Interviewee

Helen Hamer, Senior Lecturer/Phd Candidate, School of Nursing, University of Auckland, Auckland, New Zealand

Article

Hamer, HP., & McCallin, AM., (2006) Cardiac pain or panic disorder? Managing uncertainty in the emergency department. Nursing & Health Sciences, 8(4): 224-30

Summary

In this IPP-SHR podcast Michael Bouwman talks with Helen Hamer about her research into the difficulties health professionals' face in distinguishing between cardiac pain and panic disorder within an emergency room context. Helen and Michael discuss Helen's motivation for doing this research, the difficulties associated with diagnosing panic disorder and the ways in which health professionals go about managing such uncertainty and ambiguity.

Transcript

Michael Bouwman: Introducing Helen Hamer, Senior Lecturer in Mental Health at the University of Auckland, New Zealand and Doctoral candidate. Helen is also a registered Psychiatric and General Nurse with experience in New Zealand and the UK. I’m speaking with Helen about her article, ‘Cardiac pain or panic disorder? Managing uncertainty in the emergency department’, which she co-authored with Dr. Antoinette McCallin. Hi Helen, welcome to IPP-SHR Podcasts, our congratulations on your work. To understand the full importance of your work we need to define the notion of panic disorder, could you please explain for our listeners the concept of panic disorder and how it differs from cardiac pain?

Helen Hamer: When people talk about a panic attack, what they’re describing is a swift crescendo of terror that comes on suddenly and unpredictably. The terror is over powering and it has a kind of all or nothing quality about it. And when you get this crescendo of terror of course you get the physiological response such as palpitations, faintness, sweating, chest pain. People also have a distortion of their time and reasoning capacity which basically engenders a fearful cognition of dying, losing control and or going crazy and an intense desire to flee the situation or avoid it in future. So I guess in terms of chest pain of course, chest pain is directly related to a problem with the heart or the circulation of the heart muscle and that’s usually related to angina which can be typical or atypical and that’s usually progressive and brought on more by exercise so it’s not usually as swift as a panic disorder would be.

Michael Bouwman: Okay, you indicate in the article that achieving a panic disorder diagnosis is difficult. Could you talk about that reasons for this and the problems that emergency nurses have in differentiating between panic disorder and cardiac pain?

Helen Hamer: Yeah, well I mean your point’s important. There is a difficulty in distinguishing because some of those symptoms I’ve described in panic disorder will mimic exactly what people are experiencing with a heart attack and I suppose for many nurses in ED they have fear cued for the urgency of peoples’ presentations. So they’re usually more likely to follow the routes of it being cardiac pain so they’ll initially exclude that. I guess the concern was though that they weren’t necessarily moving into another position of assessing after they excluded the cardiac pain but for the nurses I interviewed, they had a sense that there was something other than cardiac pain going on but most of them didn’t quite know what it was of had the language to describe that.

Michael Bouwman: One of the core themes in your findings is the notion of prioritizing time. Could you talk about your findings, especially on the creative ways some nurses have for managing psycho-social assessment in a time or emergency department setting?

Helen Hamer: I think particularly for the nurses in ED, the brief of the emergency department is to prevent death and reduce any further harm from emergency health presentation. So they have to work very quickly in their triage process. They’re timing is usually based around the probabilities of what comes into the emergency department. I think what nurses are trying to do to manage that relationship between the clients as well as looking at the technology of what they’re doing is to have a balance. And my participants talk particularly about the concept of high touch and high tech which not only can apply to health settings but also I think to our everyday lives that technology has taken on a great role in our lives and that can be at the expense of the touch and that they would kind of care for the client on the run basically. They would have creative ways of trying to, at the same time as going through the technological procedures they would ask questions that were more of a psychological nature so that they could get a sense of what was happening for the patients. And also, I suppose trying to develop some kind of partnership so that it wasn’t always about technology that they could also demonstrate their caring practice. I think the system as well doesn’t value caring practices such as talking to people.

Michael Bouwman: You’re other two themes of managing uncertainty and ambiguity and the life threatening lens highlight the ongoing ethical tensions inherent in emergency nursing. Could you talk about these findings and the insights they provide about clinical decision making in an emergency department?

Helen Hamer: Many nurses said that you can never quite tell, you are always in a bind, you might know that it’s not cardiac but their experiences had been situations where they’d done a full work up of a client, said look fine there’s nothing there and the person has gone into the waiting room and then dropped dead of a cardiac event so they felt that they always had to rule that out. Now their decision making as I said before is based on triage so they quickly have to assess exactly what’s going on. If you walk into an emergency department and say you’ve got chest pain you will immediately be sent to the resus room where they will do a full biological work up test and blood test, ECG’s and they base that on a heuristic which is the theory about probabilities, so it’s kind of pattern recognition for them. And one of the nurses in the study talked about a wonderful term which was called, ‘the end of the bed-o-gram’ which basically means this pattern recognition is so ingrained for them that they can stand at the end of the bed and by looking at somebody they can tell whether this is an aortic aneurysm or whether it’s something else. Now of course heuristics will say to you that without probabilities, we always have to be ware of when it’s not quite what it seems and there’s a wonderful way of describing this and that is when we hear the sounds of hooves, we might think horses whereas in fact it could be zebras and that the zebras are the ones that will always catch you out. So in terms of their decision making, particularly around the very subtle difference between panic disorder and chest pain they found it difficult to determine what was what because they weren’t asking the questions that are recommended in the literature to be able to say this is more psychological in its origin.

Michael Bouwman: And finally, do you have any recommendations for practice?

Helen Hamer: In terms of those recommendations for practice I would ask them to consider being a little bit braver in that their concern was that they would open a can of worms that they felt they couldn’t manage a client who possibly could get more distressed by being asked psycho-social questions. However, many clients say that they really benefit from being able to talk about the feelings associated with their obvious concern about not knowing what’s going on. The other thing I think that’s important for practice is to be able to read the clients’ notes. That was definitely in the findings that many of the nurses kept – when they went back and had the time to read the notes, they saw that the client had been in three or four or five times in the last two weeks and they had the sense that this was more than just a cardiac problem.

Michael Bouwman: Helen thank you for speaking to me today, it’s been a pleasure talking to you.

Helen Hamer: Yes, thank you.

Podcast Keywords

cardiac pain, panic disorder, anxiety disorder, emergency decision making, bio-ethics, psychosocial factors, ambiguity in diagnosis