My First Trip Sheet

The unit was dispatched to an office building for a patient in respiratory distress. The patient was found sitting on the front steps in a slouching position. Upon arrival, I took his blood pressure. Despite the call being dispatched as respiratory distress, the patient did not seem short of breath. In fact, he was alert and talking nearly the whole time he was with us. The stretcher was brought out and he was able to climb onto it with some assistance. Once in the ambulance, my partner took his pulse and respirations.

At this point the patient was alert and talking to us. My partner then applied an ice pack to the back of his neck to relive pain. When asked if it helped him, the patient said, it didn’t have much of an effect. The patient kept saying that he had been drinking alcohol to cope with the pain. When asked about last oral intake in the SAMPLE history, the patient said he drank around 12 beers in the past day. When asked about any medications, the patient says that he takes Effexor and had taken Excedrin a few ours before the call.

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Shortly after, we arrived at the hospital. The patient was placed in a room immediately, and was able to move from the stretcher to the bed on his own, with minimal help from the EMT’s or hospital staff. The patient was still alert and talking at this time. When asked about his history, the patient reported being hospitalized for pneumonia a month prior. My preceptor and the other EMT also said they had recognized him as the same person who had injured his neck in a car crash the previous winter.