Some Things to Say (part 2)

 

Chest pain. It’s our favorite thing to ask about and maybe our favorite thing to find. Never more does EMS get its chance to shine than when diagnosing the acute MI, and chest pain is how we start down that path. In many cases, everyone from the vomiting drunk to the elderly broken hip gets asked about their chest.

But next time you throw in, “Any chest pain?”, consider this. Not only do many heart attacks fail to present with chest pain at all, even among those that do, the specific symptoms may not amount to what your patient considers “pain.”

Pain means different things to different people. What I call pain, you might call discomfort, and my girlfriend might call a funny feeling. Tightness, palpitations, burning. Trying to list it all would leave you on scene for 20 minutes with a thesaurus, but if you don’t find the right words, then the answer you get might simply be “no.” And you’ll miss the big one.

The solution is in one magic phrase:

 

How does your chest feel?

I learned this gem from Captain Kent Scarna of Boston EMS, and it joins the ranks of the most useful assessment tricks out there. Because despite all the ambiguity in the chest, this one pretty much captures it all. If there’s frank pain, the patient will tell you all about it. But if there’s fluttering, itching, a feeling like they just ate a canary, this invokes that too. As a diagnostic screening, it is appropriately vague. There is a time and a place for direct questions, but when it comes to chest pain, starting off open-ended is the way to go.

How does your chest feel? Fine, it feels fine. Okay then. If you’re truly concerned you can follow up to confirm — “No pain or discomfort?” — but there’s no need to break out the Webster’s. It’s sensitive but specific; it casts a wide net, but it still unpacks fully. What else could we want?

More things to say in part 3

Comments

  1. Your central point is well-taken and one more contribution toward helping medics identify elements of the art, along with the science. Much of our art IS our language.

    Yet, I’M even surprised at my response. When I read your blog my first image was a Caution Sign!

    Why? For fear of a female patient taking the question (“How does your chest feel?”) other than as a professional query.

    Really, all that would amount to is a stumble in the continuity of assessment and care, taking a little time away from it while you communicate that you’re clear on where you’re coming from or she figures out there’s nothing to even think about. But, let’s face it, some people, not only women! are very sensitive to wording and having been abused in the past, if there is ANY ambiguity, the first place they’ll go to is suspicion.

    Maybe that’s a little far-fetched, I’ll cop to it. But I have a nuance to share; I’m talking about establishing a flow with the patient and making sure it keeps flowing!

    Since communication includes so much more than verbal cues, how about adding to the question (keep it intact) placing your own hand, fingers splayed, over your chest, indicating the region specified and, on another subconscious level, putting your energy toward yourself rather than directing it toward her. (Shift pronouns according to your sex.)

    It’s (literally!) a hand-to-heart gesture that is an effective tool that helps to establish rapport and confidence in your interactions with patients. You don’t have to offer a word, but try it on a call at the moment you feel you’re losing the patient’s trust.

    In this case, the gesture does double-duty as it is also clinically SPECIFIC.

    Great tools to work with, Brandon, the box can never have enough!

    • You know, now that I think about it, I often do throw in some kind of gesture along those lines. It’s admittedly a somewhat left-field question, and a little cueing helps. I’ve never had any problems with serious misunderstandings, as long as it’s asked in the context of a professional and serious medical assessment. The worst I’ve gotten is the occasional odd look, and when you see that, you can start chucking some adjectives to help ’em understand what you mean.

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