Achy breaky heart

Worried that a chest pain page at the end of your shift might have heart-stopping consequences? Take 10 minutes to work through this module and leverage your AMBOSS resources!

It's New Year's Eve, the hospital is staffed by a grumpy skeleton crew, and you're nearing the end of your 12-hour shift on a general internal medicine team. At 5:55 pm, you run the list of 20 patients with your senior resident and co-intern. Hopefully it's the last time today. The rest of the team heads home, leaving you to sign out (you pulled the short straw). You haven't handed the pager over yet, and just as you finish signing the last patient out to night float, it goes off.

Click the pager icon to reveal the message.

You shuffle through your signout sheet until you find the patient in question (it's one of your co-intern's patients, of course). Barnard Building! you think. That's all the way across the bridge. Maybe the nurse can just text a picture of the ECG instead of me having to go over there? You consider leaving the page for the night float intern to deal with, but they're already busy—five other pagers are going off.

Question: Since your shift just ended, should you let night float deal with this page?

Make your choice, then click on the explanation bubble to reveal the answer.

• Go home. You're off the clock, right?
• Stay. You know the patient better than night float.

Question: Could you get a picture of the ECG rather than seeing the patient in person?

Make your choice, then click on the explanation bubble to reveal the answer.

• Ask for a picture! Save yourself a long walk to the other building.
• It depends on how many other remaining tasks you need to address.
• You should go see the patient.

You head over to Barnard Building. As you walk down the long bridge dividing the two hospital buildings, you have some time to think through your approach.

Question: What information about the patient should you review before assessing her chest pain?

Keep reading to learn the most useful information you'll need to know about the patient and where to find it.

On the bridge

• Take a look at your signout sheet and brush up on key patient info that can help guide evaluation and management. Focus on the following:
  • Age
  • Code status
  • Reason for admission
  • Past medical history
  • Hospital course
  • Medications
  • Allergies
  • Recent labs
• Begin to think of the differential based on the patient information you just reviewed. There are many causes of chest pain!

Keep your differential broad. Focus on ruling out the most serious diagnoses based on the information you gather before and while seeing the patient.

You arrive at Barnard Building to find the nurses in the middle of their own signout. You can tell from their expressions who's in a rush to leave the unit and who's planning on ringing in the New Year by watching the ball drop on TV in an empty patient room. You hope you won't have to join the latter group's celebration. You find your patient's nurse signing out his patients to the overnight nurse near the break room.

Question: Now that you've found the patient's nurse, what should you do?

Make your choice, then click on the explanation bubble to reveal the answer.

• Wait for the daytime nurse to finish his signout to the incoming nurse—you don't want to be rude!
• Politely interrupt the nurse's signout, introduce yourself, and ask for more details about the situation. Then ask both nurses to accompany you to see the patient.

Sometimes a patient may decompensate during shift change. While it's unlucky timing, a potentially decompensating patient with chest pain warrants immediate evaluation.

You and both nurses arrive at the patient's room.

Question: Which of the following can you immediately assess from the doorway?

Make your choices, then click on the explanation bubbles for more information.

• General appearance
• Mental status
• Signs of cardiorespiratory failure
• Vital signs
• Level of pain or discomfort

That's right—all of the above! You assess these details in a matter of seconds. Impressive!

“Failure is not an option.”

Question: Which clinical scenario would you like to explore?

Choose an option to continue the module.

• Option 1: Cardiac emergency
• Option 2: Chest pain with stable vital signs

You leave your patient's bedside knowing that they are stabilized and not on their way to Heartbreak Hotel , much to the relief of the night float and the nurse taking over the patient's care. Good karma will follow you as you ring in the New Year from the comfort of your own home. Though, realistically, you'll probably be in bed long before midnight!

• You did an excellent job:
  • Stabilizing a patient with a potentially life-threatening condition instead of handing them off at shift change (Option 1)
  • Starting with a broad differential diagnosis and narrowing it based on the available information (Option 2)
  • Communicating effectively with the nurse to provide the best patient care possible

Congratulations on completing this module. Hopefully you now feel more comfortable assessing a patient with chest pain!

Personal story from an AMBOSS clinician

I was on my house chief rotation during my third year of residency. Overnight, the house chief was responsible for running codes and rapid responses, triaging admissions from the emergency department, and assessing “extra sick” patients signed out to night floats by the day teams. One night, I got an urgent page about a patient in another building. The patient was hospitalized for an elective orthopedic procedure and was due to be discharged the next day. He was having substernal chest pain and, since the nurses on the orthopedic floor were not used to managing chest pain, they called a rapid response.

On initial evaluation, the patient was conscious and appeared fairly comfortable. An initial ECG was normal. However, as we continued running the strip, he developed ST elevations in leads V1–V6, and then progressed into ventricular fibrillation and lost consciousness and his pulse. Luckily the rapid response team was all assembled, and we coded him according to the ACLS algorithm.

We managed to regain a pulse and stabilize the patient. Our team contacted the on-call cardiology attending, who was able to take the patient to the cath lab within 30 minutes. The left anterior descending artery (LAD) had an acute blockage that was revascularized during percutaneous coronary intervention. The patient was well enough to be discharged two days later.

The quick and efficient actions of our entire team allowed the patient to recover from a massive myocardial infarction even after he decompensated and literally died for a few minutes. Everything came together like clockwork that night, and it was amazing to see our patient walk out of the hospital after that ordeal, knowing that if he'd been at home, the outcome probably would have been very different.

The lesson I learned: A rapid response to chest pain can really make the difference!