Trauma

Right-sided chest wall pain after crowd crush — cardiac red herring

Foundation

Adult · 38yr · male

Patient Information

Dispatch	You are called to a 38-year-old male (Daniel Sorensen) at a festival main stage area reporting chest pain. He was in the crowd during a surge and was pressed hard against a barrier. A security guard says he is 'clutching his chest' and called for EHS.
Patient	Daniel Sorensen — 38yr (86kg)
Incident History	Patient was standing near the front of the main stage crowd when there was a crowd surge. He was pushed hard against a metal barrier, with the barrier hitting the right side of his chest. Immediate onset of right-sided chest pain. No loss of consciousness. No head impact. No limb injury. Crowd has since dispersed and he has been helped to the side.
Emergency Contact	Karen Sorensen (Wife) — 0412 773 512

Initial Rapid Assessment

Response	Alert
Airway	Patent. Speaking in full sentences without difficulty.
Breathing	Comfortable at rest. Breathing slightly shallow — reluctant to take deep breaths due to pain. RR 18. No wheeze. SpO2 98% on room air. No accessory muscle use. Equal chest rise bilaterally.
Circulation	Radial pulse strong and regular. Skin warm and dry. No pallor. No diaphoresis. CRT <2s. BP 126/82.
Disability	GCS 15 (E4V5M6). Alert, orientated. Anxious — worried it might be his heart. No dizziness.
Exposure	Right lateral chest — bruising developing over the right 5th and 6th rib area in the mid-axillary line. Significant point tenderness on palpation at the bruised area — pain fully reproduced by pressing on the ribs. No paradoxical chest movement. No tracheal deviation. No surgical emphysema. Abdomen soft and non-tender.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	98% (RA)	Nil	18	84	126/82	<2s	15	4 4 ++	37	–	6
15 mins	98% (RA)	Nil	18	80	124/80	<2s	15	4 4 ++	37	–	5

History Taking

Treatment Response

Diagnosis

Musculoskeletal chest wall injury — likely rib contusion or fracture (5th/6th ribs, right side, mid-axillary line) from direct impact against a crowd barrier. This is NOT a cardiac event. Key differentiating features: clear traumatic mechanism, pain entirely right-sided and focal, pain fully reproduced on palpation (pathognomonic of musculoskeletal aetiology), no radiation to arm or jaw, no diaphoresis, no nausea, normal vital signs, no history of cardiac disease, and young patient with no risk factors. IMPORTANT: while this is not a cardiac emergency, rib injury must be monitored for secondary complications — specifically pneumothorax (deteriorating SpO2, increased respiratory effort, tracheal deviation) and haemothorax. SpO2 is 98% and equal chest rise is confirmed — no pneumothorax at this time. A rib fracture requires medical review for analgesia optimisation and X-ray. EHS management is supportive.

Facilitator Triggers — if trainees miss a critical step

! (If trainees assume cardiac origin and begin the ACS protocol (aspirin, GTN) without completing history and physical — facilitator prompts: 'Before you start treatment — can you describe the pain to me? Where exactly is it? Does pressing on the chest change the pain?' Expected: trainee realises the pain is reproduced by palpation, is right-sided, and has a clear traumatic mechanism.)
! (If trainees do not palpate the chest wall — prompt: 'He has chest pain — what does the clinical examination of the chest tell you?' Expected: palpation over the right lateral ribs fully reproduces the pain. This is a key diagnostic step for musculoskeletal chest pain.)
! (If trainees do not monitor SpO2 trend — prompt at 10 minutes: 'Rib injuries can have secondary complications — what are you watching for over time?' Facilitator note: pneumothorax can develop after rib trauma. SpO2 and respiratory effort must be monitored, not assessed once and dismissed.)
! (If trainees do not arrange medical review — prompt: 'You have assessed this as a rib contusion — is there anything further he needs?' Facilitator note: rib injuries require X-ray for fracture assessment and optimised analgesia. Advise ED review.)
! (If trainees dismiss the complaint as minor and do not complete full vital signs — bystanders re-raise concern that 'it could be his heart.' Prompt: 'You've reassured everyone it's not cardiac — what was your reasoning? Can you walk them through your assessment?' Expected: trainee articulates palpation-reproducible pain, right-sided location, traumatic mechanism, no cardiac features present.)

Treatment Objectives

1. Ensure scene safety — crowd has dispersed; continue away from the main stage area.
2. Don appropriate PPE.
3. Perform Primary Survey — confirm patent airway, adequate bilateral chest rise, haemodynamically stable. No life-threatening emergency.
4. Obtain history — confirm traumatic mechanism (chest vs barrier), location of pain (right lateral, NOT central), pain character (sharp, positional, worse on breathing), absence of cardiac symptoms (no radiation, no diaphoresis, no nausea, no dizziness, no palpitations).
5. Inspect the chest — look for bruising (right 5th/6th rib, mid-axillary line — bruising visible), deformity, paradoxical movement (nil), tracheal position (midline).
6. Palpate the chest wall — apply firm pressure over the tender area; pain is FULLY REPRODUCED. This is the key finding that establishes musculoskeletal aetiology.
7. Assess respiratory function — SpO2 98%, equal bilateral chest rise, no accessory muscle use, no paradoxical movement.
8. Complete Vital Sign Survey — all parameters normal. BP 126/82, HR 84, SpO2 98%, RR 18.
9. Document the palpation-reproducible nature of the pain in your notes — this is your primary differentiating finding from a cardiac cause.
10. Offer Methoxyflurane for pain management — this will help the patient breathe more deeply, reducing the risk of atelectasis from splinting.
11. Advise the patient to breathe as deeply as is tolerable — rib splinting (avoiding deep breaths due to pain) increases the risk of lung complications.
12. Monitor SpO2 at regular intervals — a deteriorating SpO2 or increasing respiratory effort would suggest a developing pneumothorax, requiring immediate CSP escalation.
13. Reassure patient — explain clearly that his presentation is consistent with a rib contusion from the impact, not a cardiac event, and describe your reasoning.
14. Advise medical review — rib injuries require X-ray to assess for fracture and to guide analgesia. Arrange transport to Emergency Department or urgent GP review.
15. If SpO2 drops, respiratory effort increases, or the patient develops increasing breathlessness — contact CSP immediately.
16. Scenario ends with patient assessed, pain managed, reassured, and arrangement for medical review confirmed.
17. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Soft Tissue Injuries · Primary Survey · Secondary & CNS Survey · Chest Pain / Acute Coronary Syndrome · Methoxyflurane · Pulse Oximetry

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Signs/Symptoms	Right-sided chest wall pain, sharp and localised, worst at the point of barrier impact. No central chest pain. No radiation to the jaw or left arm. No shortness of breath at rest. No diaphoresis. No nausea. No dizziness or faintness. Pain is worse on deep inspiration and on palpation.
Allergies	NKDA.
Medications	Nil regular medications. No anticoagulants. No aspirin.
Pertinent History	No cardiac history. No hypertension. No diabetes. No family history of early cardiac disease. Non-smoker. Occasional alcohol. Works as a schoolteacher. No prior rib injuries.
Last Oral Intake	Lunch approximately 3 hours ago.
Events Leading	Patient was enjoying the main stage performance when the crowd surged forward. He was pinned against a metal crowd barrier. The right side of his chest took the full force of the barrier impact before the crowd eased. He felt immediate pain and was helped to the side by security staff.
Treatment Prior	Nil — security staff helped him out of the crowd and called EHS.

Onset	Immediate — at the moment of chest impact against the barrier.
Pain	Right lateral chest — localised to the area over the 5th and 6th ribs. Sharp pain, worse on deep breath or movement.
Quality	Sharp, stabbing pain on movement and deep inspiration. Constant dull aching at rest.
Radiates	Nil — pain is localised to the right chest wall. No radiation to the arm, jaw, neck, or back.
Severity	6/10 at rest, 8/10 on deep breathing or movement.