Admission Note

0012       Trauma admit arriving by air
0013       MVA w/ patient ejected from vehicle. Previously healthy, no PMH
0014       Daughter currently outside trauma bay
0015       ETA 0025
0016
0017       Alert & following commands at scene
0018       Open upper extremity fracture – pulseless
0019       1U of pRBCs and Dopamine en route. BPs running 70s/40s
0020
0021
0022       Pt arrived. Pt is unresponsive. CPR in progress
0023
0024
0025       R arm cyanosis in fingertips, immobilized in splint. Visible midhumeral bone
0026       Distended abdomen w/ bruising along flank. Absent L breath sounds
0027       Needle decompression L chest, return of rush of air
0028       Cardiac rhythm, CPR stopped
0029
0030
0031       No confirmation of airway, anesthesia at head of bed
0032       FAST ultrasound positive for intraabdominal bleeding
0033
0034       Patient being prepped for open laparotomy in trauma bay
0035
0036       Carotid pulse still palpable, faint
0037
0038
0039       No confirmed airway yet
0040       Laparotomy incision made, anesth
0041
0042
0043      Significant bleeding from abdomen
0044      Pulse check — no pulses palpable. CPR started
0045      Mask on and bagging
0046      Hanging 5th U pRBC
0047
0048      Epi 5mg push
0049
0050       Pulse check —  no pulses palpable
0051
0052       Hanging 2U pRBC
0053
0054
0055       Pulse check — no pulses palpable
0056       Rapid infusion running
0057       15 min CPR
0058       Daughter bedside. Restrained
0059       Pupil check — pupils 4 mm, non-reactive bilaterally
0100
0101
0102
0103
0104       Time of death

 

Admission note transcribed by a third-year medical student during trauma activation. Identifying details of this encounter have been modified in order to protect patient privacy.

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