Download DANGERFIELD FIRE RESCUE

DANGERFIELD FIRE RESCUE
Case#: 007 Patient: HUGGINKISS, ROBERT
Input By: SOMERSAULT, NICOLE
Patient: 01 of 01
Date: 04/08/2010
Received:
Dispatched:
Enroute:
Arrived:
Pt Contact:
Tx Arrived:
Tx Hosp:
Arrived Hosp:
Available:
Alert Time:
Addres s : 444 BUMMER AVE
City: DANGERFIELD
Shift: C SHIFT
Vehicle: R-911
Respond With: DFSO
MEDIC: SOMERSAULT, NICOLE
MEDIC: SPICOLI, JEFF
Assisted By: E-911
Nature Dispatched: UNCONSCIOUS/UNRESPONSIVE
Nature Arrived: POSSIBLE OVERDOSE/INTOXICATION
Reason for Delay: NO DELAYS
ZoneFrom: 1
Zone To: 1
Disposition: TRANSPORT
Location Type: PATIENTS HOME
Call Level: ALS – TRAUMA ALERT
Reason Chosen: SPECIALTY HOSPITAL - TRAUMA
Tx To: DANGERFIELD TRAUMA CENTER
TX By: R-911
Patient: HUGGINKISS, ROBERT
Age: 54
Sex: MALE
Race: WHITE
Pt Address: 444 BUMMER AVE
Birth Date 03/02/1956
S/S#: 001-23-1234
Pt Country: U.S.A.
Pt City: DANGERFIELD
Pt State: FL
Pt Zip Code: 33213
Phone# (212) 321-1234
Chief Complaint: The patient presents with an altered mentation
Pt Position: PRONE
Method of Injury: Fall
PMHx: Ethanol abuse, Cirrhosis, Hepatitis C
Medications: Antabuse (The patient is not compliant with his medication per his spouse.)
Pt Found: GROUND
Allergies: NKA
PMD: Alan Windsor, M.D.
LOC: The patient arouses with loud verbal stimuli and at
times, becomes combative and uncooperative. The
speech is slurred and at times, his words are
incomprehensible.
Face: There are impressions of the ground to the skin of
the face as a result of the patient lying prone. There is no
trauma or skeletal abnormality present to the face on
examination.
Airway: The airway is patent with no excessive
secretions. There is a detectible odor of a possible
alcoholic beverage on the patient’s breath. The patient
does admit to drinking about 24 beers this evening.
Eyes: Periorbital ecchymosis (Raccoon’s eyes) is
beginning around the left orbital area. The right orbit is
without discoloration. The sclerae are erythematic
(bloodshot). Extraocular movement reveals nystagmus
present in both eyes on penlight testing. The patient does
describe some visual impairment in the left eye.
Breathing: The chest wall excursion is symmetrical with no
evidence of labored breathing.
Circulation: There are strong, bilateral radial pulses present.
Head: The patient is wearing a baseball cap. Upon
removing the cap, there is a 7.5cm (3”) in diameter x 5cm
(2”) elevated hematoma to the left temporal region of the
head. Bleeding has been controlled by the natural clotting
process, which has resulted in the matting of the patient’s
hair around the wound site, making the evaluation of the
wound difficult. There is suspected crepitus to this region.
Light colored blood is leaking from the external auditory
meatus of the left ear. This blood appears to separate
from a yellowish fluid when placed on a gauze pad
(suspect positive Halo test). Periauricular ecchymosis
(Battle’s sign) is present to the mastoid region of the left
aspect of the head. The remainder of the head is without
signs of trauma. No deformities or crepitus are present to
the rest of the head on palpation.
R.Pupil: The right pupil is round, 5mm, and is
sluggishly reactive to light.
L.Pupil: The left pupil is round, 7mm and non-reactive
to light.
Neck: There is no obvious trauma to the neck on
examination. No cervical tenderness or crepitus is
present on palpation of the posterior aspect of the
neck. The trachea is midline and there is no JVD while
supine.
Chest: On exposing the chest, there are only the
impressions of the ground in the skin. There is no
crepitus on palpation of the anterior or lateral chest
walls. There are no signs of injury to the thoracic area
on visual examination and palpation. Lungs sounds
are coarse but clear bilaterally on auscultation. The
patient does cite being a smoker (2 packs/day for the
last 30 years).
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DANGERFIELD FIRE RESCUE
Case#: 007 Patient: HUGGINKISS, ROBERT
Input By: SOMERSAULT, NICOLE
R.Arm: The right arm was found positioned underneath the
patient’s body and has the impressions
of the ground in the skin. There are no signs of trauma
present to the right arm on examination. The right
arm has a good range of motion and good strength.
There is no loss of sensation present to the right arm
when questioning the patient.
vertebral column on palpation.
Pelvis: There is no crepitus or tenderness elicited on
palpation or compression of the pelvic girdle or the
symphysis pubis. Urinary incontinence is noted to the groin
area of the patient’s jeans.
R. Leg: There is no trauma present to the right leg on either
visual examination or palpation. No crepitus or deficits in
movement are present to the articulations on active or passive
movement.
L. Arm: The left arm has no signs of trauma and has good
motion. There is no loss of sensation present upon
questioning the patient.
R. Hand: There are only the impressions of the ground to
the patient’s skin on examination of the right hand. There
is no trauma present. The patient is able to move his
fingers on command with no loss of function, movement or
sensation. Capillary refill is brisk and less than 2 seconds.
L. Leg: There is no trauma present to the left leg on either
visual examination or palpation. No crepitus or deficits in
movement are present to the articulations on active or passive
movement.
R Foot: On removing the shoe, there are no signs of trauma
to the right foot on both visual examination or palpation. There
is no loss of sensation or function to the right foot on examination.
Brisk capillary refill as well as a strong dorsalis pedis pulse is
present.
L. Hand: There is dried blood present to the left hand on
evaluation. There are no open wound sites to the left hand
and the patient is able to move all his fingers on
command. No loss of function or sensation is present to
the left hand on evaluation. Capillary refill is brisk and less
than 2 seconds.
L Foot: On removing the shoe, there are no signs of trauma
to the left foot on either visual examination or palpation. There
is no loss of sensation or function to the left foot on examination.
Brisk capillary refill as well as a strong dorsalis pedis is present.
Abdomen: A 5cm (2”) well healed diagonal scar is
present to the right iliac region (right lower quadrant) of
the abdomen – suspect possible appendectomy. There
are no signs of trauma to the abdomen on examination.
The abdomen is somewhat obese and overall slightly firm
on palpation. There is no tenderness elicited on palpation
of the nine regions (4 quadrants) of the abdomen. No
masses are palpable nor any pulsations.
Blood Loss: There is a pool of clotted blood located in the
grass nearby that is estimated to be approximately 30cm (12”)
in diameter. Continuous slow leaking of lightly colored blood is
present to the left external auditory meatus which is estimated
to be approximately10ml.
Skin Moisture: The skin is slightly diaphoretic. Skin turgor is good.
Upper Back: On exposing the upper back, there are no
signs of trauma present on visual examination or palpation.
No crepitus or tenderness is present to the ribs or vertebral
column. No spinal deformity is present to the vertebral
column on palpation.
Skin Color: The color is normal.
Skin Temp: The temperature is warm.
Lower Back: On exposing the upper back, there are no
signs of trauma present on visual examination or
palpation. No crepitus or tenderness is present to the ribs or
vertebral column. No spinal deformity is present to the
Vitals
Time
B/P
Pulse
Resp. Sao2%
LOC
EKG
Glasgow Total
23:47
158 / 72
64
24
94
Responds to verbal
12
Skin Temp: NORMAL Color: NORMAL Moisture: NORMAL Glucose: Lung Sounds: W ALLS/SOUNDS
EQUAL
00:01
148 / 60
64
26
99
Responds to verbal
Skin Temp: NORMAL Color: NORMAL Moisture: NORMAL Glucose: Lung Sounds: W ALLS/SOUNDS
EQUAL
Intervention
23:47 Done By: SPICOLI, JEFF Intervention: BREATHING Type: PULSE OXI. Reason: Result: 94 Size:
Method: Attempts:
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DANGERFIELD FIRE RESCUE
Case#: 007 Patient: HUGGINKISS, ROBERT
Input By: SOMERSAULT, NICOLE
General Comment
R911 responded to the dispatched address to find a 54 y/o male prone in the front yard of the residence. It is after midnight and the
weather is clear with a warm temperature and humid. Two sheriff’s deputies are also on the scene. The patient presents with an
altered mentation but will arouse on loud verbal stimuli. Upon interviewing the patient, he stated that several individuals w ere
attempting to steal his beer and he began chasing them. During the chase, the patient stated that he fell onto the street str iking the
left side of his head. He then told EMS that he got back up and began walking but stumbled into the grass of the residence. A
neighbor who had just come home from work and was walking his dog found the patient and called 911 on his cell phone. The
patient stated that he has been drinking alcoholic beverages tonight, specifically Old Milwaukee, and thinks he remembers drinking
about 24 beers this evening. This patient is known to EMS as there have been frequent calls on this individual for issues rel ated to
his alcohol consumption. The patient’s spouse arrived on scene while assessing the patient, providing some additional informa tion
regarding the patient’s condition. Physical examination revealed a well-developed, poorly nourished White male whose mentation
is altered and when aroused, became combative at times and resistive to treatment. The patient’s speech is slurred and some w ords
are incomprehensible. There is a detectible odor of a possible alcoholic beverage on the patient’s breath. Examina tion of the head
revealed a 7.5cm (3”) x 5cm (2”) elevated hematoma to the left temporal region of the head. The wound site is somewhat difficult to
evaluate due to the clotted blood matting the patient’s hair in the area of the injury. There is suspected crepitus present to the skull
in the area of the hematoma on the left temporal region. There is also a slow leak of lightly colored blood draining from the left
external auditory meatus. This blood appears to separate into a light colored fluid on its periphery when placed on a gauze pad
(possible positive Halo test). Periauricular ecchymosis (Battle’s sign) is present to the mastoid area behind the left ear. The rest of
the physical exam is documented in the section above. Treatment included initial assessment while maintaining manual in-line
cervical spinal motion restriction. The clothing was cut and the back exposed. Rapid trauma survey of the head, neck and back were
performed. A Trauma Alert was declared due to the decrease in mentation (Red criteria of GCS  12) and possible skull fracture.
4 x 4 gauze pads were placed over the wound. A rigid cervical collar was applied. The patient was logrolled onto an adjacent long
spineboard where he was secured with cross-strapping & a cervical immobilization device (CID). Rapid trauma survey performed of
the anterior body. The patient was loaded on the stretcher, secured and placed in the back of R-911. Vital signs were assessed.
Pulse oximetry applied. O2 was administered via NRM at 15LPM. Field glucose via finger stick revealed 93mg/dl. ECG performed.
The patient was somewhat combative during the treatment, attempting to remove the cervical collar, spineboard straps off of
him and attempting to raise his head out of the CID. Attempts at cleaning and better visualizing the head injury were unsuccessful.
Venous access was attempted however the patient still was combative and would pull his arms away when being stuck with
the catheter. Ultimately, IV access was established in the left antecubital region with a 16G catheter and 0.9% Sodium Chloride was
infused at a KVO rate. Dangerfield Trauma Center was contacted via radio with no further orders advised. The patient began to stop
fighting the EMS crew in the back of the rescue upon arrival at Dangerfield Trauma Center. He was turned over to Dr. Nelligan and
the Trauma staff with a verbal report and a preliminary field report. //ns
SIGNATURE: SOMERSAULT, NICOLE
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