Troponinitis

The fringes of medicine.

You can describe three different worlds that overlap considerably in this space – the first, the world as people, that is non-clinicians perhaps perceive the machinations of hospital life. Precise, exact, strictly measured aliquots of agent A or therapy B, then there is what I at least, in my hagiographic imaginings believe to be the case, a neurosurgeon, manipulating laser beams via stereotactic guidance, MRI machines and technicians all participating together in a symphony of anatomy, science and disease.

Then, there is my world.

The messy, frequently chaotic existence that is medicine. Where, you could have pneumonia, but it might be heart failure, but we can’t exclude a urine infection.

I suspect if the average person saw the imprecision they’d have something to say; perhaps this blog is playing with fire, but there you go, call me Moses or Icarus.

The landscape of medicine, which in reality covers all aspects of human (and some would suggest non-human) illness. That is everything from collapse to memory loss, tumour-like growth to passing-on; you name it and medicine encompasses it. The medic, let’s call them ‘physician’ in almost all instances acknowledges the limitation of their knowledge, but, they see the world through a lens, like the Spiderwick Chronicles – where fairies and goblins become visible. We see what others do not.

Within this altered perception – think strong coffee rather than LSD, is the awareness first of the vastness then the limits of knowledge.

I understand your condition to a certain extent, but I will have to ask someone who has a little more specialist knowledge to clarify, and they, depending on their level of humility will do the same until you reach the person who supposedly knows the most about the least, an individual qualified black-belt style to say, ‘we don’t know, move-on.’

Finding this individual, this latter person is often a rarity, but the search is on.

Amidst these extremes exist the day to day, waves slicking against the harbour-walls. The person who finds themselves trapped in the system, in their heart knowing there is nothing wrong, but with label of ‘possible’ attached to their diagnosis.

This is the realm of the troponinitis.

I guess I should explain troponin to those of you who have persevered through my blog to this point.

Troponin is a blood test which detects a chemical released into the blood stream if there is damage to the heart. That’s it.

The test has evolved in my lifetime.

Originally, we would have someone admitted to hospital, clutching their chest and eventually a low-grade temperature in addition to raised white cell count and abnormal liver enzymes (also released by damaged heart muscle) would indicate the diagnosis. I suspect, although I wasn’t a higher-up back in those days that people would dole-out the ‘heart attack’ diagnosis with a greater degree of certainty than we do nowadays despite sophisticated chemical assays which tell you differently.

The problem with the original tests was that low-grade temperature, raised white cell count and liver enzymes could be what you get with the flu. Go figure. Heart attack or the flu. I know which I would prefer.

Over the years we have had different tests – Creatine Kinase aka CK – a test we still do now although in general because we find it a marker of muscle-tissue breakdown in general – old man lying on the floor for 12 hours and raised CK gives concern, reflects the human’s experience during that half-day alone, cold and worried (sometimes at the bottom of their stairs) and alerts us to watch the kidneys, then there were a few years of other tests – CKMB, Troponin T, Troponin I, I won’t go into them now; I imagine there were probably multinational giants making millions from the research projects of academics in UK and US university hospitals. Cynical moi?

And, today we have something called the ‘Highly Sensitive Troponin Assay’ – this test which is meant to be the sine qua-non of cardiac tests. Your trop is raised, it is heart, heart attack that is. The current holy grail of investigations;

If the patient and doctor are lucky enough to be in a situation of:

Chest pain, appropriate changes on the ECG and elevated troponin, you are home and dry; call the cardiologist. Get them on the scene; angiogram, evidence-based medication and away you go; 20 more years of productive existence.

Yet, it often is not this precise.

The pain is vague, neck, jaw, fingers, the ECG – electrocardiogram might have been abnormal to being and the troponin, well…

Troponin, this Millennial test, investigation of the iPhone generation is, despite its reputation not all that.

In most instances raised troponin (at least if raised adequately) means damage to the heart, call the cardiologists – see above;

Yet, what if the raise isn’t all that great – we are talking maybe 100 to 150 on a scale that seems to go up to the thousands.

What if the patient is old, frail, vulnerable, confused and the sequence of events opaque.

Did Moira really fall from her chair, was she pushed, overbalanced? Was it the pain, her lack of awareness, disorientation?

Without the blood test, without hospitalisation and medicine, Moira would get back to her chair in the nursing home, drink a cup of Early Grey and doze-off before dinner. In another world, the ambulance transports her to the hospital, disorientating lights and movement at the speed of hospital porter lead her though phlebotomy, radiology, ward A, B and C.

The woman at the end of this, a shadow memory of the tea sipped from china cup, in bed, cot-sides, hospital PJ’s and doctors standing round.

‘Raised troponin’

It is high, but not that high.

She has dementia – the cardiologists will manage medically (aka not use their fancy equipment to further diagnose or treat).

Her urine, it smells bad.

But, the troponin.

Not significant, says the chief, probably from the fall, the trauma, the fever.

But, it is highly sensitive.

The last voice ignored, the team walk-on, Trimethoprim is prescribed, and the ward round moves to the next bay; things happen.

Moira if she is lucky, is back in the care home later that day, if not, she enters the hospital pathway – think the East Australian Current (EAC) in Finding Nemo – the one loved by smiling turtles. And, she is off, around, here there, catch her if you can. The troponin lurking in the background. Hidden like a slug, sheltering beneath moss-covered plant-pot.

The point of this blog?

Well, not hopefully to scare, to reflect incompetence or variation in practice, more to highlight the complexities of the situation. The imprecision with which we have to tread when navigating the ins and outs of health and disease.

Sure, they have disease, but, is that disease relevant? Does it affect the length of the individual’s life? The quality?

Life-changing decisions are made daily in hospitals and GP surgeries.

The substrate is often uncertain, shape-shifting; Evidence is held-up as the panacea. The reality is different, the actuality is grey, grey, grey. Blotches of mist and fog.

It could be the heart, the lungs, too much or too little fluid, fever, infection, inflammation… troponinitis, troponiopathy, 21^st Century.