A patient arrives in the emergency department vomiting. Not once or twice, but repeatedly, leaning over the bedside basin, pale and sweating, clearly miserable. Between episodes, he tries to explain what happened. Earlier in the day he felt completely fine. Then the nausea started suddenly, followed by vomiting, cramping, and a cold sweat that made his shirt cling to his back. By the time he arrived in the emergency room, he looked exhausted. The story sounds familiar. Nausea and vomiting. The kind of symptoms that often point to stomach illness. Food poisoning. There may have been a small amount of diarrhea earlier, but it was minimal at best. The overwhelming symptoms were the nausea and vomiting. In the shuffle of a busy emergency department, details like that can easily blend into the bigger picture.
Emergency departments see cases like this all the time. Most turn out to be exactly what they seem: a stomach bug, something that did not agree with someone’s system, a miserable but temporary illness. At first glance, this situation seemed no different. But medicine has a way of reminding doctors not to trust the obvious explanation too quickly. Even while he is vomiting, something about the way he looks raises a quiet concern. The sweat on his forehead. The discomfort that seems deeper than simple stomach illness.
A routine test changes the picture
So a routine screening test is ordered. An EKG. Seconds later the tracing prints. Instead of the normal pattern doctors expect to see, the EKG shows ST elevations. This patient is not dealing with food poisoning at all. He is having a heart attack. Specifically, a STEMI, the most dangerous type, where a coronary artery becomes completely blocked and the heart muscle begins to lose its blood supply. The nausea and vomiting were not from something he ate. They were his body’s response to a heart in distress.
When a heart attack hides in plain sight
The patient also had diabetes, which can change how heart attacks present. People with diabetes sometimes experience fewer of the classic symptoms like crushing chest pain. Over time, diabetes can damage the nerves that carry pain signals from the heart to the brain. When that happens, a heart attack may not produce the dramatic chest pain people expect. Instead, the warning signs can be more subtle. Nausea. Vomiting. Sweating. A vague sense that something is not right. Symptoms that can easily be mistaken for something far less serious.
That is why emergency physicians often perform simple tests early in the evaluation. An EKG takes less than a minute, but it can reveal life-threatening problems almost instantly. In emergency medicine, dangerous diagnoses sometimes hide behind the most ordinary complaints. And sometimes a test that takes only seconds changes everything.
Karim Ali is an emergency physician.
