Glitches and Quirks

A number of years ago, as I was sitting in a college class, I reached down to pick up my backpack off the floor when I felt the sudden onset of intense pain in my left chest.  I sat there, unable to take a breath or even move without excruciating discomfort stabbing through my thorax.  When class ended I rushed over to the student health center and made it clear to the nurse that I was expiring from a heart attack, or something equally bad.  After some tests they concluded I wasn’t dying and let me go.  My question for them was the same that my patients ask me all the time: So, if it’s not my heart, what exactly is it?

I obviously recovered, but the episode made me aware of a general rule of thumb I invoke to people who are dissatisfied with the lack of diagnosis for their health ills.

Rule #1: The body will periodically exhibit strange, sometimes miserable, symptoms that eventually go away on their own and never lead to any long-term health problems.

That warm feeling that starts in the left shoulder and creeps up to the right ear, accompanied by tingling in the toes.  The pain in the neck that radiates into the arm whenever you breathe deeply or cough.  The sudden onset of inexplicable sweating followed by palpitations and the profound need to yawn.  A pain below the right breast that worsens when you bend over or laugh.

Frequently these symptoms lead people to seek an answer from me and other doctors.  Since some involve chest symptoms the patients are often put through a battery of tests to assess the health of the heart.  If they come through the emergency department they will receive an even more vigorous—and expensive—evaluation since their symptoms are perceived as being more acute and possibly life-threatening.  They get an EKG, echocardiogram, stress test, chest CT, lab work—all done in the outside chance that these strange symptoms may represent real heart disease.

In most cases all the testing comes up normal.  At that point the patient is dismissed from the doctor’s office or ER and told that their heart is okay.  “That’s great,” says the patient, “but you never told me what’s wrong.”

Rule #2: There are few things as frustrating as experiencing frightening symptoms for which no one can provide a satisfactory diagnosis.

I know the symptoms are real, therefore the problem must be real. What if they missed something?  What if I have a rare but deadly disease that a smarter doctor would have picked up on?  Where’s House MD when I need him?

Another experience from my youth: While I was on my surgical rotation in medical school, I developed an intense pain behind my left knee that gradually worsened to the point that I could no longer walk.  As background, you must know that the surgery training environment is no place for students to complain about ephemeral needs of the frail mortal coil—the expressed desire for sleep, bathroom breaks and food is seen as an explicit declaration of weak surrender.  As I hobbled from room to room on rounds my supervising interns and residents belittled and mocked my complaints as figments of my imagination.  Are you bleeding?  Do you have any exposed bone fragments?  No? Then you’d better get back to work.  One chief resident took enough pity on me to perform a cursory exam on my leg, but promptly declared me healthy.  This went on for several days until I was able to talk a friendly ultrasound technician into scanning my knee.  There, as plain as day, sat lodged in my vein a giant angry thrombus (I had severely injured that leg the previous year in a motorcycle accident).  At that point, armed with evidence of real disease, I was suddenly transformed from a weak medical student meriting nothing more than ridicule to a patient with a real pain deserving real sympathy.

Within a few days the clot resolved and my aching vanished.  Of course I never forgot the frustration of not knowing.  In fact, the “not knowing” was in many ways even worse than the pain.  At least in this instance I had the satisfaction of ultimately learning the cause of my misery.

When I evaluate patients with odd (we call them “atypical”) symptoms and find no evidence of abnormality, I’m happy to be able to deliver the good news that their hearts are healthy. Indeed, most patients are relieved to find out that the unusual symptoms they are experiencing are not ominous harbingers of cardiac failure even if I can’t provide a diagnosis for what they have.  Others feel let down that my thorough evaluation has not led to what they want most, which leads me to my final rule:

Rule #3: In modern medicine we’re better at telling you what it isn’t than we are at telling you what it is.

And sometimes you just have to live with this.  Sure, we all know of someone whose diagnosis of some awful problem was delayed because their doctor didn’t look hard enough, but this is the exception rather than the rule.  In most cases our medical system is really quite good at evaluating symptoms and unearthing any potentially damaging diseases if they exist. But bear in mind that the body is full of glitches and quirks that lead to plenty of symptoms but no adverse consequences and may not merit the extensive time, expense and risk of elaborate medical evaluation.

Sometimes just knowing what’s not there has to be enough.