Yesterday, I was working in a community health center where I do a few shifts a week. A woman came in complaining of chest pain, and although there were more than three dozen people waiting for scheduled appointments, we had to bring her into the pods and assess her right away. We generally discourage people from coming to the health center with acute complaints that should warrant a call to 911, but sometimes people show up on our doorstep and we have no choice.
Although we could have simply called 911 and waited for the EMTs, the doctor who was available at the moment decided to take some action before we made the call. Per protocol, we gave the woman (who has a history of heart disease and angina) a sublingual nitro, a baby aspirin, and some Maalox (just in case it was heartburn causing the pain---she has a history of severe GERD).
An ECG showed no acute changes, and since we have access to her medical history from the nearby hospital with which we are affiliated, we were able to see previous ECG readings, all of which demonstrated for us that this was most likely not an MI. Her BP was stable, her pulse was bounding and rapid, and she was hyperventilating and very diaphoretic. She also speaks no English and was extremely emotionally distraught.
I tried to comfort her in my pidgeon Spanish, but a bilingual medical assistant came to the rescue and we talked her down to a calm state after the electrodes were removed. We told her we were calling the ambulance to take her to the ER for an evaluation, and she adamantly refused, stating that she would not go under any circumstances. We persisted, but she persisted more strongly, and the doctor agreed that we could refrain from calling 911 if we kept her for a while monitored her closely, and checked her vitals every 15 minutes for 90 minutes. (Just what we needed on a busy Friday afternoon before a long holiday weekend!)
Anyway, we learned that both of this woman's two teenage sons were arrested this afternoon for drug possession, and she was absolutely distraught and panic-stricken. She is very attached to her sons, has tried to keep them out of trouble despite the neighborhood and the prevalance of drugs and violence, and she wants nothing more but for them to go to college and make a better life for themselves. The arrest came as a complete surprise---they had no prior history that she was aware of----and she was completely devastated. She had been brought to the health center by her neighbor (who really should have called 911 instead) and the neighbor had simply left her in the waiting room and disappeared, probably to play Bingo at the senior center.
After 90 minutes, her vital signs remained stable and she was relaxed and laughing with us. Despite the stress of the afternoon and the impending long weekend, we took the time to assuage this woman's fears and help her to see that maintaining calm and clarity of mind would truly serve her better than allowing herself to fall into hysterics. She herself said that she didn't know what else to do but fall apart, and by the time she left, she realized that she truly could make another choice.
Before she left, the doctor gave her a presciption for five tablets of Ativan (0.5 mg each) for her to take as needed if the anxiety and worry became too much. She was also urged to call her therapist after the holiday weekend and rescheduled the appointment she had missed this past week. As for the chest pain, we allowed her to go home rather than to the ER (since she would have refused the ambulance ride anyway), and we documented her refusal to go, asking her to sign that she indeed was refusing to be transferred to the hospital for further evaluation.
It was an intense moment, and we worked very well as a team, even though we were under such pressure to see the dozens of patients in the waiting room, some of whom had been waiting for hours.
The problem with this scenario is that we in effect reinforced for patients that they can simply walk into the clinic for acute care ( like a chest pain complaint) without an appointment, disrupt our patient flow, use valuable resources that we need in order to see scheduled patients, and then refuse to be sent to the ER for a proper evaluation. In some ways, in our desire to be kind and accomodating, we empowered the patient to take care of herself, but we also empowered her to know that she can come into the clinic and be cared for on the spot without an appointment, putting us in a very difficult position as clinicians.
We will discuss this scenario as a team, and perhaps make some decisions about how to handle similar situations in the future. Perhaps we will decide that all chest pain complaints will simply necessitate a call to 911, no questions asked, and we will just monitor the patient until the EMTs arrive. Ambulance rides and ER visits are expensive, we know, and we are acutely aware that sending someone to the ER unnecessarily is a huge waste of resources. Still, as a community health center without the means to properly evaluate every acute complaint like chest pain, we also have to protect ourselves from legal recourse if we make the wrong decision in such a situation.
There is always so much to consider and so much to learn in medicine and nursing. This was a case of taking action and assessing a situation and then making peace with our choices. Did we do the right thing? Our patient certainly thought so, but for the patients in the waiting room who waited even longer to be seen for their scheduled appointments, it was just another day in the inner city community health center.
