1. Tourniquet Time:__________ Time Converted:___________ Problem List
Name: _________________________________ Age:___
Weight: _______Lbs _______Kg
Allergies: ______________________________________
Past Med Hx:___________________________________
Past Surg Hx:___________________________________
Incident History: I have (# patients), stable/unstable, Incident occurred: ______________________________
Mechanism of injury was _________________________
______________________________________________
I am expecting to evac the patient to:________________
Estimated time to evacuation is now: ________________ ETA at definitive care is: __________________________ CASEVAC POC is: ________________________________
Tourniquet Time:__________ Time Converted:___________
Problem List
Plan 1 2 3 4 5 6 7 8 9 10

2. KETAMINE VERSED FENTANYL
TIME → BP ˅
220 ˄
200
180 HR
160 ●
140
120
Respirations R
100 80
ET CO2 o 60 40 20
Eyes 4
Verbal 5
Motor 6
GCS 15
Fluid IN
Output ml/hr
KETAMINE
DOSE:
TIME:
VERSED
FENTANYL
OTHER DRUGS

3. KETAMINE VERSED FENTANYL
TIME → BP ˅
220 ˄
200
180 HR
160 ●
140
120
Respirations R
100 80
ET CO2 o 60 40 20
Eyes 4
Verbal 5
Motor 6
GCS 15
Fluid IN
Output ml/hr
KETAMINE
DOSE:
TIME:
VERSED
FENTANYL
OTHER DRUGS

4. Pt Comfort / Positioning
TALK TO THE PATIENT – orient to time and place, explain procedures, elevate HOB,
Baby-wipe bath, pad: occiput, spine, sacrum, elbows, heels, Reposition Q2H, insert wedges and pillows,
Vital Signs
Q 15, report as a trend, trend full GCS if applicable, pulse ox is 3-4 minutes old info
Tubes
ET placement – cuff pressure esp. IN FLIGHT! Place NG & remove contents, secure Foley
Pulmonary status
Supplemental O2, monitor SpO2, Lung sounds, can he posture/position on his own? Pursed lip breathing
Ventilations
Reinforce BVM principles with helpers, end point is patient comfort, just enough to expand the chest, one hand!
Hydration
Maintenance fluids 125cc/h, Measure In and outs
Wounds and dressings
Irrigate and dress, replace wet to dry, inspect for rashes and sores, antibiotics
Splints
circulation check, tighten or loosen
Bladder care
Last void, distended? Clean Foley site
Eye Care
Contacts? Tape eyes? Drops or Ointment
Mouth
Loose teeth, mucous membranes moisturized, cleaning/ brushing
Skin
Pressure sores? Maceration due to incontinence, diaper rash?
DVT
Calf massage every Hr
Head injury
MACE Card
Acts of daily living: breathing, swallowing, coughing, drinking, eating, re-positioning, toileting, hygeine
Nursing care items: Blankets, pillows, gowns, towels, sheets, basins, trash bags, irrigation water

5. TeleMed Recommendations:
Glasgow Coma Scale
TIME
Eye Opening Response
Spontaneous 4
To Verbal Command 3
With Painful Stimulus 2
No Response 1
Best Verbal Response
Oriented 5
Confused
Inappropriate words
Incomprehensible Sounds
Best Motor Response
Obeys Commands 6
Localizes Pain
Withdraws (Pain)
Flexion (Pain)
Extension (Pain)
Call script:
“THIS IS _________________, (JOB/POSITION):___________________.
I HAVE A PATIENT WITH ___________ WHO I THINK HAS ___________,
AND I NEED _____________________________________________________.”
CHIEF COMPLAINT: ______________________________________________
BRIEF HISTORY:__________________________________
PE: VITALS: HR:____________ BLOOD PRESSURE: _________________
RESPIRATION RATE: _________ OXYGEN SATURATION: ____________
TEMPERATURE: _________ MENTAL STATUS (AVPU): ______________
BRIEF EXAM: ____________________________________________________
_________________________________________________________________.
“I NEED _______________.” (CONSULTATION, HELP, ADVICE, TRANSPO…)
TeleMed Recommendations:
1.Fluids/Meds:
2.Interventions:
3.Procedures:
4.Red Flags:
5.Other:

6. Priority of Procedures
Problem List
Plans 1 2 3 4 5 6 7 8 9 10
Priority of Procedures