2019-05665

Item 9, 13, 17 (partial), 18 (partial)

EFTA00073831

# Bureau of Prisons Health Services Clinical Encounter

| Inmate Name: | EPSTEIN, JEFFREY EDWARD |

| :--- | :--- |

| Date of Birth: | 01/20/1953 |

| Encounter Date: | 08/10/2019 07:25 |

Sex:

Provider:

<table><tr><td>Reg #:</td><td>76318-054</td></tr><tr><td>Facility:</td><td>NYM</td></tr><tr><td>Unit:</td><td>Z04</td></tr></table>

Emergency Code - Resuscitation Event encounter performed at Special Housing Unit.

## SUBJECTIVE:

Emergency Note Provider:

## Team Members:

## Code Events:

<table><thead><tr><th>Type</th><th>Value</th><th>Date</th></tr></thead><tbody><tr><td>CPR</td><td>Compressions</td><td>08/10/2019 06:35</td></tr><tr><td>EKG/Monitor</td><td>Lifepak</td><td>08/10/2019 06:39</td></tr><tr><td colspan="3">No shock advised</td></tr><tr><td>CPR</td><td>Compressions</td><td>08/10/2019 06:40</td></tr><tr><td>Oxygen</td><td>15 L</td><td>08/10/2019 06:47</td></tr><tr><td>IV Access</td><td>Peripheral IV</td><td>08/10/2019 06:48</td></tr><tr><td>18 g Left AC</td><td colspan="2">Page 001 of 148</td></tr><tr><td>Airway</td><td>Endotracheal Tube</td><td>08/10/2019 07:08</td></tr><tr><td colspan="3">ET Tube 7.5 24CM to L Lip line Placed by Paramedics</td></tr><tr><td>Medications</td><td>Epinephrine 1mg IV<br>(b)(6) ; (b)(7)(A) ; (b)(7)(C)</td><td>08/10/2019 07:10</td></tr><tr><td colspan="3">Epinephrine 3 doses and Sodium bicarb 2 doses administered by paramedics of the Freedom of Information and Privacy Act</td></tr><tr><td>CPR</td><td>Compressions</td><td>08/10/2019 07:11</td></tr><tr><td>Medications</td><td>Sodium Bicarbonate 1 mEa/kg IV</td><td>08/10/2019 07:11</td></tr><tr><td>IV Fluids</td><td>Normal Saline 0.9% 1000 ml</td><td>08/10/2019 07:12</td></tr><tr><td>Medications</td><td>Epinephrine 1mg IV</td><td>08/10/2019 07:13</td></tr><tr><td>CPR</td><td>Compressions</td><td>08/10/2019 07:14</td></tr><tr><td>Medications</td><td>Sodium Bicarbonate 1 mEa/kg IV</td><td>08/10/2019 07:14</td></tr><tr><td>Medications</td><td>Epinephrine 1mg IV</td><td>08/10/2019 07:16</td></tr><tr><td>CPR</td><td>Compressions</td><td>08/10/2019 07:17</td></tr></tbody></table>

## 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:

# Appearance

Yes: Unconscious

Generated 08/10/2019 08:10 by

RN

Bureau of Prisons - NYM

Page 1 of 2

EFTA00073832

Inmate Name: EPSTEIN, JEFFREY EDWARD

Date of Birth: 01/20/1953

Encounter Date: 08/10/2019 07:25

<table><tr><td>Reg #:</td><td>76318-054</td></tr><tr><td>Facility:</td><td>NYM</td></tr><tr><td>Unit:</td><td>Z04</td></tr></table>

## Exam:

ASSESSMENT:

Cardiac Arrest

## PLAN:

New Consultation Requests:

<table border="1"><tr><td>Consultation/Procedure</td><td>Target Date</td><td>Scheduled Target Date</td><td>Priority</td><td>Translator</td><td>Language</td></tr><tr><td>Emergency Room</td><td>08/10/2019</td><td>08/10/2019</td><td>Emergent</td><td>No</td><td></td></tr><tr><td>Subtype:AMBULANCE</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Reason for Request:Cardiac arrest with CPR in progress</td><td></td><td></td><td></td><td></td><td></td></tr></table>

Copay Required: No

Cosign Required: Yes

Telephone/Verbal Order: No

Completed by RN on 08/10/2019 08:10

Requested to be cosigned by

Cosign documentation will be displayed on the following page.

Page 002 of 148

Withheld pursuant to exemption

(b) (6) ; (b)(7)(A) ; (b)(7)(C)

of the Freedom of Information and Privacy Act

Generated 08/10/2019 08:10 by

Page 2 of 2

RN

Bureau of Prisons - NYM

EFTA00073833

# Bureau of Prisons
Health Services
Cosign/Review

Inmate Name: EPSTEIN, JEFFREY EDWARD

Date of Birth: 01/20/1953

Sex:

Provider:

Encounter Date: 08/10/2019 07:25

Cosigned by

Withheld pursuant to exemption

(b) (6) ; (b)(7)(A) ; (b)(7)(C)

of the Freedom of Information and Privacy Act

Bureau of Prisons - NYM