I peeked into the emergency room cubicle as our nurse manager filled me in. "Fifty-two-year-old. Sudden nausea and weakness. Blood pressure's low: 66 over 40. Only history is obesity surgery four years ago." Vincent, my fellow attending, stood at the bedside. Mr. Dexter, the patient, was alert and uncomplaining. "Can't be too sick. Probably vasova-gal," I thought, walking on. The vasovagal reaction is a catchall term for a transient condition involving fear or pain, such as gastrointestinal upset, that causes low blood pressure, slow heart rate, and in some cases fainting. Patients who have had gastric bypass surgery, a treatment for obesity that dramatically reduces the size of the stomach, often experience such upset. The condition usually passes quickly. An hour later, Vincent buttonholed me. "Could you help me look at his heart?" he asked. "We've given three liters of saline, plus dopamine [a blood pressure booster]. Blood pressure won't come up. EKG shows no heart attack. No fever, headache, chest pain, or abdominal pain," he added. "Maybe the ventricle wall isn't contracting right. EKGs don't always pick up heart attacks."
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