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COMBO: Transport/Refusal/Canceled/Unfounded/Gone (94/93/87/90/96) 93K1 dispatched to the emergency call for the INJURY?. Transport: What pt told you (subjective) Upon arrival, unit found approx? X y/o M/F, conscious, alert, breathing?, standing/semi-Fowler’s in bed/sitting in chair, in no obvious distress? Pt reports chief complaint starting X days ago (SAMPLE/OPQRST). Pain X out of 10. “Pt quote.” Pt denies consumption of alcohol/reports drinking N alcoholic beverages when? Pt states PMHX of? Pt reports/denies HNBP, HA, CP, SOB, LOC, head strike, DNV, and blood thinners. EDP: Pt denies SI/HI, auditory hallucinations, and visual hallucinations? Pt denies all other pain or injury. PD was on scene (officer X, shield Y, pct Z). Transport: What you assessed, treated (objective) Pt A&Ox4 (or A/O to what), pos patent airway, resp effort regular and unlabored? Pos distal pulses? No obvious sign of hemorrhage? PE reveals HEENT intact, PERRL, ABD SS/NT/ND×4 quads, pos PMS ×4 extremities? Gait steady? Head to toe assessment reveals X. Lung sounds clear? JVD? ABD sounds present? No other obvious signs of DCAP-BTLS. BP, PR, RR, SPO2, and skin assessment WNL (state abnormal values). S-LAMS score X. Rest of PE unremarkable. MVA: Pertinent event/damage details? Upon inspection of vehicle, unit found airbags deployed, penetrating damage into the cabin. Front bumper is deformed. No damage to side of vehicle. Pt can recall the event in its entirety? Pt was given [treatments]? INJ: Pt was offered and refused a cervical collar? ALS: Pt was given treatments by ALS, refer to unit XX’s PCR (###) for treatments and interventions. Transport: Destination At pickup location, Pt was assisted to ambulance in stretcher/walked into ambulance?, secured with straps ×5, rails x2/seatbelt?, and transported to HXY WOl and WOC. Pt was brought to ED in stretcher/walked into ED. Pt report and care transferred to receiving nurse in ED. Pt was left with their belongings. Unit was cleared from HXY and returned to service WOl. MRN: X (no insurance) Refusal After initial assessment, pt refused transport to the hospital. Pt states [care plan]. The unit informed the pt of the risks of refusal and counseled pt to call 911 if symptoms persist or worsen. Pt read, verbalized understanding of, and signed RMA, witnessed by [name, relation]. Unit was cleared from scene and returned to service WOI. Canceled Unit 93K1 dispatched to a X. Unit was canceled by dispatch while en route and returned to service WOI. Incident Unfounded/Gone Upon Arrival Unit 93K1 dispatched to a X. Unit responded non?emergent and arrived on scene WOI. Upon arrival, unit found no individuals with injuries or in need of EMS assistance. Unit was not flagged by anyone. Unit canvassed the area and searched all four corners. [Gone: Bystander advised that that individual who called was here but left/was taken by another unit.] Unit advised dispatch and asked for a callback. Unit was canceled by dispatch and returned to service WOI.
Copy 93-All Narrative
93K1 dispatched to the emergency call for the INJURY?. Upon arrival, unit found approx? X y/o M/F conscious, alert, breathing?, seated on subway platform floor, in company of PD and MTA staff, with [injury]. Pt alert but presents with disorganized thought? unable? to articulate how they sustained the injury to their head. No? witnesses were present on scene to report events leading up to Pt's injury. Pt solely shares “quote.” Pt refused to answer questioning on their medical history, allergies, medications, or present symptoms. Pt alert but refused to answer questions on time or event. Positive and self maintained airway; respiratory effort regular and unlabored - Pt refused L/S assessment; Pt moved all 4 extremities spontaneously, and without noticeable complaint. Visual PE scan reveals: X; otherwise, intact HEENT; PERRL; no? obvious guarding noted. Pt refused BP, PR [noted for purposes of advancing PCR], SpO2, and BGL assessment. RR and skin assessment WNL. Pt's gait mildly unsteady. Head to toe assessment reveals no other signs of DCAP-BTLS. Rest of PE unremarkable. At pickup location, Pt assisted to standing height?, offered evaluation, but Pt refused. Pt guided to street level?, re-offered evaluation, but Pt continued to refuse. MTA and NYPD assisted with attempts to convince Pt to be evaluated, but Pt then walked away from EMS, reiterating they have no medical complaints and do not need medical evaluation. Pt last seen walking southbound on X St at X/Y St (give intersection) sidewalk, ambulating steadily?, in no obvious distress. 10-93 refused all signaled. 93K1 cleared scene WOI.