If you have severe upper back pain, there’s one test you’d better make sure the ER gives you; otherwise you may end up dead from multi-organ failure.
A man, 60, presented to the ER with severe upper back pain.
It’s not uncommon for people with intense back pain to visit an ER. This case seemingly was no different.
The man, I’ll call him “Ken,” had slipped while exiting the shower a few days prior. He hadn’t fallen, though; he had “caught” himself.
He felt fine afterwards but then, a few days later, began experiencing very troublesome pain in the upper area of his back, between his shoulder blades. He attributed this to a muscle strain from the slip.
At the ER he told the doctor he had slipped and almost fallen a few days prior and thought that perhaps a muscle had been pulled.
He underwent a chest X-ray, which turned out normal. The doctor gave him an injection of a painkiller, believing that the situation was muscle related, and told him to follow up with his primary care physician.
Within seven days, Ken was dead from multi-organ failure, with the upper back pain having been the first symptom of his heart attack.
His wife decided to sue the doctor and the hospital. I know all this because it was a lengthy litigation transcript that I had proofread.
What really struck me was that something similar had happened to my mother years ago – only she had survived, thanks to vigilant care at her second ER visit, that had been absent at the first only days before.
After the wife described the first ER visit, I immediately knew what the malpractice event had been.
Before I tell you, I want to first emphasize that one need not have a medical degree to know this information. It’s what I call “pamphlet information” – facts that might be found in a pamphlet in a medical waiting room or inside the exam room.
Facts are facts. We only need know how to read to then know some information – regardless of our educational background.
In my case, I learned of this small but extremely important fact after bringing my mother to the emergency room when she had chest pain.
What the doctor at Ken’s first ER visit should’ve done was order blood tests – which he had not. The particular blood test that very likely would’ve saved Ken’s life is for an enzyme called troponin.
Ken’s ultimate diagnosis, at the second ER visit, which was at a different hospital, was a heart attack. Two days after his first visit, he began experiencing more upper back pain plus frequent vomiting.
The medical team at the second visit had immediately drawn blood to get the troponin level, which turned out to be through the ceiling. Right then and there Ken and his wife were told he’d had a heart attack – which had occurred two days before.
We grow up hearing that chest pain could mean a heart attack. Sometimes we also hear that shortness of breath, feeling lightheaded and even having nausea can mean a heart attack.
But how often do we hear that upper back pain as a solitary symptom can mean a heart attack? Very seldom.
This is why Ken and his wife immediately had connected the intense back pain to the almost-fall in the bathroom. It never had dawned on them that the symptom could be cardiac related.
Upper back strain from almost falling?
The timeline, to them, fit nicely: slip on shower floor, the body twists a little in the process of “catching” oneself, then straightens out. This can seemingly wrench a muscle somewhere in the back.
But actually, straining an upper back muscle is highly unlikely in this scenario. If anything, a lower back strain just might result, since any twisting to catch oneself would involve the lumbar area. The upper area wouldn’t twist much at all.
Furthermore, when a muscle is suddenly pulled, the pain is usually immediate, on the spot. Ask any athlete or gym-goer. This is especially true of back pain.
I myself have acutely strained “something in my back” from doing the deadlift exercise. The discomfort was immediate.
Have you ever wrenched something in your back from shoveling snow or bending over and picking something up? You feel it on the spot.
I knew a woman who threw her low back out reaching forward to grab something inside her refrigerator. The pain was immediate.
In Ken’s case, the pain came “a few days” after his slip, according to the wife’s testimony. He had felt perfectly fine after the slip, and for one or two days following, then suddenly had been hit with the pain.
This is not how muscle strains or sprains work. I’ve had many of them throughout my life from gym workouts and playing volleyball: the pain is immediate.
Do not confuse acute pain with DOMS: delayed onset muscle soreness. DOMS is notorious for showing up two to three days after a tough workout, with the in-between period feeling normal.
Few people can’t tell the difference between a sore, “overworked” muscle from a killer workout and a more sinister type of pain from an injury.
Bottom line: If you suddenly begin having upper back pain, and some unusual but fairly benign movement (such as reflexively maneuvering one’s body to prevent a fall from a slip) occurred a few days ago and at that time had not caused any pain – it’d be wise to consider other possible causes.
This is especially true if you have blaring risk factors for coronary artery disease. In Ken’s case, he was male, 60, had used tobacco for years and had diabetes. He also didn’t exercise. That’s five big risk factors.
The first ER doctor never went over any of these, according to the wife who had been present in the exam room. The doctor had been pretty much in and out.
What the Doctor Should’ve Done; My Mother’s Experience
A man of 60, with diabetes and a tobacco history, presents with sudden sharp upper back pain. He tells the doctor he slipped a few days ago.
What should’ve blared out to the doctor were the risk factors and description of the symptom, never mind some slip on the shower tiles.
An ER doctor would know that sudden severe upper back pain could mean a heart problem. The wife told the examining attorney during the deposition that the doctor wanted a chest X-ray to see if anything was “pulled” or “torn.”
We can’t take every recount from the distraught wife as 100% accurate. An X-ray will not show a pulled or torn muscle.
X-rays are mainly to reveal issues with bones, though they can also reveal pneumonia and other non-bone related problems; but not muscle injury! This is pamphlet information.
It’s likely that the wife’s memory was clouded and that the doctor had ordered the X-ray to check for an aortic aneurysm (which will show on an X-ray). A rupturing aortic aneurysm can, indeed, cause only upper back pain.
When the X-ray came back negative, the doctor dismissed the complaint as muscle related and sent the patient on his way. There’d been no order for a blood draw to check troponin levels!
When I was only 27, zero risk factors for a heart problem and reported to the ER doctor that I regularly worked out, never smoked, etc., etc., he still ordered a troponin test! It’s all about leaving no stone unturned.
I had presented with a racing heart – my only symptom. But I certainly had not been a candidate for a heart attack, with my perfect medical history and status – yet that blood draw was done (normal, of course; diagnosis was panic attack).
Ken had multiple big risk factors. Just the solitary symptom of intense upper back pain should’ve netted a troponin test. It’s really a “duh” moment here. Why didn’t the doctor have this blood draw done?
When my mother went in for chest pain, it was one of the first things done. The result was normal.
However, if the first result is normal, standard medical care dictates that a second test be done several hours later. That’s because after a heart attack, it could take several hours for this enzyme to leak from damaged cardiac tissue and make it into the bloodstream.
So my elderly mother stayed at the ER for the second test – which was normal. She was sent home with the recommendation to take acid reflux pills and follow up with her primary care.
Had Ken’s troponin been taken at the first visit, it would have been very elevated. First off, this is what his second ER team, at the different hospital a few days later, told his wife.
Secondly, by the time Ken had gotten to the first ER, he’d already had the upper back pain for at least a day, which would’ve been plenty of time for significant troponin leakage to be detected!
And had this test been given to him at that first visit, he would’ve immediately been diagnosed with a heart attack and undergone treatment two days sooner than he actually had. Two days! That sounds to me like the difference between dying and being saved.
At the second ER visit, Ken’s wife was told that over the past two days, his liver and kidneys had been starved of blood and were in acute failure. His lungs were also affected. There was no saving him at this point.
As for my mother … she felt fine after that first ER visit. Then two days later she was distressed over shortness of breath, but didn’t have chest pain this time. It was back to the ER with this solitary symptom.
Again, the troponin was immediately drawn. This time it was “in the grey range” and she was admitted. An echocardiogram followed, which was abnormal.
She was then urged to sign consent for a catheter angiogram – a procedure that looks inside coronary arteries for blockages.
The procedure revealed diffuse coronary artery blockage; “she’s going to need bypass surgery,” a doctor told me.
I was told by three other physicians that without the surgery, she’d likely have a massive heart attack within a week.
This is frightening because many people won’t go running to the ER for only shortness of breath after having been discharged from the ER only a few days before being told their heart was fine.
The troponin draw detects a heart attack, NOT clogged arteries and imminent heart attack.
Had my father and I had a lax approach to the shortness of breath two days later … my mother would’ve had a massive heart attack soon after. Turns out she required quintuple bypass surgery — and had it that very evening! And to think that the doctor at her first ER visit had dismissed the chest pain as acid reflux!
The Takeaway
Any symptom that can be caused by a heart attack warrants a troponin test. This is especially true if the patient has risks for heart attack.
How a doctor could overlook Ken’s age, history of tobacco use, diabetes and intensity of upper back pain as all pointing to a possible heart attack is beyond me.
The troponin test is extremely sensitive, a marvel of modern medicine, and its numerical value can mean the difference between life and death.
