Continuing with the February heart theme, let’s explore chest pain. This a common complaint that brings patients to the see the doctor. Chest pain is one of those vague medical complaints that could occur for many reasons. It is never a symptom to ignore or take lightly. The problem most often faced as a patient is, what to do when you have chest pain. Of course, this will depend on a lot of different factors; age, medical history, location and severity of the pain, etc. Some patients will go to an urgent care center, thinking that they will avoid long Emergency Department wait times.
Is the urgent care setting appropriate for a chest pain evaluation?
Well, that is a loaded question. For now, let’s look at a scenario where the urgent care setting was not appropriate.
Imagine your 70-year-old mother called to let you know that she was having chest and back pain that started that morning. She said the pain worsened after she cleaned the house. Your mother mentioned she had a cold for a few days and thought her chest may be sore from coughing. When she was describing the symptoms to you over the phone, she was audibly short of breath. You mother assured you that the chest pain symptoms were strictly from her coughing, and she was going to call her primary care doctor.
The PCP was able to fit her into the schedule the following day.
A few hours later, your mother calls the PCP back with worsening symptoms. She complained of nausea, was sweaty, and the chest pain was a little worse. The nurse on the phone tells her to go to the local urgent care center for evaluation.
Upon arrival to the urgent care center, your mother checks in with the receptionist and you both have a seat in the waiting room. About an hour later, your mother was called to the treatment area. The nursing assistant that was taking the vital signs was concerned that your mother’s blood pressure and heart rate was high and alerted the nurse. Your mother was whisked back into a room. Another hour drifts by and you see an ambulance pull into the parking lot. The paramedics hurriedly get the stretcher from the back of the truck and enter the building.
The nurse comes to the waiting room and informs you that your mother is having a heart attack and needs to go to the hospital. The nurse explained that there were some abnormal findings on the ECG and her blood work showed elevated troponin levels. Troponin is a protein found in the cells of the heart muscle and when those cells are damaged, the protein is released into the blood. Troponin is not detected in the blood of someone with a healthy heart.
At the hospital, the doctor calls your name and invites you into a conference room. The doctor explains that there was a blockage in your mother’s coronary artery and needed surgical intervention to restore the blood supply to her heart. As she was being prepped for the percutaneous coronary intervention (PCI), her heart went into an arrhythmia, and she was receiving cardiopulmonary resuscitation (CPR). The prognosis was not good, and the doctor asks if you would like to come back and see your mother.
The door opens into the trauma bay where your mother is lying, unresponsive in the hospital bed. How did this happen? How did the soreness from coughing in your mother’s chest result in her being surrounded in a room full of strangers trying to keep her alive? Unfortunately, the team’s efforts to get your mother’s heart back into a regular rhythm was not successful, and she died.
You are left with a million questions running through your head, but you cannot process anything but grief.
Analysis:
This is a 70-year-old woman with a past medical history of high cholesterol, high blood pressure and asthma. She called the primary care provider with complaints of cough, chest pain and back pain. Then called back a few hours later with worsening symptoms and told the nurse at the PCP that she was sweating and nauseated. The nurse sent her to the urgent care instead of the hospital where she could have quickly received the surgical interventions that she needed to open up her coronary artery before and save her life.
The nurse at the PCP had a record of her past medical history which included hypertension and high cholesterol. The past medical history, coupled with her new onset chest pain, nausea, sweating and shortness of breath should have been a red flag to send her to the emergency room for a cardiac work up.
Did the providers at the urgent care center call 911 soon enough? By the time she arrived at the urgent care center, time was critical. The past medical history was unknown to the urgent care providers and the chief complaint was “cough” as entered into the medical record by the receptionist. With a complaint of cough, the nurse did not prioritize that patient in the triage queue. The urgent care providers were at a disadvantage with not knowing those vital pieces of information.
Part of my job as a legal nurse analyst helping the family members navigate the medical records and explain what happened to their loved one. While having the answers will not make a difference in the outcome, it may bring some closure.
