Put the Pieces of the Puzzle Together With These Two Reports

by Frank Scahill

I have been telling juries for decades that Emergency Room records and the Ambulance Call Report/Prehospital Care Report are the two most important medical records they can use to “put the pieces of the puzzle” in order. The EMS records and ER records can be described as a window into the truth of what happened to the plaintiff before the view is blocked by the Doctor the plaintiff was referred to by his lawyer. The EMS and ER records can be used to portray an accurate picture of what happened to the plaintiff at the scene of the accident and their complaints in the ER, what tests were performed and what diagnosis was made. Contrasting the accurate representation of the plaintiff’s symptoms and physical condition, as documented in the Ambulance Call Report and ER records with the plaintiff’s complaints to his “Litigation Doctor” after the lawsuit was contemplated or filed can be highly effective.

What is important to highlight in the Ambulance Call Report/Prehospital Care Report? Remember the goal of the EMS crew is to assess the level of injury, treat emergent care issues, stabilize the patient and transport that patient safely to a trauma center. What will be recorded on the EMS sheet?

Vital Signs: Respiration; Pulse rate per minute; Blood Pressure. Your plaintiff claims she was in agony at the scene but all vital signs are normal. No increase in respiration; pulse rate or blood pressure surely does not comport with the plaintiff’s description of the accident and injuries.

Head Trauma: The EMS record always includes a description of Head Trauma and Loss of Consciousness (LOC). You will most likely see a notation “DENIES LOC OR HEAD TRAUMA” followed by “AOx3” alert and oriented to person, time, and place. You may also see a GSW score (Glasgow Coma Scale). Lowest score is 3 and highest is 15. “PEARL” Pupils Equal And Reactive to Light, is often followed after these entries.

Objective Physical Assessment: The EMS description of injury is equally helpful. A typical description will read: “Patient is a 69 y.o. female found ambulatory at the scene. Pt. c/o pain in both knees and her nose following an MVA. Pt. is seat belted driver of front end impact with airbag deployment. Pt. has no other obvious signs of head injury. Denies loss of consciousness, headache or dizziness, Denies back pain. Pt. has no obvious deformity, swelling or bleeding at injury site, full range of motion, pt. was transported to ER without incidence, no treatment was given.”

Treatment Given: How the plaintiff got in the ambulance will be recorded. Did she walk; removed by chair, backboard; was a Cervical Collar placed to stabilize the neck or more importantly, did the plaintiff refuse C-Collar? Was oxygen administered, was a limb stabilized, were restraints applied?
All of the notations above can be used to your advantage in contrasting the plaintiff’s description and mechanism of injury with what was accurately recorded by the unbiased medical expert, the EMS technician.

The Emergency Room Record is a treasure trove of details to use to your advantage. The record will be in electronic from and you can show the ER record to the jury on a projector screen while you are cross examining the plaintiff’s expert medical witness. Contrast what the plaintiff’s physician is telling the jury was the mechanism of injury for the alleged shoulder tear, knee tear, cervical or lumbar pathology with the findings in the ER record.

The ER record will have critical fields:

Chief Complaint
Pain Scale
History of Present Illness
Review of Symptoms
Past Medical History
Physical Exam: Musculoskeletal & Neurologic assessment.
Vital Signs
Medical decision Making: Orders
Diagnostic Tests
Differential Diagnosis
Prescriptions

Each one of these entries can help a defendant. I find it most effective to jump from the plaintiff’s physician’s records from the Doctor testifying to the ER record. Three weeks post-accident the plaintiff’s pain scale is noted as 10/10 by the plaintiff’s Doctor while in the ER the pain scale was 4/10 and the plaintiff’s pain was described as mild, in no acute distress. The plaintiff’s Doctor documents Range of Motion (ROM) deficits which show severe limitations when the ER records document full range of motion (FROM) with no tenderness to palpitation, no swelling, no ecchymosis (bruising). You can use the “First Responder’s Report” and the ER record to full advantage on summation.

“Ladies and Gentleman, you recall I told you in my opening statement the Ambulance Call Report and Emergency Room record were windows into the truth about what happened to Mr. Plaintiff. I have highlighted those entries for you because I want you to know that what happens to medicine in a courtroom is not what you experience in your everyday life. In the real world you go to the Doctor to get better. When you are involved in a Personal Injury Lawsuit as a plaintiff you go to the Doctor forever but you never get better while your case is pending. The Emergency Room Record and EMS call report document for you, by First Responders, what actually happened. The Doctors and EMS workers that made those entries are eyewitnesses with no agenda, no stake in the lawsuit. They are not paid $7,500 to testify here as was Dr. X. They have no interest in a lawsuit or a personal injury case. Their only role as First Responders is to treat the patient and provide proper medical care. They are under a legal obligation to accurately and truthfully report their findings. Why didn’t the plaintiff call them to the stand to testify if this case is legitimate? Why didn’t you have the opportunity to hear what they had to say? The answer is obvious to you as the entries in the Hospital record….”

I have attached the proper request form for the FDNY EMS report. The cost for the record is $2.25, the best money you can spend in the defense of a case. Don’t forget the HIPPA authorization when requesting the records.