Bureau of Prisons Health Services Clinical Encounter¶
| Inmate Name: Date of Birth: 01/20/1953 Encounter Date: 08/10/2019 07:25 | EPSTEIN, JEFFREY EDWARD | Sex: Provider: | M | Race: WHITE RN | Reg #: Facility: NYM Unit: | 76318-054 Z04 | ||
|---|---|---|---|---|---|---|---|---|
| Emergency Code - Resuscitation Event encounter performed at Special Housing Unit. | ||||||||
| SUBJECTIVE: | ||||||||
| Provider: Emergency Note RN | ||||||||
| Provider | Team Members: Role | |||||||
| RN | ||||||||
| Team/Code Leader Code Events: | ||||||||
| Type | Value | Date | ||||||
| CPR | Compressions | 08/10/2019 06:35 | ||||||
| EKG/Monitor | Lifepak | 08/10/2019 06:39 | ||||||
| No shock advised | ||||||||
| CPR | Compressions | 08/10/2019 06:40 | ||||||
| Oxygen | 15 L | 08/10/2019 06:47 | ||||||
| IV Access | Peripheral IV | 08/10/2019 06:48 | ||||||
| 18 g Left AC | ||||||||
| Airway | Endotracheal Tube | 08/10/2019 07:08 | ||||||
| ET Tube 7.5 24CM to L Lip line Placed by Paramedics | ||||||||
| Medications Epinephrine 1mg IV 08/10/2019 07:10 Epinephrine 3 doses and Sodium bicarb 2 doses administered by paramedics | ||||||||
| CPR | Compressions | 08/10/2019 07:11 | ||||||
| Medications | Sodium Bicarbonate 1 mEa/kg IV | 08/10/2019 07:11 | ||||||
| IV Fluids | Normal Saline 0.9% 1000 ml | 08/10/2019 07:12 | ||||||
| Medications | Epinephrine 1mg IV | 08/10/2019 07:13 | ||||||
| CPR | Compressions | 08/10/2019 07:14 | ||||||
| Medications | Sodium Bicarbonate 1 mEa/kg IV | 08/10/2019 07:14 | ||||||
| Medications | Epinephrine 1mg IV | 08/10/2019 07:16 | ||||||
| CPR | Compressions | 08/10/2019 07:17 | ||||||
Comments:¶
Responded to a body alarm at 0635 for medical emergency on 9S, Upon arrival Inmate was received on the floor of his cell unresponsive with CPR in progress by correctional officers, Inmate was Cold, with circumferential Bruising around the neck and posterior mottling, Pupils Fixed and dilated, No Palpable pulses, Call place for EMS, CPR Continued, AED Placed No shock advised, CPR Continued, inmate transported to HSU treatment room with CPR in progress, 18g hep lock to L AC, O2 15 Lt ViA BVM, Pulse Check NO SHOCK advised. EMS and Paramedics arrived 0656, Placed on cardiac monitor asystole Resumed CPR, Inmate was intubated by Medics, 3 Rounds of Epinephrine administered, Pulse Check asystole, Inmate was transported to Local ER with CPR in progress.¶
OBJECTIVE:¶
Exam:¶
General¶
Appearance¶
Yes: Unconscious¶
| Inmate Name: | EPSTEIN. JEFFREY EDWARD | Reg #: | 76318-054 | |||
|---|---|---|---|---|---|---|
| Date of Birth: | 01/20/1953 | Sex: | M | Race: WHITE | Facility: NYM | |
| Encounter Date: 08/10/2019 07:25 | Provider: | RN | Unit: | Z04 |
Exam:¶
ASSESSMENT:¶
Cardiac Arrest¶
PLAN:¶
New Consultation Requests:¶
| Consultation/Procedure | Target Date | Scheduled Target Date | Priority | Translator | Language |
|---|---|---|---|---|---|
| Emergency Room | 08/10/2019 | 08/10/2019 | Emergent | No | |
| Subtype: | |||||
| AMBULANCE | |||||
| Reason for Request: | |||||
| Cardiac arrest with CPR in progress | |||||
| Copay Required:No | Cosign Required: Yes | ||||
| TelephoneNerbal Order: No | |||||
| Completed by | RN on 08/10/2019 08:10 | ||||
Requested to be cosigned by MD.¶
Cosign documentation will be displayed on the following page.¶