The two women sat quietly in a corner of the busy ED, almost lost in the business of people being shuffled off to get labs and x-rays. The elderly woman sat with her head bowed in prayer or pain while the younger woman looked anxiously at her. Even though the chief complaint was “chest pain” she had been brought in her daughter’s private vehicle instead of an ambulance. When the intake nurse heard that they had come from the county courthouse where the older woman was a witness in a civil trial, she had nodded knowingly and written down “anxiety” on the chart as the chief complaint. The triage doctor had “seen” her within minutes of her arrival, but he was being crushed by all the ambulance patients lining up in the hallway. So he told the PA to do a “cardiac workup” and rushed off to see another, more serious patient.
Even the PA was too busy for this anxiety case to get much more than a passing history. So there they were, sitting in the post triage waiting area. She had been seen by a nurse, a doctor, and a PA. The initial EKG didn’t show any ST elevations, but also had deep Qs in V1 and V2. The computer noted “Consider anteroseptal infarction”. It had been signed quickly by the EP, but essentially disregarded in light of her anxiety and age.
“Is your chest still hurting, Mom?” the younger woman asked the octogenarian.
“I think I’m just fine…but it does still hurt a little,” she said with a forced smile as she patted her daughter’s hand reassuringly.
“Miller!” the tech almost shouted to the crowd in post triage.
“Here,” the younger woman said as if dutifully answering the teacher’s class roll call.
“Follow me,” the heavy set woman in scrubs said blandly and started to walk away.
“She’s really not feeling well,” the younger woman said plaintively. “Couldn’t she get a wheelchair?”
The tech spun around to reveal her irritation, but relented when she saw the frail old woman. “I’ll be back,” she said with a mild huff, and disappeared as rapidly as she had appeared.
“Is the pain still in your arm, Mom?”
“Not so much,” she replied softly. “But now it seems to be up in my throat.”
“Does it feel like indigestion?” her daughter queried trying to reassure her.
“I’m sure that’s what it is,” the old woman said nodding her head.
When the tech returned with a wheelchair for the elderly woman to walk over to, her daughter asked, “Should she be doing this with her chest pain?” The tech just shrugged. So the daughter turned to a random nurse who was walking briskly by, “My mom is having chest pain. Is it OK for her to go down to x-ray?”
At first the nurse seemed alarmed at the question and annoyed at yet another interruption. “I’ll go get the doctor,” she said.
The daughter had barely sighed her relief when the nurse returned and said cheerily, “The doctor knows about her. She’s fine.” And rushed off before the daughter could reply.
“Just wait here,” the tech said perfunctorily. “It won’t take long.”
“Are you OK, Mom?” The older woman just grimaced.
True to her word, the tech returned to Mrs. Miller in a few minutes. Just in time for another technician to shout her name again. “I’m here to take you to the lab,” the young girl in scrubs announced cheerily.
“Isn’t she supposed to have some aspirin or something for her pain?” the daughter asked.
“I don’t know about that,” came the reply. “I’m sure they’ll give her something when she gets to a room.” And without further opportunity to protest, the technician wheeled the patient away.
With similar efficiency, the patient was soon back with bandaids on her arms. But now, even her patience was beginning to wear thin. “I really don’t feel well,” she confided softly to her daughter. “I wish I could lie down. I’m feeling a little faint.” Before her daughter could rise to protest to another passerby a nurse came around the corner and again announced: “Mrs. Miller?”
“I think she needs to lie down,” the daughter said with concerned frustration. The experienced nurse, sensing the potential catastrophe that was brewing moved quickly to wheel Mrs. Miller to the Main ED. The daughter looked at her watch and even though the intake and triage area seemed very efficient in their busyness, a little under two hours had passed since their arrival.
“Has she had any aspirin yet?” the PA asked, finally arriving to examine the patient.
“Nothing,” the nurse replied while quickly hooking her up to the monitor and hanging the bags for a potential IV.
“We’re going to give you some aspirin and some nitroglycerin, Mrs. Miller,” the PA said loudly assuming the elderly woman to be hard of hearing. Within a minute the nurse had administered both. Within another minute the patient began complaining of a severe headache and worsening chest pain. “I think I’ll get Dr. Andrews involved,” the PA said with tamped alarm. “Can we get another EKG?”
Soon the whole group was at the bedside looking at the second EKG. A single millimeter of ST elevation was now evident in V1 and V2. “When did this all start?” the doctor asked Mrs Miller somewhat confused. Before she could answer he turned to the PA: “And excuse me; why are you seeing this patient? I thought you were in Fast Track.”
“I was over at the court house,” the little lady warbled, cutting off the PAs attempt to defend herself. “We didn’t hit anybody and the lawyer was trying to say that my husband caused the accident. We were just sitting there. I would never lie. The lawyer just kept shouting at me. I just got so confused. And then my arm started hurting.”
“I’ve never liked lawyers,” the doctor said to the nurse. “But beating up little old ladies on the witness stand really takes the cake. I think we better alert the cath lab. Mrs. Miller,” he continued, “it looks like your EKG has changed since you arrived here. We probably ought to take a look at the blood vessels in your heart. You might be having a mild heart attack.”
“I wondered if that was what it could be?” she answered. The PA and the patient’s daughter looked at each other in frustration. Within a few minutes a cardiologist appeared and spoke briefly with Mrs. Miller. Despite the questions about her pain, she continued to defend her testimony on the stand. Soon she was gone to the cath lab and the PA returned to Fast Track.
“90% LAD lesion on that little lady from the court house,” the cardiologist said to the emergency physician as he passed on his way out the door to the parking lot. “But she’s doing fine now. By the way, how long was she here?”
“Too long,” he replied with a hint of embarrassment. “She came by car and got triaged as an ‘anxiety’. She might have even had her infarct sitting in the waiting room. I think we might have just dodged a bullet on this one.”
“Hey, you know what they say, my friend,” the cardiologist said with a forgiving shrug. “Sometimes you’re good. But it’s better to be lucky.”
“And excuse me; why are you seeing this patient? I thought you were in Fast Track
Um, because the doctor told the PA to see the patient?
PAs in our ED care for chest pain patients without being questioned why. Even in the fast track portion we get overflow of all types of patients. I hope this comment will not give patients a reason to believe we PAs are incapable of caring for them.