Reader Comment: A Child’s Chest Pain

A reader recently commented on the SW101 post Will My Child Have A Heart Attack with a disturbing letter about her child.  It has now been granted its own blog.  I have written my own comments in throughout the letter in red italics to make me appear extra important and potentially infallible.

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Thank you for that article. My typically healthy 6 year old daughter has been complaining of chest pain, burning on the left side of the neck and feeling her heart “in her throat” as she says. This is not a big deal.  Kids say this stuff all the time.  It goes along with the ubiquitous “Tummy ache”, “I’m full”, “My eyes hurt”, “I need a drink of water”, and “Where’s my bear you can’t expect me to sleep in such harsh conditions so until you find my bear I’m going to sit here and attempt to poop my pants in protest so start lookin’ quick, POPS.”

She says it goes too fast and she gets dizzy and has actually passed out several times while doing minimal activity. This IS a big deal.  Kids don’t do this…ever.  True loss of consciousness in a 6 year old kid has a genuine cause.  In the elderly, things like autonomic instability lead to syncopal episodes (pass out when they stand up).  Add 90 years to your kid’s life, and your letter wouldn’t have won itself a full blog post.

I have taken her to several Dr’s, only to be told “kids don’t have heart attacks”.  I agree.  Kids don’t.  Adolescents do, however.  And young adults in their early 20’s do too. I’m at my wit’s end with this and worry over it constantly.  You’re right to be.  The hair is starting to stand up on the back of my neck over this one.

She had bloodwork to check her cholesterol about 14 months ago and it was high. Genetics..ding!  ding!  ding!  That, or you’ve set her up with a continuous Big Mac infusion pump through her sleeping hours.

She recently had it checked again and it was 259. That’s worse than mine…and I’m 37 spending most of my time with my butt glued to a chair while I hover like an anxious hen over my blog. Her sister (age 10) had a cholesterol level of 126. Luck of the draw, kid.  I’d see the bet and raise it if I were her. They eat virtually the same thing and my 6 year old is only 40 lbs, so she isn’t overweight. Another sign of a genetic component…which makes this just fantastically unfair.

This is now starting to affect her normal playing routine because she says running/playing make it hurt worse. REALLY bad sign.  Kids run.  Especially skinny kids.  They RUN.

I’ve been told it’s constipation ?, seriously?, reflux probable in ADULTS, heartburn same thing…grown ups, not kids, pulled sternum maybe the strangest musculoskeletal diagnosis I’ve ever heard….but so far no Doctor feels it is anything to worry about.  Are you seeing actual doctors…in actual America?  I hear the medical system on the plains of Balinor is a bit iffy.

She had a EKG and it showed she was tachycardic based on her age?  EVERY kid is tachycardic compared to an adult and a few arrythmias this is like saying “oh, we had some red wine”.  Some arrythmias KILL YOU, others are meaningless…and everything in between.  What kind of arrythmia?, however her pediatrician feels that could be normal for her age. ‘Could be?

Her teacher at school tells me she complains 5-10 times a day and says ‘my heart hearts’.  My 3 year old boy is obsessed with candy, but I’d guess he rarely actually asks for it 10 times in one 24 hour period (considering he sleeps for about 14 of them).

We live in a very small town population 4?, and have to travel 120 miles to a ped. cardiologist worth it…however they won’t see her without a referral and her pediatrician doesn’t feel it is necessary I suspect an insurance issue.  How hard is it to make a referral, even if only to help reassure mom?

If you have any suggestions for me I would love to hear them. I’m worried
that even though diet has been modified and the rest of the family has no cholesterol issues (grandparents do) that this high level is affecting her.  Do you know of any other tests that I could suggest her Doctor perform? Short of a cardiac catheterization, I’m not aware of any other helpful tests in this situation. He has also shrugged off any suggestions of a heart echo.

Final Thoughts – (I’ll dispense with the red italics, even though it makes me feel Extremely Important):

I can’t be certain that your story is completely true, because I don’t know you and haven’t seen your daughter’s medical file.  It also rings a bit fantastical since I’ve spent lots of time around pediatricians and have never seen one as cavalier as what you describe based on the small amount of information you’ve provided me.  As a rule, I do not believe that many doctors are lazy, incompetent, negligent…or drunk.  If you’re going to a licensed child specialist physician, they probably know what they’re talking about.

That said, IF your story is completely true, my advice is to knock on doors – pound on them if you have to.  Walk up to any door with an M.D. on it (be wary of any other initials except perhaps D.O.) – until you get a referral to a pediatric cardiologist for an echo.  Women walked for 5 solid hours under the Haitian sun to have their child seen in our clinics when I did relief work there, so you can cross vast distances for your child too.

The echo, in my opinion, is the first place to start.  Your child also probably needs medication for the cholesterol issue – or will in the very near future – and if your pediatrician seems to be cavalier about this, you may need to look for one that is more aggressive.  But diet changes won’t help this situation much, and exercise could be dangerous until you rule out structural heart disease.  It’s almost impossible to find cardiomyopathy without imaging, and totally impossible to find early atherosclerosis without a significant work up by a cardiologist.

Rest assured, there is a doctor out there who will find in in their writing hand to put in 10 minutes and refer you to a specialist if your story is as legit as it appears on this blog.  If it takes spending a week in a larger city, fine.  If it takes getting on an airplane, DO IT!  If what you said is true, and there are no additional conveniently omitted facts, your child needs to see a specialist.  Do NOT stop pestering doctors until she does.

Finally, let me say that while my heart goes out to you, remember that I am a doctor…but not YOUR doctor.  And this is a blog, not my clinic.  As you can see by my responses, I’m giving my honest opinion, but also being silly.  I write this blog for fun, not to extend my day at the office.  Therefore, these responses qualify only as  suggestions and musings, not medical advice.  A licensed physician, who has actually seen your daughter and evaluated her entire history, is the one who needs to make a real recommendation in this situation.  It completely annoys me that I find it necessary to say that….the world these days is run by lawyers.

All joking and useless lawyer pandering aside, my responses in this blog really boil down to one thing:  Keep knocking….

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Numb and Numb-er

I’m happy to announce that I now drive a Mercedes-Benz.  It’s true.  A real in-the-steel-and-glass Mercedes.  The model is a C-180, which is the 4-cylinder, 4-door model.  The smallest engine they make (great gas mileage).  To boot – it’s green, my favorite color.

I’m a doctor now, people.  Apparently helping sick people entitles me to the high-life.

Truth is, here in Germany, the term “hooptie” is a known, legitimate noun.  The term is used to describe nice German cars that are (usually) bought by Americans and then run into the ground.  You can pick up BMW and Mercedes hoopties for 500 euros.

 

merced
Mine looks just like this one...but way cooler.

My car isn’t exactly a hooptie.  In the States, it would probably have cost at least $5,000, maybe more.  I don’t really know because I’ve never been in the market for Mercedes-es.  But I got mine here for a few thousand bucks.  It’s still in good shape and as long as I take care of it (an expensive proposition in Germany), it should get me around for at least a few years.

That is…unless it takes a few years until my new monument to affluent living is allowed to take me anywhere.

Take the Army’s torrid and longstanding love affair with bureaucracy and combine it with 1000 years of rulership of the masses in Europe, you get the process I dealt with just to be allowed to drive a car.

Buying the car is easy.  But in this Germo-Americo Funkenthink, the quagmire starts there.  You first need a special driver’s license, which requires a half-day class and then a 130 question test ( which I immediately failed by about 15 questions).

You also have to have insurance on a car before you actually register it.  And, the car needs to be inspected.  But you can’t drive it to the inspector’s unless you have it registered and insured.  But if you fail the inspection, you’ve just registered and insured a car that sucks.  So, you have to de-register it (I did that – twice – before I settled on the Mercedes).  De-registering requires a trip to the local customs office (American) plus a second trip to the other customs office (German, 35 min drive), numerous forms, money, waiting and…all the while you still need the insurance.

So, I’ve been a little reticent to drive much unless I have to.  I’m always wondering if I actually have all the paperwork and proof that will allow me to stay out of jail were I to get pulled over.

Instead, I came up with an alternative (heh, heh):

Through some highly unfortunate events in my brother’s life, I ended up with his Harley motorcycle.  Now, make no mistake – I owe him for this very expensive bike.  It was a ‘take-care-of-my-hoss-for-awhile’  kind of proposition.  Of course, being a deeply loyal brother, I immediately agreed to “help out”.  But, not being a big Harley-lover, I…well, I sold it.  And I bought a BMW motorcycle instead.  Initially, I sold it to help fund out trip out here, and a portion of the Harley money was a HUGE help in getting us here.  That said, I GUESS whatever money we had left over should have been sent back to my saintly bro.  But with all these fantastic German road machines around, you sorta just get Beemer Fever.  What was I supposed to do?

And anyway, my bro is about 10,000 miles from me.  Is he really going to come get me when he realizes I sold his Harley?  I mean, c’mon, I did the guy a favor!  BMW vs. Harley is a no-brainer.

 

bmw
Mine's just a LITTLE less shiny and has panniers.

So I now fly along the German Autobahn on a R1150 RS BMW.  Riding a bike like that, in this part of the world (any part of the world if you worship BMW bikes) is an experience that is hard to replicate.  Harder to describe.  At 80 miles an hour, I blow by stunning autumn trees, taking in their blurred resplendence in shimmering hues of gold and yellow and red.  “My” bike purrs along effortlessly.  When I lean over the gas tank and duck behind the faring, the engine sounds something like a sewing machine, but even softer, maybe more like two feathers rubbing together.

There’s only one problem…Germany is COLD.  The other day I left for work in the dark, road sparkling with frost, at a temp of -2.5 Celsius.  Buh-rrr.  And this is only OCTOBER.

The night before, I had received a notification in the mail that my car did not have the correct license plates due to a dating error in the – you guessed it – insurance policy.  So, should I be pulled over in my esteemed Mercedes for any reason, I could expect to be hog-tied, whipped and sent back to the States crisply folded into a shoe box.

Thus, while my longsuffering wife dealt with the paper-pushers in Hiedelburg, I rode the bike to work, frost and chill notwithstanding.  I do have some decent riding gear I picked up when I first got the Harley.  I have a jacket with armor in the shoulders and arms, and pants with knee and hip pads.  I have big thick gloves – also a “gift” *ahem* from my bro – and good riding boots.  All the gear is made to withstand serious wind and rain.

 

jeff_daniels1
"Got a little nippy back there going through the pass, eh Har?"

But I’m not sure any gear will hold up for long when receiving a direct 80 MPH sub-freezing air blast for 40 straight minutes.  Mine didn’t.  By the time I got to work, I was so cold most of joints wouldn’t bend.  I walked into the clinic like I was in a body-cast.  I don’t think I even spoke to my first 3 patients that day because I couldn’t unclench my jaw.  I just nodded compassionately with my hands buried in my armpits and gave ’em whatever drugs they wanted.

I probably should have just sold the Harley and given whatever money we didn’t need back to my brother.  But instead I chose to buy a Beemer with the extra cash and freeze my face off in Germany.  If you love BMW motorcycles, you’ll understand completely.  You’ll probably applaud me for such a wise and intelligent idea.

I’m cheering, anyway.

Graduated – No Crying

The last days of residency passed – perhaps with a bang, and certainly no whimpers – and I am now full into my first week as a real, live doctor.

Everything feels the same, but with more sleep.

My graduation ceremony occurred 4 days ago, on Saturday.  For as emotional as I felt that night, I managed to survive the entire ordeal without much blubbering.  This had largely to do with my particular approach to the ceremony itself, which involved a skateboard, a wacky helmet and some iffy poetry.

Since there are only 6 graduating residents from our program, each of us enjoys (or endures) a sizeable amount of limelight as we graduate.  It starts with a picture slide show of us from our earliest days up to the present.  Some of my shots were strange, if not embarrassing, as you might imagine.

We are then introduced – for an agonizingly long time – by a faculty member.  Here our history, foibles and dreams are put on display for all in attendance to see.  This part can also be rather painful too.

It was then my turn to speak.  We aren’t given time-limits on our speeches.  As mentioned, there’s only 6 of us, so I guess we have the berth and he right to ramble a bit if we want to.

I survived the process with almost zero public display of emotion.

I’m not sure why this was some sort of goal for me.  I’ve always been a lousy crier.  I’m good at complaining, whining, moaning and bellyaching, mind you.  Rather too good.  But my crying skills must have atrophied somewhere in my childhood.

If I were to guess, I suppose it happened when I was about 5 years old and my biological father had just punched his girlfriend in the face.  He then leered at me and asked, “You gonna cry about that like a little girl?” in a drunken haze.

“Nope.”  I said.  And I never have.  These days, I can only cry when Ariel gets her statue of Eric blown up by King Triton, or the Broncos trade their franchise quarterback to the Bears.

So, I have some issues.  Fine.  I’ll bet you do too.  Intellectually, I admire the Roger Federers of rhe world who can stand on the international stage with unabashed tears streaming down their cheeks when they lose (or even win, sometimes) their latest tennis match.  Emotionally, I want to smack them with their own tear-stained pink hankies, tell them to find their purse and go back to the parlour where life doesn’t hurt so much.

Anyway, I wasn’t going to cry.  Smash my thumb with a hammer…we’ll talk.  But for this?  No way.

So, my approach was to first ride my Sector 9 longboard skateboard up to the podium wearing a tin foil-wrapped, overly-festooned bike helmet.  Why such a rather dumb graduation display?  Why, especially, at a solemn ceremony for a new practitioner of the healing arts?

sector9Aside from the fact that medicine is frequently too pompous and full of itself, I figured that if I could keep it fun and light, I could keep my eyes dry.  Plus, I ride my longboard to work most days, and I religiously never wear a helmet of any kind, much to the dismay and consternation of virtually every person I meet on the hospital campus.  For 3 years I’ve put up with near-constant haranguing to wear a helmet.

Why don’t I wear a helmet?  Well, I just figure that anyone traveling less than a mile, at about a mile an hour, while less than 3 inches off the ground…should garner me the right to feel the wind in their hair.  Granted, there isn’t much wind at that speed…and I don’t have much hair.  But that’s my metaphorical argument, people, and I’m sticking to it.

I also think that Americans are too stupidly safe these days.  We think we have allergies to things that 6000 years of humanity had no problem with.  We pad every corner in our houses and put seatbelts on our T.V.’s just in case the wall trembles and pushes that deadly thing over on a kid.  We have warnings on things like plastic 5-gallon buckets and nylon shower curtains.  Frankly, the fact that my children will never ride barefoot in the back of a bouncing pick up truck, screaming like golden-haired eagles as the wind whips wildly into their eyes, brings me no end of sorrow.

I grew up burning leaves, shooting bottle-rockets out of my hand and hunting fish with a whittled stick.  I think life is risky, and living life is an exercise in managing that risk.  Knee-jerk safety measures without true analysis of risk leads to heard-mentality that rarely leads to anything but really really bad groupthink: racism, genocide, militant nationalism, day-glo, Milli Vanilli, toilet-seat-shaped pillows for airplane flights that everyone carries around airports but never actually use for more than 10 minutes, to name a few.

So, in truth, I don’t wear my helmet when longboarding because I’m determined to not become a Nazi.  Gotta admire a guy like that, right?

Anyway, I understand that most of you dear readers will find fault in my little tirade, and will probably want to admonish my opinion about helmets just like all of the faculty, nurses, staff and freaking maintenance workers I see.

But take heart!  You don’t need to worry!  I rode to the podium in a helmet for the first time.  Just to make everyone happy.  Just to acknowledge that I’ve finally heard the message.  I give up.  It’s time to be responsible and extra-duty safe.  I’m a doctor now.

‘Course, my helmet was covered in tin foil and had sticks extending from it in every direction with tinfoil balls on the end of the sticks…but it was a helmet.

Then I delivered a poem.  It was supposed to be a rap – with a thumping beat and maybe a couple of dancers and lights flashing/spinning with everyone on their feet, their hands in the air all hip-hoppin’ on the floor.

But I’m white.  I’m a doc.  I’m in a tie.

Forget it.  It’s a poem.  A really bad 1-2-3-2 rhyme sequence that rhythmically scans like ice cream might feel if you were dumb enough pick a pile of it out of a sandbox and eat it.  But, in honour of my creation and the initial inspiration for it, I allowed that I would not in fact be delivering a rap, OR a poem that night.  It would be an amalgam, a mixture…a PAP.

This is fitting, of course, since we were all gathered to celebrate my new status as a fully-trained family medicine doctor.

My Pap made my mom cry.  I think my Dad too.  Kinda my wife.  And most of the people I talked to afterward said it made them a bit misty.  My goofy, two-bit hyper-syllabic tossed salad?

Cool.  People cried.  I didn’t.  I was too busy looking goofy, or saying goofy things.

Dear old Dad would be proud.

Twisted Knee – What I Did

Here’s a follow-up to the case about the twisted knee (read about it here, if you want the background):

Options for treating and working up the guy’s knee included simple stuff like rest, ice and a knee immobilizer. Additionally, my fantabulous American health care system gave me the options of providing the pt with a CT or MRI, Xray and/or referral to a orthopedic specialist. I also could have mentioned that skiing and any other sport involving coordination + velocity should be bypassed from that moment forward.

I picked R-I-C-E, first and foremost. R-est, I-ce, C-ompression and E-levation tend to cover a multitude of musculoskeletal injuries. I put a knee-immobilizer on his leg, which really does little for the joint other than force it to stay still, which leads to much less pain, which leads to less involuntary muscle flexion, which might help healing but helps the pain for sure. Finally, I prescribed clinical-strength anti-inflammatories. I did not get imaging or send him to a surgeon.

It has been about a week now, and he is doing reasonably well. It will be a long time until he forgets to think about his knee when he is doing any sport. He may never have perfect use of his knee, although I still expect a full recovery at this time.

MRI is considered the gold-standard for knee (and joint) injury. But a good physical exam by a real smart doc (jury’s out on me) is statistically just as likely to identify joint pathology. When I started med school, this ohooollldd doc gave us a lecture on the physical exam. I can see why they picked this guy for the lecture because he stood up there growling for an hour about how he could diagnose pathology just as well as these “young docs who don’t know nuthin’ except for how to order more technology.”

doc.jpg“You can learn all you need to know just from the physical exam.” He said often, before falling asleep and asynclitically engaging his coffee cup.

His dictum is less true when it comes to detecting early cancers, etc., but he is right to some extent. We use more imaging than we need to, and it contributes in a small way to the higher cost of medical care in America. This patient is recovering as fast as can be expected (that is to say, sloooww) under the circumstances. He probably wouldn’t heal any faster with surgical intervention, either. He just needs to wait it out.

And I hope he keeps skiing.

You Be The Doc – Twisted Knee

Below is a case I saw recently that challenged me. You be the doc and tell me what you would do. In a few days I’ll describe the plan I settled on with my patient:

ski.jpgThe Story: Young man, approximately 30 years old. Exercises regularly, in very good shape. Recently was skiing and tried to swerve. His left ski continued in the same line but his body and the other ski turned more than 90 degrees to the right. Before he could right himself, he heard an audible “pop” in his left knee, and then he crashed (I asked if the wipe out was at least cool…he said no, it was slow and goofy. He was barely moving). When he tried to get up, he felt excruciating pain in his knee and throughout his whole leg. He was barely able to get down the hill and could hardly walk to the car. Conveniently, someone else was driving home.

He came to see me on crutches, nearly incapable of putting weight on the knee. The accident happened approximately 24 hours prior to seeing me. He said the knee did not swell dramatically and that some motions hurt intensely and others weren’t so bad.

ski3.jpgThe Exam: The knee looked almost totally normal compared to the right one. I couldn’t see any swelling and couldn’t make fluid waves by bunching up the skin and tapping on it. The lateral (outside) and medial (inside) edges of the joint were not painful to pushing. The patella (kneecap) and the ligament that holds it in place were aligned well and not tender. There was no laxity in the tendons and I couldn’t push the lower leg in and out (called the drawer sign).

However, determined to cause him massive pain in some way, I succeeded by holding his foot at the sole with his leg extended and twisting like I was turning a faucet. The pain was so bad he broke into a sweat, got out of breath, and gave me a seriously murderous look. The pain was equally bad rotating the other direction. Most other motions of the joint did not cause pain but there was some stiffness.

The Choices: Here are some of the things I considered for a plan:

knee-mri.jpgA.) MRI
B.) R-I-C-E. This is the acronym for Rest, Ice, Compression, Elevation
C.) Knee immobilizer
D.) Xray
E.) Referral to orthopedics for eval and probable surgery
F.) Narcotic pain meds + B
G.) Non-narcotic pain meds + B
H.) All of the above
I.) Tell him to learn to ski better and not be such a clutz (KIDDING, kidding, didn’t really think this about the guy…I’ve bailed like an idiot more times that I can count on my surfboard)

Surf Story

Yeah, yeah, I know. This blog’s about medicine stuff. Usually. But hey, it’s a blog. The whole point is to write about stuff you like, right? Other than medicine, I love books and most sports. Of all sports, I love surfing more than any of them. So, if you can stand to regularly read this blog…you’re gonna get lots of medicine, with the occasional odd topic – like surfing – thrown in. So here you go:

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surf.jpgIn the sport of surfing, wave size is much less important than wave shape. Even an average surfer can ride waves up to twice his size (termed “double-overhead”) without much problem if the wave is shaped perfectly.

But perfect waves are rarely found anywhere but in surf magazines. The reality is that finding that kind of shape is a long process. It frequently involves terrifying moments of thinking the perfect shape has been found, only to realize the error once trapped in the jaws of an ill-shaped beast.

The best-shaped waves look like a cone laying sideways on the water. One end of the cone is a tube, but the other end is completely open – waiting its turn to become a “barrel” as it follows the rest of the wave. The contours of the sea-floor, coupled with the direction of energy in the water are largely responsible for making these perfect shapes. With so many variables, each wave is different and you can’t predict what you’ll get.

One early morning I went to surf with my two buddies Matt and Greg – on a day that by all predictions would see some huge waves (we tracked all the detailed ocean and weather info thru the Scripps Institute in San Diego). We arrived before dawn; parked on a cliff out of view of the ocean.

It was so cold you could see your breath, and I wimped out – deciding to change into my wetsuit while still in the car. My suit was still wet and cold from the previous evening (a source of pride for surfers – it means they surf a lot), so the warmth of the car was enticing. But I watched my braver, tougher, cooler, more god-like friends dress faster under the street light. By the time I was pulling on my booties, they had already slipped away into the darkness. The fact that they took off so fast was a sure sign that the predicted swell had hit sometime during the night. They probably could hear the surf crashing from where we were parked. When there’s swell – no surfer waits for anyone.

When I got out of the car, I felt the vibration of an exploding wave reverberate through the pavement of the street and into my rubber booties. This day was going to be huge! I shoulda dressed outside, I thought. The spot we’d picked was called “Jelly Bowl” (no idea why), and I had never felt a crashing wave from that break all the way out in the street.

But when I arrived at the cliff overlooking the break – I was shocked. The waves were enormous. Rolling in faster and further off-shore than anything I’d ever seen in this area of Santa Barbara, they slammed back into the water with a boom that was deafening. Even after the wave collapsed, it formed a wall of white-water that was easily 10 feet high.

Matt was already paddling out into it. My other friend, Greg, was just wading in. I was planted on the cliff, wondering how my friends would fare. Today, the size coupled with a horrible shape made things dangerous. I’m not sure if Matt had thought much about what he was doing before he headed for the outer break.

Greg, a strong swimmer, never made it past the whitewater. Due to the extreme swell direction, coming in from a sharp northern angle, he got swept south along the shore, about 100 yards out. Every time he paddled directly away from the shore, he’d move a few feet, and then be met with a wall of whitewater that pushed him under and swept him further down the beach. I didn’t see him again for over 30 minutes – and when he did show up…he was walking.

My attention was focused on Matt. In a slight lull, he had managed to make it past the walls of whitewater, and was actually pushing out past the “impact zone”. This zone is the worst place to be. It is where the lip of the wave that has been gradually building finally flips over and crashes back into the ocean. Getting caught in the impact zone on a big day will carry a surfer so deep into the water that it gets dark. During that time, there is no way to know where “up” is, and no way to decide which direction to swim for the surface. Often the hapless surfer is rolled along an ocean floor that is littered with coral or rocks or hopefully sand, for extended amounts of time – sometimes for over 2 minutes (try holding your breath for that long while at rest…it ain’t easy). Many people caught in the impact zone have blown out eardrums, shattered kneecaps and worse.

Matt was paddling frantically out to sea, hoping to avoid just such a fate. His goal was to find a good take-off spot to ride one of these monsters, if one existed. By that time, he had probably realized that the waves were too big and to misshapen to really ride. But paddling out in this type of surf is a major commitment. Once you wander into the impact zone, it is very hard to get out. As incoming waves build, they suck the water away from the shore, effectively creating a short-lived current moving directly away from land. Any surfer who makes it past the whitewater, must continue seaward past the impact zone – the outward currents on a big day make it almost impossible to paddle back into shore. At that point, they either need to ride some sort of wave in, or be dragged in underwater.

Matt thought he had made it past the impact zone, because most of the waves seemed to be breaking closer to shore, and he quit paddling. Now he just needed one good-shaped wave that would take him far enough into shore that he could quickly paddle to the sand before the wave behind it caught him.

I could barely see him – at least 300 meters off shore – a black wetsuit surrounded by a black, roiling sea. The only noticable thing was the tiny white tip of his surfboard sticking out of the water, the single plaintive beacon that gave away his whereabouts.

The problem was that the impact zone is a moveable location. The zone moves further out to sea with bigger waves, because they crash further out. Deciding where to sit for a wave is an exercise in probability. And Matt had underestimated.

From the cliff I could see a dark line forming further out than any of the other ones had – it was the beginning of the largest wave so far. Matt was still unable to see it because it was too dark and too far out. I was screaming at him from the cliff “Paddle out! Paddle out!” The sky was just turning a shade lighter than black. Too slowly, he turned his head and saw me on the shore. Knowing that only two things make people scream at surfers from shore – sharks and huge waves – Matt did the only thing he could…he turned his board and paddled frantically seaward.

At some point, Matt saw the wave bearing down on him. The goal was to make it over the top of the wave before the lip started its downward motion. As long as the wave was still building, he could theoretically get over it before it carried him with it down to the sea floor.

I watched painfully as Matt paddled. The wave was coming in so much faster than he was moving out. By now, he was paddling up the incline of the wave. At any moment it was going to break, and carry him with it. He was a tiny black spot, poised by this point in a completely vertical position on the face of the wave. Still he paddled. And I knew he wasn’t going to make it. The lip of the wave was forming, still a good 6 feet above him.

And then he pulled a “low-yield” maneuver – he pushed the tip of his board into the face of the wave, and attempted to swim through it, hopefully emerging through the back side. This move is tricky, because the surfer is basically testing the strength of the wave. He has entered directly into the strongest part of the water, and if there’s too much force inside he’ll never make it out. But it was a good idea on Matt’s part, because he would have been toast the other way. It was a last-ditch effort. All I saw before the wave came crashing down was a white spot – like a tiny magnolia flower stuck in the center of an endless black velvet curtain.

And I never saw Matt again.

Nah. He came back. But it would’ve been a cool story to say that. In truth, he made a good choice. Because it was so dark out, I didn’t see him for almost 5 minutes, and was pretty worried that he had “gone over the falls”. But eventually I saw him catch a smaller wave, and ride it through the impact zone, past the white water and into shore.

In the end, I turned out to the loser. I hadn’t gone out at all. I’d sat and worried on the beach. Although unspoken between us, the sentiment was evident. No true surfer does that. A hundred other times, we’d been out in tricky surf, and each of us had tales of danger and near-misses to tell afterward. This time, only the 2 of them did. I could only marvel at their exploits – like a soccer-mom or a T-ball coach.

It was the last time I put my wetsuit on in the car.

Will My Kid Have A Heart Attack?

I do physicals on teenage kids all the time. Usually, I’m clearing them to play sports at their school. I’m often temped do a fairly perfunctory exam because…really, how unhealthy can someone be at 13?

Statistically, there isn’t much to worry about. Most kids are just fine. Pretty much almost every kid is perfectly healthy and there’s nothing to find on physical exam because there’s nothing there to find. But, like everything in life, this isn’t 100%. There will always be a small percentage of kids who are, literally, living on borrowed time because of a congenital heart defect that nobody detected when they were born. Some defects don’t show up until the child is in h/er late teens and usually only cause problems during a strenuous workout or just afterward (probably because their heart was already starting to fail but they couldn’t tell).

gordeeva_grinkov.jpgEvery time I do a sports physical on a child or young adult, I’m reminded of the Russian pairs figure skating couple Sergei Grinkov and Ekaterina Gordeeva. If you have heard of them, it isn’t likely you’ve forgotten them. They were arguably the best pairs figure skaters in the history of the sport – certainly they were the undisputed champions from the mid-1980’s through until the mid 1990’s. I was pretty young kid when I saw them win their first gold medals at the 1988 Calgary Olympics, and I still remember their performance. This was one of the greatest years in figure skating history. It was the year of Katerina Witt (meeeow to this 14 year old), and the stratospheric leaps of Brian Boitano.

In all, the pair skated in 31 senior and professional competitions, winning 24 of them, including gold again at the 1994 Lillehammer Olympics. Woven throughout their skating careers is an inspiring romantic tale as well. The pair fell in love in the late ’80’s and were married in 1991. By the time they won their second gold medal, much of the world was in love with them, too. They skated with impeccable skills, but unlike many of the technical wizards of today, they were pure art in fluid motion. To prepare for some of their greatest performances, the pair traveled throughout Europe and studied sculpture masterpieces of the Renaissance – then mimicking on ice the poses they saw captured in marble. Their love story was touching, their success inspiring, their artistry was eternal.

Then suddenly, after a ho-hum practice in Lake Placid, New York in November 1995, Sergei collapsed while still on the ice. He’d had a massive heart attack, and died later that day. He was 28.

Aside from the tragedy of the event, the question remains: What happened? Why would someone simply drop dead at such a young age and in such excellent physical condition? It’s a scary thought and happens with a reasonable amount of regularity. Sergi was a very young man, but it can happen to teenagers. It can be boys or girls. It happened to a pretty good soccer player while I was in medical school.

What happened to Sergi Grinkov was different than the cardiac condition that more commonly afflicts young adults and kids. He had clogged arteries. Although his heart muscle itself was young and very strong, the coronaries that supply blood to that muscle were clogged so much that one pathologist said they looked like the coronaries of a 70 year old man. So, he had a heart attack normally reserved for septuagenarians. Could his neighborhood family doctor have prevented the condition? Then, no. Today…maybe. The only indication that there was a problem with Sergi’s coronaries was based on a family history of men in his family dying in their early 50’s of heart attacks. Today we have better cholesterol measures and might even have considered angiography for him. So, he might have lived…if his childhood screening physicals were done well.

The more common condition to affect kids and young adults – and it often leads to them dropping dead during physical activity, is called hypertrophic cardiomyopathy (HCM). HCM is the leading cause of sudden cardiac death in adolescent children. There are lots of variants of the disease, but the most worrisome is when the heart muscle is so large that it can’t push blood out of the left ventricle – usually because the septum between the left and right side of the heart is too big.

Things to watch out for are similar to the things any mother would worry about in their kids. Shortness of breath “is the most common symptom”. So? The kid’s been running. But you can also look for dizziness, feinting and be attuned to the description of “feeling my heart beating in my chest.”

HCM is rare in general. Something around .5% to .2% of the U.S. population are estimated to have it. In people with a strong family history of the diesease and thus get echocardiographs, around 25% of them will turn out to have the disease. However, mortality in those who have the disease is about 2-4%, which is a bit dicey.

HCM, and Sergi’s condition, both can be treated if they can be detected. The best way to catch both is to be suspicious about the possibility in their first place. A primary care doc can start with an EKG, and then get the patient in for an echo if there is any concern. One thing to be happy about – it is VERY rare for either of these diseases to show up in someone without any sort of family history. Knowing history, then, is the secret.

Below is a YouTube video of Grinkov and Gordeeva at the Lillehammer Olympics. It’s grainy, but still amazing to watch.

Bajillion SPF or clothing?

Was recently asked if it was better to use SPF 50 lotion all day or to just have kids wear clothes when they’re in the sun.  By “better”, I mean which is better protection against skin cancer?themonk.jpg

The answer is clothing.  Clothes are always better than sunscreen no matter what the SPF rating.  Here’s some other surprising facts:

– sunscreen has never really been proven – by scientific means – to prevent skin cancer.  We know it stops certain kinds of UV light, but no one can say for sure that it prevents skin cancer. 

– not all clothing is sun-proof.  Especially many types of swimsuits.  If they don’t specifically say they’re sunproof on the label – and you aren’t paying an arm and a leg for the fact- they probably aren’t.  Of course, hats and thick clothing do block sun rays of all types.  But don’t just automatically assume that since your kid is wearing a bathing suit or thin shirt that s/he is protected from the sun.

– there’s two major types of UV light: UV-A and UV-B.  If you sit around all day in UV-A light, you’ll get super-tan and never really end up burnt.  It’s UV-B that causes the burns.  So, traditionally, suntan lotions stopped UV-B to keep people from burning and yet still allow them to tan to the point of looking like they’re from a different race.  Lately, it’s been figured out that UV-A light actually does change a person’s genetics…deep in the skin where the melanocytes reside.  This is not DNA you want to be messing with.  Of the skin cancers, melanoma is the really bad one and the one to be most feared.  Given that UV-A is the kind of light that causes the best tans, can you guess what kind of light is used almost exclusively in suntanning parlors?  That’s right.  UV-A.  Ask any dermatologist and they’ll freak out about tanning beds.  They’re a HUGE risk for skin cancer.  The best option if you want to be brown?  Use the lotions.  They’re getting less orange every day.

Mavericks Contest

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If you want to see some of the best big-wave surfing in the world – happening right on the West Coast – you can watch it live on myspace by clicking the above link this Saturday morning starting at 8 am PST.  Live.  Some of the best big wave surfers in the world.  I checked out the list and a couple of the Mavericks locals are in the line up.  Same guys that have been doing this stuff for years.

Mavericks is probably the biggest known wave on the west coast of the U.S.  It rivals Hawaii in size, but blows the little islands away in sheer intimidation factor.  Unlike the tropical island waves that are 80 degrees F and crystalline blue, Mavericks is fridgid, surrounded by rocks and swiriling with strong currents.  The water is a deep green that quickly turns nearly black when you go under… and the wave is located right in the middle of the “red triangle“.  I’ve never surfed there…not sure I ever will.  

If you miss the show, I’m sure there’ll be clips.  Check it out.

Is Tow-In Surfing Cool?

You be the judge.  I say YES.  This video is easily one of the coolest big-wave surf videos I’ve ever seen…and I’m not alone. The video has been viewed over 5 MILLION times. It’s totally real. The wave’s about 60 feet high. Surfer is a real guy – Mike Parsons. Name of the wave is – aptly – Jaws.

It lives in Hawaii.