The young woman was waiting for her mother to be discharged from the hospital when the pain started. “My chest is hurting,” she told me.

This is a phrase nurses hate to hear, since we immediately start to worry about heart attack. But this woman was young, and didn’t look unwell. The chances of her chest pain being cardiac trouble, rather than indigestion or some other minor problem, seemed slight.
Theresa Brown, R.N.

I asked the standard next question: Had she had this kind of pain before?

Her answer startled me. “When I had my heart attack,” she replied.

The alarm bells went off in my head, but I couldn’t react the way I usually do when a patient complains of worrisome chest pain. This woman was not a patient. She was a hospital visitor, the daughter of a patient getting ready to leave.

In the hospital, people who aren’t employees fit into one of two categories: patient or visitor. But when visiting family members or friends become ill on a hospital floor, it’s not easy to care for them. We don’t know anything about them or their health history. We can’t offer standard inpatient care because they aren’t registered in the system. They are here, and they are sick, but they are not yet patients.

Should one of my patients complain of chest pain, there is a specific set of procedures I would follow. I would call the intern, get an EKG, maybe draw blood to measure a blood chemical that shows the level of cardiac injury. I would also take vital signs to make sure the patient was stable and consider putting her on a heart monitor, until the doctor arrived. It would be a flurry of activity, but I would be calm. As long as the patient stayed conscious, and her vitals were acceptable, the chest pain wouldn’t be an emergency.

But now I found myself in a completely different situation. This woman had chest pain and a history of heart attack, but she was a visitor. There was no doctor assigned to her case to come see her or order an EKG, no mandate for sticking her and drawing her blood, and no medical record number for processing lab work. Her vital signs could tell me whether she was stable, but without her full medical history, I had no context for interpreting them.

Under the circumstances, I had three choices. I could wait and see how she did over time, I could call a code and bring in a rapid response team, or I could take her to the hospital’s emergency room.

Waiting struck me as a very bad idea. Time is muscle when someone has a heart attack. If the woman was having a second heart attack, then faster treatment would limit the permanent damage. Calling a code seemed like an overreaction that might take needed care away from patients on the floor. The woman was uncomfortable, but she wasn’t crashing. Hurrying, I snagged a wheelchair, and headed to the emergency room six floors down.

Riding down in the elevator, the woman started to feel worse. She began crying and complained that the pain in her chest was increasing. Suddenly I worried that not calling the code had been a mistake. I knew so little about this woman. My assumption that she would stay stable during our short trip to the emergency room had been based on intuition, not knowledge. Bringing in a rapid response team would have covered our bases.

We reached the E.R. without her crashing, and I burst into the triage area. “Patient’s daughter, sudden onset of chest pain, history of M.I.,” I said warningly, raising the specter of the woman’s past myocardial infarction — her heart attack. The triage nurse glanced at me with a mix of irritation and gentle sympathy. “O.K.,” she said, barely looking up as she handed me a clipboard of patient forms.

Suddenly I understood. The emergency room specializes in turning people into patients, deciding what is a true emergency and what is not. It’s what they do every day. The young woman’s chest pain felt like an emergency to me because I couldn’t help her in the way I know how. But in the emergency department, a little chest pain doesn’t get them worked up. Taking care of people they don’t know is their job.

In the book “Illness as Metaphor,” Susan Sontag wrote that all of us have “dual citizenship in the kingdom of the well and in the kingdom of the sick.” She described illness as an existential crisis in which we reluctantly enter “the night-side of life, a more onerous citizenship.”

That day, with my patient’s daughter, I realized that illness can be a bureaucratic crisis as well. Even inside a hospital, a sick person is not a patient if she doesn’t have an admitting physician, a diagnosis and a numbered plastic wristband.

Fortunately, my patient’s daughter wasn’t having a heart attack, but her cardiac rhythm was abnormal. She was admitted, and she stayed a few days while the doctors figured out what was wrong.

Meanwhile, her mother was ready to leave the kingdom of the sick. She got her discharge paperwork from me and went home, or perhaps she returned to visit her daughter in the hospital.