All records regarding this patient's ED course of examination, treatment, and findings - in addition to his brief in-hospital stay - were originally obtained with permission of the receiving hospital. All identifying references to the actual patient have been deleted, to preserve patient confidentiality.
A Summary of the Initial ED Examination and Impressions
(ALL the following notations are QUOTES from the ED Pt Care Record):
(0200 hours) Initial VS = B/P 116/73, pulse 120, ventilated respirations, temp of 36.6 C.
Patient follows no commands in ED.
Spontaneous eye opening.
Purposeful movements.
No past medical history available.
Warm, dry, (pink), white male, nasally intubated, awake, agitated.
Multiple contusions to face/forehead.
Right eye hematoma with edema and laceration.
Pupils equal and reactive to light - 7 (constricting to 4) millimeters bilaterally.
Extra ocular movements intact.
Ears, nose, teeth all intact and without abnormal findings.
Neck placed in collar.
No "steps" noted in spine.
Rapid respiratory rate with clear breath sounds bilaterally.
Abdominal exam = contusion left upper quadrant, abrasion right lower quadrant.
All quadrants soft with no masses.
Bowel sounds appropriate.
Pelvis stable.
Extremity exam = abrasion left shoulder, and bilateral knee abrasions.
Movement of all extremities.
After paralysis, rectal exam shows decreased tone, with heme-negative stool.
Heme-negative urine.
Normal prostate.
Patient is awake and opens eye to voice, does not follow commands.
A Summary of the ED Course of Treatment:
We arrived at the ED's door at 0157.54 hours. Upon transfer to the hospital bed in the "Crisis Room," the patient was immediately put on a ventilator, at a rate of 12 ventilations per minute (FI02 80, Tidal volume of 700, PEEP at 2.5).
The patient's persistent, forceful attempts to defeat restraint and immobilization continued.
At 0205 hours (7 minutes after our arrival) the patient was paralyzed and sedated with IV injections of 70 mg Zemuron (rocuronium bromide) and 4 mg Versed (midazolam).
Exams were performed, blood analyses ordered, a Foley catheter was inserted, consults were obtained. X-rays of his C-spine and chest were ordered.
For a More Detailed Chronology of the ED Treatment,
go to "Detailed ED Treatment/Exam Chronology" (link below)
The ED "Diagnostic Impressions" were as follows:
If you haven't already, and you wish to NOW,
go to any or all of the following Case-Related Files:
Email Charly at: c-d-miller@neb.rr.com