Living with Dementia

It might be the last thing to cross your mind, sitting on the front porch of your homestead, looking over the panoramic views.  But health emergencies are a contingency that must be taken into account, like every other potential danger.  Some are sudden, and there really is not a lot that anyone can do about them – a massive heart attack, or a big stroke.  And while medical science can help maintain an individual who has suffered debilitating illness, it is usually at great emotional, psychological, and financial expense.  Lives are changed, dreams are shattered, and families must struggle to find a new normal.

But there are other conditions that present us with warning signs – red flags that herald the beginning of something much worse.  If interpreted and acted on promptly and properly, heeding these symptoms can help to prevent disaster.  I have seen the results of both circumstances, where families have been spared by rapid medical evaluation and intervention, and other instances where an individual and their loved ones were not as lucky.  With these situations in mind, I would like to share a list of several symptoms that should never be dismissed as “just growing old,” or “it’ll pass,” but should warrant at least a visit to a primary care provider, or an emergency room, for further investigation.

But, first, a disclaimer.  This information is for educational purposes.  I am giving you general medical symptoms and classical 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 experiencing, any of these conditions, you MUST SEEK PROMPT MEDICAL ATTENTION.  I want to impress on you the severity of some of these signs, and educate you as to some of the conditions that they might represent.  It is up to you, and you alone, to act on that information in your particular circumstance.  After reading about some of the diseases associated with these symptoms, 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, please, please go to an emergency room for evaluation and care.  In life, and especially in medicine, it is always better to be safe than sorry.

Now, back to the topic at hand.  There are a myriad of chest pain complaints, and even more causes.  There are also a lot of important organs residing in the vicinity – the heart, lungs, diaphragm, stomach (yup, just beneath and to the left of the lower rib margin), esophagus (the connection between your mouth and stomach), trachea (connecting your upper airway to the lungs), aorta (the main blood vessel off the heart that delivers blood to the rest of the body), not to mention nerves, bones, muscles, lymph nodes, and skin.  All of these organ systems can be involved in chest pain in some way.  Some are benign, like gastroesophageal reflux, or heartburn (which should still be managed with the help of a doctor, because longstanding heartburn can predispose an individual to esophageal cancer), or a strained muscle from heavy lifting (signs of this are that the pain started right after lifting, is a sharp, muscle strain-like pain, is localized to one specific spot, can be reproduced by pressing on the area, and is relieved by ice, hot packs, or medicines like ibuprofen).

But there are other types of chest pain that are not as easily explained, and may signal a potential problem.  Chest pain that can be described as pressure or crushing, right under the sternum (breastbone, in the middle of the chest), and may radiate to the left arm or up the left side of the neck, is very concerning for a heart-related condition.  Classically, a doctor that hears that constellation of symptoms presumes you are having a heart attack until it can be proven otherwise.  And, if that kind of chest pain is also associated with nausea (feeling sick to your stomach), vomiting, or profuse sweating, get to a hospital!  DO NOT try to work through it, or hope it goes away, or pop two pain pills and go to bed.  A classic medical saying in these settings is “time lost is heart muscle lost.”

Besides the ultimate adverse outcome (death), the main concern in treating heart attacks quickly is avoiding weakened heart muscle.  The more time you take to get to the hospital, the more you lose of the heart’s pumping function, which makes the heart weaker.  Your heart pumps 60-100 times per minute, every minute you are alive, to deliver blood containing oxygen and nutrients to every cell in your body.  The pain associated with a heart attack is caused by the death of heart muscle cells.  The body does not replace heart muscle with new muscle cells – the area is scarred over and does not contract with the rest of your heart.  This can lead to an insidious and debilitating condition known as congestive heart failure (CHF), which essentially means that your heart has trouble pumping effectively enough to meet your body’s metabolic demands (for oxygen and nutrients).  People who suffer from this condition feel weak, short of breath, tired, and have trouble with swelling, especially in their legs.

The best step you can take when you have pain that could be the presenting sign of a heart attack is to call 911.  I would also have a bottle of aspirin available in your house, and maybe in your car.  Tell the operator exactly what you are feeling – tired, sick to your stomach, dizzy, lightheaded, about to pass out, sweaty, having trouble breathing, numbness or pain in your arms or legs – in addition to the quality (sharp, dull, pressure, crushing), location, and if there is any radiation of your pain.  Tell him or her when it started, what you were doing when it started (for example, exercising or doing chores versus sitting in a chair, or if you awoke from sleep with the pain).  It is also very important to tell the operator any medical conditions that you are being treated for and the medications that you are on, as well as any allergies to medicines or foods.   If the operator thinks you might be having a heart attack, and there are no contraindications, he or she should tell you to take three or four baby aspirin (81mg) and chew them.  If it is at all possible, DO NOT just swallow the aspirin, as chewing them will increase the speed that the medicine will enter your bloodstream.  However, if you have any contraindication to taking aspirin (including an allergy), avoid it until you get to the hospital for medical treatment with a trained physician.  Once you have done what you can, wait for help to arrive, and tell the EMS and the doctors exactly what you are feeling, when you are feeling it.

There is another type of chest pain that the much rarer than the crushing-type pain of a heart attack.  But I want to mention it, because it is much more frightening, and knowing about it and acting quickly could help save your life.  This type of chest pain is a sudden, sharp, boring chest pain that starts right under the sternum and feels like it comes out of your back right between your shoulder blades, or may be under your left shoulder blade.  People again describe having difficulty breathing, as well as feeling very sweaty and cool, that their heart is racing, and some notice that their left arm is numb and cool.

The constellation of symptoms above, especially in the setting of trauma, like a car accident or sudden deceleration (but it can also happen with very high blood pressure, and rarely spontaneously), is very concerning for a condition known as aortic dissection.  In this disease, there is a tear in the wall of the aorta, the main blood vessel of the body.  Blood, under pressure from the pumping action of the heart, can enter and further damage the wall lining.  If the wall of the aorta ruptures, blood quickly leaves the veins and arteries, enters the chest, and the poor individual dies from massive blood loss (exsanguination).

The only course of action for someone suffering from this condition is to get to a hospital immediately.  While there are several courses of action after diagnosis (mainly surgery versus strict blood pressure control), this is only after being stabilized and monitored closely.  This is a very serious condition, and must be treated quickly for the possibility of a good outcome.

Another type of chest pain that should prompt a call to a medical professional is one associated with breathing difficulties.  The combination of these two symptoms means that there is something definitely wrong in the chest that needs to be addressed.  Three of the most concerning pulmonary conditions that present with chest pain and shortness of breath are pulmonary embolism (or PE), pneumothorax, and pneumonia.  All of these conditions can present in a similar fashion, but it is usually the time frame and the severity of the pain and shortness of breath that differentiates them clinically.  When describing the quality of the pain, many people state that it is a sharp, stabbing pain that occurs when they take a deep breath.  The location of the pain is another sign that can help differentiate these illnesses from heart disease.  While cardiac, or heart, problems, are generally localized to the left side of the chest, pain from pulmonary sources occurs when the lining of the lungs (the pleura) is inflamed and irritated.  Another quality of the pain that can sometimes separate pulmonary from cardiac conditions is that movement can make it worse.  But, like everything in medicine, this isn’t always the case.

Pulmonary embolism (PE) is a condition where a blood clot enters the lung vasculature and causes some of the lung tissue to die.  The pain, like that felt in a heart attack, is a result of dying tissue.  The amount of pain, the severity of the shortness of breath, and the overall outcome for the individual are all determined by the size of the clot and how much lung tissue is affected.  There are certain conditions, habits, and events that predispose someone to developing PE.  Factors that can be changed or avoided include smoking (never do it, because it is essentially poison to blood vessels!), and stopping to walk during long car drives and airplane flights (to avoid blood clots developing in the legs due to sluggish blood flow and stasis, then breaking off and traveling to the lungs).  This also occurs when someone is bed bound or immobile for long periods of time, like after breaking a leg and having it casted.  In these situations, you may have to take a blood thinner or receive physical therapy, in order to make sure you are moving enough.  If you suffer from any of these predisposing conditions, and you start to feel the symptoms described, call 911 immediately.  And even if you don’t, you should still be evaluated.  You need to go to a hospital and have imaging of your chest done to help diagnose the condition.  If you are diagnosed as having a PE, you will most likely need to be hospitalized and started on a blood thinning medication.  Pulmonary embolism is an emergency and very dangerous, so you need to treat these warning signs seriously and quickly.

Pneumothorax is a much rarer condition that presents with similar symptoms to PE.  The main symptomatic differences of pneumothorax from PE are the suddenness and the circumstances under which it occurs.  A pneumothorax essentially means that air (pneumo) is trapped outside of the lung, but still in the chest (thorax), and is caused when there is a hole somewhere in the lung itself, letting air escape.  The seriousness arises because the chest is a closed container, with air becoming trapped between the outside of the lung and the chest cavity.  With each breath, more and more air leaks through the hole, causing the lung to collapse and the contents of the chest to be pushed away from the affected side.  A pneumothorax is classically associated with trauma to the chest – for example, a gunshot or stab wound, or a fractured rib puncturing the lung.  But it can also happen spontaneously in people who suffer from lung disease like emphysema or COPD (because there are balloon-like weaknesses in the tissue known as blebs that can rupture), or very tall, thin people who smoke (for unknown reasons).  This condition is an emergency, and is one of the reasons why any person who has difficulty breathing needs to get to the hospital immediately for diagnosis and treatment, which is usually to insert a tube into the chest cavity to allow the air to escape and the hole in the lung to heal.

The last condition I would like to discuss – pneumonia – usually does not present as quickly as the other two conditions.  It is an infection of the lung tissue by a virus or bacteria that causes shortness of breath, and, if it touches the pleura, can cause inflammation and chest pain.  Most cases present relatively slowly, over several days to a week, and are include contact with other sick individuals, fatigue, fever, cough (with or without green or bloody sputum), nausea, sometimes vomiting.  But sudden chest pain with shortness of breath, in the setting of fever, can represent a very virulent and nasty form of pneumonia.  It is not something you want to (and most of the time, cannot) “ride out at home.”  This is a medical emergency that needs powerful antibiotics, special monitoring, and, potentially, the thought of temporary intubation in the setting of extreme weakness and illness.  Treatment is aimed at avoiding becoming septic (having the bacterial infection enter your bloodstream and infect your whole body simultaneously) and dying.

Now, just a couple of words in closing.  The conditions I have listed above are rare emergencies, true, but they do happen.  I want to provide you with the knowledge and understanding to help if, God forbid, you find yourself or a loved one suffering with a case of heart attack or some other emergency.  Learning to observe and recognize some of the symptoms listed above, as well as what they might mean and what you need to do if you find yourself in that situation, like learning to interpret and plan according to the signs of the seasons, can go a long way in helping to avoid or survive a serious medical condition.

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