Clinician trusts instincts and diagnoses an unlikely heart attack

I used to work in a clinic owned by a Native American tribe. One Friday afternoon around 3:30 pm a male tribal member, about 30 years old, came in to be seen. He complained of pain in his left upper chest, just below the lateral aspect of his clavicle.

The patient denied trauma, but told me the pain started three days earlier. It began while he was stacking some wood. He said the pain had come and gone several times. He denied shortness of breath, but did report some nausea and sweatiness.

The patient did not take anything for the pain. He did not smoke, and did not have a significant medical history. He was overweight, but not diabetic. He wasn't having any pain at that time.

The nausea and sweatiness he complained of bothered me. Not the symptoms of your common muscle strain. We did an EKG. It wasn't normal, but there were no Q waves, ST depression or elevation. It just didn't look right. I'd worked several years in a small ICU. I'm a critical care registered nurse and had seen more than my share of EKGs and cardiac patients.

I told the patient that I wasn't 100% sure, but that I was concerned, "There might be something going on with your heart."  I went on to tell him that, to be on the safe side, I felt that we needed to call 911 and have him transported by ambulance. I figured he'd refuse to go by ambulance, and maybe not even go to the hospital. I obviously wasn't confident, but I was also very uncomfortable with just letting him go home.

Surprisingly, the patient agreed to the ambulance. The paramedics came and while getting him ready for transport, they reviewed the EKG and called the ER doctor to review the history and physical exam findings. They were questioning my diagnosis, but transported him anyway. He had indeed had a heart attack, but recovered well.

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