Albert’s pain

Shahar Madjar, MD

Editor’s note: This is the first of a two-part series on pain by Dr. Shahar Madjar.

On a cloudy Tuesday evening, in the fall of 2016, Albert’s life was about to become even more complicated.

Albert was 32. His dog, Blacky, had died several weeks earlier. He and his girlfriend, Georgina, had just moved into a small rental apartment building. Albert and Georgina’s belongings, still in boxes, were scattered all over the floor of the living room, on their bed, and on the kitchen table. The neighbor downstairs, a retired teacher who wore glasses so thick you could never see his eyes, practiced drumming when he felt lonely, every night.

Albert had just started a new job as a sales manager in a downtown store selling recliners whose brand name rhymed with ‘Hazy Toy’. When Albert took the job, he was told that the recliners just sell themselves. That wasn’t true. Some customers raised concerns about the stain-resistance qualities of the fabric, others were questioning the durability of the electrical reclining mechanism, the cushions were not soft enough, and besides, the recliners were too expensive. Albert’s base salary was small, and he never made a bonus.

Tuesdays were particularly slow. On his way home from work, Albert bought a large pepperoni pizza and a six-pack of beer. Georgina was away, visiting her sister. Albert was resting in the living room, and binge watching ‘Breaking Bad’. He was eating his pizza, one slice after another, and drinking beer, one can after another. Downstairs, Eyeglasses was drumming a tune that sounded almost like Ain’t Misbehavin’.

An hour later (the pizza box was empty, the beer cans were rolling on the floor), Albert suddenly felt a “crushing pain” in his chest. He was short of breath, and nauseated. He was sweating all over. He went to the bathroom and stuck two fingers in his mouth trying to throw up, but nothing came out. He found TUMS tablets in one of the boxes and took two, but the pain only intensified. Albert called 911 and was taken by an ambulance to the emergency room.

The ER doctor asked Albert about his pain, the way many good doctors do, by following the PQRST acronym:

P stands for provocation and palliation: what makes the pain worse, what makes it better?

Q for quality: is the pain sharp or dull? Is it stabbing, burning, or crushing?

R for radiation: where did the pain start? Does it go anywhere else? Did it start elsewhere and then moved to its current spot?

S for severity: how intense is the pain on a scale of 1-10?

T for time: when did the pain start and how long did it last?

Here is a short story about the PQRST acronym and chest pain. The story is taken from my medical school days: Sackler School of Medicine was a 10-floor building with three main elevators. Eliezer Kaplinski, a professor of cardiology was our teacher. His hair was always well-kept, and his stethoscope was always slightly protruding from the inner pocket of his 3-piece suit. We listened very carefully in Kaplinski’s class and wrote down every word of wisdom he uttered because we knew that in the final exam, Kaplinski would not use questions written by a teaching assistant, or taken from a database of pre-written questions, but he himself would write questions so complex even the brightest of students might find challenging. So, it comes at no surprise that I remember Kaplinski’s words about diagnosing heart attacks using the PQRST acronym: “A classic heart attack is an elevator diagnosis,” he said. “Enter the elevator with a patient on the ground floor, ask him the right questions about his chest pain, and when you reach the tenth floor, you should have made the correct diagnosis.”

The warning signs of a heart attack are chest pain that feels like uncomfortable pressure, squeezing, or fullness; the pain typically lasts for a few minutes, and may radiate to one or both arms, the back, neck, jaw or stomach; shortness of breath may accompany the chest pain; other symptoms may include cold sweats, nausea, light-headedness.

Now, back with Albert in the emergency room: when asked where his pain was, Albert pointed to his xiphoid (the lowest part of his sternum, or chest-bone). He told the doctor that the pain started after he ate a whole pizza and drank six-pack of beer; and that he had been under a lot of stress at work; he told the doctor that the pain was 7 out of 10 in severity, and that it radiated nowhere; “it started about two hours ago and it is still going,” he said, and than added, “it is a crushing pain.” Albert told the doctor that his father had acute chest pain at a young age, and was later diagnosed with heart disease.

Was Albert having a heart attack? Will he survive this episode? Is pain an effective warning sign, or a malfunctioning flashing red light? I shall return.

Editor’s note: Dr. Shahar Madjar is a urologist working in several locations in the Upper Peninsula. Contact him at smadjar@yahoo.com or at DrMadjar.com.