Episode #372: Smells Like Teen Spirit

0:00Welcome back to the Barbell Medicine Podcast, where we bring modern medicine to strength, conditioning and strength conditioning to modern medicine. I'm your host, Dr. Jordan Feigenbaum, and today we delve into another mystery case, this time focusing on a situation where a common practice in the strength community resulted in a life-threatening medical emergency. We have an expert internal medicine physician, Dr. Austin Baraki, the second most handsome doctor in North America, to help us navigate the case and ultimately, hopefully, come up with the correct diagnosis. But this is a real medical case and it is for edutainment purposes only.

0:31please see your physician if you have any questions about this now on the other end of the line is the second most handsome doctor in north america dr awesome baracki what's up dude hey uh excited it's been a little while since we've done one of these so hopefully i'm not uh too rusty and and i guess that little teaser you gave already has my mind kind of racing a little bit trying to see what scraps of a differential diagnosis i can yeah yeah just based on uh just based on what you provided but yeah looking forward to it yeah it should be fun a few announcements before we get into it. Two things.

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1:35Now if you're like, what is Power Building? I don't get it. Well, we're just combining powerlifting and bodybuilding together to try to get the best of both worlds for people who enjoy that type of training. I tend to like that type of training. So this is near and dear to my heart. Instead of the original programs coming with one singular program, this includes three programs. They're all 16 weeks long. There's a three-day version. There's a four-day version. Both of those are designed to take people to like a one rep max test or a powerlifting meet if they wanted to do so. But we also included a non-competition type template for people who like training the big three.

2:07So squat, bench press, and deadlift, but aren't really going to max out their lifts or go to a powerlifting meet. So it's a fun style of training if that's what you're into. And so now we wanted to support more people through that. Also, we expanded the text so you kind of know why you're doing what you're doing. So you can check that out on our website. We just released that. It's also on the app, and you get access to both if you purchase through the website. I'll say my prediction now. This is what we have to do before any one of these cases. I have to predict whether or not you're going to get it, and historically I've erred on the side of entertainment and said, well, you're just not going to get it.

2:39So people listen. I really don't think you're going to get this one, and I don't say that. I am – look, you impress me regularly. I think you're very intelligent. Well, you communicate well. A lot of other superlatives. We could keep going, but this is a family show. I don't want to get too misty. I don't think you have enough information. Well, that's on you. To be clear, that's not on me. It's on the people writing the case report. All right. Well, sounds like I'll learn something, which is great. You're ready, though? Sure. Let's do it. All right. Let's do it. Okay. Dr. Austin Baraki, you just got word that a 38-year-old man is en route to your hospital due to concern for a heart attack.

3:23While you wait for the patient to arrive, you're getting the report from the paramedics who are bringing him in. About an hour ago, paramedics were called to the patient's office by his coworkers out of concern for the patient's health. Upon arrival, the paramedics noted that the patient reported severe chest pain and shortness of breath, and his skin also appeared to be bluish. An EKG in the field was suspicious for a STEMI, a particular type of heart attack. And so the paramedics wanted to bring the patient to your hospital, which is a cardiac center. Upon arrival to your hospital, the patient is alert and oriented, but appears uncomfortable.

3:59He continues to endure severe chest pain located behind his sternum. He also says that he's short of breath and his hands feel sweaty. He said it all started during his workout that morning, but he wasn't sure what was happening and went to work anyway. Before cardiology can come and whisk the patient away to the cardiac cath lab, He says that he's also been recently sick. He says he's had a runny nose. He's been sneezing, has a sore throat and a cough, but he denies having any fever that he was able to measure at home. On his way out of the emergency department and into the with the cardiology team, the patient denies that he has any active medical problems or any history of this.

4:36He doesn't use any drugs, but he does smoke cigarettes and he drinks about 10 drinks per week. So, Dr. Baraki, that is the information that you have from when he showed up to your hospital before you start going down your differential diagnosis rabbit hole. If you want to play along at home, this is where you would pause the podcast, try to come up with your own differential. And if you've never done it before, I encourage you to do so. Just pause this thing, come up with an idea of like, hey, what could this be? Ideally, more than one thing. Although, as I keep reminding listeners, the length of your differential diagnosis only needs to include the correct diagnosis.

5:10So anyway, yeah, it can be helpful to go through the systems of the body and say, hey, which one of these things could relate and potentially cause this patient's presentation. So this is the time to pause. If you're not pausing, Dr. Baraki, take it away. What do you think about this patient? Yeah, this is a concerning story, a concerning presentation. And for the sake of the edutainment value of this, mainly the educational aspect, since you prompted the audience to try to do this, I'll return to kind of how I tend to build a differential diagnosis in these situations. And I think the key aspect of this as a skill is having an organizational structure to your thinking, because it helps you work through problems in a systematic way.

5:53Because I see chest pain near daily. And so that means I see hundreds and hundreds and hundreds of cases of chest pain over the course of many years, if not, you know, into the thousands. And even though the patient is coming in with chest pain, the kind of source or cause for that chest pain can be any number of things. The mark of, I think, less skilled differential diagnostic reasoning, or what maybe some lay folks in the audience who are trying to play along might tend to do, is immediately jump to very specific diagnoses as things that could be going on, right? This is what I see oftentimes, even with medical students and even with residents and trainees, when prompted for a differential diagnosis, they jump to, well, what is the first specific diagnosis that comes to mind.

6:38And what I often end up doing is try to pull them back from jumping to very specific diagnosis and think in terms of more broad buckets, as I tend to call them. And what the nature of these buckets are kind of varies based on the complaint. And that's where you need some experience to be able to build these kind of organizational frameworks. So for a situation where somebody has pain someplace, it ends up being a very useful way to organize things into these buckets by using the anatomy of that area. And so as we've done before, when we've talked about chest pain, for example, you know, we think about, well, what are the things in the chest that can potentially hurt that, you know, have a nociceptive event in this case.

7:18So we have the skeleton, the ribs, the chest wall, even the skin. And then as we go deeper, there's the lungs and the pleural surfaces, there's the heart and all the structures of the heart that can potentially contribute to pain, like the muscle of the heart, most concerningly, as well as the pericardium and some other structures. And then we have the esophagus even deeper in there as well, as well as some other things that I'll set aside for now. And so then we start to see, well, if I overlap things like chest pain and shortness of breath, then I start to see, well, now I'm really much more localized to like the cardiac and the pulmonary systems a bit more than I would be, for example, to the esophagus, which can still contribute to that, but less likely, less common, and certainly less common than some issue going on in the skin, for example.

8:08So then we start to kind of prioritize these things. So in this patient, we have a syndrome of acute chest pain and shortness of breath, which both using this kind of anatomic structured way to organize things, as well as just what's the most immediately life-threatening, we're going to hone in on the heart and the lungs. And you notice that I still have not said myocardial infarction or heart attack or pulmonary embolism or pneumothorax. These are all specific examples of diagnoses, but these are all kind of emergency things that are kind of no misdiagnoses in these systems. And so the idea is if I know that I need to be investigating the heart and the lungs, well, what tools do I have available to me to do so?

8:46There's going to be the EKG, which was already done. There's going to be some form of chest imaging, like a chest x-ray, sometimes certain types of CT scans of the chest. And given the suspicion that arose from that EKG, this patient, as you mentioned, is appropriately getting whisked off to the cardiac catheterization lab because a myocardial infarction or a heart attack or some form of what we'll call more generally an acute coronary syndrome is definitely the most concerning upfront possibility. There are a number of potential causes of acute coronary syndrome. You can have atherosclerosis, a topic we've talked about a ton on the podcast where one of your plaque, coronary plaque ruptures and leads to a kind of a thrombus or a clot forming in your coronary arteries and limits blood flow to the heart muscle.

9:28But that can happen through a lot of other ways too. You can have spasm of your coronary arteries. You can have a dissection of your coronary arteries. You can have lots of other mimics of a myocardial infarction like this. And so taking that off the table up front would be the first and most important thing to do. Now, you mentioned, you know, in the teaser for this, that I'm unlikely to get this. And so I think that, you know, based on that alone, my leading, you know, source of concern or leading suspicion, you know, even though that is the correct thing to rule out, I'm going to end up probably having to think quite a bit more broadly beyond this first and most urgent concern as we get a little bit more information.

10:09But so far, what you've described justifies the upfront kind of evaluation and management, depending on his vital signs getting whisked off and at least getting that heart catheterization done. But if it's a negative, for example, if his coronary arteries all look actually clear and there's no evidence of a clot or a plaque rupture, of course, he could have still experienced some form of a corner artery spasm or something like that, there's still some things that can mimic it that could end up looking normal when they do take him to that lab. But I might also have to expand my thought process.

10:42And one of the curious things you mentioned is this skin appearance of being a little bit blue. The idea that he has what might be cyanosis is not something that is commonly seen when somebody just has a straight-up regular run-of-the-mill quote-unquote heart attack, that there may be some cyanosis or change in skin color. Most concerningly would suggest maybe it's this oxygen level super, super low, which would be detected when they check his vital signs. And that would actually take me in a little bit of a different direction, you know, to start thinking about some other potential causes and contributors, which I will come back to should they become relevant upon getting a little bit more information here.

11:23So I have little objection to what they did up front, but I'll be curious to see what happens next to take us in a different direction. Yeah, very good framework. Okay, what is the problem? What is the general area? What are all the systems in the area that can possibly contribute? And you'll note that as you go further down like these different systems, they can actually lead you further away from the actual area a person is experiencing pain, for example, or where you think the, you know, anatomy, the relevant anatomy is. Yes, we'll see what happens here. Well, look, the guy went to the cardiac catheterization lab, and in the lab, the EKG done there showed that he had sinus tachycardia, so a rapid heart rate, but normal rhythm.

12:01But the cardiology team interpreted the EKG not as a STEMI, a particular type of acute coronary syndrome, but as normal male pattern ST elevation. And so this is just like widespread ST elevation in many of the electronic leads that you use to get the EKG. It's thought to be due to early repolarization. It's benign, and it's commonly seen in young, healthy male athletes. Although, again, there's some additional workup that needs to be done to confirm that, hey, this is actually not a heart attack. This is a normal finding. We'll get to that. A portable chest X-ray was also done, and that was normal.

12:39So they turfed him back to you. They said, we don't want this guy. We can't do anything. So now you finally get your first set of vital signs. His heart rate was 115 beats per minute. His blood pressure is 135 over 85. His respiratory rate is fast, 24 beats per minute, breaths per minute, and he's 84 % for his pulse ox on supplemental oxygen. He's got no fever, however. His physical exam, well, the patient appears ill, uncomfortable, and anxious. He's struggling, appears he's struggling to breathe. His neurological exam, well, he's alert and oriented. He's moving all of the extremities well, but, yeah, he does have some difficulties breathing.

13:21Cardiac exam is a rapid rate that you can hear, but no murmurs, rubs, or gallops. His peripheral pulses are strong. His lung exam, it's got rapid breathing, as mentioned, but they're clear to auscultation, so listening to them bilaterally, his lung sounds are normal. Musculoskeletal exam is normal, so no swelling, no tenderness, no weakness. His skin does appear clammy, particularly in his palms. He is actively sweating. His lips and nails appear kind of bluish gray, according to your resident, but you haven't actually laid eyes on the patient just yet. You're coming down and you're waiting for labs and an echocardiogram to come back.

13:58So, you know, while you're on your stroll to the emergency room, what's going through your head? This is also another time where you would pause the podcast and think about, does this information put you in any different direction? Yeah, super interesting. Okay, I was taking a lot of notes there while you were chatting. A little interesting how long it took me to get a set of vital signs. I imagine he actually had vitals before he went to the cath lab, but you finally revealed those to me here. So yeah, benign early repolarization is a finding that is pretty common on EKG and patients in this demographic, men in their 30s, 40s can certainly have it.

14:35Although when somebody comes in with acute onset crushing substernal chest pain, I can totally see why the EMS folks and the folks in the ER were reluctant to call that a benign finding and instead treated this like it could be, you know, mycardial infarction or some form of acute coronary syndrome. So moving forward, I will say, you know, the rapid heart rate is something that is a little bit actually less common in patients who have that STEMI diagnosis unless they're going into shock. So that's already something that is seen a little bit less often here, his blood pressure and some of the other things are not getting my attention nearly as much as his respiratory situation.

15:12He's breathing fast and his blood oxygen level is low as we suspected based on that suggestion of maybe he's looking a little blue, which is again, unusual. The fact that his chest x-ray is normal is reassuring for some things relating to the lungs, but is not sufficient to evaluate things super thoroughly. And we've ultimately seen, you know, it seems like not really done much additional evaluation of his heart just yet. So he would still get blood testing related to his heart, like troponin levels and all sorts of other things as part of this evaluation regardless. But really, I'm updating kind of the problem that we're trying to solve now.

15:48So instead of a patient who's just coming in with acute chest pain and shortness of breath, I'm likely to assume that this is a relatively new onset, you know, what we'll call hypoxemia or low blood oxygen levels and cyanosis with chest pain and shortness of breath kind of as an associated finding. So really the thing I'm trying to solve ASAP is why is this patient's blood oxygen level 84 %? And I assume that that number you gave me is while he's breathing ambient or room air. And so the first thing that we would do is, and this is both a treatment and can be useful diagnostically, is slap some oxygen on this patient and see if it helps.

16:29If it does help, that sends us down a certain path of issues that do respond to oxygen. And if it doesn't help, that actually sends us down a different path of other types of causes for this sort of thing that do not respond to oxygen. Just a brief correction. And this may surprise you because it surprised me because there was no further mention of this. So maybe I'm just giving this away. The 84 % was actually on supplemental oxygen. Okay. Yep. All right. Still leaving open the question of what was it before they put them on oxygen and did it improve? Or how high have they cranked it up? because usually you just crank the person up to 100 % and then you take them down from there to see how little do they need.

17:10I will tell you that they did not mention the specific amount of supplemental oxygen. However, it could be at 100 % and this is the exact, this would be the same. Okay. Pulse Ox reading. Got it. So essentially you're telling me that we have a situation where we have a patient who has hypoxemia that is not responding to supplemental oxygen, which is useful for working through this problem. One example of types of conditions that can cause this are called shunts. And a shunt basically means that blood that has already passed through the body from the arterial side and kind of given its oxygen off to the tissues and come back to the heart on the venous side to kind of pick up more oxygen to make another trip out to the body when it doesn't actually pass through the lungs effectively to pick up oxygen, but instead it kind of skips a step from the right side of the heart over to the left side of the heart, or if it shoots through the lungs way too quickly for a variety of reasons, it doesn't have an opportunity to pick up new oxygen.

18:14And so in that situation, I can pour all the oxygen I want into your nose or into your lungs, and it's not actually getting to the blood that it needs to get to. So one of the immediate concerns that I end up worrying about in these types of situations is whether there's some form of shunting going on in the lungs or in the heart. This can be assessed through certain types of imaging, CT scanning, and echocardiogram of the heart. And I would also be curious to look at those blood vessels in the lungs using some of those tools. One of the other things that comes to mind when I see or hear about a patient who has a blood oxygen level that is essentially locked at around 85 % and will not budge no matter what.

19:00This is actually a kind of a textbook description of an unusual and uncommon situation where a patient has been exposed to some sort of substance and that substance has led to a change in their hemoglobin. Hemoglobin is the protein in our red blood cells that normally carries around oxygen. And upon exposure to certain substances, drugs, things like that, it can sometimes have this kind of structural change that limits its ability to carry oxygen. And that state is known as methemoglobinemia. And so this is another, again, uncommon situation. But whenever I hear about a patient whose oxygen pulse ox is like 85-ish and it's not budging, methemoglobinemia is a source of suspicion.

19:46And so at this point, I think the most immediate and urgent things to do is A, to look more carefully to evaluate for some form of shunt, whether in the lungs or in the heart. And then aside from that, I would be talking to this patient about what substances they may have recently ingested, supplements they may have recently taken, because there are certainly drugs and supplements that can cause that condition to try to get a better sense of it, as well as sending off an arterial blood gas with what's called co-ocimetry and some other things to look for how much methemoglobin could there be in the patient's blood, because that would be another test of choice.

20:25And then there are specific treatments for that if that's what we end up finding. The only thing that doesn't entirely fit with that last diagnosis, even though it's an interesting and compelling one here, given the patient's age and like the potential exposure and things like that, is you don't usually expect methemoglobinemia to present with like crushing chest pain, which is a little unusual as far as why somebody, you know, with a, you know, some form of shunting might have chest pain is if they have a, you know, for example, a septal wall rupture or something like that, like some form of maybe had congenital heart disease and he had a kind of a catastrophic structural or structural catastrophe in his heart, for example, that happened abruptly and led to some pain, things like that.

21:09So that's kind of where my mind is right now, looking for structural anatomic reasons for shunting and then thinking about methemoglobinemia while getting some further imaging of his heart and lungs and getting a better history from him. Today, I learned of a new fear that I have, which is having a structural catastrophe of virtually anything in my body. Yeah, exactly. All right. Well, look, we got some labs and some imaging for you. All right. So first off, some labs that you probably would have expected to get a little earlier here. So his hemoglobin is mildly elevated, 17.1. His white blood cell count is also mildly elevated at 12.5.

21:46Normal kidney function and liver-associated enzymes. His CK level is 945, which is elevated. His lactate is 3.5, which is also a little bit elevated. His CKMB is 29.9 percent. Normal is less than 3%. This is a marker that was historically used for damage to the heart. It's not as sensitive and specific as troponins are, but it does tend to rise and fall faster. So anyway, they drove this. They pulled this, and it's 29.9%, but it does have a normal troponin level and a normal D-dimer, which your head is going to explode from the D-dimer. They did an echocardiogram, which revealed a structurally and functionally normal heart with no pericardial fluid collection.

22:32so at this particular time this would be another time to pause the podcast and refine your differential diagnosis if you're playing along at home Dr. Baraki, does any of this change what you're thinking about? What's going on with this patient? This podcast is brought to you by Biggs At Barbell Medicine, we spend a lot of time talking about what it takes to build a body that can handle high level performance but the recovery and health side is just as critical Over the last six years, an incredible team of healthcare professionals did something that most people thought was impossible They helped rebuild the body of legendary Olympian Lindsey Vonn after a series of devastating injuries.

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23:38You get 15 % off your first order at wearfigs.com with code FIGSRX. That's wearfigs.com, code FIGSRX. Yeah, helpful in some ways, not terribly surprising in others, I suppose. So one question I would have, you know, this patient has a hemoglobin of 17 which is technically normal, but a little higher than we tend to see in a lot of people. And so when we see slightly higher than expected hemoglobins, one of the possible causes is, of course, in the fitness space, is this patient on anabolics or testosterone or something like that. So that's one question. But the other is that our hemoglobins can go up as a compensation if we have chronically low blood oxygen levels.

24:20And so we see this, for example, in people who are smokers. Or if you are a high-level athlete, you might go and train at altitude for several months or something like that. That's a way to make that happen, that kind of compensatory response. So what would be interesting is looking maybe if we have any access to prior records of this patient, prior labs, prior sets of vital signs, if he had any issues with that. You mentioned he's a smoker, but man, 38 years old is still a bit too young to develop severe enough chronic hypoxemia in most cases, unless he has some other kind of second hit or, you know, multiple lung diseases, which were for some reason not apparent on his chest imaging, right?

24:59Most of these other lab findings don't get me terribly excited relating to his kidneys, his liver, the CK, I don't really care about at that level. The lactate is just a sign of like, I'm kind of a little worried about this patient. It's not insanely high, but it's not low either. just tells me there's something probably bad going on. And so the more useful thing you gave me was the echocardiogram. I'm going to have to make some assumptions about how this echocardiogram was done and what specific maneuvers and tests and things like that that they did if they specifically looked for evidence of shunting on this echo.

25:29There's some things that are getting a little bit into the weeds here related to things like called a bubble study and things like that to look for shunts in the lungs or shunts in the heart. But if I'm going to take this at face value and say that it is indicative of normal heart structure and normal heart function, then that does take off some of those A structural catastrophes that I mentioned. For example, if the patient did have some kind of, you know, septal defect or wall rupture or something like that that led to some shunting where it shouldn't have been. And then also the other types of shunting that would have been evaluated.