heart of the matter

Today will be the first of a series of postings pertaining to what is refered to as the chief or presenting complaint. First on our list of problems is chest pain. A common complaint and one that is fraught with potential disaster for the patient and the ER doc.
Let's start with the anatomy. To the ER doc the chest is bordered to the north by the nose and its southern extreme is the lower abdomen. The body's perception of the source of heart pain is unpredictable. The innards of the chest cavity are full of structures which when diseased or damaged can spell death and disability with little warning.
For everybody region or part, the conscientious ER doc begins his or her differential diagnoses with the vascular bits. The heart, arteries and veins are the most likely structures to kill the patient when their warranty expires. Heart attacks (myocardial infarction) are caused by blockages of the coronary arteries. These vessels supply the heart muscle with oxygen and nutrients. The aorta is the main artery in the body. All oxygenated blood leaving the left ventricle of the heart and heading to the rest of the body exits via the aorta. A dissection of the aorta is a ticking bomb which can kill in minutes if not detected and treated promptly.
Blood clots can also cause life threatening chest pain. Clots that form in the legs can break off travel through the right side of the heart and end up in the pulmonary (lung) arteries. A large clot can kill.
There are many other potentially lethal diseases that present as chest pain. Infections of the heart from viruses, bacteria and even parasites can lead to death. A collapsed lung, or lung infection are slower acting but still carry the potential for disaster.
Even the humble digestive tract, as it traverses the chest can blow a gasket and flood the chest cavity with bacterial laden, acidic stuff. Never mind the joys of acid reflux.
The difficulty for your caring ER doc is that the symptoms for any and all chest problems often overlap. Many a patient with a heart attack (MI) has complained of indigestion. For the fairer sex the symptoms of an MI may be even more subtle. Shortness of breath or even just increased fatigue may be the only symptom of an MI. Diabetics often have "silent MI's", heart attacks with no specific pain.
The triage nurse or EMT in the ambulance are the first line of defense. An EKG that is normal doesn't preclude an MI but can be helpful if it shows the specific patterns of acute damage to the heart muscle. Blood tests, x-rays, a good history and physical exam all contribute to the decision making process. To fully rule out an MI may take up to 8-9 hours, as the proteins that leak out of the injured heart muscle may take that long to show up on the blood tests.
MI, pulmonary embolus, aortic disection, collapsed lung, torn or ruptured esophagous, pneumonia, pleurisy, muscle strains, reflux, neuralgia... The list of diseases that present with chest pain goes on and and.
Help an old ER doc. Don't tell me at age 19 that you have heart pain and can't breath. Describe the location, quality (sharp, burning, pressure), onset, duration, and radiation (pain moving from chest to jaw) and level (0-10, no 20,50, or 1,000) when asked by the EMS, nurse, PA or doc. The triage process is not perfect but it allows the overworked ER staff to get to the sickest, most urgent patients first. Wait your turn. Our goal to relieve pain and suffering. We will get to every patient. The ER is not the deli counter at the supermarket. The order of arrival even if by ambulance is not the issue.
Don't smoke, exercise regularly, eat a low fat/cholesterol diet, see your doctor as recommended.