the next section we're actually going to spend a certain amount of time on um biom medicine and I don't want to emphasize biom medicine too much because really we are one of the main tasks that we have together is learning this traditional vocabulary and sort of understanding how a system of medicine that's been around for hundreds of years can be effectively applied to whatever diseases we happen to encounter and whatever symptomatic manifestations we happen to encounter in clinic that being said for certain diseases we really can't skip um a little bit of a biomedical review because there's a certain amount of diligence we need to do to protect ourselves and our patients and make sure that we're not missing something so anybody who has ever encountered chest pain for whatever reason and called uh you know the advice line at Kaiser or whatever if you say the words chest pain they say go to the ER and that's it they're done they don't want to hear anything more they don't want to hear about acid reflux or anything like that if say chest pain especially if you say like me hey I'm a you know I'm a 49y old man and I have chest pain they're like put down the phone and go to the ER they don't care what you ate they don't care anything like that you know chest pain is like this big red flag alarm Bell for for them so I will suggest that for us in clinic we also want chest pain to be a a bit of an alarm Bell um and not that you're going to refer automatically immediately for any kind of chest pain but even at this early stage where we're not we don't have patients directly under our care we want to start thinking about this and start developing a little bit of a Criterion about what we need to do so let's talk generally about chest pain actually let's use black so um the area of the chest just for an anatomy review and this is a little bit silly but let's do it anywhere um how do we identify the chest anatomically what are some markers that we can say that makes the chest the chest and not some other part of the body body above the diaphragm is important and very importantly it's also the thoracic region right what makes something part of our thorax as opposed to our abdomen it seems really silly but yes the rib cage right where we have ribs is our chest and our thorax where we don't have ribs is going to be our abdominal region right or our cervical region up up and above so um thoracic region rib cage obviously a thoracic vertebra is a vertebra with a rib attached that's what makes it thoracic 12 of them some people have 13 but most of us have 12 ribs and you know T1 has that first uppermost rib and it's tucked right at the base of the right underneath your um upper traps right and then T12 is going to be right around the bottom right you know the kidneys are tucked underneath T12 right got a couple floating ribs down there too so we think about this as being the upper Jou right upper Jou region kind of but yeah the upper Jou region and the upper J we think of as the lungs the heart and the paric cardium um because of this thoracic and rib cage relationship there is a little bit of shaoyong going on here for lateral sides of the rib cage so anything on the side of the rib cage we could still call it chest pain but sometimes it's called um it's called a lateral ribs side distension or something like that but it could also be considered chest so just to open that up a little bit um there's a ton of channels that go through this you know we've got the three hand and leg Yin channels the um we've got the gallblader channel we've got the stomach Channel all these go up the front but um when we think about what organs might be involved we definitely think about the lungs the heart sometimes we think about the liver as well if it's the side of the rib cage and occasionally there's a couple of small stomach manifestation ation that can be um chest pain generally when we think about pain the reason we have pain is an excess is obstructing and this excess could be fire or heat it could be cold evil cold contracts canals cold is painful right it can be static blood could be fleem and of course it could be different kinds of cheat constraints as well it could also be something not moving because of um something not moving because of deficiency so deficiency sometimes especially young deficiency in the chest we're GNA see this especially for the heart um when we think about heart Yang the heart Yang really governs the entire chest this pump is supposed to move these fluids through the chest and if the heart young is not moving very well and we start to get we we start to develop patterns where things stagnate in the chest and we know that heart disease is one of these things so the modern biomedical disease category of heart disease is often often has a underlying condition of heart Yang deficiency and sometimes some FL and blood stasis on top of that as well so broadly speaking when we talk about chest pain we can certainly have chest pain from lung conditions and usually there'll be cough or something like this and most of us have had a painful cough where you get a cough and it's so bad that it hurts you know when you cough so this can certainly be like a lung heat a Flem heat which we'll talk about um acute chest pain almost always has to do with either a lung condition or potentially with a stomach condition um and the stomach condition there is usually going to be something around um esophageal reflux conditions right and these are very commonly mistaken to be you know a heart attack when people get acid reflux really hard they can think a horrible horrible thing is H happening to them but it's actually just stomach tea counter flow right so for instance um I had strep throat a number of years ago they gave me penicillin for it turns out I had never had penicillin in my life and I ended up with just the most extreme heartburn I had ever had in my life and I was like sitting there on the floor like grasping my chest like thinking that I was having a heart attack except that I knew that I wasn't you know we were chesting my blood oxygenation levels and my wife was feeling my pulse and everything and I had a little bit of an acid taste so I knew it was just esophageal reflex but it was really really really intense um luckily I had an MD friend that called in a zpack for me instead of the penicillin and I got rid of my strep um but yeah it was super super intense and this is fairly common um to have this a chest pain that's associated with gastrosoph reflux disease or heart burn right um another area of chest pain is anxiety right so anxiety is very very common and acute anxiety certainly can cause chest pain too and we'll talk about that in a second and oo let's wait for a break and then we'll talk about propping room in just a second um so chronic chest pain often longstanding much more common in the in the elderly and it often comes and goes so chronic chest pain the demographic is often the elderly but not usually not not always excuse me uh uh it's often episodic and it often has some sort of blood stasis XU is blood and or Yin deficiency involved sometimes young young deficiency also and then any kind of chronic chest pain the classics tell us it is difficult to treat and I bring that up not to say you shouldn't try and treat it but to suggest that if you do have somebody coming to you whose Chief complainer among their complaints is chest pain and it's been with them for a long time you shouldn't expect that putting six acupuncture needles in them is going to resolve them of that condition like it generally is going to put to a longer treatment plan to get the results that you want to get um I actually did a CU seminar on um heart disease in Chinese medicine and it was it was encouraging on the one hand because there was a lot of really interesting research about it and about how different Chinese herbs can really help with heart disease and stuff like that but it was depressing because the specialist from mainland China also suggested even if you're using TCM to treat heart disease you can expect to treat it for the rest of the patient's life it's because it's taken so long to get there that they can expect to have some sort of herbal input for basically the rest of their life um so we'll talk very briefly about um the externally contracted chest pain so um chest pain and one of these we talked about already today heat evil in the lung say because we know what it is and this is going to be chest pain with a cough right and this would be an example of you know if a patient comes to see you and they say I have chest pain with this cough I wouldn't see that as a as an urgent referral if it's something that developed um relatively recently and they have copious yellow fleem or something like that you're saying okay well this chest pain you're experiencing is probably because you have some sort of path pathogen stuck in your lungs right um we expect this cough to be loud or sometimes they say hyperactive cough and we expect to have yellow flim and we may expect to have fever or other heat signs the F here could also be potentially bloody if the heat is more acute um and we expect the tongue to have a yellow coat and a red body our textbook pulse would be rapid and maybe slippery showing us the presence of Heat and the presence of Flem uh another lung pattern that we may have is cold evil in the lung and this is our image of cold Flint um the pain here will be worse with cold uh cough with pain and then we expect our fleem to be more white color so this is review this is review um two different kinds of chest pain that may be associated with cough and just an opportunity for us to review these two any questions about these two sort of brands of external evil that may sink into the lung and these are not exterior diseases because they're now in the lung organ itself the heat evil is in the lung the cold evil is in the lung um the main differentiators are you know the yellow flam versus the white Flem and whether there's heat signs in the person or not I'm hoping this starts to sound pretty straightforward at this point okay I see enough kind of nods mixed with blank stairs but these together I'll be enough we'll go on to the next next slide about this um dung mentions a pattern called chest bind pattern which I'm going to table for now we're not going to go into chest bind pattern it's a six confirmations pattern let's not worry about that um when we look into miscellaneous internal patterns miscellaneous and internal patterns for chest pain the first one that dung talks about is consumption pattern and I mentioned this earlier today this is pulmonary tuberculosis and even though I kind of joked around earlier and said you know Victorian dramas we remember these you know um people coughing blood into their handkerchiefs and things like that and then swooning and drawing rooms or whatever they did during Victorian times um tuberculosis is Alive and Well in our world you know we have to take TV tests as healthc care practitioners it affects many many many many people tuberculosis is an incredible disease um they actually the the mahong D which is a a tomb from Han Dynasty China that we have a lot of our original Chinese um classical sources drawn from from about 200 ad they exhumed one of the bodies of in in this tomb and inside the lungs they found 1700 year old tuberculosis that they were able to cultivate and turn into a living culture in a Petri dish which just sounds like a phenomenally bad idea to me um but but I mean way to bring the curses of the ancestors upon you but I'm just I bring that up as a point to just say that tuberculosis is a really interesting interesting pathogen and of course the ancient Chinese were aware of it um when we look at consumption what it does it gives you a dull chest pain um and then we see Yin Vu heat symptoms with scanty maybe bloody Flem so really this looks like lung Yin deficiency a type um we may see a type fever we may see uh night sweats five Palm or five heart heat all of these are possible and that's again Palms of the feet SES of the palms of the hands soles of the feet the chest um it's called consumption because weight loss is one of the signs or symptoms of this so we can think about this is being a kind of Yin deficiency right when people lose weight it's their substance withering away right um and obviously this person also has difficulties breathing um and there's an interesting sign called finger clubbing let me see if I can pull up an image of that see what I can find and just see if we can see what this looks like because finger clubbing is is because the oxygen is not actually getting all the way out to um to the extremities and let's pull this up and sorry graphic image coming but you can see I think this is actually a pretty good one you can see this kind of rounded finger clubbing that happens on some people where the Tim fingertips end up being round rounded um let see if there's another good picture of it yeah here's another one where you can see these fingertips are very rounded and this is one of the signs of pulmonary TB is this finger clubbing so there's another one that we can see it kind of gets bigger and rounder towards the tips of the fingers and this has to do with the the um inability of the oxygen to reach the extremities and changes in the tissue that happens there so if you do see this you know you may be looking at somebody's hands and they have respiratory problems and you see this kind of thing you know you may suspect that there may be some sort of tuberculosis active for them there's other reasons as well that we won't get into today our consumption pattern which we called as a kind of lungan deficiency um again here we see this purple red tongue we think of the red as being inefficient heat and purple being long long standing and so there's there's this image that we see especially with upper Jou issues where the the yin deficiency ends up going purple instead of red because this upper jaia is responsible for pumping Chi and fluids through the whole body the blood and the fluid so if the upper jao Chi goes down we get a Yin deficiency the upper upper jaqi and Yin goes down we get a Yin deficiency but also we get a decline of the circulation in general leading to this signs of stasis as well test pain pattern is blood stasis which I'm going to put parenthetically is very similar to sort of an angina pattern um this is one of several different ways that the Chinese traditionally described um uh uh heart disease right U so blood stasis means that the blood is not flowing so this may be coronary artery disease although there's a heart vessel obstruction pattern which is a little bit more common to this but we expect the pain here to be pain is fixed this is blood stasis right maybe piercing um and if it is upper gou blood stasis we may have panting have cough you may have spitting blood so this is blood stasis of the whole upper gel and this dark complexion which is common with especially upper upper Jiao blood stasis patterns and our pulse here is a textbook blood stasis pulse which is going to be rough or choppy synonyms for each other and then sometimes fine if the reason that it's fine is that the blood has been depleted by being St stuck so we know that blood stasis can cause blood deficiency we have a certain amount of blood that should be in circulation if it's stuck in the chest it's not circulating so the pulse ends up being kind of fine as well yeah so ATO question TB is infectious so consumption pattern is an infectious lung Yin deficiency pattern yes lung y deficiency brought on because of a specific pathogen which we've identified as tuberculosis yeah um in the direction of this Blood stasis in the first pattern that that D talks about is sort of General upper J blood stasis and he's going to mention one that's a little bit more specific which is heart vessel obstruction which we're going to say has a rough equivalent to coronary artery disease have you all studied coronary artery disease yet in your Western Medical Sciences so the blood vessels that are on the surface of the heart that are supplied directly by the heart with blood that then supplies the blood from the heart so interestingly the blood is a muscle um doesn't actually have um supply of oxygen from the blood inside the heart the muscle is supplied with blood from vessels on the outside of the heart and these are called the coronary arteries and these are the most likely ones to actually get clogged right and so coronary AR artery disease or heart vessel obstruction means that these vessels that supply the the heart muscle with blood are clogged and thus the heart muscle doesn't have enough blood to pump effectively um and this is you know can lead to it can lead to angina which mean just means chest pain but also a myocardial what did I just do myo cardial infarction or an MI which is known as a heart attack an infarction I believe means an obstruction um so this kind of pain is often described as an oppressive pain or a piercing pain um it has a radiating pattern often and we're going to talk about um biological differences between uh female female bodies and male bodies uh with this um rating pattern to shoulder sometimes the neck or the arm more commonly on the left side you can also get epigastric pain so pain in the region below the sternum it often involves heart palpitations or irregularities in heartbeat and we all sort of have at least like a comic book image of what this disease is or maybe something we've seen in the media or something like that where you know somebody grabs their chest and feel a pain or something like this um often there's a regular heartbeat to this um uh it can be episodic so not all of it is a type of um a heart attack that just lays you out and kills you or hospitalizes you immediately but actually my brother M had a heart vessel obstruction SL myocardial infarction he just felt this oppressive pain all day long and kind of felt like crap all day long and ended up coming home and um my sister was like you need to go to the hospital and turns out he had had you know he had actually had to have triple bypass surgery that day so it doesn't always knock you right on your butt um when we think about what happens here it starts with a heart Chi deficiency and the Heart Chi can't move the blood so sometimes is also heart young deficiency and there's things that we can do to boost the heart Chi right um and Chi of chest so if the heart Chi and yang is not moving the chi of the chest fleem starts to accumulate so this leads to an accumulation of FL and the Flem starts actually obstructing things and so I think this is also very accurate compared to um uh what we know in modern times that there is this this one of the reasons we get heart vessel obstruction or obstruction of the coronary arteries is because our blood starts to get thick and sludgy and hits these plaques on the side of the of the vessels and especially if our blood is very rich or if we have a a diet high and inflammatory things like um uh simple sugars and things like that then the vessel gets narrower and narrower and narrower until it gets it gets clogged by all this cholesterol in the bloodstream right and this thickening of the of the walls these plaques forming on the sides of the walls would be considered a type of fleem as well right and we can get into a long sidebar discussion about the relationship with um cholesterol and heart disease and how it's actually much more about inflammatory diets and high consumption of sugar and things like that rather than um High consumption of cholesterol but that's sort of a sidebar and we'll just suggest that this gradual accumulation of inflammation and obstruction is ALS is also understood as a kind of flim um our pulse here can be choppy it can also be intermittent right um and we call this regular oh sorry Siri just decided it was I was talking to it choppy but it can also be irregularly I'm sorry it's regularly irregular so which we call the dii not a good pulse to have so that's bump bump bump meets misses a beat and bump bump bump um there may be fleem here um if this happens suddenly or acutely this is called a kind of reversal so people look like they go into shock if You' ever seen somebody have a heart attack um it's it's very dramatic um where they look suddenly violent they get cyanosis of the lips they get clouding reversal and they go unconscious and they get really pale um interestingly uh the Ancients also I shouldn't say ancients because it's not that long ago but the Chinese of several hundred years ago identifi the the people that are most like to get this are middle-aged people who work or think excessively this was the D the demographic that they identified and I just love that thinking thinking excessively is thought of as you know a cause of disease as is working excessively um another example of FL turning into hard things yes stones but plaque on the insides of arteries Okay so we've talked about a couple different ways that things can stagnate in the chest right we talked about blood stasis as sort of the precursor then heart vessel obstruction as perhaps the the next step in the evolution there um and let's see we've only got let's go ahead and take just two more minutes and then we'll take another break to talk about um um Livery as a source of as a source of chest pain so you know dong isn't calling it Livery um stagnation is calling it a binding depression of liveri but we can think about this as being a subset of the liveri stagnation pattern um we expect chest and RI ribs side pain um the nature of the pain has meant to be distending which means not sharp and stabbing but a little bit more Broad in general um and it can also be mobile which means you can be on one side one time one side on the other side um because it is a binding depression of Liberty we want to see that it's worse with emotions uh and other Liberty a signs so you know we talked about sighing we've talked about anger irritability um this his pattern also has a lot of overlap with what we think of as an acute anxiety attack right so it it mirrors some acute anxiety [Music] um patients that I know that have had acute anxiety attacks that are accompanied by chest pain usually identified as chest pain in the front um accompanied by palpitation so I think that there's a liver and a heart aspect to it but the high emotionality I think we point to to the liver CH not flowing smoothly and thus creating this havoc in the whole area um associated with the with the chest but in the pulse we'd expect to be wiy sorry I'm losing my slides here p is wiring and the tongue we don't necessarily expect anything to to show up on the tongue yet um the last pattern that dung speaks about is liver fire uh and this can be a distending or burning pain plus liver fire sorry symptoms SX means symptoms um there's a chance that liver fire can actually affect the lungs and we talked about this as a cough pattern right so a cough that's worse with emotions and sometimes if this liver fire is very hot if it's invading the lungs we expect a cough that may have blood in it from the heat everything worse with emotion and we could have things like headache we could have things like red eyes we might have epistaxis bleeding out of the nose if the liver fire flames upwards um tongue will be red pulse will be wiry and Rapid okay so those are the main patterns that we need the last section that we're going to cover together after a short break maybe we'll just take a 10-minute break and then we'll wrap it wrap up today's talk with um some reasons non-tcm pattern reasons why we might have chest pain and then also talk about some um when when we might want to referral refer out so I think that's really important for us to know and the other thing to remember is that it's a it's a it's a chees stagnation pattern and one of the the hall marks of a chi stagnation pattern as opposed to a blood stasis pattern is that Chi stagnation discomfort is mobile it moves it shifts blood stasis fixed boring local pain Chi stagnation is often distending mobile more Comey and then um we can't really talk about wind pain without talking about specific conditions but you know anything that comes on very rapidly or suddenly can be thought about as wind right okay well let's let's wrap up with this chest pain stuff and I do want to Pivot back to other reasons that we might be experiencing chest pain that don't fit into these neat TCM diagnostic categories and um this is more drawn from you know my own clinical experience and from talking to other providers and one of them that I'll mention is spinal misalignment and this can be chronic this can be acute um you know sometimes people try to pick something up and they'll tweak their spine and things will be just a little bit out and um manual therapy adjustments are not part of our scope of practice although there are plenty of acupuncturist that have that that kind of bone setting skill out there but it is definitely within the explicit scope of practice of chiropractors um and there are people that experience chest pain and the reason they have that is because um their spine is a little bit out of alignment or perhaps one of their rib heads is out a little bit which also can kind of happen and if this ever happened to you um and you've got an adjustment that just kind of puts things back into place that could be a referral that you consider um another reason that we already talked about is gird and if you don't know what these words are it's gastro [Music] esal reflux I'm going to call it a disorder not a disease but you could call it a disease um when the sphincter at the bottom of the esophagus esophagus the gastro esophagal sphincter doesn't close all the way acid can leak into the esophagus causing all sorts of pain that can go all the way up and down the esophageal tract um signs and symptoms that we want to know about gastropig reflux disorder we want to know if there's positionality to it so worse lying down are there trigger foods or a relationship to meal times do they have a bitter taste in the mouth these are all questions that we can ask to see if maybe there is a little bit of gird involved in this as well um often people are conscious um of if they have a little bit of gastro esophagal reflux disease um or disorder um there's often a liver Yang component to Gastro esophagal reflux Disorder so I'll just put that parenthetically that we often have a wood Earth sorry I need to be a little more legible than that so this is a very convenient five phase way of understanding this that the liver can overact on the stomach and then the stomach Chi counterflows right so liver overacts on the stomach and then the stomach Chi so often wors with stress often accompanied by clenching of the jaw and temporal headaches which are both also signs of liver Yang rising and also chest neck pain right so this kind of that's sort of a liver yangy kind of thing and sometimes when that liver Yang Rises up and puts a lot of chi in our chest and our head and our gallbladder Channel it carries the stomach CHI with it and carries the bile and the acid up into the esophagus as well um another very common one now is anxiety and anxiety we're going to get into psycho emotive stuff and just next week I believe we're going to start talking about it um But anxiety we need to think of as involving heart and liver usually usually some sort of heart and liver so typically this is going to be a liver CH stagnation with heart maybe liver blood deficiency is a very very very common cause of anxiety amongst humans today and um I mean having been in clinical practice now for a little while like I can say in the past two years I've seen so much of this I've just seen so much of this specific Zang Fu diagnosis of liver ches stagnation with heart and liver um blood deficiency um where we get these pulses that are wiy pulses that are also thin and a little bit um weak so the blood is too weak people are worn out and overwhelmed from all the emotional stress the emotional stress wears down the blood and then they get the all these anxiety issues that can result in chest pain as well um the last thing that I'll mention around um chest pain non uh sort of other reasons that we might have it uh one of them is also bruis or broken ribs so if you're talking to somebody with chest pain and they they do Impact Sports or have had a recent accident this may be worth or a recent fall this may be worth looking into if you've ever had a bruised RP I used to do contact martial arts and sometimes you know you'd get hit in the chest and you think it was a strong glow but you wouldn't really realize that you had gotten a bruised rib until you know a few hours afterwards and then it would you know hurt when you coughed laughed sat up sneezed anything like that for about six weeks afterwards so this can also be a reason that we have chest pain right is acute injury um when we think about why we might want to refer out and this is on the slides but it's definitely worth um repeating so this is a book that I find pretty useful let me stop my share over here so I can show it to you all so this book medical red flags and referrals and acupuncturist guide um this is a really good book uh let's see it's blue poppy press um it's written by an MD and it just has this great in really short great information about like hey look out for this look out for this this may be a reason that you need to refer out or um make an urgent referral transport to care and they break it down really really well about when you should do what and so the information I'm I'm drawing from here is right from here uh from that book we need to um build vocabul a little bit and there's a condition called angina which just means some sort of chest pain right and there's two let's write this down just so everybody can see see it we talk about stable Anga an unstable angina so most people that have stable angina know about it they know that they have a history of chest pain they've been to the doctor they've gotten the labs run to see what kind of you know what kind of disease progression they might have around coronary artery disease or heart disease St angina means that there's chest pain with exertion but then it goes away right so usually people know about this oh I get this chest pain when I go up the stairs but then I sit down and it goes away and they might refer it say oh yeah no that's been happening recently but I I kind of know that I have this and the general referral pattern for this is like you should follow up with your PCP or cardiy olist if they haven't checked in if it's a new complaint um and the guide says within a few days so somebody comes in they say oh I've been getting chest pain you ask when do you get the chest pain they're like every time I go up the stairs and you say does it go away after you sit down they say yes you don't need to put that person into your car and drive them to the ER right then you say look it sounds like you have stable angina this is potentially a serious issue i' like you to make an appointment with your primary care provider or a cardiologist within a few days and then you write that down in the chart referred to primary care provider for followup regarding stable angina within the next few days and you write that in your chart and then you're covered and you also know that you can check on the person next time they come in you see them in the next week and you say hey how's the chest pain oh it's about the same did you make an appointment with your PCP well no I didn't get around to it say it's really important to you to follow up with your PCP we want all the Care that we can around this stable engine is not necessarily lifethreatening but we do want to make sure that it rules out anything and they're not kind of lurking at the edge of you know 90% occluded coronary arteries just waiting for that big event right unstable angina means that um with minimal exertion they get chest pain they also have shortness of breath and if they have dropping blood pressure this is not even call 911 it mean or not even tell them to drive to the hospital you are supposed to transport them or call 911 so this is transport to and the basic idea here is the patient shouldn't drive because a patient with unstable angina that's driving may have a heart attack while they're driving and kill not only themselves but people around them right um so I would say it's actually not unlikely that you encounter a patient with either of these conditions in your clinical practice I have encountered these patients in my clinical practice you know and often they know that they have a history of heart disease um and you know you just need to be you need to be diligent and and at octagon Community Acupuncture practice we we have had a couple events where we have had to you know call the emergency room or call call 911 and have patients transported out because they were sitting in the recliner very comfortable but complaining about chest pain shortness of breath and their lips were going blue and we're like we you know this isn't a condition that we can deal with here so we need you know if if there's not somebody there to drive them then it is it is a transport time for these people um so these are the two general ideas around chest pain referrals with angina um let's go back and just finish up with some general comments about um one of the number one killers in the United States which is the sidebar about coronary artery disease and I want to fly through this and not get too in depth because you do have Western Medical disease classes but um this is the kind of information that state boards and national boards love to ask about because one of the main things they're trying to to make sure of is that acupuncturists are not a liability for people with chronic diseases so if somebody has identified you as one of their care providers they want to know that you do sort of the the basic diligence around taking care of high-risk people right so coronary artery disease is the leading cause of death in the United States and 25% of all fat fatalities in the US are due to coronary artery disease so this is how people are dying in our culture right now heart disease right stuck Hearts um there's a bunch of different ways that it can feel it can feel like heartburn it can feel like um fullness in the chest it's not always an acute myocardial infarction where somebody grabs their chest and they feel shooting pain and everything there's also um a a breakdown by sex for sure and most of the literature that's been written about this is is around people that were born anatomical males um and this is the sort of stereotype heart attack that we're all familiar with from the movies but um people that were born female uh cor coronary artery disease and myocardial inunction often isn't that acute painful thing it's often identified as a general feeling of malaise fatigue anxiety insomnia and this is my favorite one is a feeling of impending doom right so sometimes there's a collection of signs or symptoms that aren't quite as chesty as we would imagine um so I would I would suggest especially with your with your um patients that are that that are have born female that look out for these signs or symptoms especially if they have risk factors so what are the risk factors for coronary a artery disease Advanced age so older people um people of the male sex people people that are smokers people that sit down too much high stress people certain dietary conditions that are um high in transfit trans fats especially um metabolic syndrome diseases so diabetes hypertension obesity you know and a family history of coronary artery disease or elevated lipid panels right so this is your cholesterol and there's other various lab values that you can get into if you get into integrative medicine but um I don't know if any anybody ever listened to that that old d Boy song there's an old BC Boy song called heart attack man and it kind of identifies this person you know it's like this big kind of overweight Hefty red-faced dude that's kind of stressed out eats a lot of fried foods and he just you know headed for a heart attack so um be on the lookout for this person and just be aware if they are one of your patients that this is a higher risk profile for them and you don't you don't want to you don't want to neglect that necessarily um another reason for chest pain that we'll cover in the last 10 minutes here is a pulmonary embolis so pulmonary means um pertaining to the to the lungs in the chest right this is what pulmonary means and an embolis is a blood clot okay so a pulmonary embolis is marked by a sharp chest pain with unilateral or bilateral asymmetric an ankle swelling so the idea of an embolis is that this blood clot has actually blocked um there's a blood clot that often develops in the leg is traveled up the veins it goes into the it goes into the heart heart and then it actually leaves the heart and blocks one into the pulmonary circulation and blocks one of the blood vessels within the lungs um this is the 911 condition the main thing that we will look for in clinic is unilateral um usually it's unilateral asymmetrical swelling so usually it affects one leg more than the other so um you will be palpating your patients legs if you're not already a lot of people have a little bit of a deem of the ankles if notice that one ankle is swollen out to here and the other one's only like this and they're talking about chest pain or shortness of breath or if they have rapid heartbeat or bluing of the lips yeah this is a 911 kind of thing Um this can develop over time uh often these people have already seen an MD with some sort of vague nagging symptoms and maybe the MD missed it maybe they did tell a health visit and they didn't see the ankles um just be aware and I would recommend doing a little bit of research on your own to look for pictures of what this kind of unilateral swelling looks like um and just be comfortable to you know if you have a patient that has these signs and symptoms that you can kind of tie them together um because it is something that sometimes slips through the cracks are random things so people have all sorts of weird vasculature people have histories of injury people have all these things that can make one ankle bigger than the other or one one more swollen than the other but especially if we have asymmetrical ankle swelling with some sort of chest pain report this is what we're really looking for this is when the red you know the red lights go off this is something that's life-threatening and it's also treatable you know we can we can put in blood thinners and we can operate and do things like that to treat this so shortness of breath rapid heartbeat that kind of stuff um the last thing we'll cover specifically for aspiring acupuncturist is pneumothorax and you've probably discuss this in acupuncture class and if you haven't you will when you start to talk about points on the chest um num more thorax can happen because somebody puts a hole in your plural in your plural Sac that's that's a common reason for acupuncturist unfortunately is somebody needles too deeply on the chest and then depressurizes the plural cavity so we have our lungs and we have our plural cavity surrounding the lungs there's fluid in the plural cavity if we poke a hole in that plural cavity or poke a hole in the lung we'd have to go deeper but possible then it collapses and the lung collapses as well um this doesn't happen necessarily like popping a balloon it can be a little bit gradual so um the anecdotal story I have about this have I shared this with you all if I have already um stopped me but um one of my colleagues who has an acupuncture practice in New York City when he was in in Acupuncture school he and a friend were practicing needling the thorax and his friend was a physical therapist and this guy was like ah he was a martial artist they both thought they had good anatomy and so they were both practicing needling the thorax and um they did the technique like they both thought it was supposed to be done and then they both went home and then his buddy called him up said hey I've got this weird cough and he said and his friend said yeah I've got this weird cough too and it turns out they had both given each other numo thoraxes um while practicing needling they were both young and healthy and you know they went to the they went to the doctor and it it it healed naturally and for young healthy people this is often how neox is dealt with you can actually just sometimes you don't even go to the hospital you can just recover from it but um we want to be careful about this so a sudden spontaneous sharp unilateral chest pain with shortness of breath um could be a numo thorax um we can get shortness of breath we can get bluish skin caused by the lack of oxygen we can get fatigue rapid breathing and heartbeat and a dry hacking cough the body's trying to cough out this lung irritation but obviously you're not going to get anything the lungs know there's something wrong because they're collapse one of them is collap or one lobe of the lung will be collapsing in on itself and you're trying to cough that out but obviously it's not going to produce anything I mean I I I I think that there was something about the way that I communicated it last semester which didn't didn't quite land appropriately um and I think it's because I said that these two people gave each other numo thoraxes and they ended up fine um which is actually I mean uh I think I also suggested that not every numo thox needs emergency medical attention which is true that being said is everybody listening um that being said if you suspect that your patient may be suffering from a pneumothorax send him to the hospital don't tell them to go home and it might be okay um it may or may not demand emergency attention but maybe you shouldn't be the provider that makes that decision you know um let it be somebody else that says no you're going to be okay and you're going to recover spontaneously um it doesn't necessarily require a therapy for you to get better but sometimes it does um and the last thing I'll mention about this is that numor thorax can happen spontaneously and and it does happen spontaneously there's a demographic for it it's usually tall skinny men in their 20s so tall skinny men in their 20s I know a man that this happened to one of my martial arts buddies um he was about 6 foot three and might have weighed 150 pounds 155 pounds you know just a bean pole um and he was you know washing his hair in the shower and all of a sudden he had all these symptoms and he had a spontaneous numo THX um and he went to the hospital and they said well we can't do anything for you take it easy and it'll recover on it own but yeah he he uh he did have this condition so be aware that this can be spontaneous as well it was this dry hacking cough and a weird feeling of fatigue and shortness of breath yeah yeah um and I think they were trying to like trigger point the latissimus dorsi or something like that they were trying to they were trying to hit a muscle or maybe they're trying to trigger point an intercostal or something that you you just don't want to trigger point right um yeah so this this is this is definitely um you know Hazard of the trade so to speak yeah I don't mean to be flip about pneumothorax yeah and I mean the other qu the other anecdote that I'll that I'll have about this is when I was a student intern I had this brilliant brilliant uh mainland China educated doctor named Dr Jew different Dr Jew than here this is at accs and she was doing uh local needling on the upper back for a patient with upper back pain and I was like it was one of the first times I had seen it and she had a pretty good siiz needle and I was like Dr Jew aren't you worried about numo thorax and she she's sitting there and she looks up said no just don't hit the lung like not not very helpful okay that clar clarifies everything um yeah so you'll learn techniques on how to how to needle what you need to needle safely and where to be um more cautious and how to chart to cover your ass in case something does happen