L/B 911 PCR

DISPATCH:
[select name="responding_unit" value="UAS unit 4|UAS unit 1|UAS unit 10|UAS unit 2|UAS Car 45|BRAS unit 44|BRAS unit 45|BRAS unit 46|BRAS unit 47|BRAS C1|BRAS car 1| "][text name="unit_number" default=""] dispatched by [select name="variable_1" value="UAS communications center|Lincoln county communications center"] for [text name="disptach_reason" default="chest pain"]. Dispatched [checkbox name="response_code" value="code 1|code 3"].
    
RESPONSE: 
Crew responded [checkbox name="lights_and_sirens_use" value="emergent with lights and sirens|emergent without use of lights or sirens|non emergent without the use of lights or sirens|initial non emergent without use of lights or sirens upgraded to emergent with use of lights and sirens|initial emergent with use of lights and sirens downgraded to non emergent and use of lights and sirens were stopped"].  [textarea name="responce_indicent" default="There were no incidents or updates enroute."]
    
    
ARRIVAL:    
Crew found patient: [textarea="pt_found" default="Standing on the curb after being directed by bystanders"]. Patient was in [checkbox name="distress_level" value="no obvious distress|mild distress|moderate distress|severe distress|moderate emotional distress|severe emotional distress|unresponsive"] [text name="appearance" default=""]. 
    
Patient's chief complaint is: [text name="Cheif_complaint" default=""]. The primary problem appears to be: [text name="primary_problem" default=""].
    
Relevant history and events leading up to today's call: [textarea name="events" default=""][checkbox name="known_to_ems" value="Patient is known to EMS."] [comment memo="Other scene notes"][textarea name="scene_notes" default=""]

Initial ABC's:
    
Airway: [checkbox name="airway" value="airway open|airway patent|no airway obstructions"][text name="airwaydis" default=""]. 
Breathing: [checkbox name="breathing" value="breathing spontaneously|breathing regular|adequate respirations|equal chest rise and fall"][text name="breathing_dis" default=""]. 
Circulation: [checkbox name="circulation" value="no obvious bleeding|pulses intact|skin color appropriate|cap refill <2 seconds|no life threats to circulation"][text name="primary_circulation" default=""]. 

[comment memo="Treatments prior to moving to unit"][textarea name="tx_prior_to_movement" default="No treatments or interventions indicated, required, or performed prior to movement to unit."]

Patient was [checkbox name="moved_to_stretcher" value="able to walk to stretcher in unit without assistance|able to walk to stretcher in unit with minimal assistance|was able to walk to stretcher without assistance|was able to walk to stretcher with minimal assistance|Assisted stand and pivot|draw sheeted to stretcher via 2 providers|draw sheeted to stretcher via 3 or more providers|transferred to stair chair and secured as appropriate, carried to stretcher and transferred to stretcher| transferred to reeves stretcher and carried to stretcher, reeves was removed|transferred to reeves stretcher and carried to stretcher, reeves was kept in place|carried|was able to walk to unit and secured in a rear facing seat with all seat belts"] [text name="carried_pt" default=""]. Patient was secured with all seatbelts and rails raised. Pt was positioned [checkbox name="position" value="flat|low semi-fowlers|high semi fowlers|in a sitting position|on their left side|on their right side|with knees up|with legs raised|with the patients head at approximately 30 degrees|in patients carseat|in pedi-mate|neomate"][text name="position" default=""] and made as comfortable as possible.    
    
Pt was attached to [checkbox name="monitoring" value="SPO2|NIBP|4 lead EKG|12 lead EKG|ETCO2|BGL was obtained via a finger stick|BGL obtained via IV flash|prior to moving patient|in unit|only one set of vitials obtained due to extremely short transport time|only one set of vitials obtained due to paitent refusal of second set|paitent refused vitals"]. [comment memo="EKG strip showed"][checkbox name="EKG" value="4 lead EKG showed:|sinus rhythm|sinus bradycardia|sinus tachycardia|sinus arrhythmia|AFIB|AFIB W/RVR|supraventricular tachycardia|atrial flutter|junctional rhythm|first degree AV block|second degree type 1|second degree type 2|3rd degree block|VTach|VFIB|Asystole|PEA|Torsades|W/PVC'S|W/PAC'S|W/PJC'S|per paramedic"][text name="ros_heme" default=""][checkbox name="12_Lead" value="12 lead showed no ST elevation, depression, or other explanation of symptoms and was declared to be negative|12 lead showed ST elevation in leads INSERT    LEADS    and depression in leads    INSERT    LEADS|12 lead showed left bundle branch block-Unknown onset|12 lead showed left bundle branch block- known existence|12 lead showed right bundle branch block-Unknown onset|12 lead showed right bundle branch block- known existence|significant artifact present|per paramedic"][text name="12_lead_interpetation" default=""]
    
PHYSICAL EXAM AND ASSESSMENT:	

General: [checkbox name="pegeneralcheck" value="alert & oriented x4|alert to person|alert to place|alert to situation|alert to time|alert to baseline|in no acute distress|alert, but confused|well appearing|malnourished|in acute distress"][text name="pegeneral" default=""].

Neuro: [checkbox name="peneurocheck" value="gait normal|sensation intact|normal reflexes|smile normal|speech not slurred|equal strength in all extremities/at baseline|normal|neuro not grossly intact|gait abnormal|strength uneven|sensation absent|no reflexes|smile not symmetrical|slurred speech|all within acceptable limits"][text name="peneuro" default=""].

Head: [checkbox name="peheentcheck" value="normocephalic|atraumatic|pupils PEARL|white sclera|conjunctiva pink|no fluid noted in or around ears|no bleeding|no recent head trauma|did not hit head|normal mucous membranes|patient denies vision changes|nose normal|no dental injury|has dentures|has no teeth|tongue midline|tongue deviation|dental decay|all within acceptable limits"][text name="mouth" default=""].

Neck:  [checkbox name="neck" value="no gross deformity or misalignment|no vertebral tenderness|no pain with movement|C-spine cleared on scene|vertebral point-tenderness| pain with movement|normal voice|patient speaks very quietly|patient is nonverbal|patient has a gravelly voice|all within acceptable limits"][text name="neck" default=""].

[comment memo="Onset- Provocation/palliation- Quality- Radiation- Severity- x/10 Time-"]
Chest/Lungs:  [checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion|non-tender|clear and equal breath sounds bilaterally|no bruising|no tenderness|no chest pain|all within acceptable limits"][text name="lungsandchest" default=""].

Abdomen:  [checkbox name="abd" value="normal visual inspection|no distension|soft non-tender|surgical scar|umbilical hernia|diffuse tenderness over entire abdomen|denies possibility of pregnancy|has no uterus|all within acceptable limits"][text name="abd" default=""].

Musculoskeletal: [checkbox name="pemskcheck" value="normal range of motion|without increased pain on palpation|no crepitus|no obvious deformity|strength normal in all extremities|fine motor skills intact|abnormal range of motion|pain on palpation|strength not present|crepitus|obvious deformity|in all extremities|left upper extremity|right upper extremity|left lower extremity|right lower extremity|did not assess|unable to assess|unable to assess due to altered mental state|unable to assess accurately due to level of consciousness|unable to assess accurately due to unresponsive, unconscious, pulseless, and apneic state"][text name="MSK" default=""].

Skin: [checkbox name="peskincheck" value="no rashes|no skin tears|no swelling|no lesions|no discoloration|pink|warm|dry|pale|cool|cyanotic|flushed|clammy|hot|warm|diaphoretic|lividity|mottling|jaundiced|skin tear|swelling|good turgor|poor skin turgor|scattered bruising|scattered skin tears|scaring and scabs consistant with recent IV access"][text name="pe_skin" default=""].

Psych: [checkbox name="pepsychcheck" value="pleasant, calm, and cooperative|judgment and insight intact, understands treatment, thought process is logical/linear and age appropriate with normal affect|limited understanding of situation|limited understanding of disease process|presents with anxiety that is appropriate for situation and is receptive to education by crew|has a plan made|unpleasant|not calm|uncooperative|does not have a plan|does not understand treatment|impaired attention/concentration|judgment and insight not intact|mood instability|anxious but able to self soothe|anxious but receptive to calming techniques|anxious and inconsolable|belligerent|states they feel safe at home|forgetful|history of dementia|unable to assess|unable to assess accurately due to altered mental state|unable to assess accurately due to level of consciousness|unable to assess due to unresponsive, unconscious, pulseless, and apneic state"][text name="pepsych" default=""].
    
TREATMENT: 

Non Medication interventions performed:
[checkbox name="checktx" value="20g IV in LAC was placed by this provider. Site cleaned with aseptic technique with good flush and draw, and was secured as appropriate|20g IV in left hand was placed by this provider. Site cleaned with aseptic technique with good flush and draw, and was secured as appropriate|20g IV in left forearm was placed by this provider. Site cleaned with aseptic technique with good flush and draw, and was secured as appropriate|18g IV in LAC was placed by this provider. Site cleaned with aseptic technique with good flush and draw, and was secured as appropriate|18g IV in left forearm was placed by this provider. Site cleaned with aseptic technique with good flush and draw, and was secured as appropriate|22g IV in LAC was placed by this provider. Site cleaned with aseptic technique with good flush and draw, and was secured as appropriate|22g IV in left hand was placed by this provider. Site cleaned with aseptic technique with good flush and draw, and was secured as appropriate|22g IV in left forearm was placed by this provider. Site cleaned with aseptic technique with good flush and draw, and was secured as appropriate|20g IV in RAC was placed by this provider. Site cleaned with aseptic technique with good flush and draw, and was secured as appropriate|blood drawn|IO placed. Site cleaned with aseptic technique with good flush, IO secured as appropriate|CPAP|c-collar applied due to change in condition- C-spine no longer cleared due to change in complaint|cool pack applied|limb splinted|calming techniques including breathing exercises and visualization were used with success|no non medicated interventions preformed or indicated|Pt declined IV access|IV access was considered and IV access was looked for, however no reliable access was found and there was no immediate or impeding need for IV access, not attempted|IV access was considered, however due to ________ was not done, all meds likely to be given are able to be given via other means"][textarea name="nonmedtreatment" default=""]

Medications administered:
[checkbox name="meds_given" value="no medications given|324 mg aspirin given PO|Duoneb given with improvement|duo-neb given without improvement|4 mg zofran administered IV patient reports improvement|4mg zofran administered PO patient reports improvement|50mcg fentanyl given IV patient reports improvement|100mcg fentanyl given IV patient reports improvement|1000 mg IV tylenol hung on gravity patient reports improvement|0.4 mg nitro adminsted SL||O2 initiated at"][textarea name="med_tx" default=""].
    
    
TRANSPORT:
Patient was transported to [select name="hospital" value="CMMC|St. Marys|Maine Medical-Portland|Miles|Mid Coast| "][text name="hospital" default=""]. Crew transported patient [checkbox name="transcode" value="code 1 without use of lights or sirens|code 3 with use of lights and sirens|initially code 1 without use of lights and sirens, upgraded to code 3 with use of lights and sirens|initially code 3 with use of lights and sirens downgraded to code 1 and use of lights and sirens were stopped"]. [comment memo="Alerts called and relayed information"][textarea name="alerts_relays" default=""][checkbox name="variable_1" value="Stroke alert called.|STEMI alert called.|Sepsis alert called."]

Enroute patient was monitored as recorded and [checkbox name="got_beter_or_worse" value="remained stable with no change in pt condition|improved with treatment|decompensated|was talkative|attempted to rest and appeared comfortable, was easy to arouse with equal chest rise and fall|quiet but responsive|remained at known baseline"][text name="impove_or_not" default=""]. [text name="pt_stated" default="Patient stated"]


TRANSFER OF CARE:
On arrival to ED crew was directed to [text name="ED_location" default="triage"] where [checkbox name="other_things" value="report|paperwork|EKG's|meds hung|nitro bottle|and care"] was given to [checkbox name="reprot_to" value="RN|Doctor|team in bay|and all questions were answered to the best of crew's ability"].
    
Patient was transferred via [checkbox name="moved_to_bed_via" value="assisted stand and pivot|without assistance|2 provider drawsheet|3 provider drawsheet|4 or more provider drawsheet|reeves with several providers and removed at doctors orders|backboard with several providers and removed at doctors orders|reeves with several providers and kept in place|backboard with several providers and kept in place|able to walk from unit to ED per PT request with no assistance|carried|self scoot|assisted self scoot"] from stretcher to [checkbox name="trasnfered_to" value="hall bed and made comfortable|wheelchair|room bed and made comfortable|bay bed|walked in with the crew per pt request and walked to the chair in triage|triage room|wheelchair and brought to waiting room|walked to the waiting room"].

[checkbox name="replaced" value="Meds replaced at hospital|Meds replaced at base|Unit restocked at base|Unit throughly deconned"]    
Crew returned to service.

[checkbox name="off_times" value="
As a result of the dynamic pre-hospital environment in which limited resources are available the times noted in this patient care report may be approximated, extensive care was made to insure times are as accurate as possible."]


[shorthand name="pt" value="patient "]
[shorthand name="Pt" value="Patient "]
[shorthand name="resp" value="respiratory "]