Health catastrophes are sudden, stunning, and leave everyone touched by the disaster changed. These medical emergencies are similar to violent weather like a tornado or flood – arriving unannounced, causing devastation, and making victims, friends and families pick up the pieces of their shattered lives. And while there is no absolute way to completely prevent them, there are sometimes warning signs that can signal impending danger. Knowing what symptoms to look for, and acting on them in a timely fashion, may prevent injury and disability, and could even save your or a loved one’s life.
I started this series off with Part One: Chest Pain, because even though a lot of us know and can probably recognize the signs and symptoms of a heart attack, there are several other medical emergencies that also present with chest pain. I would like to continue our discussion by presenting several types of weakness. I find that this is another easily overlooked, and perhaps more subjective symptom than chest pain. And even throughout the day, our level of strength can wax and wane. For example, in the morning I’m dragging myself out of bed, by noon I’m about as bright-eyed and energetic (in terms of motivation, as well as strength) as I’m going to be for that day, and in the evening, especially after a long day hauling hay or splitting wood, I’m stumbling back to bed. Weakness can come and go, and it depends on so many factors, such as our energy level, state of health, and even emotional state. I will get into more detail in a little while, but the many point I would like to impress on you is that if the weakness (in fact, if any symptom, be it pain, or itchiness, or headache, or whatever) is different or out of proportion to what you normally experience, contact your healthcare provider for guidance and an exam if warranted.
At this point, I would also like to present my usual disclaimer. This information is for educational purposes only. I am giving you general medical symptoms and classic cases for your understanding. This is not for diagnosis, and certainly not for treatment. If you are suffering, or even if you are fearful that you are suffering, from any of these conditions, you MUST SEEK PROMPT MEDICAL ATTENTION. I want to impress on you the severity of these signs, and educate you as to some of the conditions that they might represent. It is up to you, based on your level of concern in your particular circumstance, to act on this information. But after reading about these diseases, I hope that you will at least call a medical professional to explain your symptoms and get more information and instructions. If any doubt enters your mind, and you are worried about you or your loved one’s health and well-being, please get to an emergency room as soon as possible for treatment. With medical concerns, as in most things in life, it is always better to be safe than sorry.
So now, with that being said, let’s return to our discussion about weakness. First of all, how do we define it? As I mentioned earlier, it is a very subjective symptom, since the human condition is so varied. How do I test and define the complaint of weakness in a frail 95-year-old grandmother versus a muscular 30-year-old farmer? The main point when evaluating someone is to ask how much weaker does he or she feel compared to baseline? Are they not able to lift two square bales as usual, or lift up that bull calf today? Or are they having difficulty handling a glass of milk?
Another very important point about weakness is whether it is affecting the entire body (global weakness), or one area in particular (focal). Everyone knows what it is like to feel globally weak – just remember the last time you had the flu or any other viral illness (mine was mono, or infectious mononucleosis – ugh). The arms and legs feel like limp noodles, and you were barely able to roll out of bed to use the bathroom or go make a bowl of chicken noodle soup (even though you didn’t feel like eating it, but you knew that you needed to eat, sleep, and drink plenty of fluids in order to recover faster). In contrast, there are many different presentations of focal weakness. It can range from not being able to lift an object with your arm (or even lift the arm up), or bear weight on your leg, to not being able to rise out of a chair (less thigh strength), or even having trouble talking or holding your eyelids open (when you’re not tired or had one too many the night before).
Time of onset is also crucial in figuring out what might be causing the weakness, and is one of the main factors in determining if it is an emergency or not. Gradual weakness that does not change much or is slowly progressive over months or years is usually not a medical emergency, except when it affects the muscles of respiration, or causes someone to be at increased risk for falls where they could injure themselves. This weakness is usually foreseen, however, and can be worked up and hopefully corrected, if the cause is found.
Weakness that is acute, ranging from one day to about one week (depending on the severity), however, is usually an emergency, and I will spend the remainder of this article discussing different causes that need to be evaluated. Most medical professionals like to split them up into one final category: those that affect the muscle itself, and those that affect the nerve supplying the muscle. This categorization helps in visualizing the underlying problem, what tests the doctors and medical staff will perform in order to find the cause, and whether or how long it might take to recover (if the underlying cause is treatable). It makes little difference initially, however, since you need to get to the hospital either way.
One of the most worrisome causes of acute weakness, from a medical standpoint, is stroke. By definition, stroke is the loss of blood supply to a portion of the central nervous system (CNS), which includes the brain and spinal cord, causing the nerve cells to starve and die. Depending on the area of the CNS affected, symptoms can really be almost anything, including weakness. For example, a list of stroke symptoms (for you to look for in addition to weakness) included, but is certainly not limited to: difficulty speaking (slurred speech, like being drunk); one side of the face having a sag or looking different from the other (facial droop); abnormal pins-and-needles sensation (like when your arm falls asleep) or loss of sensation anywhere on the body; double vision, difficulty seeing or blindness; staggering while walking, dizziness with the feeling that you are spinning and cannot stop, even when you close your eyes, with feeling sick to your stomach (nausea) and throwing up; difficulty swallowing or gagging on saliva; and trouble understanding words and conversations. The weakness caused by a stroke happens in a couple minutes to about half an hour or so in most cases, depending on the size of the area affected, and that there are no new ischemic insults. The weakness associated with stroke feels like the limb is just dead weight, or very hard and sluggish to lift and move. Fine motor function (using your fingers to write or count or move) is very hard, if not impossible.
Stroke is an emergency, and you need to get to the hospital IMMEDIATELY! The famous saying in the emergency room is “time is brain” (or heart, if you are suffering a heart attack, but that was the first article), so the sooner you arrive at the hospital, the better chance that treatment can be started and prevent further damage. Unfortunately, once symptoms start, it means that some brain tissue is already lost, and there is no way to reverse that damage. The key tests and treatments for stroke management are to identify the cause (either high blood pressure, or disease in the blood vessels that leads to plaques on the vessel walls that can break off and block blood flow downstream, or abnormal heart rhythms that predispose to clot formation), and to see if it is a stroke that resulted from a blockage of blood flow (the vast majority) or a bleed in to the brain itself (less likely, but more dangerous, and why you should never take an aspirin if you have weakness and suspect a stroke, since that could make the bleeding worse). Stroke is a terrifying disease, but with early treatment and aggressive physical therapy, people have the potential to do very well, recovering some, if not most, of their original function.
Another cause of acute weakness that is seen more often in the country is pesticide toxicity. The chemicals in pesticides inhibit the insect nervous system, and are in the same family as many chemical warfare agents, like sarin and VX nerve gas. Compounds like Raid actually work by uncoupling the transmission of nerve signals to the muscle, causing paralysis and death. Pesticide poisoning should be suspected for anyone who is exposed, or even touched or washed the clothes of someone else who worked with it, and now is suffering from weakness with muscle twitching and fasciculations (which look like squirming things under the skin), big dilated pupils (the black part of the eye), drooling or excessive saliva, difficulty swallowing, sweating, diarrhea, nausea and vomiting, headache, and confusion.
You can try to start treatment – IF YOU ARE VERY CAREFUL – after calling 911 and describing your emergency, IF you feel comfortable and confident, and IF you are not experiencing symptoms or putting yourself at risk by doing so. Otherwise, monitor the person and wait for help to arrive. This is an emergency, because the person can become so weak that he or she cannot breathe without support. Time is of the essence! You DO NOT want to expose yourself to the source of the poisoning, which could be the chemical container, the individual’s clothing, or even touching the affected person’s skin. You need to know what the person was exposed to, how much, when, and for how long, if you can find out. Try to get the person to a water source, which could be a hose (preferably) or shower, without directly touching the person. I know, easier said then done. But you don’t want to end up a victim too. Get thick rubber gloves, and undress the person, saving the clothes in several waste bags, one inside the other (in case it needs to be tested). Wash the person off, again with gloves and any other protective gear on (eye goggles, boots, etc., to try and avoid bare skin). But the main point in a case of pesticide poisoning is to recognize the symptoms, find out the possible cause, and identify authorities immediately.
Another type of weakness can occur by eating improperly canned foods and honey, and also occurs more frequently in rural settings. It is the result of eating a toxin produced by bacterial contamination of the canned item, and the disease that results is caused botulism. Symptoms start with the face, and include double vision, droopy eyelids, difficulty swallowing, and slurred speech. The weakness then spreads down the arms and to the legs. It can also cause dry mouth and constipation, which is the opposite of pesticide poisoning.
You need immediate medical attention if you feel these symptoms. If there is any hint of difficulty breathing, call an ambulance! This is not something to try and “wait out.” There are medicines and antitoxins available if the problem is diagnosed and treated quickly. Fear of botulism poisoning is also why you are not supposed to feed honey to children younger than two years old. Their stomach linings and immune systems are not strong enough to deal with any of the bacteria that produce botulism, and they can develop difficulty breathing and weakness very quickly.
Weakness can also arise suddenly after a relatively benign illness, like a cold or stomach virus. This medical condition is known as Guillian-Barre syndrome, or GBS, and is due to the body’s immune system going into overdrive after the illness and attacking the covering around the nerves. The nerves are similar to electrical wiring, and even include their own insulation covering, known as myelin. In some illnesses, the antibodies produced against the causative organism cross-react with the proteins of the myelin sheath, resulting in damage and weakness. In this condition, the motor nerves are attacked preferentially, leading to weakness without loss of sensation. It usually affects the longer nerves first, so the weakness pattern usually starts in the feet and progresses upward. Again, the concern is for respiratory distress, and the progression upward can be rapid. It needs to be diagnosed and treated in a hospital setting, and usually recovery is slow (over months) but almost complete.
Myasthenia gravis is a medical disease that causes transient, intermittent weakness. It is an autoimmune disorder, similar to GBS. However, unlike GBS, the antibodies in myasthenia affect the acetylcholine receptor. Middle-aged women and older men are the groups that classically suffer from it most often. People suffering from this disease can have a myriad of symptoms, including drooping eyelids, difficulty swallowing, as well as arm and leg weakness. In this disorder, the weakness is variable, and worsens with activity, a condition known as fatigueability. People also notice that they are weaker in the evening, after using their muscles all day long. Similar to pesticide poisoning, botulism, and GBS, the main concern with myasthenia is respiratory distress. While a majority of people suffer the milder symptoms listed on initial presentation, an unfortunate subset can present to the emergency room in myasthenic crisis, or severe weakness and respiratory compromise, sometimes requiring intubation. Treatment in the acute setting is steroids and close monitoring of respiratory function. Long-term management requires further diagnostic testing and medical imaging, and close follow-up with a neurologist.
As you can see, there are several types of weakness, some of which are more relevant to rural living, which occur rapidly and are medical emergencies. The main concern in most of these conditions is progression to a state where weakness compromises breathing. That is why quick recognition and action are important for a successful outcome. And, most of the time, with proper treatment and physical therapy in the setting of early diagnosis and care, these diseases can be treated and quality of life preserved. The important message is to seek medical attention at the first sign of difficulty, in order to avoid future complications.
As I have mentioned before, we are very fortunate to live in the country, with its freedom and openness, amazing natural beauty, and the ability to make a life off the land and become more self-sufficient. But this self-sufficiency can be double-edged, especially when it leads us to forego medical care or screenings, or if it causes us to down play serious, potentially life-threatening symptoms. Learning to observe and recognize some of the symptoms listed above, like the signs of changing weather or the seasons, as well as what they might mean, and what you need to do in that situation, can go a long way to help avoid and even survive a serious medical emergency.