Chest Pain Evaluation by EMS Personnel

One of the most important things we do in EMS is to evaluate patients having non-STEMI chest pain. In our protocol at the Columbus Division of Fire, we are to suggest and offer transport to the hospital for anyone who is experiencing or has had recent onset of chest pain. This is in our protocol because there are several causes of chest pain that are life-threatening and require emergent medical evaluation and treatment in a hospital setting.

There are several things to keep in mind in evaluating the patient whose presenting complaint is chest pain. First, the patient will usually want you to tell them the cause of their chest pain is not their heart. In fact, if they are reasonably rational and not hypochondriacs, they will look to you, as the most experienced and knowledgeable medical expert at their immediate disposal, in hopes that you will be able to determine there at the scene that their chest pain is just indigestion or some chest wall pain. Unfortunately, you do not have the proper tools at your disposal to make that determination. Though you can do a 12-lead EKG, even if that shows no obvious sign of myocardial infarction, that does not rule out the possibility the patient is having a heart attack, aortic dissection, pulmonary embolus or pericarditis. The whole expression "chest pain" is really up to the patient's interpretation. What is actually "pain"? For example, a patient having chest pain may say, "Well, it's really not a pain, but more like a pressure." Or they may describe it as a discomfort, misery, burning, tightness, piercing or just an unsettled feeling in their chest. Sometimes the pain is not even in their chest but in their jaws, shoulders, back or epigastric area. Any of these cases could have a cardiac source until proven otherwise.

The manner in which feedback is conveyed to the patient is extremely important. You have to be very deliberate and clear as you explain the severity of their condition to them. If they only hear things like, "Well, I don't see anything obvious on your EKG," then they will hold on to that statement and ignore the other things you say, like, "But we can't be sure unless you go with us to the hospital." The way in which you communicate your findings to chest pain patients is crucial to their ultimate decision to be transported. Remember, your goal is to get them safely to the hospital, so they can receive further evaluation.

Many patients with chest pain may be scared, confused or in denial. They may try to convince you their problem isn't their heart. When you start to evaluate and treat a patient experiencing chest pain, begin by instituting all the prehospital therapies you are authorized to begin. This includes (not in order of priority) oxygen, cardiac monitor, 12-lead EKG, IV, sublingual nitroglycerin, morphine, aspirin and IV nitroglycerin or paste.

It becomes more difficult for a patient to refuse when you have begun your treatment and they are hooked up to a monitor, IV and oxygen tubing. So the first question not to ask the chest pain patient when you walk through door is, "Do you want to go to the hospital?" In most cases, they will say no, or not know what to say. Your attitude and demeanor upon first interaction will set the tone for all your subsequent dialogue. If you give a first impression to the patient that their chest pain is bogus, they might believe you--because you are the medical expert and also because the patient usually wants to believe their pain really is noncardiac.

Leaving someone with chest pain who refuses transport at home is a very high-risk thing to do. Do everything you possibly can to try to get the patient to go to the hospital. This may involve getting the patient's family members or loved ones involved in helping persuade them to go. It may not be too severe or dramatic to tell the patient there is a possibility they could die if they don't go to the hospital. But as long as the patient is capable of making a decision and does not have an altered state of consciousness (due to alcohol, drugs, hypoxia, senile dementia or other factors), they may refuse transport. In that case, you need to make sure your documentation is extremely thorough and complete, including but not limited to the standard patient refusal. You may need to fill out an addendum to your regular report if you cannot adequately express the nature of the call in the narrative section the regular report provides.

Chest pain evaluation is a relatively imprecise and high-risk process even in the hospital setting, with x-rays and cardiac enzymes. In the prehospital setting it is even more dangerous. Whether it's 2:30 in the afternoon or 2:30 in the morning, always remember that the patient with chest pain is having a cardiac event until proven otherwise, and you can't prove that one way or another in the field. Your job is to do your best to persuade that patient to let you take them to the ED while you institute the therapeutic interventions afforded to you by your protocol or base station.

David P. Keseg, MD, FACEP, is medical director for the Columbus Division of Fire EMS in Columbus, OH.