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Scenario: Chest Pain at a Farmington Gas Station

Difficulty: EASY Category: Medical — Pharmacology Generated: 2026-04-04

Dispatch

Unit 3, respond to 4601 E Main, Farmington — Conoco station. Caller reports a male in his 60s complaining of chest pain. Patient is conscious and breathing. Time out: 0914.

Scene Size-Up

You arrive to find the station attendant standing next to a heavyset male sitting on a curb beside his truck. No hazards. One patient. No trauma mechanism evident — he was pumping gas when it started. You glove up.

Patient Presentation

Chief complaint: "Pressure in my chest, feels like someone sitting on me."

History (SAMPLE): - S: Substernal pressure 7/10, radiating to left jaw and left arm. Started ~20 min ago. - A: Penicillin - M: Metformin, lisinopril, atorvastatin. "I already took my baby aspirin this morning." - P: Type 2 diabetes, hypertension, hyperlipidemia - L: Breakfast 2 hours ago - E: Standing at pump, no exertion

Vitals: - BP: 148/92 - HR: 96, regular, strong - RR: 18, unlabored - SpO2: 96% on room air - Skin: pale, diaphoretic - BGL: 134 mg/dL - AVPU: Alert

OPQRST: Onset sudden, nothing provokes or relieves it, quality is pressure, radiates to jaw and left arm, severity 7/10, started 20 minutes ago.

Assessment Steps
  1. Scene size-up — BSI done, scene safe, 1 patient, medical NOI, no c-spine.
  2. Primary assessment — General impression: sick-looking male in distress. Alert. Airway patent. Breathing adequate (18, unlabored). Circulation: pulse strong/regular, no major bleeding, pale + diaphoretic skin → priority patient.
  3. Transport decision — Priority. Call for ALS intercept or go to San Juan Regional Medical Center (SJRMC is PCI-capable — advance notification should go out now).
  4. History — SAMPLE and OPQRST completed above. Classic ACS presentation.
  5. Secondary assessment — Focused cardiac exam. Listen to lung sounds bilaterally (clear = no CHF). 12-lead if ALS-capable or protocol allows. Check for JVD.
  6. Reassessment — Vitals every 5 min en route. Watch for deterioration.
Interventions
  1. Oxygen — SpO2 96% at rest but symptomatic ACS. Apply NRB at 10–15 LPM (or NC to titrate SpO2 ≥94% per some protocols). Reassess continuously.
  2. Position — Supine or position of comfort. Do not let him walk to the unit.
  3. Aspirin — DO NOT GIVE. He already took his daily aspirin this morning. The standard dose is 162–324 mg; administering an additional 324 mg on top of his morning dose risks GI bleeding and does not add cardiac benefit. This is the key pharmacology trap in this scenario.
  4. IV/IO access — Establish en route (ALS scope if not available).
  5. ALS intercept or rapid transport to SJRMC — PCI-capable facility. Advance notification: "STEMI alert, 60s male, substernal pressure 20 min, diaphoretic, ETA 8 min."
  6. Reassess every 5 min — Watch for rhythm deterioration, pulmonary edema (crackles), hypotension.
Transport Decision

Priority transport to San Juan Regional Medical Center, Farmington. SJRMC is the PCI-capable (cardiac cath) destination for San Juan County. Call ahead with STEMI alert. Do not delay transport for ALS arrival if intercept adds more than 5–10 minutes. ALS intercept en route on US-64 if available.

Key Takeaways

What this tests: ACS recognition + aspirin contraindication (already took dose).

The trap: Most students reflexively give aspirin for any chest pain. The correct answer is to withhold it — he already took his daily aspirin. Giving a second dose adds no benefit and adds bleeding risk. Document what he took and when.

Common mistakes: - Giving aspirin anyway ("it's just one more") - Delaying transport to wait for a 12-lead - Putting the patient on NC at 2 LPM when he's pale and diaphoretic (use NRB) - Forgetting advance notification to SJRMC

NM protocol note: NM protocols require aspirin 324 mg chewed for suspected ACS unless contraindicated. "Already took daily dose" is a contraindication — document it.

acs-chest-pain | aspirin | oxygen | primary-assessment | history-taking