Real vs fake chest pain

Anna Flaxis, BSN, RN · Jan 12, 2012

What I am currently seeing one of the more experienced nurses doing is the following:
Check VSs; If normal, the assessment stops, and it is assumed it's anxiety or faking.
If VSs are abnormal, an EKG is done. Then if the EKG is abnormal, the doctor is called and the protocol is instituted.
I just perceive there to be a lot of liability with this approach. VSs alone don't seem enough to R/O an MI........and is doing an EKG enough to R/O an MI?
I guarantee that if I send out every inmate with chest pain, I will be fired.
I have been doing EKGs of everyone with a C/O chest pain, and custody is beginning to give me dirty looks. I want to be thorough and careful, but I would also like to keep my job.

No, an EKG is not enough to rule out MI. Not all MIs cause EKG changes.

A helpful mnemonic for assessing chest pain is the PQRST mnemonic:

P- What Provokes the chest pain? Is there anything that seems to make it better? Worse?

Q- Describe the Quality of the pain. Cardiac chest pain is *almost never* sharp (although the pain a/w pleural embolism, a medical emergency, can be).

R- Does the pain Radiate? Not all cardiac chest pain radiates to the left arm or jaw, but can sometimes radiate through to the back or across the entire chest.

S- What is the Severity of the pain on a numeric (1-10) scale? How does this compare to previous MIs (if the person has a history of MI)? Do keep in mind, though, that the stated pain level does NOT always correlate to the severity of the MI.

T- What Time was the onset of symptoms? How long did it last? Is the pain still present?

Keep in mind that even if the chest discomfort does not "sound" cardiac in the classic sense, this does not rule out the possibility of MI, or any number of other possible etiologies that can be just as life threatening, such as pulmonary embolism, pneumothorax, aortic dissection, or acute cholecystitis (not an immediate life threat, but it will become one if left untreated). Even if it turns out to be pneumonia, the inmate will still need treatment for that.

Anxiety can certainly be a cause of non-cardiac chest discomfort, but it is only one of MANY possible causes. Just because MI sounds unlikely does not mean that the inmate does not have *something* going on that needs to be diagnosed and treated.

Mapam · Jan 13, 2012

You were right on the money! I gained more insight from your response and try to post this(emphaise try as i just lost my orginal respone to u) for my peers to read- Nursing check #1. Assesment right on

MassagetoRN · Jan 16, 2012

I work at an acute care hospital that has a locked down DOC floor, where the inmates are sent when they are shipped out. We know the ones that are fakers:

1. Frequent flyers with negative work-ups (over and over and over)

2. They are "allergic" to morphine, ASA, NSAIDS, demerol (even though they don't know that we don't use it anymore). They just want Dialudid or say that 2mg of morphine won't touch them (even though 2mg is the chest pain dose...)

3. They throw a fit and want to leave AMA when they see that we have no TV, clock, and that they're 2 pointed to the bed behind a locked door. They get 3 hots and a cot. We aren't waitresses to provide snacks, juice, coffee, etc. all night long. Also, they usually want AMA when they see that they aren't going to see the Dr until he rounds later in the morning (I work nights, when most admits happen). We see alot of miraculous healings!!

Inmates are slick, they talk and they know what to say and how to act to fake an MI. And they know that we have the check out chest pain seriously. Some will even not take their KOP meds or take other's KOPs in order to get to medical. Once they realize how strict we've gotten at the hospital, the fakers have really subsided..... Now if we could just cut down on the abcesses from skin popping and dirty needles..... but I digress....

Editorial Team / Admin · Jan 16, 2012

All true about some fakers, but we have to remain ever vigilant as one day, the "faker" will not be faking and will present with subtle s/s of crisis that could be dismissed.

Just pointing out the obvious. :)

Munch · Jan 23, 2012

One of my good friend works in the locked corrections unit in our hospital. The stories she tells me..If I had a nickle for every inmate turned patient that was as healthy as a horse, I'd quite my job and move to the Bahamas. Granted some of the inmates ARE sick on the unit, they just had or are going to have surgery, they are cancer patients, pneumonia patients, she even told me they get patients that eat things that aren't edible just so they can go to the hospital to get them fished out(when then in turn makes them a real patient). She did say that the patients that are genuinely sick usually aren't much of a problem and the ones who are malingering(the percentage who are liars are about 60%) are full of demands, needs and wants. The medications that are notorious among the locked corrections unit(which is the proper name for the unit, everyone calls it the jail ward) among sick and malingering patients alike happen to be: Morphine, Fentanyl TDS, Dilaudid, PCA's, IV Tranquilizers(most of them want everything by IV which the exception of a small amount of genuinely ill inmates who are recovering addicts and maintaining sobriety is very important to them, they won't even take a tylenol 3 for post surgical pain). Sleeping pills are popular too. My friend says that if these inmates don't get what they want medication wise she gets threats(and then they get threats by the guards), she also gets threats because like MassagetoRN said there are no TV's, newspapers, phones(only a call button) no entertainment. They get their three meals a day(which they don't get to choose like the rest of he hospital..though I am told by my friend the inmates like the food at the hospital better than at jail/prison). The only inmates on the unit that get pain medication are post op, have chest pain(that after a work up shows it's genuine), organ failure and pretty much anything else that would warrant pain medication. They get toradol and morphine(not high doses like they want..they only inmates that get high doses would be the oncology and organ failure inmates).

nursechris1 · Aug 25, 2012

We have a 37 yo inmate who had a cardiac event (after running from police) 2 days prior to entering our facility. Troponin levels elevated. Tox screen negative. Heart cath negative. He has been with us 5 weeks and we have sent him out twice with c/o chest and left arm pain. He returned both times within hours with the ER doc stating nothing was wrong with him. I noticed on his mar that the day before his last episode was his last dose of tranxene. I realized I hadn't had a complaint in days from him while on the tranxene. His bp is always low, so I don't take much stock in that. The other night he said he had a severe headache, he was having dry heaves. Chest pain. We gave him tylenol, something for nausea, and put on oxygen. I had him see mental health earlier that day and was instructed on deep breathing. We practiced that with him. He recovered quickly. So hard to know the right thing to do. Like others have said, I can't keep sending him to the ER.

cchezem15 · Aug 29, 2012

I really loved [COLOR=#003366]libran84's [COLOR=#003366]post! Definitely going to help when I start working!!!!

angelkay · Aug 31, 2012

I work in prison and as for chest pains, I have to say that some fake it to get out to the hospital etc (some inmates ahve told me they would fake chest pains becasue they dont get what they want but there will be one that you think is faking and it turns out to be real) ... But I think that the vital signs give clues too. Use your judgement and intuition. and cover your self. If in doubt, send them to your "emergency area", better safe than sorry. This is just from my own experience and I have been dealing with jails and prisons for over 4 years now.

OldcootRN · Dec 25, 2012

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.

Gretchitect · Mar 1, 2013

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.

chulada77, ADN, BSN, MSN, APRN · May 4, 2013

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.

Pranqster · May 10, 2013

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.