Walk-In With Chest Pain During a Full Schedule
It is 9:40 a.m. at a three-provider family practice. The waiting room holds 11 patients, and the next open slot is 11:15 a.m. A 58-year-old man who is not a patient of the practice walks in and tells the front desk he has had pressure in the center of his chest since 9:00. He says it feels like 'a weight sitting on me,' it spreads to his left jaw, and he is sweaty and nauseated. He is pale and speaking in short sentences. He has no known cardiac history but takes a beta blocker for blood pressure. The front desk has no established protocol for walk-in emergencies beyond calling 911. The office has an AED mounted in the hallway and two clinical staff currently rooming patients.
1. As the front desk staff member, what should you do in the first 60 seconds, and what should you NOT do?
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Do:
- Treat this as a possible acute coronary syndrome - jaw pain, diaphoresis, nausea, and pressure in a 58-year-old are red flags, not a routine walk-in.
- Immediately alert a clinician (call down the hall or use the overhead/intercom) while staying with the patient.
- Have the patient sit and stay still; do not let him walk around or leave. Loosen tight clothing.
- Call 911 per the standing emergency protocol rather than trying to fit him into the 11:15 slot. EMS transport begins definitive care sooner than an office workup can.
- Stay with him, keep him calm, and be ready to retrieve the AED and start CPR if he becomes unresponsive or pulseless.
Do not:
- Do not send him to the waiting room to 'wait his turn.'
- Do not give aspirin, nitroglycerin, or any medication on your own authority - that is a clinician decision (and aspirin is contraindicated in some patients).
- Do not delay the 911 call to verify insurance or create a chart first. Registration happens after the emergency is managed.
2. The clinician asks you to document the event. What belongs in the note, and how do you handle the fact that he is not yet an established patient?
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The note should be a factual, time-stamped record of what was observed and done, not a diagnosis:
- Time of arrival and exact words used by the patient (e.g., 'pressure since 9:00, radiates to left jaw, sweaty, nauseated').
- Objective observations: pale, diaphoretic, speaking in short sentences.
- Vitals if any were taken, and who took them.
- Time the clinician was notified and time 911 was called.
- Interventions (positioning, AED placed nearby, etc.) and the patient's response.
- Time of EMS arrival and to whom care was handed off.
For a non-established patient, create a minimal record capturing the encounter - name, DOB, contact info, chief complaint, and the emergency actions - so there is a defensible documentation trail. Do not let 'he's not our patient' stop you from documenting. Avoid speculative language like 'had a heart attack'; describe findings and actions.