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“Call Rec Chart”

Launch: Unknown Medical

Depart:

Land on scene:

Arrive Scene:

Assessment: Unconscious patient with EMS assisted ventilations. Bradycardic pulses with ineffective perfusion.

Intervention: CPR compressions initiated. Chest visibly rising with unobstructed assisted ventilations.

Assessment: Glasgow 3 Pupils fixed, dilated, unresponsive without withdrawal.

Intervention: Monitored

Assessment: Junctional bradycardia 

Intervention: #18 IV established and fluids opened. Atropine 1mg administered. BS 345

Assessment: Monitor with atrial fib with tachycardia rate 113 . Pulses palpated and radially strong. BP 145/66 Airway clear without gag response

Intervention: ET intubation accomplished. (see RT notes) 

Assessment: ET placement confirmed without abdominal sounds, bilateral breath sounds, ETCo2 gold, exhalation mist noted in ET. Easily ventilated. Monitor sats 98%.

Intervention: ET tube secured. Transferred to transport stretcher. Vitals as noted and unchanged. Fluids to KO.

History: Patient found by relative. Relative states could not contact patient, last known contact late previous afternoon. PMHx of COPD, HTN, Etohism. MD practices at SHMC.

Departed Scene:

Loaded: Without incident

Lifted:

Assessment: Vitals as noted. Monitor atrial fibrillation rate 100s.

Report to receiving ED

Landed:

Unloaded: Without incident

Admitted to ED. Report to staff.