ROYAL HOBART HOSPITAL

EMERGENCY DEPARTMENT TRIAGE FORM

Form Number: ED-TRIAGE-2018-07-29-1947
Date: 29 July 2018
Time of Arrival: 17:47
Arrival Method: Self-presented (private vehicle)

PATIENT DEMOGRAPHICS

Surname: LAHEY
Given Names: Sarah Jane
Date of Birth: 13 March 1989
Age: 29 years
Sex: Female
Address: 23 Rosewood Lane, Battery Point, TAS 7004
Contact Number: 0412 XXX XXX
Medicare Number: [REDACTED]
Next of Kin: Grandmother - Jane Lahey (Contact: 03 XXXX XXXX)

Occupation: Detective, Tasmania Police
Employee ID: CID-2247
Badge Number: TAS-3192
Emergency Contact (Work): DS Charlie Claiborne - Tasmania Police (Contact: 03 XXXX XXXX)

TRIAGE ASSESSMENT

Presenting Complaint: Hand laceration and head injury sustained during work-related incident

Chief Complaint (Patient's Words): "I fell during a search. Cut my hand on glass and hit my head."

Mechanism of Injury:
Patient reports falling during search of residential premises in Berriedale whilst on duty. States she lost footing, caught right hand on broken glass from window, and struck left side of head against wall during fall. Incident occurred approximately 1.5 hours prior to presentation.

Work-Related Injury: YES ☒ NO ☐
Supervisor Notified: YES ☒ (DS Claiborne contacted at 18:05 per protocol)

VITAL SIGNS

Time Assessed: 18:52

• Blood Pressure: 142/88 mmHg (elevated)
• Heart Rate: 88 bpm (regular)
• Respiratory Rate: 18 breaths/min
• Temperature: 37.4°C (tympanic)
• SpO2: 98% on room air
• Pain Score: 6/10 (patient self-reported)

INJURY ASSESSMENT

Right Hand:

• Deep laceration across palm, approximately 4-5cm in length
• Actively bleeding through makeshift bandaging (patient used shirt sleeve)
• Bandage saturated with blood
• Patient able to move fingers with difficulty, reports significant pain
• No obvious deformity
• Distal sensation and circulation appear intact pending detailed examination

Head:

• Visible swelling left temporal-parietal region
• Patient reports significant headache (8/10 when directly questioned, initially reported 6/10)
• Denies loss of consciousness
• Complains of nausea, light sensitivity
• Alert and oriented x3 (person, place, time)
• Pupils equal and reactive to light
• No obvious facial trauma
• Neck examination deferred pending physician assessment

NEUROLOGICAL SCREENING

• Glasgow Coma Scale: 15/15 (E4 V5 M6)
• Orientation: Fully oriented to person, place, time
• Memory: Able to recall events leading to injury
• Speech: Clear and coherent
• Gait: Not formally assessed (patient seated)
• Coordination: Grossly intact in uninjured extremities

ASSOCIATED SYMPTOMS

☒ Headache (significant, 8/10)
☒ Nausea (moderate)
☐ Vomiting
☒ Dizziness (mild, positional)
☒ Light sensitivity (moderate)
☐ Vision changes
☐ Confusion
☐ Seizure activity
☐ Loss of consciousness

PAST MEDICAL HISTORY

• No known chronic conditions
• No regular medications
• NKDA (No Known Drug Allergies)
• Last Tetanus: 2015 (confirmed, patient recall)
• Previous hospitalisations: None significant reported
• Previous head injuries: None reported

CURRENT MEDICATIONS

None reported

ALLERGIES

NKDA

SOCIAL HISTORY

• Occupation: Detective, active duty
• Smoking: Non-smoker
• Alcohol: Social (occasional)
• Illicit substances: Denied

TRIAGE CATEGORY

Category: 3 (Urgent)

Rationale: Moderate head injury with concussion symptoms (headache, nausea, light sensitivity) requiring neurological assessment. Deep hand laceration requiring suturing. Both injuries require prompt medical attention but patient is haemodynamically stable with intact airway and breathing.

PRELIMINARY PLAN

1. Move to treatment bay for wound care and detailed assessment
2. Clean and dress hand laceration pending physician evaluation
3. Neurological assessment for concussion
4. Likely suturing of hand laceration (estimated 6-8 stitches required)
5. Observation period for head injury (minimum 4 hours)
6. Pain management
7. Tetanus status confirmed current - no booster required

DISPOSITION

Initial Placement: Bay 4
Assigned Nurse: Jackson Roberts, RN
Consulting Physician: Dr. Finn Montgomery, FACEM

TRIAGE NURSE NOTES

Patient presented in obvious discomfort, holding right hand wrapped in blood-soaked fabric (appears to be sleeve from work shirt). Cooperative with assessment but minimising pain - initially reported 6/10 for both hand and head, increased to more accurate 8/10 for headache when directly questioned. Appears fatigued, slightly pale. Squinting against overhead lighting, consistent with reported light sensitivity.

Patient's account of mechanism of injury is straightforward but limited in detail. When asked to elaborate on circumstances of fall, patient provided only brief responses. States partner (identified as Detective Karl Jenkins) was present at scene but uninjured.

Supervisor notification completed per protocol for injured police officer - DS Charlie Claiborne notified at 18:05.

Patient appears stoic/controlled in presentation, consistent with law enforcement training. However, presents with elevated blood pressure and tachycardia suggesting pain/stress levels higher than patient is reporting. Will require close monitoring during treatment.

Hand wound appears clean-edged, consistent with glass laceration. Bleeding controlled with pressure but wound will require thorough irrigation and closure. Concussion symptoms warrant observation period and physician assessment prior to discharge.

Triage Completed By:
Rachel Thomson, RN
Triage Nurse, Emergency Department
Time: 19:58
Signature: R. Thomson

Form Authorisation: ED-TRIAGE-001
Distribution: Medical Record (Original), Nursing Staff (Copy), Physician (Copy), Administration (Police Notification Copy)