Describing What Happened

      Attack One is running frequently on a Saturday evening, and the crew's paramedic student, from the local community college, has been very active during this tour as a rider. Just before midnight, the dispatch is to an apartment complex for a report of a child down. Dispatch indicates a party is going on at the location.

   In fact, as the crew pulls up in front of the building, they find a large number of holiday partygoers attending an event that extends across the entire two-story building, its sidewalks and outdoor hallways, and out into the parking lot. A sound system blankets the entire area with music. Crew members make their way to the apartment from which their call originated, but cannot find a patient. One reveler suggests the child may have been taken to an adjacent apartment. There, they are referred to the next one down. Finally, at the third site, a young woman in the front room is holding a pale and unresponsive infant.

   The woman says she is the child's aunt, and doesn't know where her sister--the child's mother--is. She was called by the people in the first apartment to get the child after the child was found "not responding." No one could locate the parents, but they had called 9-1-1. They had no idea what happened to the infant, who is 6 months old; the party is very loud and crowded, and somehow the infant was found down on the couch. The aunt took the child back to the parents' quieter apartment, but couldn't get him to respond. He has not vomited and, to the aunt's knowledge, has no medical problems, though he was born six weeks premature.

   On rapid evaluation by the crew, the child responds only to painful stimuli. He shows no signs of trauma. He is mildly retracting, with a respiratory rate of 36, and no rash. The paramedics had noted large quantities of alcohol and the smell of marijuana in the first apartment, so they perform a fingerstick blood sugar. It is normal at 65.

   This infant is very ill, with an altered level of responsiveness for unknown reasons, and the parents can't be found. With the wild party on scene, the crew thinks it best to make a rapid transport to the local children's hospital and ask the police to investigate further and continue the search for the parents. A beat officer is already on scene, and crew members advise him of what details they have. They strongly suggest an investigative team be brought in, and tell him marijuana was being used in the apartment where the child was reportedly found. They will begin a report for CPS at the hospital. The crew also advises the on-duty EMS chief of the event before leaving the scene, and relay the name and badge number of the officer investigating.

   The child has no change in condition en route to the hospital. But in the medic unit, with better lighting, the crew notices some mottling of the skin in an irregular pattern over the torso. They also note the child is small and thin, possibly related to his premature status, but more pronounced than they've seen in other infants. They apply supplemental humidified oxygen and transport safely to the children's hospital.

Hospital Course

   On arrival in the ED, the child has no fever and no significant change in exam. But rapid lab tests find he is very acidotic, and the mottling of his skin becomes more pronounced in the first hour, with a noticeable straight line of clearing over his back. He is sent for a CT scan of his head and found to have small areas of bleeding in his brain. He is dehydrated, and his respiratory status deteriorates over another hour, so he is intubated and placed on a ventilator.

   About an hour after the child's arrival at the ED, a police investigator arrives with additional findings. The parents have not yet been located, but they apparently dropped the child off at the apartment where he was first found at around 2000 hours. They placed the child in a blanket on the front couch so he could be watched during the party. Apparently, one of the party guests did not know there was a child under the blanket, and sat on him for some time. After the guest left, one of the apartment residents found the child in the blanket, noted he wasn't responding and called for help.

   ED staff were also informed that a variety of illicit substances were being used in the apartment, so the child could have an appropriate drug screen performed.

Case Discussion

   The paramedic in charge of the crew asks the paramedic student how she would like to document the patient care report. With little experience in documenting a complicated encounter like this one, she suggests that a standard four-letter charting method would do little to record the important details of this patient encounter. She and the medic agree that many details of the environment and history could be critical to the child's future care and to fulfill the needs of investigations by the police, social services and CPS.

   As they work with the emergency physicians and nurses, they outline the elements that would allow them to chronologically and systematically record an event history and patient findings. Although it does not fit into an easy mnemonic, the rough descriptors are What WHEAD ("What we had") outlined in Figure 1:

• What happened?
• Evaluation;
• Assessment;
• Actions by rescuers;
• Disposition;
• What changed in the presence of EMS?
• What transfer of care and information took place?

   This documentation method is detailed in the accompanying sidebar, and can be utilized in both handwritten and electronic PCRs. What is critical for EMS providers to recognize is that no simple format can outline all the needed elements of an incident record, particularly one that has a lot of environmental factors and issues for follow-up. In this case, the paramedic and student need to focus on an unclear history of present illness provided only by bystanders, a rapid and focused physical assessment, the need for rapid removal due to patient instability and surroundings not beneficial to patient care, the lack of parents, the initiation of a legal investigation that may evolve into a child death investigation, and a transfer of care that had to occur with, again, little initial medical information.

Case Follow-up

   A detailed police investigation ensues, and is followed with action by child protective services. The parents had left their only child in the apartment of friends who had plans for a big holiday party, apparently because the parents went to attend another party. The child was asleep under a blanket and, in the party environment, was inadvertently sat upon by a partygoer who may have been under the influence of intoxicating beverages or drugs. The mark on the child's back was probably from the space between the person's buttocks, but the result was a near-asphyxiation. The child suffered hypoxic brain injury and recovered only a portion of his physical and mental capabilities. He was placed in long-term protective custody after a long hospital stay for rehabilitation. The documentation by the EMS providers was critical for the legal actions that followed.

Initial Assessment

   An infant, sleeping in his aunt's arms.

   Airway: Patent.

   Breathing: No distress, mild retractions.

   Circulation: Brisk capillary refill; pink, dry skin.

   Disability: No compromise of function to the head, torso or extremities.

   Exposure of Other Major Problems: No trauma noted.

Vital Signs

   Secondary Assessment (appropriate to presenting condition)

   Head: Soft fontanel. Mucous membranes relatively dry. No signs of trauma.

   Chest: Clear lungs, mild retractions, elevated respiratory rate.

   Abdomen: No masses, dry diaper, no diaper-area rash.

   Extremities: Moves all four, distal pulses intact. No rash.

   Neuro: Medics' exam did not arouse child, but child occasionally moves all four extremities.

AMPLE Assessment

   Allergies: None known.

   Medications: None known.

   Past Medical History: Delivered six weeks premature.

   Last Intake: Unknown.

   Event: Child found unresponsive.

Figure 1: Elements of What WHEAD? Prehospital Incident Documentation

What happened?

   For what were you dispatched?

   What did the patient tell you?

   Who is with the patient? What did bystanders say?

   What is the history of the present illness?

   This section may also be used to describe environmental conditions and circumstances; vehicle damage and use of protective devices; rescue and removal information; prolonged extrication, if needed; signs of foul play; and presence of law enforcement or delays caused by securing the patient or scene.

Evaluation

   Mental status;

   Vital signs;

   Examination--top to bottom;

   Pertinent negatives;

   Neurovascular status before and after splinting;

   Diagnostics (glucometer, pulse oximeter, ECG, 12-lead).

Assessment

   What did you think? This allows everyone to understand which protocols were being utilized and the medical decision-making taking place. What did you treat?

Actions by EMS/rescuers

   What did you do immediately?

   Immobilization and packaging;

   Airway and ventilation;

   Circulatory support;

   Warming or cooling;

   Pain control;

   Use of medications;

   Procedures.

Disposition

   Transport or nontransport;

   Why transport decision was made;

   What treatment en route.

   For a patient encounter without removal to a medical facility, document patient competence and the elements dictated by protocol for nontransports (or a no-resuscitation/termination-of-resuscitation event).

   What changed in the presence of EMS?

   What were responses with and without treatment? This is particularly important if the patient either improves or deteriorates, or if their apparent problem changes so that another protocol is initiated.

What transfer of care and information took place?

   Turnover to ED staff and, if appropriate, the condition on transfer;

   Documents given to ED staff (e.g., nursing home paperwork or DNR documents);

   Were special reports filed to ED, social services, police or other agencies?

   What belongings were given to ED staff?

   Were any other follow-up needs identified?

James J. Augustine, MD, FACEP, is an emergency physician from Washington, DC. He is the director of clinical operations at EMP Management in Canton, OH, and serves as assistant fire chief and medical director for Washington DC, Fire and EMS. He is a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, OH, and a member of EMS Magazine's advisory board.