On this call, you’re dealing with an individual on the street who has fallen from a bicycle and is disoriented.
This scenario includes:
• Consultation with Clinicall
• Refusal of treatment
Items marked with an * will auto populate when using the CAD Fetch tool during field training sessions
The Call: Street Fall Event (E180345689) |
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Location for Data Entry |
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*11:38 – Dispatched for a call, MPDS 32 – Unknown problem (Person Down) |
Incident > Times/Details > Times |
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Your dispatch to the scene is hot |
Incident > Incident > Mode |
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*En route to the incident address and receive the CAD information in Siren and start a new PCR. Address is 2985 Virtual Way, Vancouver |
[Accept CAD information – edit PCR]
Address used when CAD not available. |
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*11:42 – Arrive on scene. |
Incident > Times/Details > Times
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On arrival, bystanders say they saw a man weaving on his bicycle on the road, come to a stop, and fall to his hands and knees, then crawl over to a wall where he is now sitting. |
Incident > Incident Location > Location Type
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Primary > Scene Findings > Location Patient Found |
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Bystanders were not sure if he’s still conscious or not. |
Comments > Add narrative |
At Patient’s Side |
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11:45 – You approach the man and speak to him. |
Incident > Times/Details > Times |
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He opens his eyes and responds with slurred speech and incomplete sentences. |
Vital Signs > Vital Signs > GCS > 3 – 4 – 6
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His ABCs are fine |
Primary > Primary Survey
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You notice he’s pale and sweaty. |
Assess / Tx > Assessments > Skin Assessment |
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He has some minor abrasions on his knees and hands. |
History > Injury > Cause of Injury
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Comments > Narrative (at end of call) |
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Because the patient is disoriented, you ask if he’s used alcohol or drugs and he says no. When you ask him if he has any medical conditions, he tells you he’s diabetic and takes Metformin. |
History > Patient > Past Medical History >
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You take a blood sugar and find that it is 1.6 mmol/L. |
Vital Signs > Vital Signs
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You determine he’s alert enough to manage his own airway. |
Assess/Tx > Assessments > Airway Asssessment
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You offer him glucose gel and he takes it. You administer half a tube, which is 15 gms. |
Assess/Tx > Procedures > Drug Therapy |
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You perform a set of vitals on the patient. Pulse: 88 Reg Resps: 20 BP: 126/80
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Vital Signs > Vital Signs |
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Within a few minutes of taking the glucose gel, his colour has improved and he has stopped sweating. |
Assess/Tx > Procedures > Edit > SaRC
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He’s able to tell you that although he ate normally today, he went on a longer bike ride than planned. |
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The patient tells you his diabetes is normally well-managed and it’s been a few years since he had a significant episode of hypoglycemia. |
History > Patient > Past Medical History > Edit/Add Details |
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Based on the patient’s presentation you enter a chief complaint of low blood sugar. |
History > Patient > Complaints > General/Minor > Add Text |
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You now offer to clean and bandage the minor abrasions on his knees and hands. He declines. |
Assess/Tx > Procedures > Wound/Burn Care > Reason for Not Administering |
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The patient states that he’s fine and doesn’t want to go to the hospital. He’s able to articulate the risks associated with hypoglycemia. He’s a few blocks from home but no one else will be home for a few hours. He plans to eat and monitor his sugar levels when he gets home. |
Comments > Edit Narrative |
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You perform a second set of vitals: · Pulse: 72, and regular · Resps: 16 · BP: 124/78 · BG: 4.2 |
Vital Signs > Vital Signs |
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The patient refuses transport |
Outcomes > Patient Disposition/Other > Patient Disposition |
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Because the patient was in an altered mental state at the start of the call, you call Clinicall regarding the refusal of care. You provide the event # and use SBAR to describe the situation. The paramedic specialist acknowledges what you’ve said, and they verify with you that the patient is able to demonstrate capacity to refuse treatment. The paramedic specialist agrees that the patient is capable of caring for himself. |
Outcomes > Patient Disposition/Other > Consultation |
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You advise the patient to let their physician know about the incident. |
Comments > Narrative > Add Comments |
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Before the patient leaves, you gather the information you need from him: · Name: George PracticePractice · Date of Birth: January 5, 1970, |
Patient ID > Identification > Patient
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Address: 5 Omineca Drive, in Prince George, |
Patient ID > Identification > Patient Address |
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Physician: Chris How |
Patient ID > Identification > Contact Persons |
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PHN: 987 654 3210 |
Patient ID > Health Card > Health Card |
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George signs the Refusal of Care waiver |
Review > Signatures & Waivers > |
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Your partner Maya serves as the witness. |
Review > Signatures & Waivers > |
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You complete the event narrative |
Comments > Edit Narrative |
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You use the Required Fields menu to finish any missing fields |
Review > Required > Link To
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You enter hypoglycemia as your impression |
Impression > Impressions > Providers Impressions (Type) |
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You finalize the PCR |
Review > Print Preview > Finalize |