Chest Pain in a Crowded Waiting Room
At 21:10 on a Friday, a 58-year-old man walks into triage reporting 'heartburn' that began 40 minutes ago after a large meal. He rates it 5/10, describes it as a burning pressure behind the sternum radiating to the left jaw, and says it is not relieved by two antacid tablets. He is diaphoretic and pale. Vitals: HR 104, BP 148/92, RR 22, SpO2 96% on room air, T 37.1 C, pain 5/10. He has a 25-year history of type 2 diabetes, smokes one pack daily, and his father died of a myocardial infarction at 61. The department has 14 patients waiting, two resuscitation bays are occupied, one monitored bed is free, and the only physician is suturing a hand laceration. Registration asks him to sit and complete paperwork because 'we have a queue.'
1. Assign a triage acuity level and justify it using the specific findings. What immediate actions must occur before any registration paperwork?
Read the worked answer
Acuity: emergent/level 2 (high-risk, time-critical). This is not a stable 'chest pain to be seen' presentation.
Reasoning from the data:
- Symptom pattern: burning substernal pressure radiating to the left jaw in a diaphoretic, pale patient is cardiac until proven otherwise; antacid failure and post-prandial onset are classic distractors that cause mis-triage.
- Risk profile: diabetes (often blunts anginal symptoms), active smoking, age 58, family history of premature MI. Pretest probability of acute coronary syndrome is high.
- Physiology: HR 104 with a normal temperature suggests sympathetic drive, not fever; BP 148/92 and RR 22 indicate a stressed, potentially ischemic patient.
- Constraint: 14 waiting patients and one occupied physician do not change the patient's acuity - they change where he waits. He must not sit in an unmonitored queue.
Immediate actions, in order:
- Move him directly to the free monitored bed; apply continuous ECG, SpO2, and automated BP cycling.
- Obtain and interpret a 12-lead ECG within 10 minutes of arrival and show it to a clinician; do not wait for registration.
- Establish IV access, draw troponin and basic labs, and give aspirin per protocol if no contraindication.
- Notify the physician verbally that a possible ACS is on the monitor - this is a legitimate interruption of a lower-acuity procedure.
- Complete registration retrospectively or use a quick-register/alias process; paperwork never precedes stabilization.
2. The ECG shows 2 mm ST elevation in leads II, III, and aVF. The physician is still suturing. Describe your next 15 minutes, including how you escalate and what data the receiving team will need.
Read the worked answer
Recognize: inferior STEMI. ST elevation in II, III, aVF with reciprocal change would confirm; either way this is an activation-level ECG.
Next 15 minutes:
- Escalate loudly and specifically: state the patient, bed, and finding ('Bed 3, 58-year-old male, inferior STEMI on ECG, needs you now'). A named clinical finding justifies pulling the physician from a laceration.
- Activate the STEMI pathway per policy - cath lab notification, on-call cardiologist, and pharmacy for antiplatelet/anticoagulant orders.
- Prepare for instability: inferior infarcts can involve the right ventricle and vagal tone; obtain right-sided leads if ordered, keep the crash cart nearby, and avoid nitrates if the patient becomes hypotensive or has right ventricular involvement.
- Continuous monitoring: watch for bradycardia, heart block, and hypotension; have atropine and pacing pads ready per protocol.
- Documentation package for the cath lab: symptom onset time, first medical contact time, ECG time and findings, vitals trend, aspirin/other meds given with times, allergies, IV site, renal function if known, and consent status.
- Family/communication: assign a second nurse to update the family and obtain history (contrast allergy, anticoagulant use, prior stents).
- Reassess the queue: the charge nurse must redistribute the remaining 14 patients; this is an operations decision, not something to solve alone.