Symptoms and prevention of sudden death and heart failure

Photo: M24.ru/Mikhail Sipko

“Man is mortal, but his main problem is that he is mortal suddenly,” these words, put into Woland’s mouth by Bulgakov, perfectly describe the feelings of most people. There is probably no person who is not afraid of death. But along with the big death, there is a small death - clinical. What is it, why do people who have experienced clinical death often see divine light, and is this not a delayed path to heaven - in the material M24.ru.

How “sudden” is cardiac arrest?

The opinion of some people that death is inevitable in the presence of heart failure is not entirely true. To understand the problem, you should consider the reasons for its development:

1. The main etiological factor of the acute condition is heart attack. Human death occurs in 20% of cases within 72 hours after a “vascular accident.” Over the course of 3 to 8 weeks from the onset of persistent ischemia, patients with ventricular tachycardia and atrial fibrillation due to the death of some myocardial cells are at risk.
2. A decrease in left ventricular contraction with an output of 40% or less leads to congestion and disturbances in systemic hemodynamics, including in the heart muscle and brain. According to statistics, death occurs in 40 out of 100 such patients within five years.
3. Rhythm and conduction disorders. Especially often the cause is ventricular tachycardia and extrasystole.
4. Syncope conditions associated with structural changes in the myocardium or vagal effects accompanied by physical activity. This mechanism often underlies sudden death in professional athletes.
5. Use of class I antiarrhythmic drugs in treatment. Numerous studies indicate their ability to cause severe arrhythmias, especially when serum potassium levels are reduced.

The risk group, when death due to heart failure is highly likely, includes people with bad habits, atherosclerosis, diabetes and hypertension. Also plays an important role:

• obesity;
• left ventricular hypertrophy;
• elderly age;
• constant stress;
• physical overload;
• renal dysfunction;
• genetic predisposition.

Quite often, after studying a case of sudden death, several causes and provoking factors acting simultaneously are identified.

In previous sections, we talked about how chronic stress gradually destroys the cardiovascular system and each subsequent stressor makes it even more vulnerable. But one of the most striking and best-known features of heart disease is that heart attacks are common during stressors. A person receives unpleasant news; his wife died; he lost his job; a child who is considered long dead returns home; he wins the lottery. The man cries, screams, rejoices, sighs, holds his breath, amazed by the news. Soon he suddenly clutches his chest and falls dead from sudden cardiac arrest. A strong negative emotion, such as anger, doubles the risk of a heart attack within two hours of its onset. Thus, during the trial of O. J. Simpson, Bill Hodgman, one of the prosecutors, began to experience chest pains when he stood up for the 20th time to argue with Johnnie Cochran, and even fainted (don't worry, he survived) . Because the cardiovascular system is so vulnerable to strong feelings, every Las Vegas casino has a defibrillator. There is even evidence that traveling to New York is a significant risk factor for heart attacks¹.

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¹ This is evidenced by the results of a famous study published in 1999 by Nicholas Christenfeld and colleagues from the University of California at San Diego (did you expect it to be New York University?). The authors did an excellent job of ruling out other factors. They showed that this risk does not occur in other cities in the country. Its reason is the unconscious choice of place of residence (that is, who, except the eternally tense, prone to illness

This phenomenon has been well studied. In one study, a doctor collected newspaper clippings that reported the sudden death of 170 people from cardiac arrest. He identified events that appeared to be associated with these deaths: illness, death, or the threat of loss of a loved one; acute grief; loss of status or humiliation of self-esteem; mourning, anniversary of the death of loved ones; physical danger; threat of injury or rehabilitation period after injury; an important victory or intense joy. Other studies have confirmed these findings. During the 1991 Gulf War, a decrease in fatalities in Israel was attributed to missile malfunctions rather than a decrease in the incidence of sudden cardiac death among frightened pensioners. The 1994 Los Angeles earthquake also saw a spike in heart attacks¹.

The actual causes are obviously difficult to determine (since it is impossible to predict what might happen, and it is impossible to interview dead people to find out how they felt), but in general cardiologists agree that sudden cardiac arrest is simply an extreme case of acute cardiac arrest. stress causing ventricular arrhythmia or, even worse, ventricular fibrillation and ischemia². As one might assume,

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hearts of crazy people, wants to live in New York?). It is not a function of socioeconomic status, race, ethnicity, or immigrant status. It's not that people happened to be in New York at a time of day when heart attacks are generally more common (like commuters during work hours, for example). And not New York doctors, who often confuse other illnesses with heart attacks. The most common causes were anxiety, fear, and greater disruption of sleep-wake cycles than elsewhere. And this was before the September 11 attacks. Naturally, like all other native New Yorkers, this study gives me a kind of perverse pleasure, and I cannot argue with its conclusions.

¹ I once received a letter from the Chief Medical Examiner of Vermont describing his investigation of what he believed to be a case of stress-induced cardiac arrest: an 88-year-old man with heart disease died of a heart attack next to his favorite tractor, barely able to get out from home. His 87-year-old wife was found dead in the barn, also having died of a heart attack, but later than he did (she had no previous history of heart disease, and the autopsy found no abnormalities). Next to her lay a bell, with which she called him into the house to have dinner.

² Don't be afraid of this jargon. In ventricular fibrillation, half of the heart, called the ventricle, begins to contract rapidly and chaotically, but does not pump blood as well as it should.

it is related to the sympathetic nervous system and occurs more often in damaged heart tissue than in healthy tissue. A person can die from sudden cardiac arrest even if he has never suffered from heart disease, despite increased blood flow in the coronary vessels; however, autopsy often shows that such people had significant atherosclerosis. Sometimes completely mysterious cases occur when seemingly healthy 30-year-old people who do not suffer from atherosclerosis become victims of sudden cardiac arrest.

Fibrillation appears to be the most important event in sudden cardiac arrest, based on animal studies (for example, ten hours of stress makes a rat's heart more vulnerable to fibrillation over the next few days). As one of the reasons, the muscle of a diseased heart becomes more electrically excitable and therefore prone to fibrillation. Additionally, the activation of heart-stimulating factors becomes erratic during times of extreme stress. The sympathetic nervous system sends two symmetrical neural pathway projections to the heart; theoretically, during strong emotional arousal, these two projections are so activated that they lose coordination with each other - severe fibrillation compresses the chest, and the person falls.

Deadly pleasures

Among the various causes of sudden cardiac arrest, one is especially interesting: an important victory or intense joy. Consider the scenario where a person dies after learning that he won the lottery, or when death occurs during sex - but here the person at least dies happy. (Several decades ago, such a case occurred with the former vice president of the United States; the medical details of the incident became the object of especially careful study because the patient was found not in the company of his legal wife.)

The possibility of dying from pleasure seems absurd. Aren't stress-related diseases caused by stress? Can a joyful event destroy us in the same way as a sudden grief? The fact is that the manifestations of both are very similar from a physiological point of view. Intense anger and intense joy have different effects on the physiology of the reproductive system, on growth function, and most likely on the immune system; but regarding the cardiovascular system, their effects are very similar. Once again, we are dealing with the basic concept of stress physiology, which explains similar reactions to different situations: it doesn’t matter if we are too hot or too cold, we are prey or predator, some organs of our body, including the heart, do not care which way we are knocked out of allostatic equilibrium, they are only interested in the degree of imbalance. Whether we weep and bang our heads against the wall in grief or jump and scream in ecstasy of joy, both make serious demands on a sick heart. In other words, our sympathetic nervous system probably has roughly the same effect on our coronary arteries whether we're experiencing a blind rage or a mind-blowing orgasm. Diametrically opposed emotions can have remarkably similar physiological expressions (this reminds me of the famous quote by Elie Wiesel, the writer and Nobel laureate and Holocaust survivor: “The opposite of love is not hatred. The opposite of love is indifference”). When it comes to the cardiovascular system, anger and ecstasy, grief and joy, become equal challenges to allostatic balance.

Women and heart disease

Although men are more likely to have heart attacks than women, heart disease is the leading cause of death among women in the United States, accounting for 500,000 deaths per year (compared to 40,000 deaths per year from breast cancer). And the incidence of heart disease among women has been rising, while mortality from cardiovascular disease among men has been declining for decades. In addition, while the severity of heart attacks in women is equal, they are twice as likely to cause disability as in men.

What does this data say? The increased likelihood of disability after heart attacks may be an epidemiological incident. Women are still less likely to have heart attacks than men and, on average, begin having heart attacks ten years later. Therefore, if a man and a woman have the same serious heart attack, the woman will statistically be ten years older than the man. And therefore it will be more difficult for her to recover.

But what about the rising incidence of heart disease among women? It is associated with various factors. In the United States, obesity is a serious problem primarily among women, and it increases the risk of heart disease (as we will see in the next chapter). Additionally, although smoking rates in the United States continue to decline, they are falling more slowly among women than among men.

Naturally, stress also plays an important role. Kaplan and Carol Shively studied the subordination hierarchy of female monkeys and noted that chronically subordinate animals developed atherosclerosis twice as often as dominant females, even on a low-fat diet. Evidence related to social hierarchy has also been obtained from human studies. The increase in the number of cardiovascular diseases in women began during the period when they began to actively work outside the home. Maybe this causes stress? Some studies have shown that working outside the home does not increase the risk of heart disease in women. Provided that they are not busy with clerical work. And provided that they have a good relationship with the boss. So try to figure it out. And just to dispel the myth that as more women work outside the home, the more men take on household duties, another factor that increases the risk of heart disease in women who work outside the home is having children.

Why does stress increase the risk of cardiovascular disease in female primates and women? Due to the actions of our "prime suspects" - too much stimulation of the sympathetic nervous system, too much production of glucocorticoids. But there is an additional factor that causes very controversial assessments - estrogen.

When the previous edition of this book was published, no one was interested in estrogens. It has been known for decades that estrogen protects against cardiovascular disease (as well as stroke, osteoporosis, and possibly Alzheimer's disease), mainly because estrogen acts as an antioxidant, ridding the body of harmful oxygen free radicals. This explains why serious heart disease in women often occurs after menopause, when estrogen levels drop. This was widely known and was one of the rationales for estrogen hormone therapy after menopause.

The important role of estrogens in protection against cardiovascular diseases is indicated not only by morbidity statistics among the population, but also by serious experimental studies. As we will see in Chapter 7, stress causes estrogen levels to decrease, and Kaplan's subordinate female monkeys had estrogen levels as low as ovariectomized monkeys. And if a female who had had a low status for many years was given synthetic estrogen, raising its level to the level characteristic of dominant females, then her risk of atherosclerosis decreased. Remove the ovaries of a high-status female and she risks developing atherosclerosis. The conclusions of such studies seemed clear.

Then, in 2002, a landmark report was published based on the Women's Health Initiative's study of thousands of women. Its purpose was to evaluate the effect of eight years of hormone therapy after menopause, when women took estrogens and progestins. This was expected to demonstrate exemplary protective effects of such therapy against cardiovascular disease, stroke and osteoporosis. After five years of research, scientists mixed up who took the hormone and who took the placebo. The ethics committee of this gigantic project called for it to be stopped. Why do you think? Maybe the benefits of estrogen and progestin were so obvious that the committee decided it was unethical to give half the women just a placebo? No. It turned out that estrogens and progestin increase the risk of heart disease and stroke so much (while still protecting against osteoporosis) that continuing the study is not only unethical, but simply dangerous to the lives of the subjects.

It was a real bomb. The main news of the year. Similar trials have been stopped in Europe. Pharmaceutical companies began to stop production. A huge number of women who have entered menopause have begun to doubt that they need estrogen replacement therapy.

How could this happen? Conflicting results from years of clinical statistics and careful laboratory testing on the one hand, and extensive, excellent research on the other? One of the most important factors was that, for example, Kaplan's experiments studied only the effect of estrogen, while the most extensive clinical study studied both estrogen and progestin. Perhaps that makes all the difference. In addition (here is an example of the petty quibbles that scientists love and drive everyone else crazy), the dose of hormones mattered, as well as the type of estrogen (estradiol, estrol or estrone, synthetic or natural hormone). Finally, and this is also an important point, laboratory studies were based on the hypothesis that estrogen protects against the onset of atherosclerosis, but cannot get rid of it once it has already occurred. This is quite logical, because, given our Western style of nutrition, atherosclerotic plaques begin to form in us after 30 years, and not after menopause, that is, at 50 or 60 years.

The debate is still ongoing. It may be that taking estrogen after menopause does not protect against cardiovascular disease, but it is likely that estrogen produced in a woman's body at a younger age does. And stress, by reducing estrogen levels, can thereby contribute to the development of cardiovascular diseases.

Death by Witchcraft

It's time to explore a topic that is very rarely discussed in the scientific community. Proven examples of death from witchcraft are known in all traditional non-Western cultures. The person ate forbidden food, insulted a leader, slept with someone he shouldn't have slept with, or committed an unacceptable act of cruelty or blasphemy. Outraged villagers call a shaman, he performs some ritual manipulations in relation to the offender, sculpts a voodoo doll or “curses” the person in some other way. And the intruder falls dead.

Ethnobotanist Wade Davis and cardiologist Regis Desilva of Harvard researched this topic¹. Davis and Desilva object to the term "death by witchcraft" as it strongly smacks of Western condescension towards "native" loincloths, nose bones, etc. They prefer the term "psychophysiological death" and note that in many cases even this the term is not entirely accurate. Sometimes the shaman knows which one

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¹ Wade Davis is horror fans' favorite nerd. As detailed in the references section, his previous research focused on the possible pharmacological basis for the existence of zombies (humans in a trance without their own will) on the island of Haiti. Davis's Harvard doctoral dissertation on zombification was first published under the title "The Serpent and the Rainbow" (The Serpent And. The R in bow), and then it was made into a creepy horror film with the same name - the dream of any graduate student, the topic of the dissertation which raises doubts among reviewers.

villagers is seriously ill, and claims to have “cursed” him to confirm his reputation. Or a shaman can simply poison a person in order to thereby confirm his “magical” abilities. It also happens that a shaman curses a person in front of everyone, and the whole village says: “The curse works; this man is doomed, so don’t waste food and water on him.” A person who is not allowed to eat and drink simply dies of hunger; However, another curse has come true, and the shaman increases the fee for his services.

Nevertheless, cases of psychophysiological death do occur. They aroused the interest of some of the great physiologists of the last century. Walter Cannon (the man who invented the concept of “fight or flight”) and Kurt Richter (a great authority in the field of psychosomatic medicine) interpreted the mechanisms of psychophysiological death differently. Cannon believed that its cause was an overactivity of the sympathetic nervous system: a person is so excited by the fact that he was cursed that his sympathetic system “winds up”, narrows the blood vessels, they burst and this leads to a fatal drop in blood pressure. And Richter thought that the reason for such death was the overactive work of the parasympathetic system: a person, realizing the seriousness of the curse, simply gives up. At the same time, vagus nerve activity increases and the heart rate slows, until the heart stops, due to what he called a “vagal storm.” Both Cannon and Richter were never able to test their theories, since they were never able to find anyone who died from psychophysiological death, witchcraft or anything like that. It later turned out that Cannon was probably right. The heart almost never stops directly from a “vagal storm.” Davis and Desilva suggest that such cases are simply obvious examples of death from sudden cardiac arrest, when sympathetic activity leads to ischemia and fibrillation.

This is very interesting and explains why psychophysiological death can occur in a person who already has heart disease. But psychophysiological death in traditional societies has a strange feature: it can happen to a young person who is unlikely to have any cardiac pathology. This mystery remains unsolved, perhaps indicating a hidden risk of heart disease that we are not even aware of, or perhaps it demonstrates the power of cultural beliefs. As Davis and Desilva write, if faith can heal, it can also destroy.

Personality and Heart Disease: A Brief Overview

Two people find themselves in the same stressful social situation. But only one of them develops hypertension. Two people have been going through ups and downs for ten years. But only one of them develops cardiovascular disease.

Such individual differences may be due to the fact that one person already has a pathology of the cardiovascular system, for example, poor patency of the coronary arteries. Perhaps it is also due to genetic factors influencing the mechanics of the system - the elasticity of blood vessels, the number of norepinephrine receptors, etc. Perhaps the difference is the presence of risk factors - which of them smokes or eats more foods rich in saturated fats? (Interestingly, individual differences associated with such risk factors explain less than half the variance in heart disease.)

When two people face the same stressors, big or small, their risk of cardiovascular disease may also be related to their personality traits. In Chapters 14 and 15, we'll look at some of these factors—how hostility, Type A personality, and clinical depression increase the risk of cardiovascular disease. Unfortunately, such personal risk factors have a rather strong influence. But fortunately, there is often something you can do about it.

This discussion is the first example of the style of analysis that we will use in subsequent chapters. In a short-term physical emergency, the cardiovascular response is vital. But in a situation of chronic stress, the same reaction becomes dangerous. Its negative effects are especially harmful when interacting with the adverse effects of an overactive metabolic stress response, which we will discuss in the next chapter.

Previous – Chapter 3: Stroke, Heart Attacks and Death by Witchcraft | Next – Chapter 4. Stress, Metabolism and Asset Liquidation

Disease clinic

I would like to draw special attention to the fact that the death of a patient due to cardiac failure is not actually “sudden”. There are symptoms that begin several days or even weeks before sudden death.

Harbingers

In the vast majority of cases, warning signs are noted a couple of weeks before death. According to statistical studies, 75% of people experience certain symptoms. But many do not pay attention to them, considering them as temporary and transitory deterioration. It could be:

• fatigue when performing usual activities;
• transient rhythm disturbances of various types, most often with an increase in the frequency of contractions;
• constant unmotivated weakness;
• fainting;
• shortness of breath with slight exertion or at rest.

Along the left ventricle

Signs also indicate a type of deficiency. If the function of the left ventricle is impaired, the movement of blood in the pulmonary circle worsens, simulating pulmonary pathology. In this case, the following deviations are observed:

• severe lack of air with attacks of suffocation (cardiac asthma);
• pale skin;
• tachycardia;
• painful cough with pink, foamy sputum;
• moist coarse rales in the lungs, which are sometimes heard without the use of a stethoscope.

Right ventricle

If the functioning of the right ventricle is impaired (a problem with the systemic circulation), the symptoms are as follows:

• severe sweating;
• blue color of the nasolabial triangle;
• visible swelling of the veins in the neck;
• shortness of breath, turning into suffocation;
• decreased blood pressure;
• weak pulse that is difficult to palpate;
• enlarged liver and bursting pain in the hypochondrium on the right;
• swelling of the distal legs;
• leakage of fluid into the abdominal cavity (ascites).

Any type of heart failure gradually turns into total or mixed. In this case, general symptoms will be observed. And the likelihood of sudden death will increase many times.

Signs before death

For a dying person with cardiopathy, there are a number of signs and symptoms:

• sharp pain behind the sternum;
• significant increase in heart rate;
• rhythm disturbance (ventricular fibrillation or tachycardia);
• loss of consciousness;
• tonic convulsions;
• a special type of breathing (Cheyne-Stokes) - frequent and deep, then slow and convulsive;
• the heart stops working;
• the skin becomes gray;
• pupils dilate.

Death during sleep from heart failure occurs as a result of increased blood flow to the myocardium, which increases the load on it. In the presence of cardiac pathology, this can sometimes cause the development of arrhythmia or re-infarction with a fatal outcome.

What to expect from the doctor?

The doctor will ask questions - be prepared to answer them. When you see a cardiologist, you will be asked:

• When did you first experience symptoms that seemed suspicious for heart disease, such as chest pain (angina) or shortness of breath?
• Are the symptoms continuous or sudden?
• How severe are your symptoms?
• What helps resolve these symptoms? If you experience chest pain, does it go away with rest?
• What worsens or triggers symptoms? If chest pain occurs, does physical activity make it stronger and help it continue?
• Has there been a history of heart disease in your family?
• Have you been diagnosed with high blood pressure, high cholesterol or diabetes?

Why do young people die?

The risk group includes not only older people. In approximately 5% of cases, sudden death due to heart disease occurs in young people. The following conditions provoke it:

• sharp and prolonged vasospasm;
• significant myocardial hypertrophy;
• physical and psycho-emotional overload;
• taking drugs, alcoholism and smoking;
• cardiomyopathy.

Almost half of the dead were obese, a quarter of them were smokers, and 10% had insulin-dependent diabetes mellitus. Approximately 5% had a family history of similar episodes.

Interesting Facts

Scientists conducted studies in which it was noted that death from heart failure at a young age was most often correlated with structural features of the musculoskeletal system. The dead were:

• high asthenics;
• with signs of discrepancy between the two front teeth;
• with curvatures of the sternum, spine and lower extremities.

Also at risk were young people who had disturbances in the structure of the cardiovascular system:

• increased tortuosity of the aorta;
• reduction in the diameter of the largest artery;
• drop-shaped or reduced in size heart.

Symptoms and diseases

A study of cases of mortality from cardiac pathology in young people showed that some time before death they had the following symptoms:

• headache and dizziness;
• loss of consciousness;
• pressure surges;
• rhythm and conduction disturbances;
• mitral valve prolapse;
• vegetative-vascular dystonia of the hypertensive type.

How to prepare for a doctor's appointment?

• Write down any symptoms you experience, including those that do not seem like symptoms associated with heart disease.
• Write down personal information that includes a family history of vascular or heart disease, stroke, high blood pressure, or diabetes; stressful situations or changes in lifestyle.
• Make a list of all medications, including vitamins and supplements, that you take.
• Ask your family or friends if they remember any information that would indicate heart disease.
• Be prepared to discuss your diet and lifestyle. If you are not following a diet or exercising regularly, be prepared to receive instructions from your doctor about lifestyle changes you should make during treatment.
• Write down questions you want to ask the doctor.

Your appointment time with your doctor is limited, so try to come up with a list of questions that can help you have an effective consultation. Here is a sample list of questions:

• What causes these symptoms and condition?
• What treatment is indicated for me?
• What foods should I eat and what should I avoid?
• What is the acceptable level of physical activity for me?
• How often should I check my cholesterol and have a cardiac screening?
• If I have other health problems, how can I treat them together?
• Are there any restrictions?
• Should I consult other specialists?
• Are there alternative drugs to the drugs that were prescribed to me?
• Are there any brochures or other self-study materials available? What websites do you recommend?

How to prolong the life of a patient: expert advice

First, I want to clarify that there is primary and secondary prevention of sudden death. The first applies to people who have not experienced life-threatening conditions, but are at risk. In the second, a set of actions is aimed at preventing a repeat episode.

I would recommend that anyone who has a high risk of dying from a heart attack do the following:

1. Take medications recommended by your cardiologist. These are beta blockers, ACE inhibitors, blood thinners (Acetylsalicylic acid), statins and omega-3 fatty acids. Use nitrates for ischemic disease.
2. Stop arrhythmia attacks with class III medications (Sotalol, Amiodarone). In the absence of their effectiveness, agree to install a modern cardioverter-defibrillator. Good results are shown by radiofrequency ablation, which eliminates the source of excitation in ventricular forms of arrhythmia, and myocardial revascularization.

For primary prevention, people at risk need:

1. Take appropriate drug treatment for a disease or condition that can be fatal (coronary artery disease, cardiac failure). Use blood thinners, lower cholesterol, drugs to load the heart and dilate coronary vessels.
2. Systematically visit a specialist and conduct ECG studies and Holter monitoring. Call a doctor immediately if the condition worsens.
3. Reconsider your lifestyle. This includes: giving up bad habits, maintaining a sleep-wake schedule, reducing physical activity, eating a healthy diet with limiting or eliminating fats and salt.

The relevance of the problem of sudden death due to heart failure remains high. Therefore, it is important to carry out mandatory prevention and follow all specialist recommendations. This will not only increase the patient’s life expectancy, but will also significantly improve its quality.

Receiving Prescriptions

If you have a myocardial infarction, it is usually diagnosed by emergency physicians, or less often when visiting a doctor. After a heart attack, it is recommended to take care of yourself and be attentive to your health: early post-infarction angina leads to repeated heart attacks.

If you are interested in reducing your risk of heart attack, talk to your cardiologist about risk factors and ways to prevent heart attacks.

Since doctor's orders can be laconic and not always clear, it is a good idea to prepare for a consultation with a cardiologist. Below is information to help you prepare for your doctor's orders.

Common signs of a heart attack

The following are signs of a heart attack. You may have one or more of these signs.

• Pain, tightness, or discomfort in the chest.
• Pain, tingling, or discomfort in the arms, back, neck, jaw, or stomach.
• Difficulty breathing at rest and during mild physical activity, such as walking a few blocks or climbing a flight of stairs.
• Wheezing (wheezing or wheezing when breathing).
• Sweating.
• Rapid or irregular heartbeat.
• dizziness or lightheadedness.
• Indigestion (burning or discomfort in the upper abdomen (belly).
• Nausea (feeling of vomiting) with or without vomiting. This is a common symptom of heart attacks in women.

If you think you are having a heart attack, call 911 immediately. You do not need to drive to the hospital yourself. Emergency medical technicians (EMTs) can begin treating you while en route to the nearest emergency room.

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