Real vs fake chest pain - page 3

by Findingmynitch | 20,338 Views | 28 Comments

I am relatively new to working in corrections and am at a county jail. One of the big problems I am having is discerning who is lying and who is not.......particularly about chest pain. I am curious with what assessment... Read More


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    I've been a correctional nurse in a state prison for better than 8 years and CCHC nurse so I do understand your situation. Our protocal is to do an EKG on ANYONE incarcerated that c/o chest pain. So what if security gives you "the stink eye" when you do obtain a EKG? YOU are the health care professional, not them and it's YOUR license that is on the line. Your job security comes from giving good care not from the bullies with a badge. If this continues, go see your HSA and report the officers in question. Your license could depend on it.
    Oldest&Ugliest and kd7hfw like this.
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    Ive learned that a very short conversation can help weed out the fakers : basically in my institution "faking" results in a ticket and loss of privileges. Also IMs are charged for medical services 5$ (which is not charged if the complaint is real). So after chest pain complaint I might say "ok, I will bring you to the ER and do an EKG, if its normal you will be charged 5$ and get a ticket. You would not believe how many of them sign the "refusal of medical services" form I always have handy. If they really have chest pain, they will not care about the charge, etc. Our protocol for any chest pain complaint starts with an EKG, so I always give them the option of saying no its not chest pain, and signing refusal on the way to the ER.. that way I am not delaying care if they are not faking. If they are faking but willing to be charged, there is very little you can do - you have to provide care. Thats the nature of correctional nursing .... your patients are criminals. If security interferes, just document the hell out of it.
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    As an agency nurse that fluctuates units I tend to get TONS (up to 10) reported Chest pain cases during the first day of my rotation. The inmates know what s/s to say they are experiencing. I tend to go cellside and do an observation/assessment and go from there. Many of them want a conversation by a new face. Of course I work in a facility right now that is a 24 hour lockdown, one nurse, no provider, and up until now the nurse has been male or elderly.
    A person experiencing a true MI or cardiac emergency are fairly easy to spot. Diaphoretic, vitals abnormal, demeanor off, EKG abnormality, guarding, etc. Usually I have a baseline EKG for comparison so that helps too. If you are familiar with your patient it helps as you can tell if they are in distress and not their "normal" selves.
    tewdles likes this.
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    I look at the big picture, including histroy. Is this a 18yo athletic male vs 55yo obese diabetic male s/p CABG? I always run an ECG on c/o CP. If V/S are normal and ECG neg, I tell them that everything looks good so far. That often weeds out the legit cases.
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    Quote from Multicollinearity
    Just screening vital signs sounds negligent to me. I do a lot of EKGs. I also look at the overall picture. Is the patient diaphoretic? Skin color? Is the inmate just off the daily transport bus, coming out of protective seg. and afraid? Is the inmate displaying signs of using medical to avoid being somewhere else? Does it look like he wants out of the cell block or off the yard?

    We cannot just ship everyone out who claims chest pain, and we've got to walk a fine line. You are absolutely correct that you would be fired if you shipped out all inmates who claim chest pain. A lot of their chest pain is muscular (non-cardiac), from excessive exercise. If it does not appear to be a classic MI which requires an emergency response and MONA, gather all your observations and evidence, call your on-call provider, and let them decide the disposition (i.e. back to cell, follow up with HCP, or ED, etc).
    If you don't have a protocol (which is a severe deficiency if you don't), this post gives you some of the best screening advice you will find. About the only thing I would add is to ask the inmate to describe the pain, and to show you exactly where it is. A lot of inmates point to the esophageal area or somewhere else along the midline, indicating a GI cause. Others describe almost any pain between the belt line and the neck as "chest pain" because they know that it will get a swift reaction.

    Vital signs alone are not enough to rule out an MI. While BP, pulse and respiratory rate should logically be elevated if one is occurring, there are exceptions. Same thing with a depressed O2 sat. In a situation like this, I had rather be accused of doing too much. In addition to vital signs and a physical assessment, we review the chart for any prior cardiac history and run an EKG, then call the provider (if it occurs when there is not one on the premises). Most of our providers have fax machines at home, so they can directly view the EKG and the other assessment findings. before making a decision.
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    As everyone else has said follow protocol. At a minimum gather VS, auscultate, feel the pulse and do the EKG. You're documentation needs to show as much objective data as possible to CYA. Ignore security and their eye-rolling. 99 times out of 100 it'll be malingering but do not chance that 1 person all due to security. Ultimately you are responsible for their care, you hold the license, and you will be the one in court. Not security. Also because of the court bit, make sure to exclude any subjective data like "appeared to be faking." I wouldn't just go handing out aspiring and nitro... unless it's ordered for that inmate. But if you feel you need to give it then you likely need to contact a provider and/or send out to ER.
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    I work in correction and see a lot of inmates for chest pain. Always follow the protocol. Use your nursing judgment. You can always call the on call doctor. You will see a lot of heart burn reported as chest pain.
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    Although our facility has a "chest pain" protocol, it reads as though we treat all chest pain as though it is cardiac. If I tried to follow the protocol to the letter, there would be negative consequences. Our protocol was written to protect the organization. It really does not guide the nurse.

    I wanted to thank all of you for your responses. I learned a great deal from all of them and feel much more confident when faced with chest pain in corrections.
    Last edit by Findingmynitch on Sep 16, '13
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    Work around them long enough and you'll develop a good BS meter, lol. I go from them premise that they're lying until enough adds up to make one reasonably infer that their symptoms are real.

    Look at age, history, and risk factors. Then ask them the same questions many times looking for changes in story. Try to localize the pain and pay close attention to the OPQRST. Provocation and palliation will tell you a lot to differentiate between pulm., MSK, CV, or GI induced chest pain. Take your vitals which may or may not help. I don't have an EKG at work much less ASA or NTG, lol.

    To protect me and the facility, I asked specifically about this when I was hired to take over the clinic. I told the three administrative ranks that are above me on the totem pole that if I felt a CP needed to go to the hospital that I'd send them. However, I promised not to rollover and assume everyone was telling the truth. As I hinted, all inmates are liars. I don't care how friendly or submissive they may act. I reiterated how much liability rested on such a medical complaint, and my number one goal is to protect me from liability followed by my number two goal to protect the agency from liability. The inmate comes third. I've seen jailers get panicky and want to send inmates that I rightfully called bull on. Regardless, we don't pay any medical bill unless the facility somehow caused the injury. If they go to the ER its on the inmate - not the jail.

    I've seen A LOT of people having a MI, and I can't remember any who were being dramatic about it in my roles as a RN or paramedic and add to that MANY medical calls I've been on as a police officer. When the inmate starts yelling, beating or kicking the doors, etc. I infer that they're not having a substantial problem. I love it when they become violent and scream "I can't breathe." If they weren't getting enough oxygen that behavior would quickly subside.

    Truth be told, I really enjoy the job.


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