Too Many Chest Pains

There are at least 50 words in the Eskimo languages for snow, 25 in mainstream Swedish, and supposedly 180 or so in the Sami language of the nomadic inhabitants of the northernmost parts of Norway, Sweden and Finland.

But there are even more words than that for “chest pain” among my patients, many of whom do not consistently or fully comprehend the English phrase “If you have chest pain, call 911 or go to the nearest emergency room”.

This Saturday I had three serious cases of chest pain, but of course they all used different words, like “empty feeling”, “tightness” and “pressure”.

“The medical term is PAIN”, I patiently explained to all three. They all had normal EKGs. “Thirty years ago that would have been more reassuring than it is today”, I told each one of them. “But today we have blood tests that can show heart muscle damage that doesn’t ever show up on an EKG. So today’s standard of care is that you get to the emergency room where they can do these blood tests.”

One patient got pain free after a “GI cocktail”, which numbed his irritated esophagus, so I agreed to leave it at that, with a caution that new pains might require urgent reevaluation. Another agreed to go to he ER, declined the ambulance and seemed to understand my concern that his wife could find herself transporting a medical emergency patient singlehandedly on a winding road with sketchy cell phone reception. His wife also understood. The third patient accepted the ambulance, and left the building accompanied by the attendants, only to part company with them in the parking lot.

My compliance officer, after I told her we’ve got to figure out how to discourage Walk-in chest pains with our Saturday skeleton crew, asked about legal risk when the two most recent cases declined the ambulance. I wasn’t worried; the first one I counseled thoroughly, and the second one left the building in the company of EMS. Once EMS takes over, my responsibility ends, that’s well established, no matter what qualifications the doctor in the field has.

We have posters, pamphlets, mailings and all kinds of communications that encourage coming to see us for nonemergent medical problems like coughs, sparing, earaches, rashes and the like but to quickly get ER care for chest pain, severe shortness of breath and the like.

Every month at our Quality Assurance meeting we look at how many ER visits in our patient population could likely have been handled in the office instead. I don’t have statistics on how many people delay care for a serious cardiopulmonary condition by insisting to be seen by us first, but it sure happens.

We definitely need to do more training with front desk staff about this, but I know many patients will not admit to the receptionist that what they have is chest pain; they will try some of the other words instead.

So before Saturday, I think I’ll have to come up with some new, catchier posters about the fact that they all mean the same thing: PAIN.

And that in turn means: NOT HERE.

4 Responses to “Too Many Chest Pains”

  1. 1 Will July 31, 2018 at 1:47 pm

    As a Paramedic, I would use a string of adjectives so that they could chose. Because we were missing a lot of accurate answers when the pts were confined to “pain”

  2. 2 jane August 15, 2018 at 7:28 pm

    Let me give you the flip side of this: Last year my husband went to acute care with bronchitis. Almost every winter, at least once and often for weeks on end, he suffers respiratory illness whose symptoms include burning pain in the bronchi on coughing. His dimwitted former PCP used to label this illness “pneumonia” every winter and dish out Cipro plus steroids (yes!). So hubby told the acute care people that “he had pneumonia”. I winced, because of course it triggered “How do YOU know THAT?” sneering from all who heard it.

    Having pigeonholed him as an unreliable witness, they plainly ignored his description of symptoms and told him that because he Had Chest Pain, he needed to go to the ER for a Cardiac Workup. Note: Our insurance company refuses to pay for ER visits for a non-life-threatening illness; they did not ask about financial toxicity risks. The non-MD provider was being shadowed by a med student who claimed confidently that angina could feel exactly like bronchitis. Did this imply that every time anyone gets bronchitis, even if it’s five times in a winter, he should get the Cardiac Workup every time?

    We assured them that if he were treated for a respiratory illness, we would not sue in the 1/1,000,000 event that it was not; the response was open, contemptuous disbelief. The paperwork they gave us upon departure stated that he had been advised to go to the ER for “chest pain and pressure”, which was a lie as he had explicitly denied feeling pressure. Incidentally, the urgent care clinic was owned by the hospital he’d have gone to.

    Conclusion: We did not rush to the ER, hubby did not die, and there is still money in our savings account. Win-win!

  3. 3 Jessica Parker August 17, 2018 at 7:17 pm

    Just curious why it should just be one word to describe several different feelings. Yeah, there may be some chest PAIN but when it comes to describing something that is happening it can make a difference if it’s tightness or out of breath or an empty feeling. Also, the opening to this is eskimos have 25 different words for snow because they are always around snow and that specific word for “impacted snow” or “slippery snow” , “wet snow” etc. makes a difference when it comes to what needs to be done in the situation.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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