Emergency medical technologists (EMT) arrive in a quarter of an hour. Based on hospital protocol, an intravenous line is inserted in patient’s right arm; he is administered morphine sulphate 10 mg, aspirin, beta blocker, supplemental oxygen by mask, sublingual nitroglycerin; an electrocardiogram (ECG) tracing is radioed to the local emergency room while he is in the ambulance. Sublingual nitroglycerin was given with minimal relief of pain. He receives nasal 100% oxygen but is not intubated. His respirations are more than 30 per minute and shallow. His skin is cool and clammy. Blood pressure: 110/78. The substernal pain is slightly relieved with medications and rest. EMT calls emergency triage nurse at nearest community hospital regarding middle-aged white male complaining of severe chest pain. He is breathing rapidly and perspiring.
The patient arrives in the emergency room and is seen immediately by a triage nurse. He complains of severe chest pain when descending the stairs to the kitchen; the pain persists . Nurse inquires if he has had a previous a history of chest pain. “No,” the patient answers. She assesses his vital signs: heart tracing on electrocardiogram, respiratory rate, and temperature. She searches for any previous medical record in the computerized system to share with a physician. She is following protocol for chest pain and patient estimates pain at 7/10. He received an additional 10 mg bolus of morphine sulphate that eases his pain. On auscultation a very soft holosystolic11I.e. the sound extends over the contraction, ejection, and relaxation portion of the heart cycle. murmur is heard over the precordium. Respirations are labored. Tachycardia is evident 110 bpm.