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EMS, Patient Care, Training, You Make the Call

You Make the Call – Document THIS

Ah, you all have gotten used to not having a weekly challenge, so let’s get back to basics.  How about the different ways to describe skin?  Instead of being crazy like some of my lab proctors in college finding the most exotic and disgusting photos, I’ll send along one of my own.

I know I have already turned a few stomachs with the photos of my burns, but that was about pain control and had to be done to make a point.

There is no point in this.  Unless of course, you have no idea how to describe this wound in writing.  Yes, that was a challenge.

You may ask questions as to specifics not clear in the photo, but having the wrist and hand in the picture gives all the info you need for size, color and location.

I have been known to add a little of my college education to a PCR narrative or two, but only when sure.  So when I awoke this morning with the following mark on my forearm and my daughter asked what it was I told her and she wrinkled her face.

So my question to you is, how would you document this mark on my forearm?You make the call.

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  2. Joseph Schmoe June 6, 2010 4:39 pm

    E226 responded C3 to a reported arm injury. E226 arrived on scene and were led to the kitchen area of a SFR where we found a 35 yr old male seated at the table. Pt was A&OX4 and appeared in minimal distress. Pt. was complaining of a small blister type injury to the inside of his left forearm approx. 3″ proximal to his wrist. Pt. denied any itching or pain to the affected area and said that the blister was first noted this AM upon awakening.

    Pt. denied any known traumatic event within the last 4 days, any medical history, allergies or medications. Pt. did, however say that he had a TB test administered approx 20 hours prior to our being called.

    No coughing was observed.

    E226 performed pt assessment, took vitals and obtained pt info.

    Pt. was transported by Great Big Ambulance Co. to SFCRH BLS without further incident. E226 then returned to service.

    Just a wild-ass EMT1 guess Hap, hope I was wrong. Good luck.

    • medic424 June 8, 2010 1:50 pm

      looks like shingles or maybe you were getting intimate and now have genital herpes on your arm

      • medic424 June 8, 2010 1:59 pm

        maybe you were cooking bacon and got splattered or it could be the start of necrotizing fascititis

    • medic911911 June 8, 2010 8:11 pm

      could it involve a creepy crawly known as a packsaddle

  3. Joseph Schmoe June 6, 2010 12:39 pm

    E226 responded C3 to a reported arm injury. E226 arrived on scene and were led to the kitchen area of a SFR where we found a 35 yr old male seated at the table. Pt was A&OX4 and appeared in minimal distress. Pt. was complaining of a small blister type injury to the inside of his left forearm approx. 3″ proximal to his wrist. Pt. denied any itching or pain to the affected area and said that the blister was first noted this AM upon awakening.

    Pt. denied any known traumatic event within the last 4 days, any medical history, allergies or medications. Pt. did, however say that he had a TB test administered approx 20 hours prior to our being called.

    No coughing was observed.

    E226 performed pt assessment, took vitals and obtained pt info.

    Pt. was transported by Great Big Ambulance Co. to SFCRH BLS without further incident. E226 then returned to service.

    Just a wild-ass EMT1 guess Hap, hope I was wrong. Good luck.

  4. Brad June 6, 2010 6:31 pm

    I would agree with Joe Schmoe, looks like a PPD or very small blister of idiopathic orgin

  5. Sean Eddy June 6, 2010 6:42 pm

    ALS Response for traumatic injury. Canceled on scene, no patient contact. 🙂

    • medic June 9, 2010 12:34 am

      yea this is such a BS call, I totally agree with you lol

  6. michael June 6, 2010 7:07 pm

    Pt. is a 35 y/o male found at home with a small blister on inside L. wrist. Pt has recent HX of yard work. Pt. has future of scratching, rubbing, Calamine lotion and maddness.

  7. Joseph Schmoe June 6, 2010 4:39 pm

    E226 responded C3 to a reported arm injury. E226 arrived on scene and were led to the kitchen area of a SFR where we found a 35 yr old male seated at the table. Pt was A&OX4 and appeared in minimal distress. Pt. was complaining of a small blister type injury to the inside of his left forearm approx. 3″ proximal to his wrist. Pt. denied any itching or pain to the affected area and said that the blister was first noted this AM upon awakening.

    Pt. denied any known traumatic event within the last 4 days, any medical history, allergies or medications. Pt. did, however say that he had a TB test administered approx 20 hours prior to our being called.

    No coughing was observed.

    E226 performed pt assessment, took vitals and obtained pt info.

    Pt. was transported by Great Big Ambulance Co. to SFCRH BLS without further incident. E226 then returned to service.

    Just a wild-ass EMT1 guess Hap, hope I was wrong. Good luck.

  8. Burned-Out Medic June 6, 2010 10:44 pm

    i hope you’ve already had chickenpox.

  9. Brad June 6, 2010 6:31 pm

    I would agree with Joe Schmoe, looks like a PPD or very small blister of idiopathic orgin

  10. SeanEddy June 6, 2010 6:42 pm

    ALS Response for traumatic injury. Canceled on scene, no patient contact. 🙂

  11. michael June 6, 2010 7:07 pm

    Pt. is a 35 y/o male found at home with a small blister on inside L. wrist. Pt has recent HX of yard work. Pt. has future of scratching, rubbing, Calamine lotion and maddness.

  12. burnedoutmedic June 6, 2010 10:44 pm

    i hope you've already had chickenpox.

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  14. runswithscissors June 7, 2010 4:26 am

    I like the canceled on scene no pt contact… or a blister on anterior wrist, signature here, good bye.

  15. runswithscissors June 7, 2010 12:26 am

    I like the canceled on scene no pt contact… or a blister on anterior wrist, signature here, good bye.

  16. runswithscissors June 7, 2010 4:26 am

    I like the canceled on scene no pt contact… or a blister on anterior wrist, signature here, good bye.

  17. InsomniacMedic June 7, 2010 11:21 am

    A shameless plug for my own minor injury care… http://insomniacmedic.blogspot.com/2009/10/right.html
    but in the meantime, I go with the cancelled on scene, sent in a cab… 🙂

    • Ethan June 7, 2010 12:23 pm

      Or sent via Family Car Ambulance Service.

  18. InsomniacMedic June 7, 2010 7:21 am

    A shameless plug for my own minor injury care… http://insomniacmedic.blogspot.com/2009/10/righ
    but in the meantime, I go with the cancelled on scene, sent in a cab… 🙂

  19. Medic999 June 7, 2010 2:21 pm

    Medic999 called to assess soft San Francisco Fireman who had the audacity to call 911 for a teeny weeny iddy biddy little scald with a result blister that required a magnifying glass to actually see it.
    Pt was a nervous and hysterical wreck, crying out something about “how am I gonna run hose with this”
    and
    “Sweet lord!!! My career is over, Someone, anyone please help me!!”

    After shouting “NOT ON MY SHIFT BUDDY”

    I took him to the nearest trauma centre after activating the well known and famous SFFD Helicopter, as seen in the hit TV Show Trauma”

    As I left the scene I saw him weeping into his wifes arms with his children cuddled into his legs screaming
    “why Daddy, why!!!”

    Oh sorry, did you want a serious answer!!

    • the Happy Medic June 7, 2010 4:22 pm

      Clever, yet no one has yet to actually describe this injury with any accuracy.
      Owe! Typing that made it hurt.

      • Medic999 June 7, 2010 6:08 pm

        Right then,

        I dont know exactly where you are going with this, but I will be absolutely honest and describe what I would write in my patient report form.

        Justin describes waking this morning and noticing a small blister on the inner aspect of his right forearm. Called 999 for assistance / advice.
        O/A (On arrival) – Sitting in his chair, good colour, conscious alert and orientated. Appears in good spirits and is talkative.
        O/E (On examination) – Small minor intact blister present with a surrounding area of erythema. No further apparent injuries to find. Justin states his pain score is 2 on 0-10 scale and has taken oral analgesia with some effect (assuming some things here mate)
        all observations within normal limits and as charted.Justin describes [Insert cause of blister or unknown origin here].
        Tx – Home care advice given [Unless some really odd cause which may have further ramifications] and instructed to contact his local GP (family doctor) if any further concerns.
        No need for transport to hospital at this time and based on findings of examination. Respond Not Conveyed form completed and copies of paperwork left with patient.

        Well thats it. If you give up any ‘special’ history then I may need to rewrite, but if it is caused by a scald from hot fat or other known mechanism then thats pretty much what I would write.

  20. InsomniacMedic June 7, 2010 11:21 am

    A shameless plug for my own minor injury care… http://insomniacmedic.blogspot.com/2009/10/righ
    but in the meantime, I go with the cancelled on scene, sent in a cab… 🙂

  21. Ethan June 7, 2010 12:23 pm

    Or sent via Family Car Ambulance Service.

  22. Paul June 7, 2010 5:32 pm

    Physical Exam: 6mm water blister anterior portion forearm, with skin redness local to site of injury. Remainder of exam appears unremarkable and without complaint

  23. Local212 June 7, 2010 5:52 pm

    Patient stated he was going to drive himself to the fire station where he would relieve a co-worker for a few minutes in order to state injury occurred “on the job”. Patient is now listed as “IOD” (Injured On Duty) and will spend 9-14 months consulting specialists of all sorts while collecting full pay and benefits along with Aflac and assorted other supplemental insurance plans. Prior to being ordered back to work from his “injury” patient will submit documents requesting he be retired on “disability” and collect “66 and 2/3” pay with a yearly COLA and full benefits for himself and family for life.

    Oh….wait….you don’t live/work in my state or my station. What was I thinking. OK, so here goes: Patient was assessed and advised to suck it up and stop being such a whiny b**ch.
    The rest…well, we all know people like that don’t we?

  24. Medic999 June 7, 2010 2:21 pm

    Medic999 called to assess soft San Francisco Fireman who had the audacity to call 911 for a teeny weeny iddy biddy little scald with a result blister that required a magnifying glass to actually see it.
    Pt was a nervous and hysterical wreck, crying out something about “how am I gonna run hose with this”
    and
    “Sweet lord!!! My career is over, Someone, anyone please help me!!”

    After shouting “NOT ON MY SHIFT BUDDY”

    I took him to the nearest trauma centre after activating the well known and famous SFFD Helicopter, as seen in the hit TV Show Trauma”

    As I left the scene I saw him weeping into his wifes arms with his children cuddled into his legs screaming
    “why Daddy, why!!!”

    Oh sorry, did you want a serious answer!!

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  26. the Happy Medic June 7, 2010 4:22 pm

    Clever, yet no one has yet to actually describe this injury with any accuracy.
    Owe! Typing that made it hurt.

  27. Paul June 7, 2010 5:32 pm

    Physical Exam: 6mm water blister anterior portion forearm, with skin redness local to site of injury. Remainder of exam appears unremarkable and without complaint

  28. Local212 June 7, 2010 5:52 pm

    Patient stated he was going to drive himself to the fire station where he would relieve a co-worker for a few minutes in order to state injury occurred “on the job”. Patient is now listed as “IOD” (Injured On Duty) and will spend 9-14 months consulting specialists of all sorts while collecting full pay and benefits along with Aflac and assorted other supplemental insurance plans. Prior to being ordered back to work from his “injury” patient will submit documents requesting he be retired on “disability” and collect “66 and 2/3” pay with a yearly COLA and full benefits for himself and family for life.

    Oh….wait….you don't live/work in my state or my station. What was I thinking. OK, so here goes: Patient was assessed and advised to suck it up and stop being such a whiny b**ch.
    The rest…well, we all know people like that don't we?

  29. Medic999 June 7, 2010 6:08 pm

    Right then,

    I dont know exactly where you are going with this, but I will be absolutely honest and describe what I would write in my patient report form.

    Justin describes waking this morning and noticing a small blister on the inner aspect of his right forearm. Called 999 for assistance / advice.
    O/A (On arrival) – Sitting in his chair, good colour, conscious alert and orientated. Appears in good spirits and is talkative.
    O/E (On examination) – Small minor intact blister present with a surrounding area of erythema. No further apparent injuries to find. Justin states his pain score is 2 on 0-10 scale and has taken oral analgesia with some effect (assuming some things here mate)
    all observations within normal limits and as charted.Justin describes [Insert cause of blister or unknown origin here].
    Tx – Home care advice given [Unless some really odd cause which may have further ramifications] and instructed to contact his local GP (family doctor) if any further concerns.
    No need for transport to hospital at this time and based on findings of examination. Respond Not Conveyed form completed and copies of paperwork left with patient.

    Well thats it. If you give up any 'special' history then I may need to rewrite, but if it is caused by a scald from hot fat or other known mechanism then thats pretty much what I would write.

  30. 95ADAM June 8, 2010 2:11 am

    TYPE 1 3807 ? For work.
    An Owieee ? For kid.
    A vesicle ? For college boys.

  31. 95ADAM June 7, 2010 10:11 pm

    TYPE 1 3807 ? For work.
    An Owieee ? For kid.
    A vesicle ? For college boys.

  32. SKC Observer June 8, 2010 4:57 am

    This simple example checked me up quick on the difference between observing and documenting that and offering up potential diagnoses. There are times for that, but mostly for us non-doc types, we’re observing and documenting. Schmoe did a good job with that.

    The rest of the comments were also awesome. Thanks HM readers for giving me a good laugh or two or three!

  33. SKC Observer June 8, 2010 12:57 am

    This simple example checked me up quick on the difference between observing and documenting that and offering up potential diagnoses. There are times for that, but mostly for us non-doc types, we're observing and documenting. Schmoe did a good job with that.

    The rest of the comments were also awesome. Thanks HM readers for giving me a good laugh or two or three!

  34. 95ADAM June 8, 2010 2:11 am

    TYPE 1 3807 ? For work.
    An Owieee ? For kid.
    A vesicle ? For college boys.

  35. SKC Observer June 8, 2010 4:57 am

    This simple example checked me up quick on the difference between observing and documenting that and offering up potential diagnoses. There are times for that, but mostly for us non-doc types, we're observing and documenting. Schmoe did a good job with that.

    The rest of the comments were also awesome. Thanks HM readers for giving me a good laugh or two or three!

  36. DaveO June 8, 2010 11:30 am

    Very small blister on anterior aspect of L. wrist. Would definitely ask if you’d been in contact with poison ivy/oak/sumac….then I’d say……… “You called 911 for this !”….

  37. DaveO June 8, 2010 7:30 am

    Very small blister on anterior aspect of L. wrist. Would definitely ask if you'd been in contact with poison ivy/oak/sumac….then I'd say……… “You called 911 for this !”….

  38. PinkEMTPrincess June 8, 2010 12:45 pm

    I’d call it a small vesicle with some surrounding errythema assuming I can see clearly

  39. ry_dre June 8, 2010 1:48 pm

    I belive that this could possibly be a spider bite due to the redness surounding the bilster. transport to ER. In possition of comfort. O2 at 2 lpm N/C. Heart monitor just in case.

  40. MommaKate June 8, 2010 1:49 pm

    I would have to describe this as a small vesicle on the anterior forearm approx 3 inches above the wrist with some redness and swelling noted around the area. I would also have to assume that the site was warm to the touch. I would want to further investigate the history of this patient for possible exposure to some type of vector/contagion is the last 12-24 hours. I may clean the site with some soap and water on scene & apply a small dry dressing. If the patient requested transport (our agency does not allow for suggestions of care and refusing transport), we would have a comfortable seat in the back of the ambulance, secured of course, a further assessment to include re-assessing breath sounds (just in case wheezes start) & vitals, then have a nice easy ride to the ER. During the transport I would call the facility and expect a response of “continue transport, notifiy of any changes, triage on arrival”.

  41. Deanna June 8, 2010 3:12 pm

    Definitly does not look like a PPD wheal, I’ve planted thousands of them. I’d go with the bacon blister.

  42. DaveO June 8, 2010 11:30 am

    Very small blister on anterior aspect of L. wrist. Would definitely ask if you'd been in contact with poison ivy/oak/sumac….then I'd say……… “You called 911 for this !”….

  43. PinkEMTPrincess June 8, 2010 12:45 pm

    I'd call it a small vesicle with some surrounding errythema assuming I can see clearly

  44. Medic Girl June 8, 2010 5:47 pm

    Medic 604 responded to an unknown medical. Info states he woke this morning and imediately noticed pain in his left wrist and hand. Patient found a small intact blister with associated redness surrounding the blister. Due to the amount of pain involved pt called 9-1-1 for an evaluation.

    On arrival pt found sitting at kitchen table complaing of moderate to severe pain in left wrist and hand. Upon examination pt found to have a small intact blister with noted redness around blister on inside of left wrist. upon further exam it is noted that patient has some cyanosis (may be shadowing but I think that’s what I see) and mild swelling distal to the blister and pt is unable to move hand or fingers without severe pain. Airway patent. Pt denies difficulty breathing or swelling of tongue. No obvious swelling of face. Pt states he is having some mild abdominal cramping begining and states he is nauseated but denies vomiting PTOA (prior to our arrival). Pt does state that he is feeling light headed. Pt denies any other complaints. Upon removing pts clothes (except for his chonies ) :o) no other blisters found. Pt vitals are stable (B/P and HR slightly elevated possibly due to pain) Pt does state he was working in the yard yesterday but denies “noticing” any insect bite/stings. Pt denies and trauma or burns recently. Pt states he would have driven himself to the ER but was concerned because he was light headed.

    Due to posibility of an insect/spider bite (and possible impending compartment syndrome) Pt placed on gurney with head lowered (not trendelenburg b/p stable) IV initiated and pt placed on EKG and O2 (protocol in my area for pain management) PT given Morphine @ 2mg increments titrated to effect and pt transported to nearest most “appropriate” ER.

    With minimal information to go on this is the route of possibility I chose. Not knowing what area you live in I have no idea what insect threats you may have.

  45. ry_dre June 8, 2010 1:48 pm

    I belive that this could possibly be a spider bite due to the redness surounding the bilster. transport to ER. In possition of comfort. O2 at 2 lpm N/C. Heart monitor just in case.

  46. MommaKate June 8, 2010 1:49 pm

    I would have to describe this as a small vesicle on the anterior forearm approx 3 inches above the wrist with some redness and swelling noted around the area. I would also have to assume that the site was warm to the touch. I would want to further investigate the history of this patient for possible exposure to some type of vector/contagion is the last 12-24 hours. I may clean the site with some soap and water on scene & apply a small dry dressing. If the patient requested transport (our agency does not allow for suggestions of care and refusing transport), we would have a comfortable seat in the back of the ambulance, secured of course, a further assessment to include re-assessing breath sounds (just in case wheezes start) & vitals, then have a nice easy ride to the ER. During the transport I would call the facility and expect a response of “continue transport, notifiy of any changes, triage on arrival”.

  47. medic424 June 8, 2010 1:50 pm

    looks like shingles or maybe you were getting intimate and now have genital herpes on your arm

  48. medic424 June 8, 2010 1:59 pm

    maybe you were cooking bacon and got splattered or it could be the start of necrotizing fascititis

  49. michael June 8, 2010 7:40 pm

    He got da poison ivy, nya nya nya nya na na.

  50. Deanna June 8, 2010 3:12 pm

    Definitly does not look like a PPD wheal, I've planted thousands of them. I'd go with the bacon blister.

  51. Medic Girl June 8, 2010 5:47 pm

    Medic 604 responded to an unknown medical. Info states he woke this morning and imediately noticed pain in his left wrist and hand. Patient found a small intact blister with associated redness surrounding the blister. Due to the amount of pain involved pt called 9-1-1 for an evaluation.

    On arrival pt found sitting at kitchen table complaing of moderate to severe pain in left wrist and hand. Upon examination pt found to have a small intact blister with noted redness around blister on inside of left wrist. upon further exam it is noted that patient has some cyanosis (may be shadowing but I think that's what I see) and mild swelling distal to the blister and pt is unable to move hand or fingers without severe pain. Airway patent. Pt denies difficulty breathing or swelling of tongue. No obvious swelling of face. Pt states he is having some mild abdominal cramping begining and states he is nauseated but denies vomiting PTOA (prior to our arrival). Pt does state that he is feeling light headed. Pt denies any other complaints. Upon removing pts clothes (except for his chonies ) :o) no other blisters found. Pt vitals are stable (B/P and HR slightly elevated possibly due to pain) Pt does state he was working in the yard yesterday but denies “noticing” any insect bite/stings. Pt denies and trauma or burns recently. Pt states he would have driven himself to the ER but was concerned because he was light headed.

    Due to posibility of an insect/spider bite (and possible impending compartment syndrome) Pt placed on gurney with head lowered (not trendelenburg b/p stable) IV initiated and pt placed on EKG and O2 (protocol in my area for pain management) PT given Morphine @ 2mg increments titrated to effect and pt transported to nearest most “appropriate” ER.

    With minimal information to go on this is the route of possibility I chose. Not knowing what area you live in I have no idea what insect threats you may have.

  52. michael June 8, 2010 7:40 pm

    He got da poison ivy, nya nya nya nya na na.

  53. medic911911 June 8, 2010 8:11 pm

    could it involve a creepy crawly known as a packsaddle

  54. medic June 8, 2010 8:34 pm

    yea this is such a BS call, I totally agree with you lol

  55. medic June 9, 2010 12:34 am

    yea this is such a BS call, I totally agree with you lol

  56. Lin44615 June 12, 2010 3:58 am

    Pt complains of a vesicle on the L anterior forearm, 2″ medial to the wrist. The vesicle is approximately 5-6 mm in diameter surrounded by a patch of red inflamed skin approx. 1″ in diameter. There are no apparent bite/sting markings. Possible contact dermatitis or localized burn.

  57. Lin44615 June 11, 2010 11:58 pm

    Pt complains of a vesicle on the L anterior forearm, 2″ medial to the wrist. The vesicle is approximately 5-6 mm in diameter surrounded by a patch of red inflamed skin approx. 1″ in diameter. There are no apparent bite/sting markings. Possible contact dermatitis or localized burn.

  58. Lin44615 June 12, 2010 3:58 am

    Pt complains of a vesicle on the L anterior forearm, 2″ medial to the wrist. The vesicle is approximately 5-6 mm in diameter surrounded by a patch of red inflamed skin approx. 1″ in diameter. There are no apparent bite/sting markings. Possible contact dermatitis or localized burn.

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