6 - Heart Health & Wellness from an ER Doctor's Perspective (Dr. Ryan Sundermann)

Dr. Ryan Sundermann, ER physician, joins Dr. Dustin Arnold, chief medical officer, to discuss heart health and wellness from an ER doctor's perspective.

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Transcript

Dr. Arnold:         
This is LiveWell Talk On... Heart Health and Wellness from an ER Doctor's Perspective. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health - St. Luke's Hospital. Our guest today is St. Luke's ER medical director, Dr. Ryan Sundermann. Thanks so much for stopping by.

Dr. Sundermann:     
My pleasure.

Dr. Arnold:         
You know, Dr. Sundermann, heart attacks are a concerning event obviously and presentation the ER still is some of the first encounter individuals have with health care related to their heart disease. Take us through how that care has changed in the last 10 years of your practice in comparison to how things are going today.

Dr. Sundermann:     
Yeah, sure. So it really has had some transformation. The chief complaints remain the same. I mean, it can be fairly, you know, lots of people experience chest pain but they don't necessarily know how to interpret it, so they come and see us, you know, and lots of causes of chest pain, but when we really feel like somebody is having a heart attack, the timeliness of getting those vessels open, because a heart attack is when a blood vessel gets closed off and the blood can no longer flow through that vessel to the muscle of the heart itself, and so then the muscle actually starts to die. And so the, it used to be the patients would come in with chest pain and a lot of that has remained the same initial testing, you know, some blood work and a chest x-ray and an EKG, etc. That in itself hasn't changed a lot. The tests have become better. The blood work is obviously better, EKGs are largely the same, x-rays are the same, but a lot of the expediency in which we get those patients the treatment that they need once we've identified a heart attack as has really changed. Some of the, and I'll go into that in a minute or we can talk about that more about like why the timeliness and how fast we get them to get up to the cath lab and get that open as important.

Dr. Arnold:         
First we should talk about what are some warning signs that would be a reason for the patients to come to the emergency room. I would prefer, and I know you would too, a patient come a thousand times and be told it's nothing rather than delaying care. But what are some things that a patient should look for, whether it be a sign or a symptom that would warrant them coming to the emergency room.

Dr. Sundermann:     
You know, I tell people, especially if they have risk factors. For example, just being over the age of 40 puts you at risk. I mean, certainly people younger than that can have heart attacks, but it's uncommon. But you know, if they have their appropriate risk factors, age, smoking, family history, things like that, those are patients that, you know, we sit up and take notice and I tell people, you know, basically if you've got pain between your chin and your belly button, there's a good chance it could be your heart. You know, people complain of jaw pain, they complain of shoulder pain, back pain, upper abdominal pain or epigastric pain. We talk about nausea. You know, so those are all things that are particularly concerning. Shortness of breath, increased shortness of breath with exertion, especially if it's not going away. If it comes on and it seems to be even getting worse well obviously that's of particular concern. Chest pain and shortness of breath. Those are the things that are very obvious. But like a kind of the example I use when people ask me that question in the ER sometimes, I had a lady that came in 24 hours after she started developing shoulder pain. She pulled down her garage door that was stuck and a couple of hours later it started hurting and she was sure it was that garage door that hurt her shoulder, but it didn't hurt to move it, it was just achy and it turned out that that was her heart attack. So it can really be anything. And you know, surprisingly enough, or maybe not, maybe, you know, we're all becoming accustomed to the fact that if you think it might be your heart, we'd just rather see as sooner than later.

Dr. Arnold:        
Dr. Sundermann, you've been in emergency medicine your whole career and you know, whether it's some studies pill in the pocket study, there's some others that where patients have symptoms and either rationalize, deny that it's something to worry about, or just don't seek care. Why do you think that is? Why do you think patients just minimize symptoms and wait until the eleventh hour to come in and get something checked out?

Dr. Sundermann:     
A couple of reasons. We don't want to be sick. We don't acknowledge that we're sick. You know, we think, you know, we've all been through enough stuff that it eventually goes away. We've all had the stomach flu or a cold and it kind of goes away. But the other thing is we're all a little bit afraid of what we might find out. Sometimes, you know, if you have a persistent cough or you have some increasing shortness of breath and you know, you're all, we're all afraid of the big C, you know, is it cancer or is it some horrible thing? And so we're afraid. But in all regards and everyone, whether it is cancer or whether it is your heart or whether it is your lung, I guarantee that the treatment is not worse than the cure in that case. And the sooner you get it found out and identified and diagnosed, probably the better off you're going to do in the vast majority of cases. So that's why it's critical to get in here. You don't have anything to be afraid of. We promise we're going to treat you nice. We don't have any sticks or clubs that we're going to beat you with. Most of what we're gonna do is going to make you feel better.

Dr. Arnold:        
Well, what are some things other than activating the emergency response system, 911,what are some other things a patient can do at home prior to arrival in the emergency room?

Dr. Sundermann:         
Yeah, yeah. Aspirin if you have any risk factors at all, having some aspirin is by all means something you should have, you know, keep it in your purse or your car or you know, even keeping one in a Ziploc baggy in your wallet or wherever, someplace places accessible and chew that aspirin up and swallow it if you started having symptoms of heart attack, chest pain, shortness of breath, increased exertional pain or shortness of breath with exercise going up and down stairs, things like that. Especially if it doesn't go away, you know, if you can rest and it goes away pretty promptly, that's fine. But otherwise if you continue to have pain, the most important thing is you get to the hospital, is that your question, is what to do if I start having symptoms?

Dr. Arnold:        
Yeah.

Dr. Sundermann:   
Yeah, I mean the thing is is that those blood vessels don't typically fully unblock themselves. So getting here and getting it evaluated, but one of the few things you can do is having that aspirin. But other than that, if you have Nitroglycerin, if you've already been seen by a cardiologist or your family doctor and they prescribed that, you can definitely try that. The thing is if the symptoms go away, that doesn't necessarily mean you're okay though. So if the symptoms resolve you still need to get in. But some of those other medications can actually make some symptoms go away that aren't related to your heart. But you know, that's for us to figure out.

Dr. Arnold:         
What, on the front lines, what percentage of patients presenting with an acute or myocardial infarction have taken that aspirin at home prior to that?

Dr. Sundermann:     
Myocardial infarction. What's that?

Dr. Arnold:        
A heart attack.

Dr. Sundermann:    
Okay. Gotcha [laughs]. So say that again.

Dr. Arnold:         
What percentage of patients that are presenting with a heart attack have taken that aspirin prior to arrival at the ER?

Dr. Sundermann:     
Not Enough. You know, quite honestly, you know, a lot of them, a lot of patients that have had some sort of procedure, they've got stents in their arteries or bypass, they don't want to have it happen again. So they keep that handy. They keep their nitroglycerin. Quite honestly. The vast majority of them don't. And there used to be, it seems like there used to be a bigger campaign to really push that aspirin, but I feel like that's less than less.

Dr. Arnold:         
That was my next question. I think the, particularly heart health for women that they may have not typical symptoms should present. The aspirin, 911, chest pain, radiating in the jaw, was there's a PA for that, public service announcement for that awhile ago and that's kind of tapered off and they moved to kind of the stroke symptoms.

Dr. Sundermann:    
Yeah, yeah.

Dr. Arnold:        
Do you think that's influenced presentation? Do you think more people, because as you know, I always say Pepsi just doesn't have a Superbowl ad. They advertise all year long. And so sometimes when those campaigns end, out of sight, out of mind for patients, what do you think? Do you think that's changed at all?

Dr. Sundermann:     
Yeah. Things become in vogue, you know, and you know, these different, there's different organizations, you know, there's big organizations around stroke and big organizations and they spend their money where they think is relevant and, you know, they make a certain amount of success and then they shift their focus. But that's the thing, it's incumbent upon guys like us to make sure that there's that public awareness and doing things like that. But, or your primary care doctor talking to you about it, but you know, we're all pretty busy and so that kind of gets shoved under the carpet. So I think it's important that we maintain that level of awareness. And that also means that people got to advocate for their own loved ones if they're not seeing it. So if you have somebody that you love that's, you know, has a risk factors over the age of 40, you know, overweight, hypertension, high cholesterol, anything like that, make sure that you're paying attention to them. If you hear them saying words like, gosh, you know, I've been more short of breath or I've been having pain in my shoulder, you know, and making sure that they have that aspirin on the kitchen counter or something like that where it's easily accessible.

Dr. Arnold:        
Yeah, I think the most modifiable risk factor that is often overlooked or underplayed or under-reinforced to the patient is smoking.

Dr. Sundermann:    
Oh yeah.

Dr. Arnold:        
As an ER physician, emergency room physician. How much does that factor in?

Dr. Sundermann:     
Number one. I mean number one, two and three. You know, I mean really the thing is that when you, people come in with heart attacks, they can happen to anybody. I remember I had a high school principal actually came in one time, he was 41 years old and he had a heart attack and had no risk factors. It happened while he, when he came home from jogging. But that's not the norm. But again, people still need to be aware, but quite honestly smoking has been an epidemic and you know, the number of smokers is declining. But then you're also seeing a resurgence in younger folks and also, and then the thing is when they start young, they, that's there is a much more likely, they're much more likely to continue smoking. And then you see, you know, kids vaping now they're like, oh, well it's not smoking and we really don't have any idea. I don't, I hate to say that vaping is safer than tobacco. And I mean to some degree it might be in some respects, but the thing is we have decades and decades of smoking research, we don't have any research on vaping. And so these kids that think that it's a free ride or even adults that think it's a free ride are probably being misled you know, and even if it's not their heart, it's going to be something else. And so the thing is you just, you don't put it into your body if it's not good for you, you know?

Dr. Arnold:         
Yeah. I think it's pretty reasonable to believe that ingesting smoke in your lungs is not good at any level.

Dr. Sundermann:    
Right.

Dr. Arnold:         
Even if it is flavored...

Dr. Sundermann:     
Yeah.

Dr. Arnold:         
Or sold over the counter. I think patients do not understand that yes, cigarette smoke can cause lung cancer, but it's the nicotine that causes the peripheral vascular disease and the arterial disease.

Dr. Sundermann:     
Yeah. Squeezes those vessels, yeah.

Dr. Arnold:         
Yes it does, absolutely.

Dr. Sundermann:     
In fact, I think it's always interesting. I get back pain patients and I asked them how many of them smoke, and everybody can get back pain. But the proportion of patients that have back pain that smoke is much higher. And even some of the back surgeons like you've seen, they won't do back surgery until the person quits smoking because they know that they won't heal this fast, they'll continue to have back pain, you know, so they really have to double down and dedicate themselves to being free from that pain. And that's the same with heart disease. I mean, and then you just talk about all cancers in general, all cancers, you know, the rate of it goes up if you're a smoker.

Dr. Arnold:         
What would be your singular advice, I know that's hard to do, but to give to a patient regarding heart health and the emergency room?

Dr. Sundermann:    
Do it early. So you know I mean, but it's also never too late to start, you know? And so if it's smoking, one thing that I always tell patients that struggle with a way to quit smoking. I tell them, you know what, the first and 15th on the first and 15th pick the, of every month, you pick those days and you've got, people get disgruntled or they become, they struggle with, they've ever quit smoking before and they think, oh, I can't do this if they started smoking again. The key to quitting smoking is quitting frequently because you can train your body to do it because if you've quit once before, it's uncomfortable, but you can train your body to be without that smoke. But you got to do it frequently. And so quitting smoking is absolutely critical. And then also getting out there and getting a little bit of exercise, limiting your carbohydrates and fats and unhealthy foods like eating, you know, portion control. People think that weight loss is all about exercise. So much more of it is portion control. And then getting out there and starting to exercise a little bit at a time. If you say I can't or it's uncomfortable, two, three, five minutes, something like that once a day. And then you gradually increase that. So eating right, getting a little bit of exercise, absolutely quitting smoking and then just doing, working in coordination with your doctor and, you know, optimize your medications. You know, nobody wants to be on those medications. But the thing is the less you do, the more medications you're going to be on. So you can say, I don't want to be on those medications, but until you do the things proactively, you need to like exercise and diet, you're going to just be on more and more of them. So those are the things, exercise, good diet, don't smoke. Do that early. Don't wait till you're 65 and stay in tight contact with your primary care doc so that they can manage all that.

Dr. Arnold:        
One success that I had in my practice of getting patients stop smoking is treat nicotine like a drug, and then I would write them a prescription. Let's say they smoke a pack a day, which is 10 cigarettes. And I would say, okay, you need to smoke nine cigarettes a day for five days, eight for five days, seven for five days. Now I even tell them if it's time to go to bed and they've only smoked four and they were supposed to smoke five, sit there on the edge of the bed and just, until you finish that off. So to reinforce this is a medicine you're titrating off, it's not a habit.

Dr. Sundermann:    
Yeah.

Dr. Arnold:         
And I think that I had motivated patients that wanted to do it. They wanted to quit, but I think they found a way to look at cigarettes differently that way.

Dr. Sundermann:    
Yeah, and I think also, you know, I hate replacing one bad habit for another, but you know, temporarily using nicotine replacement. Now I understand like the vaping and it kind of mimics that procedure, but using some nicotine replacement to help overcome the urges like with the lozenges and the gum in order to get over it, it's not, you know, you don't want to stay on that long term, but there is, there's lots of good evidence to support that it doubles your success if you use nicotine replacement. So use it, but use it wisely. I, what I don't want is to get people addicted to nicotine, nicotine gum or anything, but that does happen. But the thing is is, it's critical that you get off tobacco, as well as chewing tobacco as well. You know, that's got its own dangers inherent to it.

Dr. Arnold:         
We previously mentioned diabetes. I think some physicians don't understand how type two or adult onset diabetes has a significant risk for the development of heart disease and you add smoking to that and then just you know, amplifies that risk significantly. You know, one closing question that I ask all the physicians that visit. Why did, why did you become emergency medicine physician?

Dr. Sundermann:    
You know, I had, I was starting my medical school a little bit later. I had been in the military for five years and, by the time I got to med school I had two kids in tow, which is kind of abnormal. And you know, there is definitely, as I've learned, as we all learn eventually is there is definitely a work-life balance. And I think fortunately I saw the writing on the wall. I think a lot of young physicians, their first real job that they get, you know, they work through college and high school and things like that, but the first full time job where they've got to report and it's their career is medicine. There's plenty of physicians that come in later in life as a second career. But most of them it's their first job, real job. And I don't know, they're so dedicated to it. They really don't take into consideration like how they're going to blend that family in. I think it's, it was definitely difficult, but I was fortunate in the fact that I had a wife and two kids by the time that I went to medical school. And so by the time I was picking my career, I knew that I needed to have some sort of balance. And Emergency medicine, while you do work some different odd hours and weekends and holidays, you know, I work, you know, most emergency doctors work about 15 shifts a month, which is plenty, but they, for this type of work. But it allows you that flexibility to be with your family and things like that. And I think that's important for everybody. And so for me, that's been the right choice. You know, it's definitely not the right job for everybody. But then the other thing is, one of the best pieces of advice I've ever gotten, this probably is true, just even outside of medicine is you should look around you and see where people are doing a job and you feel like you're like them and those people are happy. And the people that I felt were that were like me in the emergency department and that were happy, I thought, well that's probably a good, you know, without it's unspoken advice you can say, yeah, I can see myself being them like them and they seem happy. And that's one of the other things. I just think the people in the emergency department or a lot like me.

Dr. Arnold:         
That's, that is good advice. But, as my dad used to say advice is what we ask for when we wish we, when we know the truth, but wish we didn't.

Dr. Sundermann:    
Yeah. Right.

Dr. Arnold:         
But I do tell some ER doctors, young doctors, not ER doctors but younger physicians. They'll question whether or not they're cut out for medicine. And I always say this is a job you gotta be cut into.

Dr. Sundermann:    
Yeah.

Dr. Arnold:         
Nobody's cut out for it. You really got to work to get that life balance and that passion for coming to work every day.

Dr. Sundermann:     
Yeah.

Dr. Arnold:         
Well, Dr. Sundermann, this is really great information. Thanks for taking time out of your busy schedule. If you have a topic you'd like to suggest for our Talk On... podcast, shoot us an email at stlukescr@unityoint.org. That is stlukescr@unitypoint.org. And we encourage you to tell your family, friends, and neighbors about our podcast. Until next time, be well.