(I’m happy Bernie’s doing so well right now and I can give him a break. Still no food, though – not until we try something adventuresome, hopefully next week. For now, a medical story that may be instructive…)
Which is it – GERD or angina?
A friend of mine, a guy in his 60s, had quite a wild ride with his health a couple of years ago, and he wanted to tell his story so you may be spared the similar comedy (or better, tragedy) of medical errors. We’ll call him Joe, and we’ll rename other people and places for fairly obvious reasons. All the medical “errors” were remotely understandable – more like lapses in judgment than anything egregious.
I knew Joe in college, and we’ve stayed in touch off and on for many years. He was always in robust health, ate right, exercised, used to run, now walked. He told me his cholesterol had been high for some years – largely a result of his genes rather than eating habits, but now was well under control with statins. He’d also had periods of severe acid reflux, but, again, medication had kept further episodes at bay.
It makes sense to tell the story chronologically.
March 2013 – first symptoms
During a visit to his primary care doc, Dr. Smith, for something unrelated, Joe revealed he’d been having some mild discomfort in his chest, specifically around or in his esophagus. Twinges, little episodes of very mild pain. He explained that he did have reflux problems years earlier, and wondered if it was coming back to haunt him. Dr. Smith agreed that it could be something like GERD (gastroesophageal reflux disease), or else heart-related. In a few minutes, Smith’s assistant had Joe wired up for an EKG. Results? All’s well and normal, and Joe showed no other symptoms of heart disease like pain radiating to the left shoulder and arm, dizziness, etc.
Dr. Smith referred Joe to a gastrointestinal doc, Dr. Jones, for an upper endoscopy, where they’d stick tiny camera down your esophagus into your stomach right down to the duodenum.
April – upper endoscopy, and the GERD pillow
Dr. Jones performed the endoscopy and declared that Joe had a mild hiatal hernia (quite common for men in middle age and older), but otherwise both esophagus and stomach were unremarkable. Still, Dr. Jones recommended Joe buy a GERD pillow (a wedge-shaped foam pillow to keep one’s head and torso elevated at night), and take pantoprazole, a strong antacid which has some sketchy side effects. Joe got the pillow from Amazon for $100, and started on the new med.
(useless pillow…Amazon pic)
The pillow made no difference, nor did the pantoprazole. After a few nights of increasing chest/esophageal discomfort, he ditched the pillow.
(The hiatal hernia, Joe told me, was repaired after several visits to his chiropractor, who said he’d had good outcomes through his massaging technique.)
May – ER at the MidState Medical Center, stress test and more
As the discomfort continued, Joe and his wife Beth, who had some medical training of her own, decided it was time for an ER visit at the nearby MidState Medical Center. The ER doc sent him straight into the cardio area for a stress test with both an EKG and an echocardiogram hookup to see the heart in action and get a reading on his ejection fraction rate (how much blood is pumped from the left ventricle). He climbed and nearly ran on the treadmill till he was exhausted, then lay down on the gurney as the physician’s assistant explored the heart area with the ultrasound sensor. Results? A very healthy ejection fraction rate of 60, and a healthy and normal beating heart. So he was solid all around, heart-wise. The problem had to be GERD.
Back to his primary doc, Dr. Smith: the discomfort was worsening, especially at night. Joe was starting to take hydrocodone (left over from some previous pain issue), but the pain med took a full half hour to kick in. Smith prescribed sublingual (under the tongue) nitrostat tablets to ease the pain, noting that while nitrostat was traditionally for cardiac problems, it was also very effective in reducing esophageal pain and spasms.
June – it gets worse. Nitro, bourbon and more EKGs
At night when the pain hit, Joe would take the nitro, but it wasn’t quite enough. So he hit the liquor cabinet in his kitchen — 2 ounces of Jack Daniels, neat. “It worked wonders,” he said. “The pain went away in minutes. I told Dr. Smith about this, and he was surprised alcohol would ease esophageal pain. In general, all the doctors at this point seemed baffled by my case – but kept leaning toward GERD as the problem. The heart tests came out fine, and the pain wasn’t related to any exertion.”
(this helped him…my pic)
But soon the pain was hitting at all hours of the day and night, more and more severe, and Joe was popping nitro and swilling bourbon at 6AM, 10AM, whenever it struck.
He and Beth went back to the MidState ER. This time, another EKG and a chest x-ray, which both came back normal. The doc said to keep taking the nitro, but Joe was up to 15 (!) or more tablets a day.
The very next night, the pain was pretty severe. Beth’s patience was all but gone. They both decided on a 911 call and an ambulance ride back to the ER.
The last ER visit – on the cusp of the Twilight Zone
“Beth basically saved the day,” Joe wrote. “She told the ER doctor about my bourbon consumption, and he said, ‘That sounds excessive!’ She snapped back, ‘It is excessive.'”
The ER doc wanted another chest x-ray and stress test. “I laughed and told him no way, I’d just had a chest x-ray the night before, and a stress test just a few weeks back. Then Beth jumped in and said, ‘what he needs is an angiogram.'”
But MidState didn’t have that capability. The nearest place would be Capital City Hospital, about two hours away. The ER doc was slow to make a move on this, until Beth basically told him to call Capital City and see if they had room for Joe in the cardio unit.
The doc complied, left the room to make the call and after several minutes returned. “They told me, ‘sounds like he needs an angiogram.’ And they have a bed available and want you to come down right away.”
That night – Capital City Hospital Cardio Center
Joe was taken to Capital City by ambulance, arriving in the wee hours of the morning.
The next day Joe had a catheter (with a tiny camera) inserted from his right wrist all the way into his heart. It discovered a clog in his left circumflex artery with an 80% blockage. The following day, the cardio docs inserted a stent at the blockage site to open the artery up.
“That did it. No more pain. Not ever. I had coronary artery disease, mostly from cholesterol that’s basically congenital. I got out of the hospital, went to cardiac rehab for several weeks, and now I carry around my nitro bottle just in case. I feel fine.”
The Upshot – heart vs. GERD
Nearly every medical site you go to will tell you it’s extremely difficult to tell the difference between esophageal pain and cardiac (or angina) pain. They’ll also tell you that EKGs, x-rays, stress tests, and echocardiograms are not necessarily good diagnostic tools for coronary artery disease. The heart can behave normally with one of its arteries partly (or even mostly) clogged.
An angiogram is the only accurate diagnostic procedure.
Advocate for yourself!
My guess is we all have our share of medical “horror” stories. This one finished with a good result, but it’s obvious it took much longer than it should have.
Joe’s story underscores the importance of advocating for your own case – and if possible having your spouse or significant other or close friend join you in that advocacy. On his last visit to the ER, both he and Beth knew that an angiogram was the only solution. They needed to guide and educate the ER doc about Joe’s recent history to steer him toward the same conclusion – let’s get an angiogram! Don’t assume doctors know more about you than you do – they don’t. My own experience is that they usually (but not always) want you to take the lead in helping them make the right decision. Really good doctors want you to explore the problem with them.
Don’t defer to doctors just because they’re doctors. Do your homework and stand up for yourself. It’s your body, after all.
There it is.