Chest Pressure in the Waiting Room
At 10:15 a.m., a 62-year-old man in the waiting room tells the medical assistant he has 'heartburn' that started 20 minutes ago while walking from the parking lot. He is pale and diaphoretic, rates the discomfort 7/10, and says it radiates to his left jaw. He is here for a routine blood pressure check. Vital signs: BP 148/92, HR 104, RR 24, SpO2 95%. The clinic has an AED, oxygen, and aspirin 325 mg chewable in the emergency kit. The provider is with another patient. The MA's scope includes taking vital signs, initiating emergency response per protocol, and assisting with AED placement. The waiting room has eight other patients. The patient says, 'I'm sure it's just indigestion; I'll wait.' He has no known aspirin allergy and no history of bleeding.
1. What are the MA's immediate actions, and why is each one indicated?
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Exertional chest pressure radiating to the jaw, with pallor and diaphoresis, is suspected acute coronary syndrome until proven otherwise. Immediate actions: stay with the patient and call 911, stating 'chest pain, diaphoretic, possible heart attack'; bring the AED and emergency kit; obtain vital signs and SpO2; place the patient in a position of comfort, usually sitting; loosen tight clothing; and notify the provider immediately.
Do not let the patient walk to the car or wait for a routine appointment. Aspirin may be given only if clinic protocol or the provider authorizes it and there is no allergy or active bleeding; have the 325 mg chewable ready but do not administer without an order. Document the time symptoms began, vital signs, and each intervention. The 911 call should not be delayed while debating the diagnosis.
2. The patient refuses EMS and says he will drive himself. How should the MA respond within scope?
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Do not physically restrain the patient. Clearly explain the risk: 'The discomfort you are having can be a heart attack, and driving yourself could cause you to pass out or crash. We have 911 on the way, and they can start treatment in the ambulance.' Ask the provider to speak with the patient. If the patient still refuses, document that he has capacity, the refusal, the risks explained, and obtain an against-medical-advice signature if the clinic uses one.
The MA should not give aspirin, oxygen, or nitroglycerin without an order and should not delay the 911 call to debate. If the patient leaves, document the time and method of departure and notify the provider.
3. What handoff information should be given to EMS, and what should be documented in the chart?
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Use a concise SBAR handoff: age and sex; chief complaint and onset time; vital signs including BP, HR, RR, SpO2, and pain score; known cardiac risk factors; medications and allergies; interventions given with times; and the patient's response. Give EMS the patient's name, date of birth, and physician.
Document arrival time, triage findings, 911 call time, provider notification, all vital signs, any medication administered with dose and route, patient statements, consent or refusal, and transfer time. The record should show that the clinic's emergency protocol was followed and who assumed care. Do not document speculation about the diagnosis; document objective findings and actions.