Scenario summary
It is 5:00 am and the learner is called to assess a 64-year-old admitted patient with new chest discomfort. He is recovering from COPD exacerbation and pneumonia, was transitioned to oral antibiotics yesterday, and did not improve after his usual antacid medication.
The learner should obtain a focused history and exam, place the patient on a monitor, request an ECG and old comparison ECG, send appropriate bloodwork, and verbalize a differential for acute chest pain. Once the inferior STEMI pattern appears, the case becomes a test of interpretation, escalation, and early STEMI management.
Patient chart
| Field | Details |
|---|---|
| Patient | Melvin White, 64-year-old male, 80 kg |
| Presenting complaint | Chest pain or chest discomfort on the ward |
| Initial vitals | T 36.5 C, HR 95, BP 130/80, RR 18, SpO2 92% on 2 L nasal prongs, GCS 15 |
| History | COPD, type 2 diabetes, hypertension, GERD; admitted with COPD exacerbation and pneumonia |
| Current medications | Flovent, Ventolin, metformin, atenolol, pantoprazole |
| Exam cues | Right posterior crackles, diaphoresis, pallor, uncomfortable appearance |
| Initial equipment | Adult manikin, monitor, oxygen supplies, IV access, ECG machine |
Case progression
| State | Patient status | Expected learner actions | Triggers and modifiers |
|---|---|---|---|
| Baseline ward call | Sinus rhythm, HR 95, BP 130/80, RR 18, SpO2 92% on 2 L, ongoing chest pressure | Focused chest pain history and exam, full vitals including bilateral pulses or BPs, IV crystalloid bolus, ECG and old ECG, chest X-ray, bloodwork including troponin, differential diagnosis | Nitroglycerin drops BP to 90/50. Progress once initial assessment and ECG request are complete. |
| ECG done | Sinus rhythm, HR 95, BP 100/50, RR 18, SpO2 92% on 2 L | Interpret inferior STEMI, give aspirin, consider second antiplatelet and heparin, ask for 15-lead ECG, call senior resident or cardiology, place defibrillator pads | Give the ECG at the beginning of this state. Progress once STEMI management and escalation are underway. |
| Cath lab call | Sinus rhythm, HR 95, BP 110/60, RR 18, SpO2 92% on 2 L | Call interventional cardiology, place second IV, confirm the patient can lie flat, complete anticoagulation if not already done | End when cath lab activation and parallel stabilization are complete. |
Embedded participant and cues
The bedside RN provides the history if asked: Mr. White is recovering from pneumonia and COPD exacerbation, called about 30 minutes ago for chest discomfort, did not improve with Tums, and looks unwell. The RN is also the key operational pressure point. The learner has to communicate a concise interpretation and plan while continuing bedside care.
The nitroglycerin decision is the main clinical distractor. It exposes whether the learner is treating “chest pain” generically or connecting the ECG territory and blood pressure to preload dependence.
Debrief focus
Use the debrief to connect early ward-call structure with STEMI physiology:
- How did the learner organize the first minute of a sick ward assessment?
- What information made STEMI the working diagnosis?
- How did the learner communicate the situation to a senior physician or cardiology?
- When chest pain treatment and shock physiology pointed in different directions, what drove the medication plan?
- Did the team mobilize resources while continuing supportive care?
Phone escalation is worth debriefing explicitly because junior learners often know what needs to happen but struggle to turn that into a clear, closed-loop request.
Facilitator notes
The complete DOCX includes laboratory results, ECG links, room setup, and facilitator debriefing tips. The source case highlights common discussion topics: an organized approach to an unstable ward patient, differential diagnosis for acute chest pain, communication during a crisis, initial STEMI management, and the role or risk of nitroglycerin in specific STEMI patterns.
Source materials
- Original case: EM Sim Cases - NIGHTMARES Case 9: STEMI
- Source ECG links in the case packet: normal sinus rhythm, inferior STEMI, and 15-lead ECG with right ventricular involvement from Life in the Fast Lane.