chest pain, you said?

There once was a patient of a notorious past who came to the ER. CC is chest pain. Admit to telemetry for monitoring. Because of the chest pain complaint, orders include morphine 2 mg q4 hours, for chest pain. Enter nurse on duty. Asks patient if they are having any pain. Patient replies, not all the time, but my left arm hurts right now. Patient points to left forearm. Nurse asks the standard, on a scale of 0-10, how do you rate that pain? Patient replies with a 4. Nurse asks patient if they are having any chest pain at the moment. Patient states no. Nurse tells patient that they will get some Tylenol for the pain this time because when they go back to their 'home', they will not get morphine there. Patient receives tylenol. Nurse charts tylenol administration and documents the pain to arm and absence of chest pain.

Because pain with medication adminstration must be followed up, the nurse goes back into the patient's room to find out how effective the tylenol was. Patient states that it has not helped at all. Patient goes on to state that they said they were having chest pain the whole time that went from the heart all the way to the left arm. Nurse asks patient if they are having chest pain right now. Patient states that it is always present, that they have a 75% blockage of such and such artery. Patient states that when they were a patient at the awesome hospital, they got morphine every hour. Patient then begins to writhe around in the bed. Nurse has no choice but to go and get the morphine for the patient, who states that they are having chest pain. It is ordered. Has been more than 4 hours since the last administration. Patient is given the 2 mg morphine IV. Meanwhile, VS of T 98.7, HR 77, RR 20, BP 118/68.


Heart rhythm looks like this:

No ST elevation. Not even ST depression, as might be expected with ischemic pain. Patient is s/p cardiac cath x 8 weeks. MD is informed that patient is continuing to have chest pain. MD decides to ship patient out to hospital that performed the cath. Nurse hugs MD (not really, but she wanted to).

Fast forward two weeks.
Above patient arrives in er with seizures. Admitted to telemetry unit for observation. Has ordered tests, such as EEG, etc. Tests are negative. Neurologist tells patient that it is probable that they will be sent back 'home' today. Patient begins to have seizures again. This nurse was called in by 'friend watching over the patient' for a seizure that lasted for 15 seconds. Charge nurse then comes into room and patient begins 'seizing' episode again, in a tonic-clonic fashion involving mostly only the legs. Episode lasts 20 seconds. Immediately after episode, patient is awake and alert. No post-ictal confusion/sleepiness/nothing. Charge nurse calls neuro, gives ativan as ordered, and prepares to transfer patient to higher level facility per order. No further seizing episodes are noted after that point.

How come every time the patient was about to be sent back 'home', their problems suddenly got worse and also these problems required subsequent narcotic medications for relief? It is just frustrating to be manipulated by the system. Not saying that this patient did not actually have chest pain or that this patient did not actually have seizures. But I have yet to see a tonic-clonic seizure without some form of a post-ictal phase, even if it is just a short period of confusion. Maybe it happens? I don't know. The chest pain incident was just a ploy to get morphine. Yes, I believe that. But on the floor, we are required to treat to patient stated pain. Not too many chest pains, especially chronic as stated by this patient, have a beautifully normal sinus rhythm without any ectopy.

But there are 2 things that will get you sent to the hospital from this patient's 'home', and that would be chest pain and seizures. Sigh.