((If the EHS officer accepts the absence of chest pain as reassurance and does not treat as potential ACS — patient's GCS drops to 13, diaphoresis worsens, and she reports the back pain is now 7/10. Facilitator states: 'The patient looks increasingly unwell. Her skin is grey and clammy.'))

((If oxygen is not applied within 3 minutes of arrival — SpO2 drops to 90% on RA and patient becomes more breathless, RR increases to 26.))

((If BGL is not checked — facilitator prompts: 'The patient tells you she is a diabetic. Do you want to check her blood sugar?'))

((If aspirin is not administered despite no contraindication — facilitator prompts after 7 minutes: 'The patient asks if there is anything you can give her for the discomfort.'))

((If the EHS officer notes the patient already took aspirin this morning and withholds the dose — remind trainee via facilitator note that aspirin is administered even if patient has taken aspirin that day, as per CPG.))

((If GTN is considered — trainee must check BP before administration. If BP check is skipped and GTN is given without checking, facilitator states BP was 98 systolic — GTN is contraindicated at SBP <90 but note BP is borderline; discuss clinical reasoning. At initial BP of 98 systolic, GTN may be appropriate with close monitoring as BP is above 90 — facilitate discussion rather than rigid rule.))

((If patient is asked to walk to the stretcher — facilitator intervenes: 'The patient begins to stand. Is this appropriate given her presentation?'))

This patient is suffering from a suspected Acute Coronary Syndrome (ACS) presenting atypically — inter-scapular pain, nausea, diaphoresis and dyspnoea without classic central chest pain, in a 75-year-old female with diabetes and hypertension.

• Ensure scene safety and don appropriate PPE.
• Perform Primary Survey — confirm patent airway, assess breathing and circulation.
• Position patient seated or semi-recumbent — do NOT ask patient to walk; limit exertion.
• Apply oxygen via non-rebreather mask at 10–15 L/min — titrate to target SpO2 94–98%.
• Perform Vital Sign Survey including BGL, SpO2, BP, HR, RR, GCS, pain score, temperature.
• Perform Secondary Survey including auscultation of lung fields.
• Obtain IMISTAMBO-structured history — note atypical presentation (inter-scapular pain, nausea, no classic chest pain) in elderly diabetic female.
• Recognise atypical ACS presentation: inter-scapular pain + nausea + diaphoresis + dyspnoea + left arm heaviness = high suspicion for ACS despite absence of classic chest pain.
• Administer Aspirin (Disprin) 300mg oral — chewed or dissolved in small amount of water. Administer even though patient has taken 100mg aspirin today.
• Reassess BP before considering GTN. BP is 98 systolic — GTN is not contraindicated (SBP >90mmHg) but is borderline. If administering GTN: administer Glyceryl Trinitrate (GTN) 400 microg (1 spray) sublingually with patient seated or semi-recumbent. Reassess BP every 5 minutes before repeat doses.
• If pain remains >3/10 after 1 spray of GTN: Administer Methoxyflurane (Penthrox) 3mL inhaled via Penthrox inhaler device — patient self-administers.
• Administer Ondansetron 4mg oral wafer for active nausea if indicated.
• Monitor patient continuously — record full observations every 10 minutes (5 minutes if time critical).
• Activate Priority 1 transport — contact State Operations Centre, pre-notify receiving Emergency Department.
• Prepare for potential deterioration — have AED/defibrillator immediately available.
• 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 · Glyceryl Trinitrate (GTN, Nitroglycerin) · Aspirin (Disprin, Disprin Direct, Aspro Clear) · Methoxyflurane (Penthrox) · Ondansetron · Oxygen