack of confirmatory evidence in the interim has no bearing on this. And it's a damn cheek for the cardiologist to tell them he doesn't and then to tell him to stop smoking anyway.

The problem here is the "knee jerk" reaction at the front door of the hospital that attempts to neatly pigeonhole symptoms and channel patients down "pathways" so that independent thought by junior staff can be avoided.

He undoubtedly had chest pain when he went in. It definitely got better after a short interval. Whether the meds truly had anything to do with this is far from proven, but cannot now be disputed after the fact. And now, because his second cardiologist handled his last consult clumsily by daring to mention smoking and not venturing to repeat any of the (previously normal) investigations, rather than being delighted to hear he probably doesn't have angina at all, Sid is now determined to prove the point by seeing a third consultant, and is even less likely to quit the weed.

It's obviously been a cantankerous week, but for me Suid and Joelene, with their millitant smoking habit have hammered in the final coffin nail.

TGI Friday.

7 comments:

Steve said...

Now I'm a pharmacist, so not really trained in diagnostics. However, even I know of a really easy way to distinguish between angina and acid reflux, and that's what GTN and Gaviscon do for the pain. If GTN eases it, then it's likely to be cardiac, and if Gaviscon eases it, its likely to be an upper GI cause. Given the A&E docs had all their wonderful tests, why didn't the possibility of a GI cause occur to them? I'd have thought that having wide patent coronary arteries make it pretty difficult to get angina.

Sooz said...

It must be sooooo frustrating when people are sick and yet don't do the most obvious thing to help themselves.

Didn't it occur to him at any point that smoking might not help matters?

Shinga said...

There's a reasonable chance that 'Sid's' negative test results might otherwise have led to him being labelled with 'functional cardiac pain' rather than treated (albeit unhelpfully) with those drugs.

There is an interesting item in the New York Times about women who have negative test results and no sign of macrovascular disease but, on further testing, do show microvascular disease. [If you're bugged for a log-in, go to Bug Me Not to bypass the registration.]

Ben Goldacre has an interesting discussion that McKeith et al. harangue and intimidate their clients in ways that would have a doctor struck off if they did that to their patients.

I thought that it was just people with COPD (aka give up smoking asap, it really is trashing your life) who refused to give up smoking. Usually on the grounds that, "You don't understand. I need to cough to clear my lungs and smoking helps me".

Medically Unexplained Symptoms has MUS. Is there also, MESTNA - Medically Explicable Symptoms To No Avail?

Regards - Shinga

Doctor Jest said...

steve-- good points well made. But our local physicians treat all chest pains with a cocktail of nitrites AND PPI straight off the bat, so resolving which eases the pain gets a little tricky after the fact.

sooz-- sadly no. Sid & Joelene are the original poster boy and girl for Big Tobacco.

shinga-- erudite as ever, and thanks very much for the pointers. as you rightly say our diagnostic arts ae still a little offbeam when they encounter the atypical. Sid may yet turn out to have some more significant pathology, but somehow I doubt it....

The Locum said...

Of course, oesophageal spasm gets better with GTN too. [she adds mischievously]

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