Demar v. Chicago White Sox, Ltd., The et al

Filing 45

1st Set of Requests for Admission of Fact by Superior Air-Ground Ambulance Service, Inc. (Attachments: # 1 Exhibit A# 2 Exhibit B# 3 Exhibit C# 4 Exhibit D# 5 Exhibit E)(Brady, Brigitte)

Sêp 09 05 OB:Sla

Case 1:05-cv-05093 HR

Document 45-2

Filed 05/31/2006

S30-B32-S003

Page 1 of 2

p.4

;9..KG ATTACHED Se~i¡¡ or ER PhYSI~~!; to ¡¡m~"

~NO pcs J N tif d tv &&"-.. " i
D (;~. (/i.p,(~ .

" NO FACE SHEET 0 e ' ¡ I ~;'
NAME (LAST)

In NORCOMM

Plesse ailach c:opies of (nsur.n~e c.rdG, PublilO Aid cards, Medicare card& Qr any oth~r informational sheets.

NAE (FIRST)
CURR

k.:.G"';"",::,

DATE ~ /
RUN It 2id:.~' k- .-:Y' O.O,B.
'~--r--'.;.":

,

_l ;-

UNIT4t ~Sta1ion# ~

.- '. ' i i

'.' ì' ., ~ ~'-¡ ;'" Type of Ambulante: '0 ALS 0 BLS 0 SCT
HOSPITAL 1"0 HOSPITAL TRANSPORT

..... ËÒ"";AL R~ASO,N FOR TRANSPORpSTA11S ~OST.: ,'\ /.'

o ALS CARE .
o SEDATED WIT .

o h.ehCi\"úf.J;L (). t---,i, ;(:::,-\. ONDITION RI!QUIFIINC $ CHER

~~J' ~j~

o Angiogram a Angiopla.Ìy a CABG a Cardia¿Catheteiization
a Higher Leval of Care

¡;THER f' £;¡i1. k S 1(-; n
o HEA!NG FRCTRE. WHERE

a Insurance Requirement 0 Menta Health Services
Q No Beds Available 0 PatienFamily Choice

o Rehabilitation. S¡Jcify type: .
o Specialist Specify:

" 0 UPPER CONTTURES CJ LOWER CONTi1RES

"\ 0 f1LYSiS 0 RIGHT P LEFT 0 PARPLEGIA
i

J DUEm:

o QUADRIPLEGIA

o SlJrgery; Spacify:

a Other

"

MOBILITY'

o AMeUtJS ASS!STjtE
o t:ER-cHAIf 0 HHSTRY OF FAl

BEHAVIOR

MENTAL STATUS
o BRUI3INi3 0 BURNS

COBA~VE a COOPERATNE

" a WA! a WHEER
.. 0 A$ISIlTOAMEiUlTE

o DERESSD j!ISRUPPVE 9",ØAT X
a RESTRINS """ 0 UNRESPONSIVE! 0 APHASIC

o A$IST#TOTRSÆ

o WADERS l.GI 0 FOGEl
¡¡NPREDICTl\lE D lEARGC
.JNTN~N- 0 NEPHROSTOMy )",SELF

ELIMINATION VOID HYGIENE

o CONFUED q O\iSFNT o DIALYSIS SHUNT a ~~GE a ffAGILE 0 INCISIONS ~0'ACT i i.ERTIO;;VL.ON a UNRESPONSIVE
PATIi'NT a OTER
, ' .- 0 STAGE

WEIGHT 0 PJC LINE q RASHIÕ
I 0 STAGE

ÆEDINO 0 INCCNENr 0 FOlEY 0 A$ISTANCE
o ASIS 0 NPO 0 Nß/ G/JìU6E Q COLOSTOM 0 BEDPAN/URINAL 0 TOTAlOAAE

,-. /, 0 ULCER (DECUBITI$)
II

""\ ¡ ,kg (J STAGE il a STAGE: IV

~~
PATIENTS SOCIAL SECVRIl NUMBER

FIRST' I,? ¡' t"_' -" M('DD~L,

~ ;,"" \

RELATIONSHIP ¡~

( ~CITY"' STATE
r "'~'. ",\ \.: .:..( '(:~d" .

~-ìi.) ~.~ .' \

~x! (" \ .~
zip

CITY

Vasa G~ v\, ~.'\.
AII Past Medical Hlst5m

NoD

032~~Z¡:o9~(JA
$erviçe¡; Provided

r.\--"
Partial Paymi;nt AtTlme Of SS'vlce
:: P/VED OUT $IG. 42 J DID NOT COLLECT

Prìms:y PhysÎoian Phone:

o Alimers
i:Anemia
D Aneurysm ty:

o Airt Chrg 0 SAS 0 iMC
I:~ALS cars me i a Medcal Air v (ør;: A$ only) Unl!Jis
Q Badaging Aped 0 Obtetrl Delvee

a AED 0 2nd Unit Assls.

Please CHECK service, IndIcate amount used

',3 CASH :J CHECK, . J VISA
:: MASTERCARD ':: D'SCOER ':: AMERICAN EXPRESS
$ Amount O:llected f Charged ,,---.--..

o Arrf
Q Cancer of 1he
o Cardìac COndition Ust:

o lOwer Exremity Ampuleion

-------.-

o Bod,S" a Orl

o CCnccled Call I, Resed a PPa (fimtr
o Card Motonng 0 RespírajoryTharst SAS
Card HolderiSignature . Credit Card P"yment

y 9 a Oxyen

I Nasal Airway Adm.

of Defe or
i

o 12 Len EKG 0 RespiratoryThra Hos.
o cord Pa Adn~f1¡sttdiion 0 Res"" C~i-

o Upper Extremity Amputation

Qj ----Date of

Gredii Card Number
Expiralion Dale

o Dapr Monitor 0 Rasirirts Apied
CJ Dru Adnlstrrobn ':J R.N. SAS

o COPD
o CVA wÎth deficits a Yes 0 No Dab~ Or

Auth"
A""..', /

o Dementia Q.iebe1lc Q GJ BJeerJ

a EquÎpmenlTraspoH a R,N. Hospi!al a GenetoAnverJer a SCT Inndent Medc
o Glurorr l1 "I a Spina Immoüizatin
O H oP aK A es . a Splinting Adminlslr~OI t d. . mlfiston 0 StaIr Chair

o i"H 0 HOSP 0 PT. RES. :: Dr. OFFICE a MRI :. DiALYSIS .:.:Olh&r ":..".',. (i.

:: Depresion
o Hogpice Name:

PiCKup Locallem: ",:, A:--'Y,) i' V "': (,,

Room # "---:: ER

~perterrsion
o M'mtal Status Changes
D None
a Menial Health C,mdlUon
o Parkinson's o Renal Failure

a Hypotension

o I.AB,P' Perlusionist SAS 0 Spel Event o IAB.P. Penusloni51 Hoop. Star1Îme

i: LAB.P. SAS En tie

(; stOther '. "'/ ~. 1/.'' - ~-_H De ination; '.".. -_.
. , e'\::' ,~r 1:.1'~"'X"IJ.''''1

o NH a-HOSP q PT. RES, 0 Dr. OFFICE :: MAl a DIALYSIS

O I B .. H I I ta 1ìea1menl only. no trasport Room lI ,.--~, \.(J:i~i:---d ER' A P. osp :: 0 Sucion
o Inv""" Pra~ui- Monior a Team T""nsprl

.' /;).5(,7 r.tCY/

i: Respiratory Condition - List

._~-'---

o iimatiDn 0 TelemeltlMercylPhOfe o lsola~on Preauton 0 Traccor Spivit
o Isoletle SAs a TiansportVentilaior SAS

Driver;..

ee?t:~~~~~í.., "

It (,?;?'7 .
II

,

Atlerrdant:

1 'f5i.,!

o IsoleM HQ$pita 0 TiansportVertiator Hosp.
o Seizure 0 SuttstaC6 Abuse a Syncope 0 UTI
o Other

o IV Reid GlatT 0 Pt, Ventliator

Response Code To Patient:

~ :.
Ò

a IV Pump Hosp . SAS (Supe Amb,'.,,, "-,,i o KED / Short board 0 Noe TOTAL MILE~'-"-.- (", . 1\-

AIVSO SA -- ~ 01 - II of -(eftrMIIs.mÍl.) Pump Walling Time, fil930

o IV PTA :: UCAN

Endín~Mi'e ""i -" ~ ~-1 ~ g ~ l " ~" , ~ . \ MjI~~"' . ".. ~. Starting-~, r., ".') To,. ~

Emer~ency,-Y1~cII~2) Pre:-cfiedutet ASAP ¿,edlC31

¡; 6
æ

EXHIBIT

'"

ææ

~
~

It

Dockets.Justia.co

Sep 09 05 OB: 52a HR
!!, EMS System Ambulnnce Ae~ort

Case 1:05-cv-05093
Serial #

Document 45-2

Filed 05/31/2006

S30~832-5003

585233
tt
Cslla.C'd
R.spond Ing

SUPE OR II,: ß-DodRISamaritan
OC~TIOt-.--..

¡epartment AMBULANCE SERVICE

Licens) Department jj#;j, e ""2):5'- fr';nit --

Date l- /--1 0.3

ò3-' , o '7-Page 2 of 2

p.5

Incident # "7. ';c: C:. Patient - of ~ .-' 'I:... ~" (, -) t
Service Provided

~IBL.sIJREI"I
"g G i""s 0 Gown

(X"" )~~ .-~ '-,)

'i/A-(t' ~ ' - ~.
(First)

CREW # I NA,,~ ' .~
A) b J ¡ ')'. ,.r.:'.
B) C)
D)

~4..\
~ME (Last).

ATiENT INFORMATION

) "f .J .'

DQ~ Y''\ A\ L
\

(ì 12 i
~ \ZJ --i
zip
,PHONE

I

\0
'7

r

S
0

D'Ms.x 0 EyaShîald
~IOYØ!ì 0 Gown
0 Mas. 0 Eysoiald

Acriyoo Scene

\
L

b 4CJ

5

c¡

. ?r:;l._ 'f?;'d--ç¿p írr

i¡nroutø Hosp.

0 (OJo,.. 0 Gown
0 Mas.
0 EyesllleJd 0 Eyeshleld

DDRESS

Arrlved H()$p.
Depan Hogp~

0 Gi_- 0 Gown
0 MJs~
0 Glov.'-O Gown

i\ 'ì(

'i'J

lIT

UN\\
¡ L) f,12:J..

STATtJ

Back. in Si:rvice

E)

0 Mask 0 Ey.shlel d

BODY FLUID EXPOSURE
CHreF COMFLAINT

MEDICAL CONTROL Hps..

iGE I D.O.8~4i~X F 20CJ o U"'~ '~~ I, WEIG~

~ITALllhESSION-- '
IEDICATIONS 0 Denies

I. \'\ \? r~¡
G-

eÙA
fiTrf!-e(;) S.
CardiB~

(, l(~~i' ~ fPrl( b b-- 0

i ~'iS . "' "'0;\

"- ~' ,/ RADIO LOG # '--- --''_1' HOSP. TRANSPORTED TO
rii(¿,P-( \l
0 Denies

/! .-~ ,'~
OA DB
r'.'\

Dc 00 De

E")I ì O'~ ", l lJ(IEDIGAl HIS'fORY

TRAFFIC; 0 Light 88edium 0 Heal' 0 CCear 0 We1 DELAYEiD BY D Snow 0 Ice

0 DenIes

ß-HTN 0

Ç0f\:~ IA-a",\~\-~ ~
¡

ssDiabe1es 0 COPD

0 Seizures

0 Cancer I ALLERGIES I

OPCN
o Sulfa

0 Codeine
0 Iodine

TIME

\I I

r
i

1(.
"

i.
L

-c)

~
2 Pain

~~ont 50rien1 ttebays

EYES VERBAL. MOTOR

erbal~onlU$ SLO'~allze D Cyanoti~

Last Men!rual Period SIÇIN COLOR TEMP. MOISTURE r..NO'rmal .:ormal QNormal
o Hot

I

/ -. U Ì" \( r-

L ii~:~~\\
gr èoo--ricted

rr Moist

~G~Q~ .~. E!
. -Ò minishad D ,0 CraGkl8S

OJ.V,D. D Periph Edama
.!elood Sugar

FIELD TRAUMA

SCORE

\4i;s

3 i nappr 4 Withdraw 0 Pale/A$h~ii OWerm 2 I ncompr 3 Flexion D Flushed 0 cooi 1 None 2 Ex lens 0 Jaundiced 0 Cold 1 None 0 Ashen

0 Diaphoretic 0 0 Dilated

0 Dehydrated 0 0 Sluggish

lcil'9l.b I

0 0 Flxed
0 0 Cataract
-TIM.E

0 D RhQnchl 0 D Wheezes

0 ~peds
:: 'DOSt
ROUTE
~

',TIME'

NEURO

e/p.

PuiSE S

R f!=SPS

d
f'

R

ECG FFt-YTHM / OEFIß.': . TIME

i L2L~ Ã) P U ì "cÍc ;fIrs c j,
k; ~D 'f-V p u 14~/9 ì
~ '10 A)V P

)Ø~
E;

~ ¿) ;-'7 ).0

if.

/0 fL 1 \.J ì?/ ¡.J f~ f~ U II ?7/Qt. ~-7 :S ¡? 'v

l'Îi -

/'
.,,/

/'

/'

,'

/

"
" .,' ," -'

/

DRUG I SPLUTION

"

-'

./'

AVPU

-"r
SKIN COLOR TEMP.

~,.r--

/" ,/

'"

,/,/

/

"

/"

.'

,/../

/"
,--

AVPU
TIME
= i

EVES VER9AL ~TOA
:¡~poni .S-Orìent (!O)oeys

i

~

.

~

1

-:' erbal~~OnfUS 5""ocalize 0 Cyanotic '0 Hot
~ 2 Incompr 3 Flexion

~rmal '_~ormal Q,ormsl
0 Flushed 0 Cool

MOISTU¡:I,

L R PUPILS,

\ s 1 None 2 Extens iq .1 NOM OMMENTS I FINDINGS: C (-e" \
Hu1 ~ \." \ 't ~ ~ 1",( i

i6

2 Pal~ Inappr 4 Withdraw 0 Pale/Asherr 0 Warm
0 Jaundiced 0 Cold 0 Ashen

o Moísi . D Diaphoretic

0 Dehydraled 0 0 Sluggish

~~~~ 0 "i~d'
0 D Creckle.
D D Rhonchi
0 D Wheezes

0 0 Fixed 0 0 CaterM!

§\~ D DD /R
L R ~GS ~
0 Perlph ~~a
0 J.II.D.
.'

./""

~_.,--

FIELD TRAUMA

OAduJt D Peds

c \~\\ 9d t;rL ef p+
\
'JMc.é'_~

-'

Ul)¥¿~~ A!t"')~

00000 00000 Defib/Card ¡oversion 0 000 0 iq.ic.~ '-1'Ò+, (1~+' -.-h- i,~j +11;) ii.f','f.'- : ECG Interpretation 00000 ' ,A ~~ fr '- i~-" \0\"", r-l ¡,jAA'++Koiv -- ('i2~"Ç,. IVIIO Start '!I'--W.f3 r'-f1\~-'~,V.\ DODDO ~C5 c¡.¥"-e (~,,~ r::f1iJ.J e.' -r+- r h,',, d",\¡J fu h in f'r'.AiDi IV/IO Unable ++.: - ,", \~ 00000 ., T '.) Medicelions Admin OOOOD H//i; N Jv 01- c)f - .f+ /5 A ¡)f(b-- 7C\/,1 fN::'l ¡ . p ~,~ \J;d iJ. 50::¥\ -: - :iJ),G":, 06 Delivery 00000 g A-" ~~,J- I! - (t:, P,l: \~.\ ~~ l f+ c tT('t:~ ,"U j!-.~j ' r-&''\ r f-~.. Pacemaker 00000 /t,y l ewt- v~ ;;)6 -PS.\)t;\it..Ûx ~ Ltllú'¿ f) ~\L' Q,))\ '''2.~;.\ - Iì -:'')'. ',- tJu ..,. ;JjJ,f\ì~ Pleural Deoomp 00000 ' .JA" l" :) i rreslraints .v 00000 t .. ¿/ ''-- .." --~--, :.~!~ çjJi¥,~-, rtC( -+-1 n,o'~ Spine Immob ODDOO 9-rR I'Ä '-; . v-:; .-;; i X,,' 00000 / /, / ./ ./ 00000 .,-./ .. -,' ) CDntlnua1ion 8h~et Other 00000 .-'
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PROCEDURES Airway - Manual

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Airway - OP/NP Airway - aT/NT Airway Unable Asses.sment Communication Cricothyroidotomy

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