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.