Reader Comment: A Child’s Chest Pain

A reader recently commented on the SW101 post Will My Child Have A Heart Attack with a disturbing letter about her child.  It has now been granted its own blog.  I have written my own comments in throughout the letter in red italics to make me appear extra important and potentially infallible.

***************************

Thank you for that article. My typically healthy 6 year old daughter has been complaining of chest pain, burning on the left side of the neck and feeling her heart “in her throat” as she says. This is not a big deal.  Kids say this stuff all the time.  It goes along with the ubiquitous “Tummy ache”, “I’m full”, “My eyes hurt”, “I need a drink of water”, and “Where’s my bear you can’t expect me to sleep in such harsh conditions so until you find my bear I’m going to sit here and attempt to poop my pants in protest so start lookin’ quick, POPS.”

She says it goes too fast and she gets dizzy and has actually passed out several times while doing minimal activity. This IS a big deal.  Kids don’t do this…ever.  True loss of consciousness in a 6 year old kid has a genuine cause.  In the elderly, things like autonomic instability lead to syncopal episodes (pass out when they stand up).  Add 90 years to your kid’s life, and your letter wouldn’t have won itself a full blog post.

I have taken her to several Dr’s, only to be told “kids don’t have heart attacks”.  I agree.  Kids don’t.  Adolescents do, however.  And young adults in their early 20’s do too. I’m at my wit’s end with this and worry over it constantly.  You’re right to be.  The hair is starting to stand up on the back of my neck over this one.

She had bloodwork to check her cholesterol about 14 months ago and it was high. Genetics..ding!  ding!  ding!  That, or you’ve set her up with a continuous Big Mac infusion pump through her sleeping hours.

She recently had it checked again and it was 259. That’s worse than mine…and I’m 37 spending most of my time with my butt glued to a chair while I hover like an anxious hen over my blog. Her sister (age 10) had a cholesterol level of 126. Luck of the draw, kid.  I’d see the bet and raise it if I were her. They eat virtually the same thing and my 6 year old is only 40 lbs, so she isn’t overweight. Another sign of a genetic component…which makes this just fantastically unfair.

This is now starting to affect her normal playing routine because she says running/playing make it hurt worse. REALLY bad sign.  Kids run.  Especially skinny kids.  They RUN.

I’ve been told it’s constipation ?, seriously?, reflux probable in ADULTS, heartburn same thing…grown ups, not kids, pulled sternum maybe the strangest musculoskeletal diagnosis I’ve ever heard….but so far no Doctor feels it is anything to worry about.  Are you seeing actual doctors…in actual America?  I hear the medical system on the plains of Balinor is a bit iffy.

She had a EKG and it showed she was tachycardic based on her age?  EVERY kid is tachycardic compared to an adult and a few arrythmias this is like saying “oh, we had some red wine”.  Some arrythmias KILL YOU, others are meaningless…and everything in between.  What kind of arrythmia?, however her pediatrician feels that could be normal for her age. ‘Could be?

Her teacher at school tells me she complains 5-10 times a day and says ‘my heart hearts’.  My 3 year old boy is obsessed with candy, but I’d guess he rarely actually asks for it 10 times in one 24 hour period (considering he sleeps for about 14 of them).

We live in a very small town population 4?, and have to travel 120 miles to a ped. cardiologist worth it…however they won’t see her without a referral and her pediatrician doesn’t feel it is necessary I suspect an insurance issue.  How hard is it to make a referral, even if only to help reassure mom?

If you have any suggestions for me I would love to hear them. I’m worried
that even though diet has been modified and the rest of the family has no cholesterol issues (grandparents do) that this high level is affecting her.  Do you know of any other tests that I could suggest her Doctor perform? Short of a cardiac catheterization, I’m not aware of any other helpful tests in this situation. He has also shrugged off any suggestions of a heart echo.

Final Thoughts – (I’ll dispense with the red italics, even though it makes me feel Extremely Important):

I can’t be certain that your story is completely true, because I don’t know you and haven’t seen your daughter’s medical file.  It also rings a bit fantastical since I’ve spent lots of time around pediatricians and have never seen one as cavalier as what you describe based on the small amount of information you’ve provided me.  As a rule, I do not believe that many doctors are lazy, incompetent, negligent…or drunk.  If you’re going to a licensed child specialist physician, they probably know what they’re talking about.

That said, IF your story is completely true, my advice is to knock on doors – pound on them if you have to.  Walk up to any door with an M.D. on it (be wary of any other initials except perhaps D.O.) – until you get a referral to a pediatric cardiologist for an echo.  Women walked for 5 solid hours under the Haitian sun to have their child seen in our clinics when I did relief work there, so you can cross vast distances for your child too.

The echo, in my opinion, is the first place to start.  Your child also probably needs medication for the cholesterol issue – or will in the very near future – and if your pediatrician seems to be cavalier about this, you may need to look for one that is more aggressive.  But diet changes won’t help this situation much, and exercise could be dangerous until you rule out structural heart disease.  It’s almost impossible to find cardiomyopathy without imaging, and totally impossible to find early atherosclerosis without a significant work up by a cardiologist.

Rest assured, there is a doctor out there who will find in in their writing hand to put in 10 minutes and refer you to a specialist if your story is as legit as it appears on this blog.  If it takes spending a week in a larger city, fine.  If it takes getting on an airplane, DO IT!  If what you said is true, and there are no additional conveniently omitted facts, your child needs to see a specialist.  Do NOT stop pestering doctors until she does.

Finally, let me say that while my heart goes out to you, remember that I am a doctor…but not YOUR doctor.  And this is a blog, not my clinic.  As you can see by my responses, I’m giving my honest opinion, but also being silly.  I write this blog for fun, not to extend my day at the office.  Therefore, these responses qualify only as  suggestions and musings, not medical advice.  A licensed physician, who has actually seen your daughter and evaluated her entire history, is the one who needs to make a real recommendation in this situation.  It completely annoys me that I find it necessary to say that….the world these days is run by lawyers.

All joking and useless lawyer pandering aside, my responses in this blog really boil down to one thing:  Keep knocking….

Ode to McDonalds and Cigarettes

You can say you saw it here. This family medicine doctor – supposed bastion of all that is healthy and wholesome – recently found himself encouraging a patient to keep up the McDonald’s and smoking. Instantly after proclaiming my support of these two great sins of the developed world, I heard my program director’s voice in the back of my head saying not unkindly, “Nice job, doctor, good work…we’ll most likely kill you in the morning.” Although never tempted by cigarettes, I frequently fight the urge to hit a McD’s and constantly rail against both as all that is disjointed and wrong with our society (celery is another problem, IMO, but that’s another discussion entirely).

I saw a patient this weekend who unabashedly describes smoking about a half-pack of cigarettes a day, and has been doing it for “goin’ on 50 years now, and I ain’t quittin’ no matter what you tell me.” The patient is 78 years old with advancing COPD. When she inhales, the wispy flimsy breath she drags down into her rapidly deteriorating lungs rattles around aimlessly like a blind baboon in Grand Central Station. She then forces the air back out; little of the oxygen actually used. She is on 14 medications to treat everything from her diabetes to the high amounts of fat in her blood.

“Smoking makes me feel…” She closes her eyes, her face taking on a distant, faraway look as if she just lost herself in recollections of her torrid love affair in Paris on a college philosophy tour, “like I’m surrounded by friends when I’m actually all alone.” How can I beat that?

This patient lived a full life, been smoking for a good majority of it. Now she is stuck in that impartial vice-like vortex of half-life and half-death that American medicine has so expensively provided us. Historically, people just died when they got as sick as her. Today, people linger, in a sort of daily, living suffering. The institutions they inhabit have innocuous-sounding descriptions like “assisted-living communities”, but everyone knows what they really are. Places where the clock of mortality hangs largest on every wall, where the clanging metal hammer pounding on anvil cannot go ignored, but can’t be rushed. It pounds in measured, inexorable rhythms, indifferent to anguish it causes. Hundreds of thousands of Americans waste away in these communal halls, most abandoned by their families, waiting for that final insult and staring droolingly at the wall in the meantime. But when this insult finally does arrive – a heart attack, hemorrhagic stroke, maybe a pulmonary embolism – it shows up with a slouch, hands in pockets, irresolute, nuanced and often as slow as a sadist. These days, the Reaper arrives in a robe of gray, eschewing the dramatic and abrupt pitch black somewhere around the time we invented beta-blockers.

So, go ahead, lady. Smoke to your heart’s content (or infarct). The damage is done, really. If you did stop today, the additional few weeks or maybe even year would be so miserable for someone who loves smoking this much it wouldn’t do much for you. Mortal time isn’t everything. There’s such a thing as life quality, too.

“The other thing I love,” She continued, “is Saturdays.”

Her face, looking like gravity used physical hands to pull her face to the ground for the past 200 years, suddenly filled with a smile. Her losing battle with age suddenly clamoring to a standstill. “My wonderful daughter comes every Saturday and brings me a McDonald’s egg McMuffin sandwich and coffee. I just love that. I look forward to it all week. Say, what day is it? Maybe she’s coming today. Do you know?”

“Well, it’s Saturday night at 11. Maybe she came earlier before your care facility staff thought you needed to come to the hospital.”

“Yes. This could be. You see dear, I can’t really tell the difference between days and weeks and months and years anymore. They’re all sorta the same to me anymore. I just know my Jerry comes on Saturday and we have breakfast together. And you know…that McDonald’s does a lot of good for other people, too. They hire young kids, old folks…give people a start in life, or help them do something worthwhile. The buy all kinds of ingredients from local grocers and farmers. Why, when they moved in here 30 years ago, my son was one of the first they hired. He has his own business today. Employs 30 people.”

“Wow. I’ve never thought of them that way.”

“And them McMuffins…ain’t so bad for you, either. They fill you up, keep you fed through almost a whole day. It’s good food.”

By any primary health care measure, someone who smokes daily and eats fast food at least once a week, is not healthy. But exceptions to every rule emerge in unlikely places. This woman did not come to the hospital to make me re-evaluate my unbending belief in the immutable evils of fast-food and smoking. But her defense of their place in her own life was unassailable. This woman won’t live to be 90 years old. The end may come in the next few days, in fact. But this is true for all of us. This very moment, our lives could be required of us. Should this happen, could you depart with the same gentle serenity?

If deprived of her simple vices, could she?

I found myself answering no to both questions. So this family doctor ended up departing the room, encouraging an overweight patient with COPD and hyperlipidemia to “keep up the smoking and enjoy your McDonald’s.”

I’ll start typing my resume. I hear there’s good jobs in the restaurant business.

Carl’s Jr. Confession

carls.jpgI’m not Catholic, so I’ve never formally confessed to anyone. But I feel the need to confess to a recent crime here in the blogosphere. Here, to you, dear readers.

I went to Carl’s Jr. the other night.

Worse, I took my whole family…indoctrinating my children to high fat, high carb, high calorie fast foods. And, I showed little restraint. It was like a multi-day Roman festival to the God of Girth. Yep…not just chicken strips and maybe a grilled chicken sandwich for me. It was fries, milkshakes and BURGERS.

And I loved it. Felt like I ate real food for the first time in about 2 years.

As a family doc, I’m constantly trying to convince people to give up their addictions, vices and bad habits. Chief among them is smoking, of course, but I’m also trying to get people to eat less, exercise more and watch things like cholesterol and lipids. Then look what I go do.

Let’s break it down:

Based on the awkwardly-named “Food and Nutrition Board, Institute of Medicine, National Academies”: The average human of my body size and activity should consume the following in any 24 hour period:

-total daily calories = 2884
-fat = 20-35 (let’s just go with the full 35)
-carbohydrates = 130
-protein = 56
-cholesterol = as little as possible (the geek-ball science freaks actually put this in their report)
-sodium = 1300 mg

Here’s what I ate, in one 30ish minute tribute to whimsy and sensual overload in the form of a burger, fries and chocolate milkshake:

-calories = 1830
-fat = 90
-carbs = 198
-protein = 51
-cholesterol = 185 (for the record, there is ZERO cholesterol in the fries)
-sodium = 2720

This means that in one meal I ate all but about 1000 of my alloted calories for an entire day.  Furthermore, those remaining calories could be composed of no fat, no carbs, absolutely no sodium and approximately 5 grams of protein.  IF I managed to gnaw at some cowhide for my last 5g of protein, I would still have gone over in fat by an eye-widening 55g.  I’d also have blown out the carb-O-meter by 68, never mind the cholesterol, and I overshot the sodium by, oh, let’s just round to 1400 mg.

This is unreal.  It’s so unhealthy I’d advocate placing automatic defibrillators in these restaurants before airports and hotels and malls.  Heck, forget seatbelts, helmets and all warning stickers of any kind.  This whole building needs to be wrapped in one giant warning sticker.

But the truth is, it isn’t just about hunger (for me).  It’s also about fun, and diversion and some deeply-housed food enjoyment gong that hasn’t rung for nary a moon.  It’s an emotional thing too, because 80% of everyone in the place was from California, where the chain got started back in the ’50’s.  I was re-living my days along the central CA coast, all tired out from surfing until my arms were rubber and then chilling with my best friends, eating great food at a Carl’s Jr.  It brought back the memories, and that alone nearly justified the visit.

I realize, after times like this, that I’m just as much an addict as smokers, drinkers, sexers, stealers, the overshoppers, overspenders and druggers.  My substance is food.  I’m not especially fat – yet – but that doesn’t matter.  I use food as a stimulus, an emotional emollient..as entertainment.  There are times I pretty much can’t say no to it, even if there is ample evidence that it will shorten my time on this earth with my friends and my beloved children.

So, what can I say to my patients, most of whom are battling one addiction or another?  I suppose nothing more than that I know the struggle.  And that I lose my own sometimes, just like they do.