Chest Pain at a Community Rink
You are the only EMR on duty at a community hockey rink. A 58-year-old man collapsed on the bench at 19:42 after skating two shifts. He is awake, pale, and sweating heavily. He says the pain is 'heavy, like a weight' in the centre of his chest and radiates to his left jaw. He is nauseated and short of breath. He has a known history of hypertension and takes a daily pill he cannot name. Vital signs: radial pulse 104 and irregular, respirations 26 and shallow, blood pressure 148/92, SpO2 93% on room air. The rink is 14 minutes from the nearest hospital by ambulance; your backup is a single paramedic crew responding from 9 minutes away. The patient asks you not to call an ambulance because he drove himself and does not want the cost.
1. Identify the priority problem and justify your transport decision, including what you do before the paramedic crew arrives.
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The priority problem is a suspected acute coronary syndrome with signs of instability: central crushing chest pain radiating to the jaw, diaphoresis, nausea, dyspnea, an irregular pulse at 104, and SpO2 of 93%. These features make this a time-critical emergency, not a musculoskeletal complaint from hockey.
Decision: call the ambulance immediately and plan for paramedic intercept and hospital transport. The patient's objection about cost does not change the clinical risk. An irregular, fast pulse with chest pain raises concern for dysrhythmia, and he could deteriorate suddenly. A 14-minute transport with a 9-minute paramedic intercept is reasonable; do not delay for further assessment on scene beyond what is needed to stabilize and move.
Before the crew arrives: keep him sitting or lying comfortably, do not let him walk; give supplemental oxygen only if your protocol indicates it for his saturation and work of breathing, targeting the range your service uses; assist with his own prescribed nitroglycerin only if protocol allows and there is no contraindication such as recent erectile-dysfunction medication or hypotension; monitor pulse, blood pressure, respirations, SpO2, and level of consciousness every few minutes; have aspirin ready per protocol; and prepare for a possible cardiac arrest by having the AED and bag-mask at your side. Document the time of symptom onset and every set of vitals.
2. The patient becomes unresponsive, stops breathing normally, and you cannot feel a carotid pulse. Outline your first five actions in order and explain why each comes when it does.
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Confirm unresponsiveness and call for help. Shout and tap; if no response, activate the emergency response system and direct someone to bring the AED. This is first because everything downstream depends on getting resources moving.
Check breathing and pulse simultaneously for no more than 10 seconds. He is not breathing normally and has no pulse, so begin CPR. Agonal gasps do not count as normal breathing.
Start high-quality chest compressions immediately: centre of the chest, depth of at least 5 cm but no more than 6 cm, rate 100-120 per minute, full recoil, minimal interruptions. Compressions circulate oxygen that is still in the blood and buy time until defibrillation.
Apply the AED as soon as it arrives and follow its prompts. Do not delay compressions to set it up; have a second rescuer pad and analyze while you compress. Clear the patient before any shock.
Resume compressions immediately after the shock or after the no-shock advisory, and continue cycles with minimal pause. Switch compressors about every 2 minutes to limit fatigue. Provide ventilation with a bag-mask if a trained second rescuer is available; otherwise continue compression-only CPR until help arrives. The sequence is driven by the principle that early compressions and early defibrillation are the interventions most likely to change the outcome.