Life threatening situation? Always call 112

Case description  

by Lucia van Vliet and Yvonne Jansen – general practitioner and triage nurse Regional Commission of Inquiry into incidents and calamities

A 61-year-old man calls the post office on a Sunday morning with the complaint that he has been suffering from a burning sensation in his chest for a day. The Friday before, he had also made an appointment with his own doctor, but had not shown up because the symptoms were diminishing. The triage nurse ends up with a U2 and consults with the directing physician, after which Omeprazole is prescribed. The patient falls asleep later on the couch. When his wife tried to wake him up for dinner, she found him cold and blue. The lady called 112 but when the ambulance arrived, the paramedic found that the gentleman had been deceased for some time.

Lessons from the case
Chest pain is and remains a very difficult complaint to assess. We all know the classic symptoms of ACS (Acute Coronary Syndrome): oppressive chest pain, radiation, nausea, clammy. However, much more often we see people with chest pain, not so much pressure, no radiation and no vegetative symptoms. Then you can’t rely solely on the complaint, but you need other factors to estimate the chance of an ACS.

The run-up
Patient had made an appointment with the GP the day before, but had not come because the pain had disappeared. Keep in mind that this may have been a run-up with unstable AP. The history of the own GP also included the diagnosis of stomach complaints. As a triage nurse, it can be a pitfall to rely on past diagnoses.

What else can we learn from this case?

The presentation of complaints can be very broad and vague. Therefore, pay sufficient attention to the run-up, severity, prevalence of CVD and whether there are findings that actively support an alternative diagnosis.

  1. The severity of the pain: patient has not slept. So it’s a lot of pain. Is this more appropriate for heart problems or dyspepsia?
  2. Because of not sleeping, the patient probably sat upright: stomach problems would be reduced. Was patient known to have stomach upset?
  3. Patient’s age (in this case 62 yrs): there is a high prevalence for CVD.
  4. He describes the pain as burning. Some types of pain (stabbing pain, pain localized to a limited area, local pressure pain, pain attached to breathing, and postural pain) make an ACS less likely. However, burning pain is not mentioned in this list. Burning pain does not rule out an ACS.
  5. Don’t be fooled by a laconic, easily reassured patient. Listen to your gut feeling. If you feel that the story is unclear or does not fit into the whole, consult with the doctor and have the patient assessed.
    In addition to the classic symptoms, Thuisarts.nl also mentions that sometimes there is no pain in or on the chest but, for example, only pain in the arms, neck, jaw or back.
    – Complaints that occur more often, but not exclusively, in women, people with diabetes and older people:
    0 Shortness of breath;
    0 rapid breathing;
    0 extreme fatigue;
    0 dizziness;
    0 indefinable sensation in the chest.

NTS Usage
After triage the complaint, the triage nurse arrives at a U2 – after all, the patient had complaints from POB. After an investigation by the Committee of Inquiry into the sensitivity of the NTS, it has become clear that it is correctly adjusted. If in doubt about the urgency, always discuss this with the directing doctor. It should be clear in the question what urgency you end up with and why you want to scale it down or up. Never scale down more than 1 urgency! It is important that you never make a diagnosis yourself on the phone, so listen without judgment and with an open mind. The judgement is up to the GP.

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