The Subtlety of Emergencies

I read all of the text books in Oriental medical school. Spleen qi deficiency always has lethargy, loose stools, and abdominal distension among other symptoms. But how often do we see that pattern in practice? Sure we see bits and pieces, but more often than not,we get mixed patterns, patterns that don’t show all of the “classic” symptoms, or are much more subtle than the books say. Well...western medical emergencies do not follow the textbook either. Emergencies tend to be much more subtle than we learn in the texts and our classes. Myocardial infarcts(MI)and acute abdomens can be extremely mild in symptoms and devastating in impact.

Sally (name changed)was a woman in her sixties with a history of hypertension and gastric discomfort who woke up with some retrosternal painwhich was disconcerting but not debilitating. She was alert and without dyspnea. She had never had an EKG. The intern in the school clinic didn’t think it was serious while the supervisor, thinking it may be something to be concerned about, was going to send the patient home with his phone number “in case it got worse over the weekend. ”Was this woman having a heart attack?

According to Lilly (1998, p. 156), “up to 25% of patients who sustain an MI are asymptomatic during the acute event.” One-quarter of patients who have had a heart attack did not know it. This makes it pretty difficult for a practitioner to clinically assess whether a MI has occurred, so it is very important for us to have a very high clinical suspicion. Some other signs and symptoms of a MI that may be present with or without pain include the symptoms of an adrenaline surge (sweating, tachycardia, and cool and clammy skin), rapid, shallow breathing, dyspnea, and even a low-grade fever due to the release of inflammatory mediators.

As a practitioner of Oriental medicine, there are several things to do. First, a patient with any degree of suspicion of a MI needs an EKG. Period. No fudging, no “it’ll get better,” no “they’re too young,”“too healthy,”“too nice,” too whatever. Clinical suspicion means EKG. If you have one, great, use it. If not, the patient must go to their family practitioner, the urgent care clinic, or to the emergency room in order to get it. They are easy, relatively inexpensive, and absolutely diagnostic. Practitioners should also take vitals noting tachycardia or tachypnea. They should listen to the heart for an extra click (S4 gallop) or murmurs (especially a systolic). And the jugular venous pressure (JVP) should be assessed. Finally, if this has been done and the practitioner thinks a MI may have happened recently, it is considered first aid to give an aspirin. Not an Advil or Tylenol, it must be an aspirin because it has some ability to reduce clotting. This should all be done while the ambulance is on the way if the practitioner has high suspicion.

Acute abdomens are considered a surgical emergency and can be caused by numerous conditions including pancreatitis, appendicitis, cholelithiasis, ectopic pregnancy, dissecting aortic aneurysm, perforated ulcer, bowel obstruction or ischemia, among many others (Tally & O’Connor, 1992, p.186). Obviously, acute abdomens are very serious business with many of these conditions being fatal without intervention. But while the mythical “textbook” says that there are extreme signs of pain, a doubled-over position, and every little movement causes howls of pain, the real world is much more subtle than that. Acute abdomens can present with little or no pain, only rigidity upon palpation. Or without rigidity, and the only sign of an acute abdomen is rebound tenderness when pressure on the abdomen is rapidly released. In other words, it can be extremely difficult to determine if a patient has an acute abdomen. 

If a practitioner suspects the presence of an acute abdomen, there are several examinations that need to be undertaken. Obviously, a complete abdominal exam should be done if the patient is not in too much discomfort. Pain, tenderness, rigidity, and any pulsatile masses (a sign of an aneurysm) should be noted. During this, the abdominal aorta should be palpated and the diameter determined if the patient can tolerate it. Vital signs need to be taken with any derangement a red flag. Bowel sounds should be listened for with an absence of sounds or a difference in the normal low rumbling sound indicating pathology in the intestines. A rectal and vaginal exam should be done normally but many acupuncturists would be uncomfortable with performing these. Finally, a urinalysis investigation should be performed to help determine any pathology. In a woman of childbearing age, western medicine says that they are always pregnant until proven otherwise, so a urine dipstick pregnancy test would be in order in this subset of patients. If, after these exams, there is continued suspicion of an acute abdomen, the patient must go to the emergency room immediately.

Sally ultimately went to the emergency room and had that necessary EKG. It was negative and her retrosternal pain was considered gastric in origin. But she got everyone’s blood pumping and had the emergency room hopping. In other words, given her symptoms, it was a true emergency even if everything was fine in the end. As a practitioner of Oriental medicine, it is necessary to have a clinical suspicion for emergencies. And more importantly, not to worry if we are wrong about an emergency. Western doctors always assume the worst and hope for the best. There are no penalties for sending a well patient to the emergency room to rule out a potentially fatal condition. But there can be problems with not doing so.