Referred Pain

A 21-year-old male came to the ER with right-sided chest pain. He described his pain as “a needle being stabbed into a vein in my heart.” He used that same phrase a few times during our conversation. Fortunately for him, he did not actually have any problems with his heart or otherwise that we could diagnose. We looked for the usual causes of dangerous chest pain and found none. He likely had acid reflux from his steady diet of Taco Bell where he worked. As he explained to me, he’s poor and the food is free despite him calling it “shit from a tube.” Presumably referring to the plastic packaging the “meat” comes from.

It’s not uncommon that people will tell me they have pain in a very specific place. A patient who claimed to be an anatomy and physiology tutor told me she had pain in her ileum, which is the third portion of the small intestine just before it connects to the colon. It was odd to me that someone with her knowledge would think she could be that specific about where her pain comes from, given that I assume she understands the concept of referred pain.

The nerves that exit your spine at every level, between every vertebra, innervate a specific portion of the body. Google “dermatome map” for an idea of how this looks on your skin. There are both motor and sensory nerves coming and going. When patients have a true emergency with nerve damage, it is often a very specific level that is affected. Most of the time, pain is the biggest problem for the patient. When things affect motor function, that’s when it actually becomes an emergency.

Pain in the chest and abdomen is among the most common complaints that bring people to the ER. And yes, sometimes patients actually have an emergency condition, but most of the time they do not. Regardless, it’s not so easy to tell exactly where the pain comes from. I regularly see patients who claim that their “heart” is what is hurting, and I don’t disagree that it feels that way. However, with our usual chest pain work-up in the ER, we are pretty good at detecting any damage to the heart that needs emergent treatment. At the end of the visit, most chest pain patients go home without a definitive diagnosis. We know their chest hurts, but it’s just not something we can diagnose.

The pain could be from any number of musculoskeletal structures that surround the torso, the lining of the heart, the lining of the lungs, the cartilage in the chest, or some irritation to the nerves as they exit the spine. All of those things are perceived by the patient to be in a specific area because all those nerves have their origin at the spinal cord. And we have no test to prove which one of those things is actually causing the pain.

The esophagus and stomach are both anatomically close to the heart. Acid reflux and gastritis, or inflammation of the stomach, cause a lot of pain, and those are not things I can definitively diagnose in the ER. It leads to a lot of large work-ups for chest pain and abdominal pain. I can look for all kinds of other things, but there is no definitive test for acid reflux in the ER. As with my Taco Bell patient, at the end of the visit, we are left with a guess that something in the GI tract is causing his pain and not “a needle stabbing a vein in his heart.”

The same problem presents itself with arm or leg pain. Although the pain is felt in an extremity, the issue is often from a problem in the neck or low back because that is where the nerves are being irritated as they exit the spine. This is referred to as radicular pain.

When you go to the ER with chest or abdominal pain, you may have a 50/50 chance of actually getting a definitive diagnosis. We look for the worst things but don’t have tests for the things described above. There is no lab test, CT, or MRI that can identify pain related to pleurisy, irritation in the lining around your lungs.

You’re not crazy to go to the ER with concerning pain that feels very much like it’s coming from a very specific place. And your doctor is also not crazy when he doesn’t find anything definitive.