Section 15 (pp. MEDCOM 3218-3317)

From dKosopedia

Section 15 Pages 1 - 91 (MEDCOM 3218 - 3308)

NOTE: I am NOT a clinician. I do work in medical research and have some familiarity with medical terminology and pharmacology especially in regards to anesthesia. These cases spill into Sections 14 and 16. I note the numbers - only the page inventory for Section 15 is included.

SYNOPSIS: Section 14 Pages 52 - 121 (MEDCOM 3148 - 3217) and Section 15 Pages 1 - 91 (MEDCOM 3218 - 3308) Appear to refer to a single patient although the redaction of patient numbers makes this difficult to confirm. Age, wounds and treatment indicate a single person.

Patient is a 30 yo male Muslim Afghani "detainee" transfered from Bagram [Airbase] with a date of "admission" of 08/01/2002 and a date of "disposition" of 8/20/2002. Patient arrived paralyzed and intubated. The complaint is "multi GSW R LE" [multiple gunshot wound to the right leg] and his condition is listed as critical [15 pg. 77] without pulse in right foot or sections of the right leg. The admission form [15 pg. 91] has dates, official description and [it appears] initial medical test results. The patient is given pain killers [Demerol, Tylenol, Percocet etc.] and other drugs [Versed, Zantac, etc.] and is then admitted to surgery where some portion of his right leg is amputated "at thigh" [15 Pg. 33]. The following pages track his "care plan" both medication and non-medication [86-78] . Pages 77 - 61 are his "Clincial Record - Doctor's Orders" starting with his admission [15 Pg. 77] through his discharge and transfer order "1) Transfer Detainee Center Today" on 08/20/2002 [14 Pg. 61]. He is discharged with orders of "Bed Rest", "Haldol 2mg PO Daily, Motrin 800mg PO 3x Daily, Dakin's Solution for drs [dressing] change daily" and his condition is noted as "improved".

I assume the patient was transported to receive life saving care unavailable locally. As far as I can tell the patient was operated on almost immediately, received a total of 8 units of blood (mostly during the surgery) and despite a slight equipment incident during the operation [pg 5] survived surgery. Patient appears to have been kept intubated and on respirator post-surgery for at least several hours. (This is uncommon is ambulatory surgery but this is a very severe case.) Patient received adequate care post-amputation and was hospitalized for 19 days before being turned over to regular detention. There are records showing repeated wound cleaning (early cleanings involve dead tissue removal and notes of infection) and tissue tests for infection. One several occasions it is noted that there is a "language barrier" and the that the patient is "anxious" in the time he becomes conscious after surgery. It is also noted on almost all "intraoperative reports" (14: ) that patient is transported by litter in supine position with "armboards". Notes later say that he nodded to show understanding of basic medical commands to not disturb bandages etc. [14 pg ]

[Note: 15 Pg 77 (3294) lists his unredacted patient number as "#6" but all other references redacted. Pg 5 (#3222) (top left side) refers to a "PT #127".]

SYNOPSIS: Section 16 MEDCOM 3318-3325 are part of patient file continued in Section 15 pages 92 - 100 MEDCOM 3309 - 3317.

Patient - Arghani male "claiming to be" 16 years old - had previous bullet wound to L[eft] hip and while at IDF [Detainee/Detention Facility?] was escorted to bathroom where he broke into a cold sweat, urinated on himself and complained of dizziness. He was examined, an IV started and was transported by ambulance to medical facility on 12 Aug 02. He was hydrated, given Motrin and Dilantin. Patient refused to ambulate - medical personnel indicated belief he was being "uncooperative" - and was discharged to IDF without crutches on 15 Aug 02.

Army Section 15 med3218_3317.pdf

[NOTE: Charts seems to have been scanned from top to bottom so reports often run in reverse order. eg The first page is discharge notice.]

Pages 1 - 91 apply to single patient - continued section 14

Page 1: Medical Chart MEDCOM 3218 dated 8-2-02 Chart for tracking a number of patient vital signs covering 24.

Form entries [explanation] - data entered / not entered:

Patient Temp

HEMODYNMAICS HR [Heart Rate] Rhythm RESP. [Respiration] CUFF BP [Blood Pressure via Cuff] MAP [] PAS/PAD [] - not entered PCW [] - not entered CVP [Central Venous Pressure] CO/CI [] - not entered SVRI crossed out SP02 written [Oxygen Saturation]

[DISCLAIMER: I AM NOT A CLINICIAN.] Chart tracks (unidentified) patient vitals over a 24 hour period. Patient seems realtively stable during this time. Blood pressure rises and oxygen saturation falls somewhat in hours 12 - 2 and temp runs a little high 101.5 but nothing life threatening or dramatic.

Page 2: Medical Form MEDCOM - 3219 dated 8-2-02 Form for tracking medicine administered and urine output for several hours - presumably during surgery. Most notable drug administered Propofol - paralytic agent used primarily for administration of anesthesia - 12 [ccs?] x 2 times Several drugs administered via IV - routine for surgery.

Page 3: Another unspecified medical form [3220 ?] dated 1 Aug 02 Respiratory and Blood Gas results form. The limited information filled in: Respiratory: 09, 11, 02 Blood Gas: 10 Values seem to be within reasonable levels.

Page 4: MEDCOM 3221 dated 1 Aug 02 This form tracks drug administration and urine output LR @ 125 given @ 09 - 04 for a total of 950 JV MED 50x given @ 11,12,01,02 Propofol

Page 5: MEDCOM 3222 Patient #127 Detailed hand-written account of surgery. There appears to have been an incident towards the end of the surgery 04:00 in which the patient's heart rate rose into the 140s and oxygen saturation fell to 94.7%. "Determined fault @ E Doc [] E Doc repaired - vent exchanged [for] another." The patient was manually bagged back to 100% respiration and equipment repair/replacement seems to have solved the problem.

Page 6: MEDCOM 3223 EKG Rhythm strip

Page 7: MEDCOM 3224 dated 1 Aug 02 Lab Report - drug reports

Page 8: MEDCOM 3225 dated 1 Aug 02 Lab Report - drug reports

Pages 9-19: MEDCOM 3226 - 3236 Chemistry and lab results mostly concentrating on checking for infection ie Gramstain.

Pages 20-21: MEDCOM 3227 - 3228 ? Two photocopied typewritten pages - difficult to read. Looks like a panel of bacteria Cefoxtin, etc. A broad spectrum bacteria panel result page. (?)

Pages 22-31: MEDCOM 3239 - 3248 "Operation Report"s dated various from August 1st - August 15th, 2002 The reports range from serious "necrotic tissue excised" soon after the operation to "Dressing Changed, Wound debraded, Hemaform Removal, Wound closed & Kerlex No tactor [?] or skin applied."

Pages 32 - 47: MEDCOM - 3264 Clinical Records Anesthesia Reports

Page 48 - 59: MEDCOM 3265 - 3276 Blood transfusion records.

Page 60: MEDCOM 3277 EKG Rhythm strip

Pages 61 - 77: MEDCOM 3278 - 3294 Clincial Record - Doctor's Orders Admission [77] through release [61].

Page 78 - 86: MEDCOM 3295 - 3303 Therapeutic Document Care Plan documents Records of drugs given and procedures performed

Page 87: MEDCOM 3304 IV inflow report Aug 02, 2002

Page 88: MEDCOM 3305 Urine output report Aug 02, 2002

Page 89: MEDCOM 3306 IV inflow report Aug 01, 2002

Page 90: MEDCOM 3307 Urine output report Aug 01, 2002

Page 91: MEDCOM 3308 Admissions coding 21:14 08/01/2002

--- new patient file ---

Page 92: MEDCOM 3309 Patient Cover Sheet (discharge sheet for complete case) Afghan Male (POC) Date of Disposition 15 Aug 02 Type of Disposition RTD [Returned ?] Days in Bed 3 [Handwritten] Syeepe [Seizure?] Post ORIF L[eft] hip fx free H/O Seizure disorder

Page 93: MEDCOM 3310 Abbreviated Medical History "Afghani male c[omplained of] seizure earlier today. PT [patient] post intake of 2 bottle of water yesterday (?) today received [6 crossed and 4? written in] l[iters] NS IVF [Intravenous fluids] prior to presentation of R[ight] hip GSW[gunshot wound] & resultant femoral [?] neck frontline unable to ambulate at present". Other notes about dehydration and lack of urine output

Page 94: MEDCOM 3311 Progress Notes Handwritten (legibly) 13 Aug 02 1500 "DETAINEE CONSULT PMH: siezures [sic] x2 years on 2 meds in past name of meds unkn 6-7 episodes in past 2 years

PSH L ORIF femoral neck

Patient claims to be 16 y/o. He was recently hospitalized for GSW to L[eft] hip/buttock. He is S/P ORIF L[eft] Femoral Neck." Account goes on - patient went to bathroom accompanied at IDF [?] broke into sweat, urniated on self and complained of being confused. Vitals taken, IV started, transported by ambulance for consult.

Page 95: MEDCOM 3312 Hand written notes dated 14 Aug 02 1000 Synopsis: Patient resting quietly without seizures. Will continue meds and IV.

Hand written notes dated 15 Aug 02 Discharge Summary Synopsis: Summary of case so far and discharge orders. Notes "Patient still refuses to attempt to ambulate [using] crutches. Patient will not bear weight on good leg. Patient will be D/C [discharged] to IDF [?]. NO crutched until pat. cooperates."

Page 96: MEDCOM 3313 Nurse Discharge Sheet 15 Aug 02 Medications Dilantin 100g daily Motrin 800g PRN

Page 97-99: MEDCOM 3314-3316 Nursing Notes dated 13-15 Aug 02 Notes: Firsthand account of attempts to ambulate. "Pt. stated 'Allah' and started swaying his self side to side and swaying his head back and forth and round in a circle."

Page 100: MEDCOM 3317 Vitals Chart Dated 13 Aug 02, 14 Aug 02 Some vitals charted

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