Joan #1

Joan was in the garden hanging out the washing, she did the laundry as regular as clockwork.  Her life was normal, and had been so for the last twenty years.  She was looking forward to seeing her grandchildren later that week.  It was a sunny summer afternoon, so the clothing would be dry in no time.

Joan felt a twinge of pain in her chest, it seemed to run down her arm.

Hmmm”, she thought, “I must have stretched a bit too far”.

Joan, like many of my patients is starting to feel cardiac (or heart) pain, but like a lot of people who get it for the first time, she doesn’t recognise it as such.  Instead she puts it down to overstretching, a touch of indigestion, or something that will go away on it’s own.  Like many of my patients Joan doesn’t consider herself to have any problems with her heart – it has beat healthily for nearly 80 years without a fault, why should it be failing now?

Little does Joan know, but she is going to be one of the 275,000 people in the UK to have a heart attack this year.

But what is a heart attack?  The heart is a muscular pump, that continuously works to pump blood around the body.  All the muscles and other organs of the body need a constant supply of oxygen.  Blood carries the oxygen around the body to the organs, the blood then returns to the heart where it gets pumped to the lungs to pick up more oxygen, before going back to the heart to repeat the process.

Without oxygen, the tissues of the organ die.

As mentioned, the heart is a muscle, and the heart itself needs oxygenated blood.  So as the oxygen carrying blood leaves the heart, some of it is used to bring oxygen to the heart tissue itself.  Should the heart get it’s supply of oxygenated blood cut off, then the heart itself starts to die.

What happens in a heart attack is that one of the arteries carrying oxygen rich blood gets blocked off, and the heart muscle around that artery dies.  The medical term for this is a ‘Myocardial Infarction’.

Myocardial means the muscle of the heart, while Infarction means a reduced blood supply leading to tissue death.

For short we call it an M.I.

We used to think that it was just the lack of oxygen to the tissues that caused the injury, but what actually happens is that the lack of oxygen activates disease fighting white blood cells and these then release a range of toxic substances (mainly free radicals) into the tissue, thus damaging and killing it .

Joan’s pain was getting worse – it was as if someone was sitting on her chest.  She’d had a cup of tea, but that hadn’t helped at all.  She was considering a sip of brandy, the bottle had been untouched since Bill, her husband had died five years ago.  Maybe it would go away if she ignored it.

Perhaps a cigarette would calm her down, she swore she only smoked ‘for her nerves’, so perhaps it would help get her through the pain.

But what causes one of these arteries to get blocked?

Early in life we get small blobs of fat sticking to the inside of our blood vessels, with a healthy diet these don’t get much larger.  With an unhealthy diet these blobs of fat (called Atheroma) get larger and larger, often collecting up different types of material.  These effectively narrow the blood vessels of the body, causing a decrease in oxygenated blood reaching the tissues supplied by the affected blood vessel.

What can happen to cause a heart attack, is that this atheroma plaque can break off the wall of the blood vessel, sending a clot (or thrombus) around the body.  Blood starts to clot around the fatty plaque and the clot gets bigger.  If the clot ends up blocking one of the arteries of the heart, then the blood flow is blocked, the part of the heart supplied by that artery gets no oxygenated blood, and it dies.

Joan is a smoker, which means that she is at least five times more likely to have heart problems caused directly by her smoking.  Smoking reduces the bloods ability to carry oxygen to the organs that need it, partly because the carbon monoxide that is part of cigarette smoke is 400 times more likely to be carried by the blood than the oxygen that the organs of the body crave.

Also, smoking increases the one of the proteins that causes blood to clot, so the blood becomes more ‘sticky’, this helps form the plaques that can burst, sending them floating around the body all ready to cause a heart attack.  Smoking also increases the amount of ‘bad’ cholesterol in the blood.  It is this bad cholesterol that attaches itself to blood vessel walls in the first place to cause the atheroma plaques.

The cigarette wasn’t helping too much.  The pain was still there, and she was finding it hard to breathe.

Perhaps I better call an ambulance”, she said to herself, reaching for the phone.

…to be continued…



End of Joan, part 1.  Please let me know what you think, it’s hard to balance heavy medical stuff with making it easy to understand, and there are probably medical people reading this, tearing their hair out at what I’ve just written…

60 thoughts on “Joan #1”

  1. working with people who had various mental health problems, I observed that smoking did help when someone was having a bit of a panic, not because of the nicotine but because it forced steady controlled breathing, and because it was a fixed length of time-out before going back to a situation or task.A non-smoker, you'd take them out and chat and mooch around and maybe get a drink, it'd take half an hour or more, or they'd keep saying “I can go back in now” (three steps towards door, panic attack starts again) “no I can't” whereas a smoker would light a cigarette and not consider going back in until it was finished, takes pretty much exactly five minutes of steady breathing.

    Not that I'm advocating smoking of course. But that's my theory as to why it helps particularly nervous people to calm down.

  2. Nice one, very well done. I felt it a little heavy on the dramatisation but it appears others liked that bit just as much.However, very informative and an interesting new direction to take. I trust you won't be completely discarding the old-style posts, though? How could we live without another tale of Maternataxis and Drunks? šŸ™‚

    I've been trying to do similar with my blog recently – and encouraging others to do the same. Everyone has their own little specialism, and if we can just pass on a little information about things we know, and leave people more informed, then all the better.


    The Broken Hut.

  3. on the whole, I like it – been to god knows how many courses that said “you should look out for this, this and this as signs of a heart attack and call an ambulance, better safe than sorry” and so on, but nothing that put it in a real life context like that.Is it blog material? Not as such, it's creative writing, possibly with a view to paid writing for public information, but if I've understood correctly you are just looking to test out styles on us which is cool šŸ™‚

  4. I think this is great writing and very easy for a lay person to read. It is also informative and educational. As many people who read your blog, you more than likely just saved a human life with just your brains and your pen.Sincerely,


  5. P.S.Could you please do a post on seizures and how to tell a real seizure from a put on seizure. My friend needs this to help her with her daughter acting out.

  6. You know, you are absolutely right… It's weird in that it's one of those ideas that just sticks in your head.There is an ad campaign in the UK at the moment (to get people to stop smoking) which shows a clot travelling around the body, and I'm guessing that this just stuck in my head.

    That and lazy thinking.

  7. You think that's tided up?Cool – because I write it exactly the same way I write all my posts, as a vague stream of consciousness-type thing.

  8. I'm very sorry to hear this. If it's any consolation (and it probably isn't), but it seems to me that she died quickly and without serious pain.It's how most of us medical types would like to go if you see what I mean.

  9. Personally, I think you got the balance just right..You're not writing for a medical audience, but an audience of average, everyday people with no medical experience. And if someone's read it and thought “that's me” and got help, or decides to change part of their lifestyle, then you've succeeded.

  10. If I read that as a non-medical person then it would hold more interest for me than reading an everyday medical textbook – so well done (again). You have hit the right balance by giving the readers a character to relate to as opposed to lecturing them about their own possible shortcomings and lack of knowledge. Keep them coming Tom!

  11. The way you alternate between her inner world and the medical information keeps interest in both. It seems to me to be an effective way of holding the attention and imparting the information.

  12. Hi Tom,Personally, I didn't enjoy the post as much as others seem to (and as much I usually enjoy your writing). I think your blog is really entertaining, and informative as a by product of what you write about. I feel changing the purpose to being more informative loses the entertainment factor, but that's just me.


  13. So can I carry on smoking if I take asprin then! -There must be a way.. I know I need to quit and I am down to only a coupple/few most days now but that final hurdle is not happerning.Just reading about the latest most gory calls becomes rarther tiring, However an essential part they are. Mixed with excepts from your other job, and little peices of writing like this make people come back again and again. Well it does me.

  14. Me: “Doctor, can I have 6 more months of the contraceptive pill please”Doc: “Hmm, you smell of ciggerette smoke, do you smoke”

    (I have been seeing this doctor for over 7 years. She has my notes up on her screen.)

    Me: “yes, around 10 – 15 a day”

    Doc: “Has anyone ever told you of the dangers of smoking and being on the pill”

    Me: “Yeah.. but, I'm really having problems stopping. I tried the patches but…”

    Doctor turns away from, removes prescription for pill from printer, hands it to me and starts writing, with a hand signal towards the door.

  15. I also prefer your real-life experiences, but, I liked this. Maybe you could create a different blog?My mother was one who smoked 'for her nerves'. She would get upset, start to hyperventilate and say 'I can't breathe. I need a cigarette!'.

  16. Love it TomIt draws into relief the relationship between humanity and science – something younger techs only truly learn from their own life experience. Very good stuff.

  17. From a biomed background, I think you hit the right level of medical jargon. Anyone wanting more detail should either search the web journals, or get a text book.On a separate note: I've now been rejected from 2 of the 3 paramedic courses I'd applied for through unis. I don't know what to do or what i've done wrong. Trying to get feedback is proving hard too.

  18. OOI, if someone has an unhealthy diet, so the fat builds up as you say, but they then improve their diet, will the fat go away again? Or are you screwed for life?

  19. I have smoked since the age of 15, am now 22. I have always half-heartedly tried to give up but this gave me a shock. Not that I wasn't aware of the dangers but it's never been explained to me quite so graphically. I've just written what you posted in the front of my diary in capitals and snapped my remaining cigarettes into the bin and am going to log on to a quitting website. Thank you, I hope it works for me and others reading it. There needs to be more detailed and scientific explanations, not just shock tactics.

  20. Mind you, all the crisps and biscuits I'm going to eat in place of the cigarettes are just going to give me more blobs of fat in my blood vessels..damn it.

  21. Hi Tom,Just a comment on your pathophysiology of an MI. You talk about plaque rupture leading to embolus and then clotting, this isn't what happens. The reason that your explanation doesn't work (and I keep hearing it, I don't know where it comes from) is that atheromatous plaques generally occur in arteries. If we say that an aortic plaque ruptures, to get to the coronary arteries, it would have to pass through the arteries -> arterioles -> capillaries -> venules -> veins -> IVC -> Right Atrium -> Right Ventricle -> Pulmonary Artery -> Pulmonary Capillary Bed -> Pulmonary Vein -> Left Atrium -> Left Ventricle -> Coronary Arteries. There are two “filters” there which atheromatous would lodge in, the systemic capillary beds and pulmonary capillary beds, and would stop the plaque reaching the coronary arteries.

    Far and away, the most common pathology is that an atheromatous plaque ruptures in a coronary artery. This causes exposure of various tissue factors leading to a clotting cascade, and forming an occlusive thrombus at the site in the coronary artery, thus stopping blood flow.

    For more info, you can read This sample chapter of a text book.


    Final Year Medical Student

  22. I like your blog. It is well written and interesting. But this post has failed to satisfy me. I accept that all healthcare professionals should take a roll in health promotion, but not necessarily in your blog. Stories about blood and poo and the state of society excite me far more. And I agree with what RS said.Dr Lib

  23. I think it is great, I work for a charity that teaches basic life support including how to deal with someone having a heart attack, this is a great way to explain what hapens when someone is having a heart attack to someone with no or limited medical knowledge.

  24. Thumbs up from me.You have deservedly built up a considerable audience here and if you want to share some of “the knowledge” then you are sure to have a large number of people reading along and taking an interest, those who aren't interested can skip the post and wait for the next Poo story (because you know that's why we're here, right?).

    On a more personal note; you've shared a lot of yourself with us through this site and because of that I think a lot of people will be able to relate to you. We know you live in the same “real world” that we do, so if you were to give any advise (and I'm not saying that's what you are doing) then it will probably be well received.


  25. I've been reading your blog for ages now, Tom, but I've never been moved to write before. I really like the way you've presented this info.Maybe I'm biased, as this post was ironically well timed for me; my dad had a (thankfully mild) heart attack a couple of weeks ago and I've been hankering for all the information I can get.

    I wrote about it in my blog last week (not that anyone reads it, but) like someone said earlier, if it makes someone else reach for the phone when they get a “twinge” that won't go away, then all the better.


  26. I like all your writing Tom and enjoyed this post just as much as any other.Keep up the good work – whatever genre you choose to explore your thoughts in.

    The Girl

  27. My Mum-in-Law had cut down to 5 a day by the time she found out she had lung cancer. She died 2 months later. Give it up now.

  28. Well it's inspired discussion, which is good. I quit smoking on the 1st Jan this year. My advice is to just go cold turkey, it is hell for a few weeks but then that's it. I get frustrated watching friends and colleagues on nicotine replacement therapy suffering constant re-addiction and withdrawal every day (one is still on lozenges a year later). You will have to go through complete withdrawal eventually, unless you want to stay on patches or whatever the rest of your life. Why not just go cold turkey in the first place and suffer for a few weeks and it's over. Don't drag it out for months. Cutting down is fine, but in the end you have to just stop.Sorry for lecture but that's how it is, and the people selling patches and gum are almost as bad as the tobacco companies, as they are keeping you addicted.

    The end!


    P.S, I'm not some kind of iron-willed freak either, I'm the most mentally weak person there is. If I can do it, you definitely can!

  29. Forget the purists Tom who don't want you to change. I was looking at your very early posts after the “Writing?” post and your style has developed tremendously.Also – compare your post with that of RS comment. He may well be right but I have absolutely no idea what he is talking about!!

  30. maybe its my sense of humour, but is that the end of Joan, or the end of Joan (part 1)remember there's only 3 things guaranteed in life…… birth, death and taxes

  31. Just a linguistic comment. The clause “she is at least five times more likely to have heart problems caused directly by her smoking” doesn't really make sense. Caused directly by her smoking as opposed to someone else smoking? Or are you trying to say: “Because Joan is a smoker she is at least five times more likely to have heart problems. This is caused directly by her smoking.”?I am a regular reader of your blog and I find it very informative.


  32. sorry, don't like it -just as when Zinnia did the same thing. I'm interested in the atypical real life -the bits I don't experience- and the now, not looking-back-tidied up for publication semi-ficticious stuff or the everyday stuff we all go through. But then I already know what a heart attack is and the stats. Perhaps if I didn't I might feel differently…..and the writing is fine, I just don't like the content.I love the regular stuff -and the other blogs toy point me to. so much so I've been considering training for a nee-naw control type position here in the US.


  33. I do like it. However, I do like this blog the way it is. Your real life is way more interesting. I think you should consider a 'fiction' blog, where you can write these sorts of stories.Whatever you do, keep it up.

  34. I also prefer your real life stories with a dash of your humor thrown in to lighten the plot. Dispite that, you write well in what ever style you decide to write it up and it always makes for good reading.

  35. Good on you for putting this out there for comments, and criticisms.Compared to your usual posts this has more of an air of 'public information announcement'. It's well done, and could be a good start for an information guide/health handbook – I think the way it combines a scenario with the facts would work well in that case, but I'm not sure it's quite right for this audience.


  36. Brilliant, thank you.No one healthy asks a doctor or sufferer to describe a heart attack – most of us only have the movies to go by, which is appalling.

    Similarly thats the first real and simple explanation I've seen of 'why' or 'how' smoking can make you more susceptible – too many medical types are so bloody offhand – “you shouldnt do this because you'll be more likely to suffer that” – its actually really helpful to have a simplified picture of how we get from A to B, not just an imperious statement that we can or might.


  37. So would getting them to make a cup of tea (for themselves) work as well do you think? For me a good cuppa is the answer to almost everything.

  38. I'm sure there's something important being said there, and I know you were really aiming you comment at Tom, who understands these things, but I'd love to have that translated into English I can understand. Of course it would mean something nice and short becomes a small book, but just that last bit about the most common pathology would be great. You lost me at “atheromatous plaque ruptures” unfortunately!I probably shouldn't complain too much, my line of work, computer science has plenty of jargon, and frequently inflicts it on others too!

  39. Great post. Lets hope lots of people read it and know to ask for your help before it's too late. Very well written, even you blog's saving lives!

  40. Oh dear. Although I think the article is excellent (and I haven't read the next 2 yet), unfortunately I lost my mother-in-law 3 days ago to just this condition. No one saw it coming, it's been a huge shock to us all.

    She complained of feeling warm (which isn't unusual), with a slight pain in her chest, that went down her arm. Her husband wanted to call the paramedics, but she wouldn't hear of it, saying she'd be alright if she went to lay down for a while. He checked on her after 5 minutes, but she shooed him away, worried that he was missing the football game (she was a huge football fan herself). He got to the bottom of the stairs, something didn't feel right, so he turned around and went straight back up, but it was too late, she had gone.

    She would have been celebrating her 80th birthday at the party organised for her in a couple of weeks.

  41. Can't wait for the rest of the series :)With regard to the balance of technical correctness and accessibility, I prefer technical correctness, both when I'm writing on and reading of technical subjects.

    It might make things longer and more dense, but I think it's certainly a better alternative than statements like “Linux is an operating system, it happens to be free” or “DNA is the code that makes us what we are.”

    I thought this post struck a great balance, btw šŸ™‚

  42. OK, forget the top bit, that's just explaining why what he said happens with a heart attack doesn't work.So, on to the bottom bit (this is simplified, but means I've sort of skipped some important stuff). Basically, you get those atheromatous plaques in your coronary arteries – the ones that supply blood, and therefore that important oxygen to your heart muscle. The plaques are actually quite complex structures, which have an outside and an inside. As long as the outside is touching the blood, there is no problems, however, the stuff on the inside has stuff in it which tricks the body into thinking you are bleeding. What happens when you bleed? Your body makes a blood clot, to stop the bleeding.

    Unfortunately, the outside layer isn't as strong as we would like, doing things like getting your blood pressure up can cause the outside bit to rupture, thus letting the blood get to the inside bit. Suddenly, it thinks it's bleeding, and the body tries to stop the bleeding. But because you're not actually bleeding, the clot that would be on the outside, is not on the inside, it fills up the coronary artery so nothing can get past, and suddenly, all that blood with it's oxygen can't get through, and supply the heart muscle, and viola you have a heart attack.


    Final Year Medical Student

  43. A grand everyday description of the onset of a possible MI, well done! Good to be reminded of the technicalities. It might help to point out the Paramedics dont go travel along this thought line one the door is opened and we are presented with a very sick patient. From the accumulated knowledge of our training and experience, one knows at first glance that something is seriously wrong. Our first action is to get the patient sat down and on oxygen and if they are able to continue breathing on their own, everything else becomes a bonus!In the interest of debate and discussion.

    There is always the smoking paradox to contend with! The patient smokes to calm themselves in anxiety generating situations and here they are in one of the most frightening situation. Joan becomes desperate for a few puffs just to take the edge off! Like all addicts its at these times when stress levels climb towards the stars that our need becomes that much stronger. Many times have I heard the plea, I really need a fag (cigarette)? Although the correct reply is always in the negative, I have always wondered if this is the logical answer! Consider the situation from the nicotine addicted patient side. Joan has probably smoked for the previous sixty odd years and although this activity may well be the cause of her present condition, denial of her present need will only increase her stress and anxiety levels. The act of giving up smoking is known as a precipitating factor in some M.I. sufferers! This additional stressor is apposed to the situation one is trying to encourage! So what if Joan ignores medical advice and smokes a cigarette, say whilst one is taking a history. She lights up (preferably not whilst snorting on oxygen!) and takes a puff. Its an ordinary cigarette that is being smoked, not a spliff! Joan has a quick draw and almost immediately exhales the offending smoke. She then has another and by the time she draws for a third time, sufficient nicotine has entered her bloodstream to have a positive effect on her dopamine receptors which then trigger the release of stress relieving hormones!

    Which is the best course of action? The smoking paradox!

  44. depends on the setting. At a lot of places like colleges or sheltered workshops and so on where people who suffer from panic attacks might be trying to get back into the swing of things, drinks aren't allowed in the main rooms.So a non-smoker starts having a panic attack and indicates they want to leave the room, a staff member/link worker/carer/call it what you will goes with them to make sure they're okay.

    By my reckoning, to make a cuppa, wait for it to cool to drinking temperature, and drink it, takes at least twenty minutes. If a college/workshop session is an hour long, twenty minutes is a bit much, and probably more than the person needs… and it then puts them at a disadvantage for the next session.

    Possibly sudoku puzzles are the way forward…

  45. Thanks Tom. The medics who attended said exactly the same, and it was a comfort, as is knowing her last words to her husband weren't tainted by the sorrow of passing.

    All the professionals who attended that day were brilliant, compassionate and considerate, so much so that the impression they left on those affected will never fade.

  46. Recently I have spent a quite a big slice of time recovering from severe anxiety and agitation, at the local mental health day hospital at Newham. Due to the cultural differences in the groups it was hard to tell exactly how many patients suffered from anxiety and related agitation. From the number of walk-outs, particularly with relation to talking workshops, I would think its quite high. The quickest people to calm down were the smokers, who also made up quite a large subgroup within the patient population. All including some non-smokers regularly attended together in the smoking room where for some, precious cigarettes were borrowed and begged by stressed-out nicotine addicts. Although it saddened me to see sick patients, suffering because of the dire financial situation they found themselves, the bright side was the development of a very positive group dynamic. They all shared their fags with who ever was in need and this led to low-key, direct communication. After nearly an hour sat in groups where at times the only sound was the odd cough, the scrape of a chair when some-one legged it or the facilitator verbally having a hard time encouraging patients to talk about there experience of mental health problems, within ten seconds of the end of the session, all the smokers where in place on their favourite chair, puffing away and most talking freely about anything that took their fancy! The quite ones or the silent, were in the main only at the start of their accelerated journey towards recovery. By the end of my stay at the day hospital and I found the whole experience immensely beneficial and enabling in my return to positive health, I was left wondering just how much help the smoking room culture had been in my recovery, I suspect quite a lot! At least we didnt have to become friends in adversity, having to stand about smoking outside in the January cold. I dont think that would have helped in the slightest and most likely would have resulted in someone either throwing a wobbly or succumbing to hypothermia. Now I do realise that the coffin nails will get most of us in the end but in most cases that should be well into the future. Anxious and agitated people have a hard enough time living healthily in the present and as such tend to not be too concerned about the distant future. Sometimes a wee puff is just what the doctors didnt order, but there are times when they willing to allow the nasty habit, especially if they think it will help. Where as the hospitals staff actively encouraged affected patients, to cut down or stop their heavy drinking or substance abuse as negative influences on mental health, smoking was not seen as a particular priority at this sensitive time.Seeing as I am writing this, I may as well take this opportunity to publicly thank all the staff and fellow patients of the Newham Mental Health Day Hospital, who helped me and others along the road to a better life, struggle it may be!

  47. or as one of the service users/clients/patients/call them what you want said to me, “I'm stressed out and mood-swinging enough with everything going on, inside and outside my head, without trying to quit smoking as well!”

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