((If the trainee does not ask about the nature of the aspirin 'allergy' — patient becomes more distressed and insists she 'cannot' take aspirin. Prompt: husband adds 'she's never actually had a serious reaction — it was a rash on her arm when she was about six'.) Facilitator note: the CPG states aspirin is administered even if the patient reports a prior reaction, unless hypersensitivity to aspirin/salicylates/NSAIDs is confirmed. A childhood rash does not constitute confirmed anaphylaxis or hypersensitivity. Trainee must recognise this distinction and administer aspirin.)

((If the trainee administers high-flow oxygen via NRB mask and does not titrate down toward 88–92% SpO2 target for COPD — patient's husband states 'she always uses low-flow oxygen at home, her doctor said too much is bad for her'. Facilitator note: COPD patients require controlled oxygen. Target SpO2 88–92%. Uncontrolled high-flow oxygen risks CO2 retention. Trainee must titrate oxygen appropriately.))

((If GTN is administered without first confirming blood pressure ≥90 mmHg systolic — patient's BP is 98 systolic, which is borderline. Trainee must confirm BP before each GTN dose and recognise that BP is within the threshold. Facilitator note: GTN is indicated here — systolic >90 mmHg. However, the trainee must verbally confirm BP is adequate before each dose.))

((If aspirin is not administered within the first 5 minutes of clinical contact — patient's pain score escalates to 9/10 and she becomes more diaphoretic. Facilitator note: aspirin administration should not be delayed in suspected ACS. Prompt trainees to address the allergy concern and administer.))

((If the trainee does not request ambulance upgrade/Priority 1 transport — patient's GCS drops to 14 at 8 minutes, becoming confused. Facilitator note: this is a time-critical cardiac presentation. Early pre-notification of receiving facility and Priority 1 transport are essential.))

((If pain score remains >3/10 after first GTN spray and Methoxyflurane is not offered — patient states 'the spray didn't do much, I'm still in a lot of pain'. Facilitator note: per the CPG, if pain >3/10 after 1 spray of GTN, Methoxyflurane should be administered as per ACS protocol.))

This patient is suffering from a suspected ST-Elevation Myocardial Infarction (STEMI) with a concurrent COPD exacerbation contributing to hypoxia, compounded by patient reluctance to accept aspirin due to a reported childhood allergy.

• Ensure scene safety and don appropriate PPE. Attention to hand hygiene will be given throughout the scenario.
• Perform Primary Survey — establish patent airway, assess breathing and circulation, confirm GCS 15.
• Position patient seated or semi-recumbent — limit exertion, do not allow patient to walk.
• Apply SpO2 monitoring immediately — initial reading 89% on room air.
• Administer oxygen — initiate via nasal cannula at 1–2 L/min targeting SpO2 88–92% given known COPD. If unable to achieve target via nasal cannula, upgrade to simple face mask 5–8 L/min. Do NOT administer high-flow uncontrolled oxygen to a COPD patient.
• Complete Vital Sign Survey — HR 108, BP 98/64, RR 24, SpO2 89% RA, GCS 15, BGL 5.8 mmol/L, Temp 37.1°C, CRT 3s, Pain 8/10.
• Conduct SAMPLE / IMISTAMBO history — specifically explore the nature of the aspirin 'allergy' (childhood rash, no anaphylaxis — not a confirmed hypersensitivity reaction).
• Administer Aspirin 300 mg orally (chewed or dissolved in a small amount of water) — the CPG states aspirin is administered even if the patient reports prior aspirin use or is on anticoagulants; a childhood rash without confirmed anaphylaxis/hypersensitivity does not constitute a contraindication. Explain clearly to the patient why it is important.
• Confirm GTN is not contraindicated: systolic BP 98 mmHg (≥90 mmHg — threshold met), HR 108 bpm (50–150 bpm — threshold met), no PDE5 inhibitor use in previous 24–72 hours.
• Administer GTN 400 microg (1 spray) sublingually — patient must be seated or semi-recumbent. Do not shake GTN bottle prior to use.
• Reassess pain score 5 minutes post GTN — if pain >3/10 and BP maintained ≥90 mmHg, administer second GTN 400 microg (1 spray) sublingually.
• If pain remains >3/10 after first GTN spray: prepare and administer Methoxyflurane (Penthrox) 3 mL via Penthrox inhaler — patient self-administers intermittently to maintain analgesia. Reassess pain score.
• Reassess BP before every GTN dose — confirm systolic ≥90 mmHg prior to each administration.
• Consider Ondansetron 4 mg oral wafer if patient reports nausea or vomiting — confirm no contraindications (no apomorphine use).
• Continuously reassure patient — maintain calm demeanour, keep patient still and supported.
• Record full observations every 5 minutes given time-critical presentation.
• Arrange Priority 1 ambulance transport with pre-notification of receiving facility (suspected STEMI). Provide IMISTAMBO handover to transporting crew including: aspirin administered, GTN dose/s administered, Methoxyflurane initiated if given, COPD with controlled oxygen in use, aspirin allergy discussion documented.
• Scenario ends on arrival of ambulance and IMISTAMBO handover.

Clinical references: Chest Pain / Acute Coronary Syndrome · Oxygen · Aspirin · Glyceryl Trinitrate (GTN) · Methoxyflurane · Ondansetron · Chronic Obstructive Pulmonary Disease (COPD) — Acute Exacerbation · Primary Survey · Pain Assessment