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SOAP – Not just for your hindquarters anymore – Conclusion

August 01

The original plan was to type out one of these sections daily until I had finished it, BUT thanks to a standby yesterday that went a whole 4 hours longer than it was scheduled for I didn’t get a chance to post yesterday. SO lucky you. You get a double dose of documentation in a single setting… Don’t you feel special 😉

The A section is the place for your assessment of the patients condition, I know over the years we have all been told we don’t diagnose in EMS and that’s true, but it’s also a misconception. You HAVE to form some kind of opinion of what is wrong with the patient, otherwise how do you decide what to do for them? You have an opinion – write it down, the diagnosis box at the hospital will be filled in by the ED doc, and I don’t care how big a rock star you are. He isn’t going to just copy what you write down. Don’t be afraid to form an opinion of what is wrong with the patient or to express that opinion; even if you never say the words your treatment tells everyone what you suspect is wrong.

In the scenario patient we’ve been documenting his injuries are obvious and I would have absolutely no qualm with writing them down as you will see, but what about nana who presents with a medical condition you can’t be quite as sure of? You still will have formed an opinion of what is wrong with her, but you can’t be sure if it’s CVA, A TIA, or is secondary to a previous CVA and she’s just presenting with a case of generalized weakness. Two little letters R/O (rule out) come in extremely handy in these situations. You can list every suspected injury, illness or condition with confidence when preceded by the letters R/O; this is a suggestion to the ED that based on your assessment you believe they should look for ______________.

Generally speaking, that should be sufficient to satisfy even the most ardent defenders of the “we don’t diagnose” argument.

You wouldn’t dream of walking into the ED and in your hand off report telling the doc: Well Doctor Smith, the patient presented with an asymmetric smile, slurred speech and arm drift that occurred suddenly about 30 minutes ago, but I have no idea what’s wrong with her…. You would say she’s suffered a stroke. If you would say it don’t be afraid to write it as well, granted we can’t tell if the patient is having a TIA, or a CVA, but at this point neither can the doc… He needs to see if the symptoms resolve and examine the scans, but if this is a concern for you then list your assessment as: R/O CVA/TIA

Enough of my SOAPbox (pun intended) grandstanding, back to the narrative.

A:

Tension Pneumothorax

Intra-abdominal bleeding

Hypoglycemia

Fx Left Femur

Scalp Lac 

During our exam we confirmed each of these injuries; I have no problem writing them exactly as I did, if it makes you feel better put an R/O in front of them.

Finally the last section P – procedures – this is the section where you document EVERYTHING you did for the patient. This is one of the sections I see A LOT of people skimp on, I was guilty of it myself until I was set straight by my paramedic partner in an ED lounge one day. He had a valid point and I adopted the things he told me and my reports have never been better because of it.

We are required to obtain consent from our patients before we ever touch them right? DO you document it?

What about how the patient got into the ambulance, or if you fastened all the straps on the cot?

Then there is always how the patient got into the ED… I think you get the drift.

DOCUMENT DOCUMENT DOCUMENT – more than any other THIS is the section lawyers have a field day with, if it isn’t here you DID NOT do it period.

Disclaimer first – the treatments below are based on our local protocols, and any ALS interventions were suggested by one of our paramedics whom I greatly respect… I am a basic so if I botch the dosage or something it’s because I didn’t know any better – (that’s why I’m going to paramedic school next month after all)

P: Consent, assumed control of patient’s C-spine from bystander, primary survey, survey interrupted to perform needle decompression (10g, 2nd intercostal space, midclavicular line, with flutter valve), ventilatory assistance via BVM with reservoir and 15 LPM O2, initial survey resumed, Trauma activation called into St. Injury Trauma Hospital, interview, CMS check, C-collar sized and applied, Pt log rolled onto long spine board and secured with spider straps (back exam performed during log roll), head blocks applied and patients head and blocks secured to board with 2″ tape, CMS check, Patient loaded onto cot using long board by crew, foot of long board raised aprox 6 inches by placing med box under it (Trendelenburg), all 5 straps fastened and side rails raised, patient loaded into back of ambulance by crew, Patient transported emergent to St. Injury Trauma Center, vascular access (bilateral A/C, 14g angio, blood pump), BGL, fluid challenge 20ml/kg started (1600 ml total), vitals, 3 lead cardiac monitor, head to toe survey, 50ml (25 gm)D50 administered via established IV – Right arm, CMS check of Left leg, traction splint applied (to help relieve pain), CMS check of left leg, 12 lead cardiac monitor, vitals, repeat BGL, monitor decompression site for patency, call in consult to S.I.T.H Dr. Bones to administer 2 mcg/kg fentanyl, order received from Dr. Bones 1 mcg/kg fentanyl IV. 80 mg fentanyl IV via established IV in left arm, vitals, CMS check, patient unloaded from ambulance by crew on cot and wheeled into ED – red 1, patient transferred from cot to bed on long board by crew with assistance of SITH staff, hand off report given to trauma team RN, Patient and care transferred to SITH ED staff without incident.

John Q. Rockstar NREMT-P, Ambulance Company

————————————END OF NARRATIVE—————————————

While some of the treatments the patient got may be open for discussion, there is NO question about what was and what was not done for this patient.

So let’s take a look at the narrative from top to bottom start to finish.

 

NARRATIVE

Ambulance 123 and engine 456 dispatched emergent to go fast speedway at 123 any street for an auto-ped MVC

U/A found approx 20 YO M pt lying next to the race track in a semi prone position. Patient’s c-spine is being held by track employee and two other track employees are talking to the patient. Patient’s pants have a large tear in them in the left upper leg region and the left leg is bent at an awkward angle. Blood is visible in the patient’s hair and the patient appears very pale.

S: Pt is a 23 YO M. Patient states he “Can’t breathe” and his “chest and leg hurt”. Patient speaks in one to two word sentences and is confused and disoriented. Patient states that “a car drove right over me!” Patient states he isn’t sure how long ago this occurred.

HEENT: no complaints – pt states he “thinks he feels blood running down his face, but it could be sweat”

Chest: pt C/O pain to left chest – Pt denies having this pain before the collision, breathing/moving makes it hurt worse, pain is described as being sharp and squeezing at the same time, patient denies any radiation, pt rates the pain a 10

Back: no complaints

Abdomen: Pt C/O pain on palpation, patient denies any pain before accident, “you pushing on it” makes it worse, pain is described as dull all over his abdomen with no specific site, patient denies any radiation, patient rates the pain a 6

Pelvis: no complaints

Lower extremities: Pain to Left upper leg, patient denies having any pain before the accident, trying to move it makes it worse, pain is described as sharp and pulsating, patient denies any radiation, and rates the pain as a “12″

Upper extremities: no complaints

Allergy to PCN

Medications: insulin

PMHx: DM 2

Patient does not remember the last time he ate.

Patient also states he has a headache and some dizziness. Patient denies N/V/D as well as any LOC, but says he isn’t sure about that.

Bystanders give verbal report as follows: patient was walking from the pit area when he was struck by a vehicle traveling at a high rate of speed. Bystanders say that car did in fact drive over the patient saying he collapsed on impact and went under the car. Bystanders add that the patient was unconscious until just prior to our arrival. Bystanders also report that patient has not been moved and that track personnel were to him almost immediately keeping him still and “holding his head”.

O:

INITIAL EXAM

Airway: Open and patent

Breathing: Rapid w/ poor movement

Circulation: rapid radial pulse, minor bleeding from scalp lac, no major bleeding found

Skin: Pale, Cool, diaphoretic, cyanosis noted around lips

LOC: confused and abusive, won’t follow commands

Head: Blood in hair, no active bleeding, no other wounds noted, PERRL

Neck: No DCAP/BTLS noted, possible tracheal deviation to the right, positive JVD

Chest: Contusions noted to left chest, no paradoxical movement, crepitus and tenderness on palpation, breath sounds absent on left

Abdomen: slightly distended, tender to palpation

Pelvis: No DCAP/BTLS – intact and stable

Upper legs: Swelling, tenderness, deformity of left upper leg, normal CMS

Lower legs and arms: no injuries noted

Posterior: No DCAP/BTLS

Initial vitals: 90/50, pulse 150, respirations 36

GCS: 13 (eyes – 4, verbal -4, motor -5)

Sensory and motor function: normal

SECONDARY SURVEY: performed after initial interventions – en route to hospital

Airway: patent

Breathing: improved movement of air, less work to breathe, breath sounds now present on the left although diminished

Circulation: no major bleeding noted

Skin: pale, cool, diaphoretic, cyanosis around lips is improved

Vitals: 100/60, pulse 110, respirations 30

LOC: unchanged

GCS: unchanged

BGL: 40

Head: blood in hair from approx 4″ long scalp lac, no active bleeding, no battle sign or raccoon eyes, no drainage from ears or nose, face is atraumatic, PERRL

Neck: trachea appears more mid-line, JVD is no longer present – No DCAP/BTLS

Chest: unchanged

Abdomen: distension and tenderness are both increased from prior exam

Pelvis: unchanged

Upper extremities: NO DCAP/BTLS, Good CMS function

Lower extremities: Left leg in traction splint – CMS present, right leg no injuries noted

ONGOING EXAM: Performed after secondary interventions

BGL: 80

LOC: Patient is awake and alert, less combative and able to follow commands

GCS: 15

Breathing: movement of air continues to improve

Vitals: 110/70, pulse 110, respirations 30

Skin: unchanged

Neck: trachea remains midline and JVD remains absent

Chest: breath sounds still diminished on the left

Abdomen: distension/tenderness continues to worsen

Distal CMS on Left leg still intact and adequate

A:

Tension Pneumothorax

Intra-abdominal bleeding

Hypoglycemia

Fx Left Femur

Scalp Lac 

P: Consent, assumed control of patient’s C-spine from bystander, primary survey, survey interrupted to perform needle decompression (10g, 2nd intercostal space, midclavicular line, with flutter valve), ventilatory assistance via BVM with reservoir and 15 LPM O2, initial survey resumed, Trauma activation called into St. Injury Trauma Hospital, interview, CMS check, C-collar sized and applied, Pt log rolled onto long spine board and secured with spider straps (back exam performed during log roll), head blocks applied and patients head and blocks secured to board with 2″ tape, CMS check, Patient loaded onto cot using long board by crew, foot of long board raised aprox 6 inches by placing med box under it (Trendelenburg), all 5 straps fastened and side rails raised, patient loaded into back of ambulance by crew, Patient transported emergent to St. Injury Trauma Center, vascular access (bilateral A/C, 14g angio, blood pump), BGL, fluid challenge 20ml/kg started (1600 ml total), vitals, 3 lead cardiac monitor, head to toe survey, 50ml (25 gm)D50 administered via established IV – Right arm, CMS check of Left leg, traction splint applied (to help relieve pain), CMS check of left leg, 12 lead cardiac monitor, vitals, repeat BGL, monitor decompression site for patency, call in consult to S.I.T.H Dr. Bones to administer 2 mcg/kg fentanyl, order received from Dr. Bones 1 mcg/kg fentanyl IV. 80 mg fentanyl IV via established IV in left arm, vitals, CMS check, patient unloaded from ambulance by crew on cot and wheeled into ED – red 1, patient transferred from cot to bed on long board by crew with assistance of SITH staff, hand off report given to trauma team RN, Patient and care transferred to SITH ED staff without incident.

John Q. Rockstar NREMT-P, Ambulance Company

————————————END OF NARRATIVE—————————————

After reading through it top to bottom, do you have any question as to why this guy is in the ambulance, what is wrong with him, or how you intervened to try to help? Can you say the same thing about the last narrative you wrote?

Til next time…..

 

 

Posted by on August 1, 2011 in documetation, EMS, legal, Paramedic School

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