Pain – When is it an emergency?

One of the most useful skills that I picked up practicing medicine is the ability to read between the lines.  For instance, when a young man comes for a well check-up that isn’t required by his school or employer, he has a question about his penis.  99% of the time, he will leave without ever mentioning the real reason for his visit.  I have learned to ask the right question, which is, “Why are you REALLY here?”  The same is true for most people who come to the office complaining of pain in their head, chest or abdomen.  They won’t say it but what they really want to ask is, “Am I going to die?”  Luckily, the answer is, more often than not, “No.”  However, (there is always a however in medicine) there are certain very serious, life-threatening conditions that are hailed by intense pain.  I hope that you never need to use this information but better to have and not need, than need and not have.

1.  The worst headache you have ever had could be an cerebral hemorrhage or stroke which have different causes and devastating effects.  If this headache is severe and is accompanied by any change in your cognition, level of alertness, vision, movement or sensation – call 911.

2. Sudden, excruciating pain across the chest and/or back can mean aortic dissection, which is very serious.  Picture all your blood moving very nicely through your aorta (your largest artery) and then the wall of that artery tearing.  The blood now isn’t going where it is supposed to go and is going to places it shouldn’t go.  This is the opposite of good.  Sudden chest pain that worsens with movement, doesn’t go away with rest and is accompanied by shortness of breath can be a sign of a pulmonary embolism – a blood clot that has travelled to you lungs.  Also, very bad.

3.  Heart attack pain is often ignored.  It can be severe which usually prompts patients to go to the ER or call 911.  It can also be mild and vague.  Usually, the discomfort of a heart attack will be described as squeezing or pressure on the chest.  It can be accompanied by jaw pain, arm pain and tingling, upper back pain, nausea, sweating and shortness of breath.  If you are having any of theses symptoms, do not ignore them.  Get some help.

4.  Abdominal pain can hallmark a variety of serious conditions.  For brevity’s sake and so that you won’t be up all night worrying, I will approach them generally.  Most abdominal pain is nothing to worry about and has to do with something you ate or drank.  But, if you have pain that is sudden and severe, is much worse with movement, travels to your back or other areas of your body, or is associated with sweating and/or changes in your heart rate, get to an emergency room.  There are too many serious things that it can be to mention them all here.  The abdomen is chock full of really important body parts (as well as a few that you don’t need) that can kill you if they become blocked, ruptured, infected or twisted.  Again, you don’t have to worry about every cramp or pang but if something does not feel quite right, get help.  It is much better to be safe than sorry.

5.  Pelvic pain in men that is acute and severe can signal testicular torsion.  It usually presents with pain on only one side and there is about a 6 hour window during which the testicle can be saved.  Acute pelvic pain in men can also be a sign of appendicitis or bowel problems but testicular torsion is usually the one that grabs attention.  Since most men hate to ask for help, I thought I’d open with that.  Pelvic pain in woman is very common but when it is severe, sudden and accompanied by nausea and vomiting, it needs to be taken seriously as it can be a sign of ovarian torsion, ectopic pregnancy or appendicitis.  These are conditions that cannot be ignored.

At first glance, the fine line between pain that is emergent and that which is less serious may be scary.  How do you know?  You should be comforted by the fact that you do not need to know, you just need to use your common sense.  When you start to get that feeling that something might be very wrong, you need to take advantage of the fact that you most likely live in a place where an ambulance or an ER is just a phone call away. It is an overused idiom but when it comes to your health, very true that it is better to be safe than sorry.  Of course, as I write this, I am worrying about all of you hypochondriacs out there – you know who you are – who will read this and think the worst.  I comfort myself with the fact that you were thinking the worst anyway.  (I’m saving hypochondriasis for another weeks’ topic.)  I am trying to reach out to those of you who ignore the signals your body is sending.  There are no medals for toughing it out but there are, unfortunately, plenty of tragic consequences for not seeking the help you need.  It is your body and it is the only one you get.  The worst case scenario if you go to the ER and there is nothing wrong, is that you will be sent home.  Home and healthy is a great outcome – it is nothing to be embarrassed about.

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