Mr W is a 70-something obese gentleman. He was first on my ward in late August- early September. He'd been admitted with chest pain. One at a time we ruled out the more serious causes.
ECG - normal; troponins - normal - probably not a heart attack; "Don't worry Mr W, its not your heart".
V/Q scan - machine not working; CTPA - patient cannot tolerate scanner, although scanner can tolerate his weight; echo - no right heart strain*; "Don't worry Mr W, its probably not your lungs".
Sigh of relief. Not one of the biggies.
But at least twice a day, I would be called to see him. "Its me chest, doc" and I would be assured that this was the worst pain ever. And at least once a day, I would order an ECG, fearful of missing an MI. All other times I would check his obs (his heart rate and blood pressure never changed, even tho he claimed to be suffering with the pain) and then reassure him and get him additional pain relief.
In the meantime, I'd trawled through his notes. Chest pain was a big feature in his hernia-inducing set of notes. Each time the same thought process had been followed - to finally send him home with more pain meds. I also noted he had fibromyalgia.
I took hint and called the pain team.
The next day, he was reviewed and started on a new medication. And then we sent him home, with a suitcase full of his meds - most of which were for pain - surprise, surprise.
A couple of days later his GP called me. Terrified that he was calling to let me know that he was re-admitting Mr A, I geared myself up to deal with an insistent GP. Instead I found that he didn't know that Mr A had been discharged. He had rung to ask me to get Mr A seen by the psychiatric team while in hospital as he never seemed to be home long enough to be seen as an outpatient. Too late! His GP agreed to try and sort it out quickly.
Then about six days ago, I was writing out a TTO, when I overheard one of the nurses taking handover for a patient who was coming to our ward. "Name? A; ....chest pain......normal ECG".
I knew it was him again.
From the time he came to the ward, we've been trying to send him home. After all, it has been ruled out that the chest pain that brought him in was not cardiac. But he assures me that if we send him home, all he has to do is call the ambulance and come back.
I can understand his fear that it is cardiac. But he has had this pain for quite a while, and from his description, its quite different to cardiac pain. However, no amount of reassurance or pills seem to help. The consultant has decided not to discharge him til he has a psych review.
In the meantime, I've become immune to his chest pain - I asked the nurse to check his obs, but thats it. I'm not running around to get an ECG or bloods done. There are better things to spend the NHS' limited resources on. Bad enough that he's occupying an acute medical bed, without an acute problem.
I have a fear lurking at the back of my mind, that one day an MI is going to be missed.
But its his fault. He shouldn't have cried wolf.
*pulmonary embolus aka blood clot in the lung - two direct tests: a V/Q scan (involves injecting one type of radioactive isotope and then inhaling another and seeing whether the difference between the two images is different), a CTPA (a CT scan of the chest using an iv contrast); if not one can use a blood test to look for the break down product of blood clots (d-dimers) - but not used in this hospital; or an echo to determine whether there is any right heart strain - caused by resistance in the vasculature of the lungs.
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