venusianPunk
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- Sep 15, 2026
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- #1
15 SEPTEMBER 2008
ca. 20:30 LOCAL TIME
While posted at the clinic's counter, PT (32 yof) presented via self (ambulatory w/o asst.; hobbling gait, seemingly unable to bear weight on her RLE) C/O traumatic injury secondary to aggravated battery; PT assisted (x1) into storage room and placed supine on metal table as makeshift PT bed; PT expressed SOB, and was sat into a high Fowlers before moving on.
At scene, PT found to be conscious and breathing; without exsanguinating hemorrhaging; stable cervical spine; airway open and patent; breathing at a fast rate, normal depth, and somewhat labored - intermittent and frequent deep, nonproductive coughing fits; skin with full color, dry, warm, and with normal turgor; pulse {radial} present at a fast rate, regular rhythm, and strong quality; PEARRLA; AO 4 and GCS 15 (E4 V5 M6); PT appears without life threat(s).
PT C/O traumatic injury (R lower leg) sustained from an episode of aggravated battery (approx. 30 min PTA, PT describes having been in/near the sewage system of the district and crossing paths with a "scrawny" male brandishing a pipe-like weapon whom demanded "everything I had;" the attacker then proceeded to strike the PT with said pipe, primarily against her RLE, before the two disengaged); PT assessed and vitalized with findings including negative LOC, negative head/neck/back strike, negative blood thinners, negative exsanguinating hemorrhaging, cough, dyspnea, HTN, pain (acute onset, provoked on mvmt. and palp., sharp/shooting quality, 10+/10 severity, onset ca. 20:00 local time, no Tx PTA), sinus tachycardia (12-L), and tachypnea; NKDA; no PMHx; no Rx; per paramedic assessment/judgement and PT HPI/presentation/vitals, PT is likely suffering a displaced Fx (R fibula) - however, without physician assessment, imaging, and/or exploratory surgery, this is not a definitive diagnosis.
IV 18 g L AC established and secured, albuterol/ipratropium 3 mL NEB (A/W support), ceftriaxone 1 g w/ NS 0.9% 250 mL (broadline antibiotic), ketorolac 30 mg IV (anti-inflammation and pain mgmt.), morphine 4 mg IV (pain mgmt.), NS 0.9% 1 L IV (rehydration), O2 2 LPM NC (supportive and hypoxemia [preventative]), ondansetron 4 mg IV (nausea [preventative]), and splint (R lower leg, short-splint) w/ adjustable-height crutch applied.
PT responded well to all treatments - frequency and intensity of both cough and pain diminishing, and PT was able to remain still-enough for the splinting process. Morphine worked to where paramedic had to be extra-careful as to a potential overdose, however this was avoided entirely - PT remained somnolent for some time and was repetitively re-assessed and re-vitalized without further developments. Later, PT roused fully and was able to escort self (with her clinic-provided crutch) and was told that she would be followed-up with PRN for further pain mgmt. and possible-surgery should the injury require it.
Incident, results, and conclusions relayed to clinicians; signatures obtained.
End of report.
- M. Romero-Torres, EMT-P
ca. 20:30 LOCAL TIME
While posted at the clinic's counter, PT (32 yof) presented via self (ambulatory w/o asst.; hobbling gait, seemingly unable to bear weight on her RLE) C/O traumatic injury secondary to aggravated battery; PT assisted (x1) into storage room and placed supine on metal table as makeshift PT bed; PT expressed SOB, and was sat into a high Fowlers before moving on.
At scene, PT found to be conscious and breathing; without exsanguinating hemorrhaging; stable cervical spine; airway open and patent; breathing at a fast rate, normal depth, and somewhat labored - intermittent and frequent deep, nonproductive coughing fits; skin with full color, dry, warm, and with normal turgor; pulse {radial} present at a fast rate, regular rhythm, and strong quality; PEARRLA; AO 4 and GCS 15 (E4 V5 M6); PT appears without life threat(s).
PT C/O traumatic injury (R lower leg) sustained from an episode of aggravated battery (approx. 30 min PTA, PT describes having been in/near the sewage system of the district and crossing paths with a "scrawny" male brandishing a pipe-like weapon whom demanded "everything I had;" the attacker then proceeded to strike the PT with said pipe, primarily against her RLE, before the two disengaged); PT assessed and vitalized with findings including negative LOC, negative head/neck/back strike, negative blood thinners, negative exsanguinating hemorrhaging, cough, dyspnea, HTN, pain (acute onset, provoked on mvmt. and palp., sharp/shooting quality, 10+/10 severity, onset ca. 20:00 local time, no Tx PTA), sinus tachycardia (12-L), and tachypnea; NKDA; no PMHx; no Rx; per paramedic assessment/judgement and PT HPI/presentation/vitals, PT is likely suffering a displaced Fx (R fibula) - however, without physician assessment, imaging, and/or exploratory surgery, this is not a definitive diagnosis.
IV 18 g L AC established and secured, albuterol/ipratropium 3 mL NEB (A/W support), ceftriaxone 1 g w/ NS 0.9% 250 mL (broadline antibiotic), ketorolac 30 mg IV (anti-inflammation and pain mgmt.), morphine 4 mg IV (pain mgmt.), NS 0.9% 1 L IV (rehydration), O2 2 LPM NC (supportive and hypoxemia [preventative]), ondansetron 4 mg IV (nausea [preventative]), and splint (R lower leg, short-splint) w/ adjustable-height crutch applied.
PT responded well to all treatments - frequency and intensity of both cough and pain diminishing, and PT was able to remain still-enough for the splinting process. Morphine worked to where paramedic had to be extra-careful as to a potential overdose, however this was avoided entirely - PT remained somnolent for some time and was repetitively re-assessed and re-vitalized without further developments. Later, PT roused fully and was able to escort self (with her clinic-provided crutch) and was told that she would be followed-up with PRN for further pain mgmt. and possible-surgery should the injury require it.
Incident, results, and conclusions relayed to clinicians; signatures obtained.
End of report.
- M. Romero-Torres, EMT-P
