Real vs fake chest pain

Orca, ADN, ASN, RN · May 13, 2013

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.

adgesmeraldiamond · May 16, 2013

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.

daugh · May 21, 2013

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.

Findingmynitch · Sep 17, 2013

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.

OfficerRNBSN · Sep 19, 2013

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.

esca2006 · Oct 6, 2016

Wow, such detail, this is immensely helpful and gives me a glimpse of what I need to do (and learn), to get myself to your level!

Truegem · Mar 18, 2017

I'm a little late to the party, but be very careful with anxiety. BP and P elevated, could be anxiety, but still could be MI. Diaphoretic could be anxiety, but still could be MI. Anxiety can be caused by the impending doom feeling with MI. SOB could be anxiety, but still could be MI. I think, in my 22 year career, I have only "diagnosed" 2 chest pains with anxiety.

angeloublue22, BSN, RN · Mar 25, 2017

We had an onsite EKG for this very reason. Spending the money on the EKG cost less than what we were paying for the ED needlessly. Follow your protocol and use your assessment skills. It's difficult one but sending them out is not a bad idea just safety reasons.

Orca, ADN, ASN, RN · Mar 26, 2017

I follow one simple rule in potential emergencies: I had rather be accused of doing too much than too little. In our system, the provider makes the ultimate call in sending anyone out. I try to provide as much information as possible so that an informed decision can be made.

Thebigguy92 · Apr 4, 2017

I am an LPN who works corrections. When it comes to chest pain I believe that it's best to be safe than sorry. I would do a full work up if the inmate has any type of cardiovascular history or any IV drug abuse history. For the rest, I take vitals and if normal talk to the inmate and see what's truly going on. More likely than not it's not cardiac related and I can implement the appropriate protocol to help them.

K9lover, ASN, RN · Apr 15, 2017

@ libran84, wow, that was a great recap of your CP inmate. I have shoals of experience most recently in a county ER and an occupational health contract. Started in corrections last August. When I do intake screening inmates launch into such a variety of issues one would be amazed they were even capable of holding a gun unassisted! This is a small county jail which sends out for EKGs/IV fluid and such so the assessment does not go as 'in depth' as yours. This is an easier decision in screening when they have not yet been booked; they do sometime really set off my *BS* meter and I tell them ERs don't treat pain anymore so if they want the ER doc to tell them they ok to book we'll be here in a couple of hours when they return.

person · Jan 6, 2018

If you have not learned you have to determine if a prisoner is telling the truth, and it works for everything not just chest pain. Look at them when they talk and watch around the lips, if their lips are moving they are lying.