It was fairly early one day when a young man about 40 years of age called in to the 112 emergency line and asked for an ambulance. The reason was chest pains. He was very calm and "showed" no signs through the phone that he was in pain or any kind of distress. So I asked him if the patient was himself or if he had someone with him that he was calling for. He replied that he was indeed the patient, and when asked about the chest pain, he said that he had had some discomfort since late the night before and then again that morning. He had no history of any kind of heart or lung problems and denied having any other symptoms. He did not use any kind of drugs, and throughout the phone call he remained completely calm. Yet there was always something that told me this was not a "normal" chest pain case.

My instincts kept telling me that there was something more going on with this man, so I dispatched two ambulances for an F1 call (F1 is our highest priority). One of them was manned with two EMT-I responders and the second one was manned with an EMT-I and EMT-P. When the paramedic arrived at the patient's home, he assessed the patient and found him not heaving any chest pain anymore. The patient was still fully concious and alert, his systolic blood pressure was 200, and he complained of leg pains and not being able to stand up. When the paramedic removed the patient's covers and took a look at his feet, they were cold and had a bluish color.

At that moment the EMTs realized the patient was very ill and needed be transported as soon as possible. The patient was overwheight, and because of that the transport was delayed because I had to dispatch a third ambulance, which carried a big enough stretcher for him to be transported on. The patient was transported immediately to the hospital. On the way, the patient's systolic pressure went down to 70, and he was getting weaker. Upon arrival at the hospital, he was sent straight to the operating room for 15 hours. He had extensive dissection and bleeding in his aorta and a damaged heart valve; both the aorta and the valve had to be replaced, so he was very lucky that he called for an ambulance when he did. He did not have a lot of time to spare.

I will never forget this caller or his calm voice telling me he was having chest pains, just as if he were telling me about the weather. And I will never forget how I first thought to myself, "He can't be the patient – he doesn't sound like he is in any pain." A trained emergency medical dispatcher knows that chest pain – even a little – can be a symptom of a heart attack in any patient age 35 or over, yet this case turned out to be even more critical that many heart attacks.

We who do this job all know that we have to use the information we are given over the phone and take into consideration not just the words, signs, and symptoms but the entire context of the situation. Sometimes it's background noise, sometimes it's just the slight tension in the caller's voice. These intangibles can be extremely useful once we've accounted for our protocols and established policies. I'm glad I followed my instincts that day.