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Scenario — Jaw ache and fatigue post-run — atypical ACS presentation in a female
Patient Information
Dispatch
A 58YO female (Mia Cartwright) has self-presented to the FAP at the Riverside Fun Run complaining of jaw aching, profound fatigue, and nausea after finishing the 10km course. She initially thought she had overdone it.
Incident History
Pt completed the 10km run approximately 15 minutes ago. Shortly after finishing she developed jaw aching, left arm and shoulder heaviness, profound fatigue, and nausea. She initially attributed it to overexertion but symptoms have not settled with rest, and she is now sweating heavily despite the cool morning air. She denies classic chest pain.
Emergency Contact
Daniel Cartwright (Husband) 0412 883 047
Initial Rapid Assessment
Response
Alert
Airway
Patent. Nil airway obstruction. Nil stridor or swelling.
Breathing
Shortness of breath present. Respiratory effort slightly increased. Nil audible wheeze or crackles. RR 20.
Circulation
Radial pulse present — regular, moderate strength. Skin pale and diaphoretic. Nil external bleeding.
Disability
GCS 15 (E4V5M6). Alert and orientated to time, place and person. Anxious.
Exposure
No rashes, swelling or visible injury. Wearing running attire. Skin pale and sweaty.
Vitals
Time SpO2 Resp Dist RR Pulse BP CRT GCS PERL Temp BGL Pain
Initial 96% (RA) Mild 20 104 118/76 <2s 15 4 4 ++ 37.1 6.2 mmol/L 6
10 mins 98% (O2 NRB 10L/min) Nil 16 96 110/72 <2s 15 4 4 ++ 37.1 6.2 mmol/L 3
History Taking
Signs/Symptoms
Jaw aching, left arm and shoulder heaviness, breathlessness, profound fatigue, nausea, diaphoresis. No classic chest pain — 'my jaw just aches and my arm feels really heavy and wrong.'
Onset
Approximately 15–20 minutes ago, shortly after finishing the 10km run.
Pain
Jaw aching — heavy and pressure-like. Left arm and shoulder feel heavy and 'wrong'. No classic chest pain reported.
Quality
Constant, aching jaw with arm/shoulder heaviness. No crushing quality.
Radiates
Jaw ache and left arm/shoulder heaviness — patient does not identify chest pain as the source.
Severity
6/10 at rest.
Allergies
NKDA.
Medications
Oral contraceptive pill (Levlen). No other regular medications.
Pertinent History
No prior cardiac history. Non-smoker. Occasional runner — this is her first fun run of this distance. No family history of cardiac disease that she is aware of.
Last Oral Intake
Water and a banana approximately 1 hour prior to race start. No food since.
Treatment
Sat down and rested after finishing — no improvement in symptoms. No medications taken.
Events Leading
Pt was completing the 10km Riverside Fun Run. She finished the course and crossed the line, then walked to the recovery area where symptoms developed at rest.
Scenario Progression and Treatment Objectives

((If Aspirin is not considered within the first 5 minutes of assessment, prompt the trainee: the patient asks 'Is there anything you can give me for this?' — guide trainees to recognise the ACS protocol.))

((If GTN is administered without first assessing BP, patient's BP drops to 78/50 — challenge the trainee to identify hypotension before further GTN doses.))

((If oxygen is not applied within 4 minutes, SpO2 drops to 92% on RA and patient reports increasing breathlessness — prompt reassessment.))

((If BGL is not checked, facilitator prompts: 'The patient mentions she hasn't eaten much today and feels a bit light-headed' — reinforce full vital sign survey.))

((If GTN is given without asking about PDE5 inhibitor use, the facilitator should pause and prompt: 'Do you have any other questions before administering that medication?' — reinforce contraindication screening.))

This patient is suffering from a suspected Acute Coronary Syndrome (ACS) with an ATYPICAL female presentation — jaw ache, arm and shoulder heaviness, fatigue, nausea, and diaphoresis WITHOUT classic chest pain. Facilitator note: female patients frequently do not present with crushing chest pain. Jaw/arm/back discomfort combined with nausea, diaphoresis, and unexplained breathlessness in a female patient should prompt cardiac assessment even in the absence of classic chest pain.

  • Ensure scene safety and don appropriate PPE.
  • Perform Primary Survey — Airway patent, breathing with mild increased work, circulation intact, GCS 15.
  • Limit patient exertion — seat patient comfortably at the FAP, do not allow further walking or standing.
  • Perform Vital Sign Survey — BP, HR, RR, SpO2, BGL, pain score, GCS, temperature.
  • Apply oxygen via non-rebreather mask at 10–15 L/min — titrate to maintain SpO2 94–98%.
  • Obtain IMISTAMBO history — confirm onset, character of chest pain, radiation, allergies, medications (OCP noted), prior cardiac history.
  • Screen GTN contraindications — ask about PDE5 inhibitor use (sildenafil/tadalafil etc.) in previous 24–72 hours; confirm BP systolic >90 mmHg and HR between 50–150 bpm.
  • Administer Aspirin 300mg oral — chewed — for suspected ACS. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
  • Administer GTN 400 microg (1 spray) sublingually — administer in seated/semi-recumbent position; DO NOT shake bottle; prime if first use. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
  • Reassess pain score 5 minutes post-GTN. If pain >3/10, administer Methoxyflurane (Penthrox) 3 mL via inhaler device — patient self-administers.
  • Reassess BP before each subsequent GTN spray; administer further GTN at 5-minute intervals if pain persists and BP maintained above 90 mmHg systolic.
  • Administer Ondansetron 4mg sublingual tablet if patient reports nausea or vomiting — confirm no contraindications. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
  • Perform Secondary Survey as clinically indicated.
  • Record full observations every 10 minutes (or 5 minutes if patient deteriorates).
  • Call CSP for urgent ambulance support transport — advise CSP of findings. Do not leave patient unattended.
  • Reassure patient continuously throughout assessment and treatment.
  • Scenario ends on arrival of ambulance and IMISTAMBO handover.
  • Attention to hand hygiene will be given throughout the scenario.

Clinical references: Chest Pain / Acute Coronary Syndrome · Aspirin · Glyceryl Trinitrate (GTN, Nitroglycerin) · Methoxyflurane (Penthrox) · Ondansetron · Oxygen