Indigestion That Is Not Being Treated as Indigestion
A 58-year-old man calls at 22:40 and opens with, 'I've got heartburn - I just need to know if I can take something.' The pain has been there about two hours. It sits under the breastbone, he rates it 5 out of 10, and it has spread to his jaw and left arm. He is nauseated, has vomited once, and his wife says he looks sweaty and gray. He took antacids an hour ago with no relief. He has a stent placed in 2019 and takes aspirin daily. He does not want an ambulance: 'If it were my heart, I'd be on the floor.' He is alert and breathing without difficulty, and says he cannot afford the bill.
1. The caller has labelled this heartburn. Which key questions should move the call off an abdominal pathway, and how do the answers affect the determinant?
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The complaint is defined by the answers, not by the caller's label.
Questions that change the pathway:
- Show me with your hand where the pain is. Does it spread anywhere else? - jaw and arm radiation is a key determinant driver.
- Does it feel like pressure, squeezing, or heaviness, or is it a burning?
- Are you sweaty or clammy? Has your colour changed?
- Any nausea or vomiting?
- Is the pain still there right now, and did rest or the antacid change it?
- Any history of heart attack, stent, bypass, or angina?
- Are you breathing normally?
Effect on the determinant: radiating pain plus clamminess plus a cardiac history plus no relief from antacid places this at the highest acuity level the chest pain protocol allows (Delta-level, life-threatening), not a low-priority abdominal call. Age and history are modifiers, not the whole answer - a young patient with the same answers still escalates.
What must not happen: the EMD must not say that sounds like heartburn or that sounds like a heart attack. Both are diagnoses, and the first one kills calls.
2. He refuses an ambulance. What should the EMD do, and what should the EMD avoid saying?
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Continue the call and the dispatch. Refusal is not the EMD's decision to make on the phone.
- Do not argue and do not diagnose. You're having a heart attack is both a diagnosis and a common reason a caller hangs up. It's probably nothing is worse.
- Use the questions as the reason: The answers you just gave me are the ones that tell me you need to be checked now, so I'm sending the paramedics. If you still don't want to go when they get there, you can tell them that in person.
- Keep him on the line and complete the questioning and instructions. A refusal given to a call-taker is not the same as a refusal given to a crew, and does not stop the response.
- Pass the refusal statement to dispatch and the responding unit so the crew knows what they are walking into.
- Record his exact words - 'If it were my heart, I'd be on the floor' - verbatim, with a timestamp.
Nuance: cost objections are usually answered, not argued with - the EMD acknowledges the concern and redirects to the assessment, which is the crew's conversation to have.
3. What post-dispatch instructions fit this call, and what should the EMD not instruct?
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PDIs given while the unit is en route:
- Sit down and stay still. Don't walk around, don't go up and down stairs, don't try to sleep it off.
- Unlock the front door and turn on the outside light.
- Have someone stay with you - don't be alone in the room.
- Gather your medications, your stent card, and your ID and have them ready.
- Nothing to eat or drink. Don't smoke.
- Keep the phone next to you. If it gets worse, call back immediately.
What not to instruct:
- No aspirin, nitroglycerin, or any other medication unless the local protocol and medical director authorise it and the screening questions (allergy, bleeding, recent surgery, already taken) are complete. He already takes daily aspirin; a call-taker adding a dose without protocol direction is practicing medicine.
- Do not tell him to drive himself or have his wife drive him.
- Do not tell him to lie flat if sitting is more comfortable - allow the position of comfort.
Rationale: PDIs are safety and scene-preparation instructions. Any instruction that alters medication or physiology must come from an approved pre-arrival instruction script, not improvisation.