EMR in Action, ctd.

Team member Mikel Kinser was at home, where his wife was hosting a couple’s baby shower for one of her coworkers:

“I was outside when I heard a loud crash and my wife yelled from inside for help. I ran inside and found one of her guests prone on the floor next to a chair that had fallen over. My wife said she fell over after saying she was dizzy and had asked for a glass of water.

Her head hit the ground hard and she lost consciousness for a moment. I told my wife to call 911. As the guest started to come around, I began speaking to her, asking her questions. She was A&OX3, not knowing what happened to her, but did know her name, where she was, and what day it was. I also took her pulse and respiration. I began feeding this information to my wife, who was on the phone with 911.

She also had a large bump on her head where she hit the ground, but no blood. She had free motion with her head and neck so I did not feel there was any spinal or neck injury. I checked her eyes for PERRL and all was good. I kept her on the ground where I found her, and checked with her for comfort (warm or cold). Paramedics arrived within five minutes of the call and took over. I relayed the info again to them: patient name, what happened and patient vitals. From there I just observed the five emergency workers. They did an EKG on her (normal) but they did find that when she stood up her BP dropped a lot. She refused transport, and I had to sign as a witness.

She remained at our house until a friend of hers could come and pick her up. We told the friend to keep an eye on her as she had hit her head and could have a concussion. She returned the next day for her car and was fine except for the bump.

Looking back on it, I felt calm going through the steps, but could have done better (I had a BP cuff in my office and I did not think about it until later). I also did not do CMSTP, which I should have. I feel worse for the things I did not do than good about what I did do, because I know from my EMR training what is supposed to be done. I can see that continued exposure to this is the only way to stay on top of it and do it correctly.”