July 29, 2008 -- "Time is brain."
The phrase is repeated like a mantra in the halls and classrooms of medical schools and hospitals throughout the country. The reminder to young trainees is that time is of the essence; the faster a diagnosis is made and treatment initiated, the less damage will have occurred.
Yet it is often the minutes and hours before a patient decides to seek medical attention that play the largest role in the ultimate outcome. Any doctor will tell you that, given the presence of certain concerning symptoms, "watchful waiting" is never the right approach.
Dr. Richard O'Brien, spokesperson for the American College of Emergency Physicians, says he often sees patients who have put off their trip to the emergency room for hours or days, ignoring worrisome symptoms. In many cases, these individuals had major symptoms which resolved. They ultimately seek help when the same symptoms return and don't go away, he says.
But why wait? It turns out that there are a number of barriers to keep people from seeking medical attention when they need it most -- such as concerns about missing prior obligations, high hospital bills, or inconveniencing others.
There's no doubt that going to the emergency room is inconvenient, both for the patient and those accompanying them. Often, says O'Brien, people end up waiting "because they don't want to bother anyone, especially their families."
Besides, if given the choice, few people would spend a nice Sunday afternoon in the emergency room.
However, often it is a simple unawareness of the gravity of the situation that keeps people from seeking medical care. The key is to know those symptoms that are worrisome and require prompt evaluation.
Paying Attention to the 'Red Flags'
While crushing chest pain is hard to ignore, many concerning symptoms are not as obvious. So, what are those symptoms that represent something potentially serious, something that shouldn't wait until morning, or even until the end of the Red Sox game?
Some of the most important symptoms are those that portend the future -- they can be thought of as "red flags" that are letting us know that something is brewing.
For example, strokes are often preceded by a TIAs, also known as a "mini-stroke." In these cases, people experience neurologic symptoms -- such as weakness, difficulty speaking, blurry vision, or confusion -- that resolve spontaneously.
"TIA is a warning sign of impending stroke and should be taken seriously as an opportunity to stop a massive stroke in its tracks," says Dr. Wendy Wright, an intensive care neurologist at Emory University Hospital. She has had numerous patients who had symptoms and then went to bed or took a nap to literally try to "sleep it off," often with disastrous results, later waking up with irreversible neurologic damage.
"It is a tragedy to think that something could have been done in the meantime," she says.
Sometimes, however, it is the combination of seemingly benign symptoms that is enough to raise red flags in doctors' minds. You may wonder why, when you tell your doctor about your screaming headache, he or she asks you about vomiting, fevers, your eyes, and your home heating system. They are doing this for a very specific reason. When certain symptoms occur together, different diagnoses may pop to the top (or bottom) of the list of possibilities in your doctor's mind.
This thought process can be seen at play for those diagnosed with carbon monoxide poisoning. Individuals exposed to the gas often present with a staggering variety of seemingly vague symptoms, including headache, vomiting and abdominal pain. As a result, affected individuals can easily be misdiagnosed with a viral illness or food poisoning.
Dr. Eric Lavonas, associate director of the Rocky Mountain Poison and Drug Center in Denver, says he becomes suspicious when he sees flu-like symptoms either in multiple family members or in patients without fever. He and other doctors are able to make the right diagnosis by recognizing the combination of symptoms, as well as asking the right questions.
To further complicate the issue, people often present "atypically," meaning that the symptoms they experience may be different than the textbook example.
"There is the classic misconception of the 'Hollywood heart attack,'" says Dr. Christopher Cannon, cardiologist and associate professor of medicine at Harvard Medical School. The stereotypical heart attack, he says, stems from what people see in the movies -- a middle aged man suddenly clutches at his chest, complains of agonizing pain, then slumps to the floor.
However, most people with heart attacks actually describe a diffuse pressure or squeezing. Says Cannon, "A real heart attack is very subtle."
Indeed, atypical presentations are often the ones that often stump doctors. When even those of us who have spent years learning to sniff out the atypical and esoteric get fooled, how can we expect the general population not to be fooled sometimes, as well?
Dr. Jesse Pines, an emergency medicine physician, advises that patients look to their primary physician for guidance on symptoms they should pay attention to, given their specific medical history and risk profile. "Because each patient's situation is different, they should look to their regular [health care] providers for guidance on which symptoms should prompt seeking urgent medical care," he advises.
Of course, good preventive and primary care is the best way to avoid the emergency room altogether. O'Brien emphasizes that regular primary care visits are part of the solution. Furthermore, he says, "Pay close attention to your body and make a serious effort to keep any medical problems you have under control."
The 'Red Flag' Symptoms You Mustn't Ignore
This list is not exhaustive, nor should it take the place of a doctor's evaluation; it is purely meant to highlight some important symptoms that shouldn't be ignored. As usual, it is best to consult with your own doctor, and seek medical attention if you are concerned.
1. Chest Pain
Discomfort that feels like squeezing, pressure, or heaviness;
Pain and sweating, nausea, or a feeling of dread;
Difficulty breathing ;
Any change in the pattern or frequency of your "normal" pain;
Pain or pressure that gets worse with exertion and improves with rest;
Pain associated with passing out or feelings of lightheadedness;
Pain or shortness of breath in anyone with a swollen or painful leg;
Feeling like your heart is fluttering or beating quickly.
2. Shortness of Breath:
Difficulty breathing that worsens when you lie flat or when you exert yourself;
Feeling like you are breathing faster than usual or are having difficulty talking;
Difficulty breathing that starts suddenly;
Worsening of formerly stable shortness of breath, such as is seen in an acute asthma attack;
Shortness of breath with fever;
Coughing up blood;
Difficulty breathing in anyone with a swollen or painful leg.
3. Symptoms of stroke or TIA
Any of these symptoms are concerning even if they are transient or improve;
Weakness, numbness, or inability to move any part of your body;
Any changes in vision, including double vision, blurry vision, or loss of vision;
Difficulty speaking ;
Feelings of dizziness, loss of balance, unsteadiness, or difficulty walking;
Recent head injury (such as a fall) or stroke;
4. Abdominal and Gastrointestinal Symptoms
Bloody stools or bloody diarrhea;
Diarrhea associated with severe abdominal pain;
New onset of constipation, or stools that look darker than normal;
Vomiting blood or vomit that looks like coffee grounds;
History of heavy alcohol use;
Vomiting or pain that is keeping you from taking your regular medications;
Abdominal pain associated with fever, vomiting, diarrhea, or lack of appetite;
Abdominal pain that becomes worse after meals;
Abdominal pain in the presence of chronic ibuprofen (or any other NSAID drug) or aspirin use;
Abdominal pain that starts suddenly;
Abdominal pain that doesn't resolve;
Any of the above symptoms associated with a history of heavy alcohol use.
5. Loss of consciousness or significant lightheadedness
Passing out associated with chest pain, palpitations, abdominal pain, shortness of breath, or headache;
Passing out associated with the presence of any symptoms concerning for stroke or TIA;
Passing out without preceding warning symptoms;
Passing out during exercise.
6. Severe headache:
Headache that starts suddenly (you can pinpoint the exact moment your headache began), like a "thunderclap";
Headache that you would describe as the "worst headache of your life";
Headache associated with confusion, fever, stiff neck, vomiting, seizure, weakness, numbness, visual changes, or pain with chewing;
Recent trauma or fall.
7. Visual Changes
Double vision, blurry vision, or loss of vision (even if transient);
History of glaucoma;
History of diabetes, high blood pressure, or atrial fibrillation;
Changes in vision associated with severe eye pain, headache, scalp or jaw pain.
8. Allergic Reaction (Following an insect sting or ingestion of any substance such as a food or medication):
Feeling like it is difficult to breathe;
Swelling of lips, face, tongue, or throat;
Redness, rash or hives over the body.
Feeling that you want to hurt yourself or someone else;
History of abuse or feeling that you are unsafe at home;
Loss of interest in normal activities;
Increased use of alcohol or substances.
10. Back pain:
Incontinence or retention of stool or urine;
Weakness or numbness of your legs or groin area;
Persistent pain that comes on with no history of falls or other trauma;
History of osteoporosis;
History of cancer;
Back pain associated with fever;
Back pain associated with burning or painful urination.