ROYAL HOBART HOSPITAL

EMERGENCY DEPARTMENT DISCHARGE SUMMARY

Patient Name: LAHEY, Sarah Jane
UR Number: 2018-ED-07291830
Date of Birth: 13/03/1989
Age: 29 years
Sex: Female

Admission Date: 29 July 2018
Admission Time: 18:30
Discharge Date: 30 July 2018
Discharge Time: 00:15
Length of Stay: 5 hours 45 minutes

Emergency Contact: Detective Sergeant Charlie Claiborne, Tasmania Police
Discharge Destination: Home (23 Rosewood Lane, Battery Point, TAS 7004)
Discharge Transportation: Private vehicle (DS Claiborne)
Discharge Status: Discharged to home care with responsible adult supervision

PRESENTING COMPLAINT

29-year-old female police detective self-presented to Emergency Department with right hand laceration and head injury sustained during work-related incident at approximately 16:00-16:15 on 29 July 2018.

FINAL DIAGNOSES

Primary:

1. Moderate Concussion (Post-Concussive Syndrome)
   • With associated post-traumatic cephalgia
   • Photophobia
   • Nausea
   • Cognitive symptoms (difficulty concentrating)

Secondary:

2. Right Palm Laceration - repaired

• 4.5cm clean laceration
• Closed with 6 interrupted sutures (4-0 nylon)
• No tendon, nerve, or vascular injury
• No retained foreign body

CLINICAL SUMMARY

Mechanism of Injury (as reported):Patient reported falling during search of residential premises, catching right hand on broken glass from window and striking left side of head against wall. Note: See physician assessment for documented concerns regarding mechanism consistency.

Emergency Department Course:

18:30 - Patient arrived via private vehicle, self-presented to triage
18:43 - Triage completed, Category 3 (Urgent), transferred to Bay 4
18:43-19:27 - Hand laceration cleaned, irrigated, sutured by RN Jackson Roberts (6 interrupted sutures placed)
19:38-20:18 - Comprehensive neurological assessment by Dr. Finn Montgomery
20:18-00:15 - Observation period (4 hours) with hourly vital signs and neurological checks
00:15 - Discharged to home care with DS Claiborne

Observation Period Summary:

Patient monitored for 4 hours post-assessment. Vital signs remained stable throughout:

• Blood pressure: 138/86 → 128/82 (improving trend)
• Heart rate: 84 → 76 (normalising)
• No deterioration in neurological status
• Headache remained stable (did not worsen)
• Nausea well-controlled with antiemetic
• Patient alert, oriented x3 throughout
• No vomiting, vision changes, or new symptoms

Investigations:

• No imaging performed (not clinically indicated)
• Clinical assessment only

Treatment Provided:

1. Wound irrigation with 750ml sterile normal saline
2. Local anaesthetic (Lidocaine 1% without adrenaline, 8ml)
3. Primary wound closure with 6 interrupted sutures
4. Sterile dressing applied
5. Paracetamol 1g PO for pain
6. Metoclopramide 10mg PO for nausea
7. Tetanus status confirmed current (no booster required)

DISCHARGE CONDITION

At Time of Discharge:

• Alert, oriented x3
• Vital signs stable
• Headache persistent but stable (6-7/10)
• Nausea controlled
• No vomiting
• Tolerating oral fluids
• Mobilising independently
• Right hand wound clean, no signs of infection
• Neurovascular status intact to right hand

Glasgow Coma Scale: 15/15 (maintained throughout ED stay)

DISCHARGE MEDICATIONS

Prescribed:

1. Metoclopramide 10mg tablets
   • Take ONE tablet THREE times daily as needed for nausea
   • Supply: 9 tablets (3 days)
   • Do not exceed 3 tablets in 24 hours
   • May cause drowsiness - do not drive if affected

Over-the-Counter Recommendations:

2. Paracetamol 500mg tablets

• Take TWO tablets (1000mg) every 6 hours as needed for pain
• Maximum 8 tablets (4000mg) in 24 hours
• Take with food if stomach upset occurs

AVOID:

• Aspirin (increased bleeding risk)
• Ibuprofen or other NSAIDs (increased bleeding risk)
• Codeine or other opioids (may mask neurological symptoms)

ACTIVITY RESTRICTIONS - MANDATORY

Effective Immediately - Minimum Durations Listed:

STRICTLY PROHIBITED:

1. Work: NO work of any kind for MINIMUM 72 hours (until 1 August 2018)
   • Includes operational police duties, administrative duties, case review
   • Medical clearance required before return to any duties
   • Minimum 7 days off operational duties even if symptoms resolve
2. Driving: NO driving for MINIMUM 48 hours (until 31 July 2018)
   • Applies to all vehicles including personal, work, motorcycles
   • Reaction times impaired even if patient feels capable
   • May resume only after 48 hours AND complete symptom resolution
3. Screen Time: NO screens for MINIMUM 24 hours (until 30 July 2018, 18:30)
   • No computer, tablet, smartphone, television
   • Includes work emails, text messages, social media
   • May resume gradually if symptoms do not worsen
4. Reading: NO reading for MINIMUM 24 hours
   • Includes books, newspapers, documents
   • May resume gradually after 24 hours if tolerated
5. Alcohol: NO alcohol until full recovery
   • Minimum 48 hours, preferably until all symptoms resolved
   • Alcohol delays concussion recovery and increases complication risk
6. Physical Activity:
   • NO exercise, running, gym, or sports for minimum 7 days
   • NO heavy lifting (>5kg) for 7 days
   • NO contact sports until medically cleared
   • Light walking only - avoid exertion causing increased heart rate

REQUIRED ACTIVITIES:

1. Cognitive Rest:
   • Rest in dark, quiet room as much as possible
   • Minimal mental exertion
   • Adequate sleep (do not restrict, patient may sleep as needed)
   • Avoid loud noises, bright lights
2. Monitoring:
   • Responsible adult must check on patient every 3-4 hours for first 24 hours
   • Patient should be easily wakeable but does not need to be woken routinely
   • Monitor for warning signs (detailed below)
3. Hydration and Nutrition:
   • Maintain adequate fluid intake
   • Light, easily digestible meals
   • Avoid caffeine (may worsen headache)

Hand Wound Care:

• Keep dressing clean and dry for 48 hours
• Elevate hand when possible to reduce swelling
• Do NOT immerse in water (brief shower acceptable, keep hand dry)
• Change dressing in 48 hours (at GP or return to RHH)

WARNING SIGNS - IMMEDIATE RETURN TO EMERGENCY

Call 000 and return to Emergency Department IMMEDIATELY if ANY of the following occur:

CRITICAL WARNING SIGNS:

• ⚠️ Severe headache that is getting worse or not relieved by paracetamol
• ⚠️ Repeated vomiting (more than twice)
• ⚠️ Seizure or convulsion of any kind
• ⚠️ Weakness in arms, legs, or face
• ⚠️ Numbness or tingling that is new or worsening
• ⚠️ Very drowsy or cannot be wakened
• ⚠️ Confusion or disorientation (not knowing where you are, who people are, what day it is)
• ⚠️ Slurred speech or difficulty speaking
• ⚠️ Vision problems (blurred, double vision, loss of vision)
• ⚠️ Loss of consciousness (even briefly)
• ⚠️ Clear fluid draining from nose or ears
• ⚠️ Severe dizziness preventing standing or walking
• ⚠️ Unusual behaviour or personality changes
• ⚠️ Severe nausea preventing fluid intake for more than 6 hours

Hand Wound Warning Signs:

• Increasing pain in hand not controlled by paracetamol
• Redness spreading from wound
• Swelling, warmth, or discharge from wound
• Red streaks extending from wound site up arm
• Fever above 38°C
• Foul smell from wound
• Sutures breaking or wound opening
• Loss of finger movement or sensation

DO NOT WAIT - These symptoms require immediate medical assessment

MANDATORY FOLLOW-UP APPOINTMENTS

1. General Practitioner Review - 3 DAYS

• Date Required: 1 August 2018 (Wednesday)
• Purpose:
  • Concussion symptom assessment
  • Hand wound inspection
  • Dressing change if needed
  • Medical certificate for continued leave if required
  • Assessment for return to light duties

2. Suture Removal - 10 DAYS

• Date Required: 8 August 2018 (Wednesday)
• Location: GP or return to RHH Emergency Department
• Purpose:
  • Remove 6 sutures from right palm
  • Assess wound healing
  • Confirm full hand function
  • Document final outcome

3. Return to Work Assessment - BEFORE returning to operational duties

• Required: Medical clearance from GP or Occupational Health
• Timing: Minimum 7 days post-injury, only after complete symptom resolution
• Assessment must include:
  • Confirmation all concussion symptoms resolved
  • Cognitive function assessment
  • Fitness for operational duties including firearms use
  • Hand function adequate for duty requirements

MEDICAL CERTIFICATES PROVIDED

Certificate 1: Unfit for All Duties

• Period: 30-31 July 2018 (2 days)
• Status: Completely unfit for all work
• Review: Required 1 August 2018

Certificate 2: To be determined at GP review

• Further certification will be issued by GP based on symptom progression
• Expect minimum 3-5 days total off work
• Operational duties: minimum 7-10 days

PROGNOSIS AND EXPECTED RECOVERY

Concussion:

• Most symptoms should improve significantly within 7-14 days
• Complete recovery expected within 2-4 weeks
• Small percentage of patients experience symptoms beyond 4 weeks (post-concussive syndrome)
• Early rest and adherence to restrictions improves outcomes

Hand Wound:

• Expected to heal without complication
• Full function should return within 2-3 weeks
• Minimal scarring expected with proper care
• Suture removal at 10 days

Return to Full Duties:

• Light administrative work: Possible 3-5 days if symptoms resolved
• Full operational duties: Minimum 7-10 days with medical clearance
• Premature return increases risk of complications

SPECIAL INSTRUCTIONS FOR RESPONSIBLE ADULT (DS Claiborne)

Monitoring Requirements - First 24 Hours:

Check on patient every 3-4 hours (do not need to wake if sleeping peacefully):

• Ensure patient is easily wakeable
• Ask simple questions (name, where they are, what day it is)
• Observe for warning signs listed above
• Encourage rest, fluid intake, medication compliance

When to Seek Help:

• ANY warning sign occurs → Call 000 immediately
• Uncertainty about symptoms → Call Healthdirect (1800 022 222) for advice
• Symptoms worsen instead of improve → Return to ED

Support Patient to Follow Restrictions:

• Remind patient not to check phone/computer
• Maintain dark, quiet environment
• Assist with meal preparation if needed
• Ensure medications taken as prescribed
• Transport to follow-up appointments as needed

DISCHARGE SUMMARY FOR GP

To: Patient's nominated General Practitioner
Re: Sarah Jane Lahey, DOB 13/03/1989

Dear Doctor,

Your patient attended Royal Hobart Hospital Emergency Department on 29/07/2018 following work-related injury. Please see above for detailed summary.

Key Points for GP Review (01/08/2018):

1. Concussion Assessment:
   • Symptom progression (should be improving)
   • Cognitive function (concentration, memory)
   • Physical symptoms (headache, nausea, dizziness)
   • Consideration of further leave if symptoms persist
   • Referral to specialist if symptoms not improving by 2 weeks
2. Hand Wound:
   • Inspect for signs of infection
   • Change dressing if needed
   • Confirm healing progressing appropriately
   • Arrange suture removal at 10 days (08/08/2018) if not done by patient elsewhere
3. Return to Work:
   • Patient is police detective in operational role
   • Requires complete symptom resolution before operational duties
   • May consider light administrative duties after 5 days if asymptomatic
   • Full operational clearance requires comprehensive assessment
   • Consider referral to Occupational Health if complex return-to-work issues
4. Red Flags:
   • Symptoms worsening instead of improving
   • New symptoms developing
   • Symptoms persisting beyond 2 weeks
   • Any warning signs → direct patient back to ED

Note: Physician assessment documented inconsistency between reported mechanism and observed injury pattern. Medical treatment provided appropriately regardless, but administrative review may be conducted separately by employer.

Please contact RHH Emergency Department (03 6222 8308) if you require further information.

NOTIFICATION TO EMPLOYER

Tasmania Police - Detective Sergeant Charlie Claiborne

As per protocol for injured police officer, supervisor has been:

• Verbally briefed on injuries and treatment
• Provided written discharge summary
• Informed of mandatory work restrictions
• Advised of follow-up requirements
• Notified of mechanism inconsistency for administrative review

DS Claiborne confirmed understanding and availability to provide monitoring and support during recovery period.

ADMINISTRATIVE NOTES

WorkCover Notification: Not applicable (circumstances require administrative review prior to any compensation claim processing)

Incident Classification: Work-related injury during operational duties

Documentation Distribution:

• Original medical record: Royal Hobart Hospital
• Copy to: Patient
• Copy to: Patient's GP (with consent)
• Copy to: Tasmania Police (DS Claiborne)
• Copy to: Hospital Administration (police officer injury notification)

Billing: Bulk-billed (no cost to patient)

CLINICAL CONCERNS DOCUMENTED

Medical Assessment Note:

Dr. Finn Montgomery's comprehensive assessment documented significant inconsistency between reported mechanism of injury and observed injury pattern. Specifically:

• Lateral head impact not consistent with reported forward fall
• Isolated palm laceration without defensive injuries inconsistent with fall mechanics
• Absence of other expected fall-related injuries

Medical treatment provided appropriately regardless of mechanism. However, this observation has been:

• Formally documented in medical record
• Communicated to supervising officer
• Noted for potential administrative or safety review

Patient was given opportunity to clarify mechanism during assessment but maintained original account. Medical staff have no reason to disbelieve patient but note the clinical inconsistency for appropriate documentation purposes.

DISCHARGE CHECKLIST - COMPLETED

☑ Patient vital signs stable
☑ Observation period completed (4 hours minimum)
☑ No deterioration in neurological status
☑ Patient alert, oriented x3
☑ Patient able to tolerate oral fluids
☑ Responsible adult available for transport and monitoring
☑ All discharge instructions provided verbally and in writing
☑ Patient demonstrates understanding of warning signs
☑ Responsible adult demonstrates understanding of monitoring requirements
☑ Discharge medications prescribed and explained
☑ Follow-up appointments scheduled
☑ Medical certificates provided
☑ GP referral letter prepared
☑ Hand wound care instructions provided
☑ Patient questions answered
☑ Contact information for concerns provided
☑ Supervisor notified per protocol

DISCHARGE MEDICATIONS AND PRESCRIPTIONS

Prescription Written:

• Metoclopramide 10mg tablets, 9 tablets (3 days supply)
• Authority: Dr. Finn Montgomery, FACEM
• Date: 30/07/2018

Patient Advised to Purchase:

• Paracetamol 500mg tablets (over-the-counter)

Wound Care Supplies:

• Sterile dressing supplies provided for first change in 48 hours

CONTACT INFORMATION FOR PATIENT

If Symptoms Worsen or Concerns Arise:

Emergency (Warning Signs): 000

Royal Hobart Hospital Emergency Department:
Address: 48 Liverpool Street, Hobart TAS 7000
Available: 24 hours, 7 days

Healthdirect Australia (Health Advice):
Available: 24 hours, 7 days

Patient's GP:
[To be filled in by patient with their GP details]

Tasmania Police Support:
Detective Sergeant Charlie Claiborne: [Work contact on file]

DOCUMENTATION COMPLETED BY

Discharging Physician: Dr. Finn Montgomery, MBBS, FACEM
Position: Head of Emergency Department
Date: 30 July 2018
Time: 00:15
Signature: F. Montgomery

Discharge Nurse: Jackson Roberts, RN
Position: Senior Nurse, Emergency Department
Signature: J. Roberts

END OF DISCHARGE SUMMARY

Form Authorization: ED-DISCHARGE-SUMMARY-001
UR Number: 2018-ED-07291830
Page: 1 of 1

Distribution:

• Medical Record (Original)
• Patient (Copy)
• General Practitioner (Copy)
• Tasmania Police - DS Claiborne (Copy)
• Hospital Administration (Copy)

CONFIDENTIAL MEDICAL DOCUMENT