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Home My WebLink About10-7304r f^ 7 SR rn ( -,I ? IN THE COURT OF COMMON PLEAS C'-) -urn 70 OF CUMBERLAND COUNTY, PENNSYLVANIA <v Ac' ANNA M. BILZ, GUARDIAN OF JAMES M. BILZ, JR., a minor, Plaintiff VS. . JAMES M. BILZ, SR., . Defendant C -n n 3ma a C-- DOCKET NO. 10-7304 v C)rn ` CIVIL ACTION PETITION FOR APPROVAL OF MINOR'S SETTLEMENT AND NOW, comes the Parties who state the following: 1. Plaintiff Anna M. Bilz, is an adult individual residing at 574 Crossroad School Road, Carlisle, Cumberland County, Pennsylvania. 2. Plaintiff Anna M. Bilz is the grandmother and guardian of James M. Bilz, Jr., a minor. 3. Plaintiff, James M. Bilz, Jr., is a minor, whose date of birth is February 4, 2005, and who is presently 5 years old. 4. Plaintiff, James M. Bilz, Jr., resides with his father and grandmother at 574 Crossroad School Road, Carlisle, Cumberland County, Pennsylvania. 5. Defendant, James M. Bilz, Sr., is an adult individual who resides at 574 Crossroad School Road, Carlisle, Cumberland County, Pennsylvania. 6. Defendant, James M. Bilz, Sr. is the father of the minor Plaintiff. 7. This matter involves a motor vehicle accident that occurred on June 27, 2009, in Hanover, York County, Pennsylvania. 195848.1 8. At that time, James M. Bilz, Jr., was a passenger in a vehicle operated by James M. Bilz, Sr., who lost control of the vehicle leaving the roadway and striking a utility pole. 9. As a result of the accident the minor child sustained personal injuries including a laceration to the head. 10. The minor child was seen at Hanover Hospital and referred to Hershey Medical Center where he has been treated by Dr. Kurtiz Moyer. Portions of the medical records are attached hereto as Exhibit "A." 11. The injuries including a head laceration that required closure have resolved and a current report from the Dr. Moyer and photographs of the child are attached hereto as Exhibit "B" and Exhibit "C." 12. At the time of the accident James Bilz, Sr. was operating a 2000 Honda Civic owned by Anna Bilz which had $5,000.00 in first party medical benefit coverage. This coverage was exhausted and no other sources of medical coverage were available. 13. The family made contact with Goodville Mutual Casualty Company and an agreement was reached whereby further medical claims for James Bilz, Jr. would be presented, paid and included in the final settlement. 14. Goodville has paid $24,128.00 for medical expenses for James M. Bilz, Jr. 15. The parties have negotiated a settlement in the amount of $29,128.00 of all claims on behalf of James M. Bilz, Jr., arising from this accident. 16. Anna M. Bilz, as guardian of James M. Bilz, Jr., agrees that the settlement amount is fair and reasonable and properly compensates said minor for the injuries sustained. 195848.1 17. Anna M. Bilz, as guardian of James M. Bilz, Jr., recognizes that as he is a minor the $5,000.00 paid in addition to the medical expenses is to be invested in a custodial account at an institution insured by the Federal Government and marked not to be withdrawn until James M. Bilz, Jr., reaches 18 years of age except upon Order of this Court. 18. Defendant, James M. Bilz, Sr., is defended by Goldberg Katzman, P.C. Mr. Bilz is agreeable to the settlement set forth above. WHEREFORE, Anna M. Bilz, guardian of James M. Bilz, Jr., requests this Court approve the settlement. Anna M. Bilz, Guardian James M. Bilz, a minor Thomas E. Brenner, Esquire Goldberg Katzman, P.C. PO Box 1268 Harrisburg, PA 17108-1268 717-234-4161 Attorney for Defendant James M. Bilz, Sr. u p:?gI« Dated - t ( ??C/ / ( '? Dated 195848.1 OUd-1V1C2ifd'WACt7lt EKE' Pennsylvania 1 oft https NO webcur co0webcur2/apps/ems/apprep showper ncgnlp PA EMS Report Lithocode 61697078 Service Name Station (fart Name, No. & 1pe PCR No. Date Perm Towalup Ambulance - i Ianover l Wirt Park Fire StationI MICU 49 / 6701 852 1 MICU 0901868 06882009 Incident Location County, Municipality & Incident Zip PSAP Incid. No. 300 Hiodand Ave HGH ER Rim 4, Hanover, PA 17331 YORK, Hanover Soto, 17331 Acute Care Faci lity-Hospital Receiving Agency Umverstty Hospital - Hershey Patient Name Crew anres M Srit:Jr ` C #l Tetreault, Paul 0203312 Street Address C #2 Miller, Eric EMT 16526 1 CO tQ City State tip C #4 ~ Hanover PA 17331 Primary Caregiver- C#1 Driver. C#2 G Sexe DOB Phone No Mileage Male I4 Years 021048005 717) 479-8410 out Os-Seeno Dent In ',,s Patient Number Social Sec. No. Pt Weight 60306 60307 60356 60405 V2900910 000-00-0000 Times Private Physician river's License Response lime 0 911 ERTnme 5 Dispateb 0117 OSTrme 8 Enroute 0117 Transp Assist Units Assist OS ERH Time 68 Arrive Scene 01 22 Destnaationrime 67 Contact 0124 Response Outcome Nature orlacident Total Time 148 Depart Scene 01 30 Transported ALS Time out of 153 Arrive Facility 02 38 Raspoase Mode Transport Mode Quarters Non-Emergency Non-Emergency Available 03 45 In Quarters 03 50 Patient Condition ea Scene Patient Condition at Facility Moderate I mproved ChaefComplarut " I feelOk" Current ldcds none Allergies (meds) NKDA , PMHx eczema Narrative f Dtsp MICU 49 dispatched to the above location for emergeneytiansport frorn Hanover Hospital ER Rm 4 to HersheyMedieai Center trauma bay at 0117 Reason for Transport* Pt was in an MVA with a frontal skul fracture with a large laceration that requires trauma and surgical intenventoWn oratoiing rot offered at Hanover General F jospitai This was it specialty pre transport became pt was reserving RDcephm which requires a PHRN for transport J AOS To find this 4 y/o male lying supine, awake and a9ft in attendance of RN from ER and father of pt HPI According to transfer paperwork, pt carne lo Hanover Hospital on 627109 around 2300 S1P MVA Pt was the rearseat occupent, in a car seat, strapped in, facing forward that was in an MVA Fa ker states that sometimes pt fiddles with Ina seatbek and undoes iL PCs father was driving and was trying to tend m child and went over a "I embankment down 3 & Thers was minimal nghk frond and damage to the car and pt drove away from awns and found by PD and liken byALS to HGH ER Pt had an 8-10 rm laceration from the middle of his forehead to the top of his parietal tread which was down to skull, but there w'Ps no active bleeding Pt was found by CT b Have a right frontal head fracture, no intiacerebrol head bleed, no fracture of the C-spine, mobs drawn Pt placed back on LBB aid sewed to the board Laceration was cleansed and wet to dry dressings placed with Kerlex We m pla wore t#U tAF with Rocaphin 1200 mg W, Rocepton was then converted to IV NSS 10orAw, which was patent and Infusing without difl u ty ardisc morstor in ER revealed ST rate 100-130 Pt ciurerdyden ies deist pain, SOB, 7/7/2009 12 18 PM I O-Ueli4MQ!D/e1mQUk%XWPennsylvania https //us3 webcur corialwebcur2/apps/eWapprep_5howpcr n c917p nausea, vomiting, HIA, peripheral anesthesias, or abdominal pain. 7 PE Airway, Patent, no respiratory disbmss or stndor noted BreaHung Spontaneous, run-labored, rate 22 Citculabon Distal pulses present, equadstrong and regular Noma Awake, alert, onented to person, ptace, time, and event. GCS 4-" =15 HEENT Unremarkable, PEARRL @ 3 m bilaterally, no rhinorrhea or otonhea noted Neck No ND, trachea nndt»e Skrn Warm. dry, pink Lungs Clear to ausculation throughout all fields ardenor and posterior, apex to base Chest Equal chest rise and fat no retractions or landemess noted Abd SNTvrithou t p$ipable masses, distension, discoksrations, or rigidity being noted GMU Pt was not i nconhnent of urine or feces Back No tenderness, deformity or disoobrabors. Exbermbes MAE x 4 with purpose, + strong peripheral pulses, no edema, discoiorabons, or peripheral neuiropathy EKG Sinus tachycardia rate 100-130 noted m leads lard 8 without evidence of ectopy orbiock 02 sat 99 % on room air and ptvms continued on room air for transport TxfVS See 9owchart, ALS assessment, cardiacmorutor, VS, N, NF/IV mods as ordered and already infiisirg, transport Outcome Pt transported stable Class Iff pt to Hershey Medical Center RocepNn was started and mlo die transport, the Rooephin infused and then ilwas changed to NSS 10crJhr Dun rig transport, pt slept with father next to turn on the bench seat and pt had no serimes or any dri lculties dung transfer ALS arrived HMC instable condition VS remained stable and pt stillm ST wftut CPf30WW or 3M dher complaints Pt taken to trauma room, 710IYT0C RN and trauma team without Wilier dilncutiy N intact and patentvalhotl evidence of udiltafion MICU 491ater plated available Note- PCs father signed Penn Township ambulance HIPAA fors and n otillcation of biting aulhombon form without difricully as pl is a minor Paul Tebeault RN 48-26, PHRN 203312 Time Events Provider Comments 01 33 EKG/Defib Cardiac Monitor, Rhyttm Simms Tachycardia, Rhythm at Hospital Sinus Tachycardia, Lead 11, TetreaulL 11t, AVF Paul 01 35 Vitals Pulse 126, Rasp 22, Oximetry, 991/0, B P 109/67 (Automated Cutf), GCS 4/5/6, Rasp F•ffod Tctresult. Normal, Perfusion Normal Paul 01 50 Vitals Pulse 100, Resp 22, Oximetry 991/9, B P 0961049 (Automated Cuff), GCS 4/5/6, Resp Effort Tetreault, Noma[, Perfusion Normal Patel 0205 Vitals Pulse 100, Resp 22, 0ximetry 991/., B P 104158 (Automated Cuff), GCS 4/516, Resp Effort Tetreault, Normal, Perfusion Normal Paul 02 20 Vitals Pulse 115, Resp 22, Oxmmetry 9996, B.P 0971059 (Automated Cull), GCS 415/6, Rasp Effort Tetmault, Normal, Perfusion Normal Pau) 02 35 Vitals Pulse 130, Resp 22, Oxunetry 9M B P 102/60 (Automated Cuff), GCS 41516, Resp Effort Tetremslt, Nonnal,Perfusson Normal Paw Report Generated by Med-Media WebCUR EMS Pennsylvania on 07/07/2009 @ 12 39 02001-2007 Med4ledia, Inc, Hamstwrg, PA AA rights reserved 2 of 2 7/7/2009 12 18 PM 0 /1412009 10:19 AM h 1 7 I Township Ambulance ees Charge Form - PCa: 0901868 , A Name: James M Bit Jr Address: Clty/Stotemp: Phone: Crew 1: - 1 Grow 2: d 1 13 Billing Primary 1CD9 Retatlonship to Printed On 06/28/2009 EMStat Reporting: ®1f ier, PA 1 1 Age. 4 years 479-841 SSN: 000.00-0p00 Sm Male 4 20331 , F166261 r i-' I nt Self Mad U6di a, Inc NI Rights Rewrved i i i i T T- f i I J i 1 i i 0 /14/2009 10:19 AM Pan.tdb x1me• T4 trig ldnal rime; L TS OX40m. 1 C] m'Nda bmt b cbealwd.l vWA whkAi etas p m>o ut M1424 8tti hwvaw >?o 1 >y sty 'Im js badoaat wd. anda is daewttt.d tiler the br datti'. aoadihoa 4 sash axe Ldp gL abet a eta edxal atgtdE CW6L.ga diem w bad - cadmosafte, is an& Hutt asmedlt aYp t this sole cdwdoon. ra be chw o dd t h All Xti ba: (1) th w get vp#=badwtthaat aaatuautor. AND +?unable to ambulow. J46 (a) rmuh(e to sit , b a w o otr ( e: o al e om must e met m ootdes tot; ftpajjwoftp one* as bad comfiseq) I 41se tellvw gns.Hos<. tear tits cmrQe on be Va1W; J t) n, ass polkwi `butt eotdt 8etloed - ?a .p Mc, ! 2) Date the m"Cal C of this AT THE VW QFAAMUAXM 7RANSP0? thst> the patiam to be waoYpottttd ats a ?+atabes asabm?).ace bhp t><.ra?eet bT other w oed by ttteptttttutt'a whom. i a) Caft" "WYbe ine vw (Lo ts+anspott, atoll tuithotft a {?tediaal lo¢' the dtaatlnn d , mod O atte>td aat? 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Die>#arge n uormom men t, unsdWb Tid ambtsisme olD?atebasbetoty) d Alltcs.l'raltdtlaalar 0811412009 10:28 AM *****Signed***** DATE 6/27109 HISTORY POSSIBLE HEAD INJURY, MOTOR VEHICLE ACCIDENT, LACERATION NON-CONTRAST CT SCAN OF THE BRAIN AND CERVICAL SPINE 6/27109 BRAIN Contiguous axial images through the brain were performed without intravenous contrast Findings No evidence of acute intracrarnal bleed, mass effect or midline shift Ventricles, sulci and cisterns are appropriate for the patient's age No intra or extra-axial mass density or fluid collection Note is made of the presence of a large skin laceration of the forehead without definite fracture The frontal bone is thought to be intact No definite frontal bone fracture IMPRESSION 1 No acute intracranial pathology 2 No evidence of a depressed skull fracture Full thickness soft tissue frontal scalp laceration with soft tissue defect and small degree of soft tissue emphysema CERVICAL SPINE Contiguous axial images through the cervical spine were performed without intravenous contrast Coronal and sagittal reformations were obtained There is no evidence of acute fracture or subluxation Soft tissues appear intact Incidentally noted is mucosal opacfication of the ethmoid air cells IMPRESSION No evidence of acute cervical spine fracture Preliminary report was provided by Team Health Teleradiology *****REVIEWED AND ELECTRONICALLY SIGNED BY SYED,ZEBA A MD AT 06130109 2139* ZEBA A SYED MD DD 06/28/091606 DT 06129109 0841 -AMP Admit date Order date 06127/09 2317 Study date 06/27/09 2320 PATIENT IDENTIFICATION BILZ.JAMES M JR SERV ER HANOVER HOSPITAL UNIT 0 M000238086 ACCT #. V00002900910 DOB 02104/2005 CT SCAN REPORT ORDERING PHYSICIAN: NUNCIO MASSARA DO RECIPIENTS. FAMILY FIRST HEALTH HANOVER PATIENT'S PHONE #• (717)479-8410 PAGE 1 OF 1 MR # 566 (8/01) Medical Records 07/17/2009 10:34 AM PENNSTATE HERSHEY Milton S Hersbey Medhcal Center r i ?J l NAME l DI W? DOB 0 me ..(A k LOC 2 tuc. Al 111111181H 11111 IN 111111111 IN AMES JR OOSR• 10505526 W TER V T b E. 0612612008 ISIT DA 1-1 sex, q URANCE STANDARD DEPARTMENT OF EMERGENCY MEDICINE INCOMING PATIENT REFERRAL* J I i U11 I K4qo Uy y) Date Ti a am pm Patient Name MR# Referring Facility Phone ( ) Referring Doctor Beeper Dr Request ? Cali or page post ED evaluation O Consult ? Call or page on arrival to ED O Studies O Cali or page only as needed D Orders Chief Complaint l E HPI Inc, yfrpylja? vsS P P., A 'n 14 UCLA PMH Meds Allergies j Workup PTA X-Rays >-< CT Scans Treatment PTA ? nn ETA am pm Mode of Arrival ? POV 0 BLS Call Received By ? ALS ? Life Lion Charge Nurse Notified Yes No ED Attending Notified Yes No * All Pts. Seen By ED, unless Non-ED Attending within <15 min of Arrival MR 865 Rev SMS g ??pp??ppEMERGENCY DEPARTMENT REFERRAL - INCOMING PATIENT eibw Trage 111MIN 11 110111m v Pink - Charge Nurse 07117/2009 10:34 AM PENNSTATE ® Milton S. Hershey Medical Center College of Medicine ' ED TRAUMA/RESUSCITATION FLOW.&EET/ORDER SHEET NAME TRAUMA, 7505528 MD OEFLITCH GHRISTO MRN. 7505528 DOB 01100 1145 SELF PAY OOS# EMER ¦ MDS 46325 SEX M SELF PAY VISIT DATE 07/1112009 DATE TIME RESPONSE STAT PAGE RESPONSE LEVEL 2 3 AGE SEX W, WVT TIMEPTA RI ED GZ-(. S I PRE-HOSPITAL ' EMS REPORT r EMS MEDS GIVEN Q00 ` AMR/MEDIC # P-t-1p - BP s GCS i 1f TRAUMA AT TENDANCE HELICOPTER RR 3e BAGGED MEMBER TIME ON-SCENE INTERHOSPITAL iEC-COLLAR _CID/TOWEL ROLL TRAUMA ATTEND CHART LABS _ XR CT UNK YES i MIN LOSS OF CONSCIOUSNESS NO Y LONGBOARD/KED MAST ED ATTEND _ _ _ ENTRAPPED _NO -UNKNOWN -YES # MIN SPLINT ANESTH ATTEND SELF EXTRICATED YES NO SR TRAUMA RES ~- - = 'MECHANISM OF INJURY RESPIRATORY _ WC _ CAR _ DRIVER _ BELTED _ EJECTED _ WINDSHIELD _ DAMAGE _ PICKUP PASSENGER _ AIRBAG _ # FT _ BROKEN _ FRONT _ MIN TRUCK FRONT _ CARSEAT _ ROLLOVER _ SPIDERED _ BACK _ MOD VAN BACK NONE X ST WHEEL BENT BROADSIDED _ HEAVY _ PEDESTRIAN _ BED OF PICKUP -UNKNOWN -UNKNOWN _ R _ L MOTORCYCLE _ BICYCLE- ATV _ HELMET- NONE- UNKNOWN FALL _ FT _ GSW _ CAL/MM BURN _ DIVING _ DROWNING _ FARM _ INDUSTRIAL _ SPORT _ STABBING _ OTHER SPONTANEOUS RATE SEDATED _ PARALYTIC AGENT _ 02 MASK UMIN - 02 CANNULA L/MIN ASSISTED RATE _ BVM RATE AIRWAY (ORAL/NASAL) ETI (ORAUNASAL) SIZE CRICOTHYROIDOTOMY TRACH SIZE FLUID RESUSCITATION PMH/PSH ,rrrac. - IV GAUGE SITE SOON AMT INF P TENT? 11- 9/ N MEDS P MI. LAST TETANUS ?jn 12 - _ YIN _ _ ? 13 Y IN ALLERGIES M GLASGOW COMA SCALE A 10 PRIMARY SURVEY BY OR E01 SpoohnMus CHEST ABDOMEN PELVIS voc e RESP LABORED BREATH SOUNDS R L HEART SOUNDS Y SOFT TENDER STABLE :I Response T 2 2 _10 YES PRESENT . PRESENT Y _ _ RIGID Y - - None t t _ 1 4! _ _ ES _ NO UNSTABLE PAIN ABSENT MUFFLED _ DISTENDED WHERE PRIAPISM Best Orrorlld _NO ? YES CLEAR _ _ GUARDING SCARS _ BLOOD 0 Verbal confusetl 4 WHERE q ,? DIMINISHED BOWEL SOUNDS j YES ND MEATUS Response hwr4nrrrworls 3 3 CREPITUS PARADOXICAL _ _ 4 YES NO WHERE himmin h rAlesounds 2 2 k YES _ ' None i I ) _ CHEST SYMMETRICAL MOTION i DECREASED , WHERE t YES -NO IWO -YES ^ Best Obeys oanmano Motor Response Wd*aws leml 4 4 PARALYSIS EXTREMITIES 5 P PARATHESIA PULSES S PAIN eALLOR SKIN _ I WAD/NECK AIRWAY PATENT Pam 3 3 RA it _ _ PALE H T , !-YES _ NO E*rroon n 2 2 LA 4: z t _ CYANOTIC _ COOL JVD YES NO None 1 f RL 1 _ MOTTLED _ COLD _ t t DRY _ MOIST TRACHEA MOLINE TDtal Ap*DUSScoreto GCS LL 4Y _ ACYANOTIC 1 YES _ ND GCS ponwa of Tmume Score r•nuoaii YAYMUO CDMA SCALE(GCS) (TOW Pants from above) slow Pressure Rate MR 690 02105 TIME I TIME ENT 1 OPEN FRACTURE E-ECCHYMOSIS 2 AMPUTATION A-ABRASION 3 GUNSHOT WOUND C-ANTUSION 4 DEFORMITY L-WCEMTION 5 STAB WOUND S-MUNG 6 BURN T-TENDERNESS 7 PAW PW PUNCTURE 8 RASH WDUND BURN IT PT SC I IMPAL ED OBJECT Original - Medical Record Yellow - Trauma Service Pink - ED ED TRAUMAIRESUSCITATION FLOW SHEET/ORDER SHEET C I 1712009 10:34 AM UROLOGIC EVALUATION NE ' VITAL SIGNS ROUTE OF TEMP Time Pupil Size R L Pupil React R L. Motor Function RA RL LA LL GCS Time Cardiac Rhythm P BP RR Oz Sat a T Warm Lites / B H "Pain Scale Used a i S Pediatric t Zt4 Leo Non- tC . umcahve AREA OF CONCERN NEUROVASCULAR ASSE SSMENT PULSE ASSESSED TIME TEMPERATURE COLOR CAPILLARY REFILL SENSATION MOVEMENT PULSE 1 TOTALS LABS TIME TRAM4M TIME BACK TRAM-1F TRAM-2M TWk2F TRAM-3M TRAM-3F TRAM-P T&C 1 U TI S& URINE DRUG LEGAL BLOOD ETOH OTHER SITE CRITICAL VALUES CRTWALVALUES PREPPED WITH POVIDONE-IODINE DRAWN BY GENITOURINARY FOLEY YES NO HEME + SIZE FR BLOOD AT MEATUS INSERTED BY TIME GASTROINTESTINAL RECTAL HEME + - TONE ? GOOD O DECREASED O ABSENT PROSTATE ? NORMAL ? ABNORMAL DONE BY TIME N/G (ORAUNASAL) SIZE FR INSERTED BY TIME PERITONEAL LAVAGE DONE BY DR TIME RETURN ? CLEAR ? PINK ? GROSS BLOOD AMOUNT INFUSED CC AMOUNT RETURNED CC FLUID TO LAB YES NO CARDIOTHORACIC RCT SIZE FR CVP R L LCT SIZE FR A-LINE R THORACOTOMY CUTDOWN L THORACOTOMY BY PERICARDIOCENTESIS TEE ECHO DONE BY 12 LEAD EKG YES NO NEUROLOGIC ICP BOLT INITIAL READING HALO DONE BY DR MEDICATIONS TIME DRUG DOSE ROUTE INIT Td 0ADULT Lori f%ADAN 0 P®S CtAi W CRYSTALLOID IV # TIME SOON SITE AMT LEVEL I •i i X-RAY Time C-Spine Lateral A/P Odootoid Svi rromers CXR xF elvis Cystogram Extremities CT ' Cranial Abdomen Chest Other Angiogram VENT S ETTINGS TIME RATE FLOW TIDAL VOL PEEP SPONTANEOUS RATEr _ 02 MASK UMIN - 02 CANNULA LIMIN ASSISTED RATE _ BVM RATE. AIRWAY (ORAUMSAL) _ ETT (ORAUNAML) SIZE CRICO TRACH SIZE_ BLOOD PRODUCTS PRODUCT UNIT # TIME pE AMT INF INIT LEVEL( dpA, OfF?Af/,? j?' 0j/0$$2# clf4J A`2e hoc F Ftp 1/400 • re Sip Wf AY i rosossz, 4 325 . sFCF AY vjSjr?TE I TOTALS OUTPU T ? LIAI ? TOx SEENT TIME URINE NO EMESIS RCT LCT OTHERS !16 Is TOTALS INTAKE TOTAL -? OUTPUT TOTAL -? 07/17/2009 10:34 AM PENNSTATE HERSHEY 0M Milton S Hershey ® Medical Center TRAUMA HISTORY AND PHYSICAL EXAMINATION 0 ) r' } 'I NAVE TRAUMA, 7505526 MD DEFLITCH CHRISTO MR# 7505528 DOB• 01!01/1900 INS* SELF PAY LOC. EMER ooSP 10505528 MDk 46325 SEX M SELF PAY VISIT DATE 07/1112009 Date Time O?,r Type of Trauma Brief History '(Mechanlsm of Injury) O(MVC Belted? ? Yes ? No ? Airbag r /004? D Pedestrian ? MCC ? Assault p S ? Fall ? Burn ? Electrical ? GSW ? Stab ? Other Field Resuscitation Airway IV's R 0 S Field Vitals. P BP RR' Immobilization. Fluid Amnesia? ? Yes ? No Loss of Consciousness? ? Yes ? No Field Notes A Primary Survey Trauma History Airway (Patent ? Obstructed hitubated ? 0T ? NT ? Trach Allergies Breatlimp S n 3 Breath Sounds Meds Circulation P BP RR Sat Disability Alert OeVocal ? Painful ? Unresponsive PMH Exposure Procedures ? NG-Tube ? Urmary Catheter PSH ? A-line ? CVP(s) Chest tube ? right ? left Last Meal ? DPL Last Tetanus 04MA t/l Secondary Survey, 2nd Vitals Temp _ P BP _FIR _ 02 Sat _--, WT - ? HEENT Head Q t aw CwatAl Eyes , G Ears TM's Battle's F Face Maxilla Mandible Nose Denbba Mouth Dentures Neck Tenderness Crepitus Trachea ML >Acf Chest Wall Tenderne s Crepit us Lungs L A-. B ( ( } Sack Tenderness Crepitus 1 Heart Abdomen Distention BS Tenderness Rectal Tone Heme Prostate LLAQ PENIS. Stable X e, 5 Tenderness or LEGEND Vascular Exam RadiaQ!- Right/Left Femoral J-4- DP old- PT -1k 1 J L -laceration Cfx -closed fracture ' FX -open Resident Signature enovmr_ur . Title Dale Time a M /P m fracture Ab -abrasion C -contusion Ong - MR 611 Rev 5108 w_ ?W TRAUMA HISTORY AND PHYSICAL EXAMINATION copy - Traa ma senwes 1110 111 ICI IN 1111111 TRAUMA HISTORY AND PHYSICAL EXAMINATION LEGEND 1-laceration 2--fracture 3--.abrasion 4--contusion ri 07/17/2009 10:34 AM i t r I I 1 I t 11 ' NeurologrcalTxam Glasgow Coma Scale Trauma Score Cranial Nerves Spinal Cord In fury C None 2 Open to Pain SBP Resp Rate Motor 3 - Open to CommaMNoice 0-0 0-0 Propnoceptlon 1-7 t - Eye Opening 4 - Spordaneoes 1 - 1-9 1-049 T Verbal Response 2 - s36 2 - 5069 Sensory Pinprick 1-12 1-None 2 - InompreliereabldNoens to Pam 3 - 25-35 3-70-90 4'coniuse?dC nnsso?bhk Pain 4-10-24 4 >90 5- AlerMientedllmeracts GCS DTR's L 1-5 Motor Response 0 - 3-4 1- None 2 - Oecerebrate 1 -5-7 , 3 - Oecorbcate 2 - 8.10 4 - Withdraw 3.11-18 5 t.ocalues Pain 4-14-18 re t i 6 Obeys Total Total LaWStadies Eveieaied PT Troponln U/A PTT Myogloblri 7 BIII CPK r Drug Screen ALT - Amylase ; ABG ALP Ica ETOH ECG TEE BHCG. X-Rays CSR Pelvis CTScans Head Read. CSpine Lat Extremities Abdomen NWWAL AP Others Odontoid Angio T & L Spines WS Problem List Attending Note/Plan .//, INUA 494 de I r. _ _ .. _ Attending SignatureJOate/Time V MR 511 Rev 5108 Ong - Chart TRAUMA HISTORY AND PHYSICAL EXAMINATION `'y "a""u oarvicw r r-.r_.... r..._ 07/17/2009 10:34 AM PENNSTATE Milton S. Hershey Medical Center College of Medicine NAME; TRAUMA, 7505528 LID DEFLITCN CHRISTO MR, 7505528 IINNSS SELFIPAY00 LOC EMER OOSM 10505526 1ADN 46925 SEX ?t SELF PAY VISIT DATE 07111/2008 ?_-- 4WMXANEST Date Height y =` Time We] ht Consulted by Emergency Department Dr ee Sex History _Physical Exam Assessment & Plan CC: B l d General Appearance Vital S s Assessment: ASA PS ?- E e ted / nbelte ? MVC /' L ;R BP P l 135 I ? Fall u se njurt f MCC SO, too ' Temp 2.1 l u?-vt 1-- ? Other Glasgow Coma Scale = HP) ;n Atrw Jam` tact Ade uate Injuries Cervical Collar in lace place q 0 Marginal Level of Pain (I - 10) o ? Difficult Time of Incident Vent ation Mechanism of Injury HEENT ,I/Adequate spontaneous ? Loss of consciousness due ? Needs Mechanical Vent l Teeth <.l+'kRL1 C?rc tlon PM Hx- Airway Malampati Score L `Qaj tl Muumal Blood Loss E) Shock Grade l 2 3 4 ? History obtained from EMS Pupils: / rp S R ? L I <750 ? Allergies ize ( b mL, 15% volume React R L _ '' 2 = 750-1500mL, 15-30% volume 3 = 1500-2000mL, 30-40% volume Chest: PP0_t C,c?F A-W 4 = 2000-2500ml., 40-50% volume ? Drugs G? Clear to auscultation - h3/" Trachea midline ? Labored breathing ? Anesthetic Plan: JC Discussed car a with trauma team ? Medical ? leadei ? Reviewed x-rays ? Surgical Heart Regular rate & rhythm ? Reviewed laboratory results ? urmur i ? Meets ctiteria for immediate P1 Pulses full Induction & Incubation ROS ? ? Accom an to CT Scan - ? Diabetes ? p y ? Accompany to OR ? Chest Pain Abdomen- ? Analgesia/Sedation ? Short of Breath Benign ? Other. ? Tender ? Monitoring ? Non-Contributing ? Bowel sounds ? All other systems reviewed-negative ? ? Other 0 SHx Y co ies Ext! _ st No furthei intervention .A Y CE 17 No apparent fa ? GU Fatytj Htstoi y: ? Foley Non-Contributing ? 1T l saw and evaluated the patient and agree with CODE- 99241 99242 99243 99144 99245 ' the resident s plan as written ?? /7 1 I O t personalty performed the evaluation. Attending Signature # G 6? ? { ?.? Resident/CRNA Signature # yO ? MR 1153 Rev 10107 Page 1 of 1 ---• - • •-- -- •- - -- .- TRAUMA ANF_STHFRIA r.nNCI11 T 0711712009 10:34 AM PENNSTATE HERSHEY Milton S. Hershey VP Medical Center -a PROGRESS-REPORT 111 N1? 111I1till 11111INI NAME. BILZ JAMES JR 7 M R# 5528 . SO 00SM. 10505528 M0 OILLON PETER W UDC 26150 008 02/0412005 VISIT DATE 08/28/2008 LOC 2MOR 2311-1 SEX M INSURANCE STANDARD 1111011111 i MR 6 Rev 5/66 Page 1 of 2 1 INVNN PROGRESS REPORT 07117/2009 10:34 AM MR 6 Rev 5/06 Page 2 of 2 PROGRESS REPORT PROGRESS REPC ue„Q.?« IIIIIIIINIIIINIINI 07/1712009 10:34 AM .ED Summary BILZ JR, JAMES - 7505528 t Final Report' * Final Report * ED SUMMARY Name: BILZ JR, JAMES HMC Number: 7505528 DOB: 02104/2005 Date of Service: 06/28/2009 CHIEF COMPLAINT Head injury HISTORY OF THE PRESENT ILLNESS The patient was a four-year-old child who was apparently in the back seat There was a history of the father literally releasing the seatbelt and the car went off the road and the child was thrown into the front seat There was no reported loss of consciousness The patient was taken to the Hanover Hospital, where a CT scan showed a possible skull fracture The patient as transferred as a stable level 2 trauma response The child complains of a headache The child denies any neck pain or back pain The child denies any chest pain The child complains of pain about the umbilicus in layman's terms The child denies any pain in his arms or legs I was present with the entire Trauma Team upon his arrival PAST MEDICAL HISTORY Negative for any known chronic illnesses as per the transferring medics CURRENT MEDS None DRUG ALLERGIES None known SOCIAL HISTORY The child lives wnth the family REVIEW OF SYSTEMS See the HPI The rest of the 10+ review of systems is negative or unobtainable PHYSICAL EXAM The patient had a cling dressing on the forehead It was gently removed There was at least a 5-cm laceration on the forehead There was no obvious hemotympanum of either eardrum The child has no obvious Battle signs or raccoon eyes The pupils are 3-4 mm and equal The entire face was nontender The nostrils were patent and dry The pharynx is pink and moist with saliva His head and neck were kept fixated, and the cervical spine showed no obvious palpable stepoff or tenderness The collar was replaced The trachea is midlme The neck veins are flat The chest wall is nontender bilaterally The lungs have equal, bilateral breath sounds, and no audible wheezes, rales, nor rhonchi Heart exam revealed a regular rate and rhythm, with S1 and S2, and no audible murmurs, gallops, clicks, nor rubs that are obvious The abdomen is soft and nontender in all four quadrants, with no obvious rebound, guarding, or palpable mass effect Bowel sounds are active The only exception is minimal subjective pain about the umbilicus which is equivocal Bowel sounds are active Percussion does not worsen the pain Pelvis is stable, nontender bilaterally All four extremities showed no obvious palpable deformities When the patient was log rolled, he had no obvious palpable tenderness or stepoff of his thoracic or lumbar spine His gaze is conjugate His speech is age appropriate The tongue was midline Handgrip ?s full Printed by Rhoads, Debra Page 1 of 2 Printed on 7/15/200913 45 (Continued) 07/1712009 10:34 AM Eta Summary * Final Report * BILZ JR, JAMES - 7505528 strength bilaterally He can flex and extend both ankles without difficulty Light touch was intact in all four distal limbs MEDICAL DECISION MAKING In light of the mechanism, the plan was to immediately evaluate him with a chest x-ray and pelvic films They showed no obvious acute abnormality CT scan was repeated of the brain which revealed a large, soft tissue laceration of the forehead, but no obvious skull fracture or brain abnormality in light of his vague equivocal pernumbilical pain, CT scan of the abdomen and pelvis was done, but no obvious acute traumatic etiology was found He was admitted by Trauma Services for further care and treatment of his forehead laceration 773285 Signature Line Electronic Signature on File Electronically Reviewed/Signed by Kimak, Mark J, MDAuthor Signature Dt/Tm 30 06 2009 06 18 PM MJK lTLD DD 06128109 DT 06/29109 0711 AM Result Type ED Summary Date of Service June 28, 2009 00 00 Authorization Status Final Author or import Date Kimak, Mark J on June 28, 2009 07 11 Verified By Kimak, Mark J on June 30, 20091818 Encounter info 10505528, HMC, Inpatient, 6128!2009 - 6/30/2009 Printed by Rhoads, Debra Page 2 of 2 Printed on 7115/200913 45 (End of Report) 0711712009 10:35 AM .Operative Report * Final Report' * Final Report * OPERATIVE REPORT Name: BiLZ JR, JAMES HMC Number: 7505528 DOB: 02/0412005 Date of Service: 06130/2009 SURGEON Dr Kurds Moyer ASSISTANT(s) Dr John Mesa PREOPERATIVE DIAGNOSIS Left forehead laceration complex 8 cm POSTOPERATIVE DIAGNOSIS Same OPERATION PERFORMED Complex laceration repair to left forehead ANESTHESIA- General endotracheal ESTIMATED BLOOD LOSS Minima COMPLICATIONS None DRAINS None SPECIMENS None BILZ JR, JAMES - 7505528 HISTORY The patient is a 4-year-old male unrestrained passenger in an automobile who suffered a forehead laceration after a motor vehicle collision The patient otherwise had no other associated injuries The patient was brought to the operating room because conscious sedation was unable to be given in the Trauma Bay and/or in the Emergency Room The only anesthesia that could be administered, according to the anesthesiologist, was in the operating room so therefore, I am in the operating room repairing this today OPERATION After signed informed consent with the patient's father, the patient was properly identified and taken to the operating room The patient was placed supine on the operating room table. After satisfactory general endotracheal anesthesia was administered, the patient was prepped and draped in sterile fashion The wound was copiously irrigated The wound was then d6brided of all devitalized tissue The wound went through the frontalis to the skull itself with some loss at the pencranium The wound was closed in layers with Vicryl through the frontalis muscle itself The deep dermis was approximated with another Vicryl suture The skin was approximated utilizing a Prolene suture in running fashion The patient tolerated the procedure well There were no complications during the Printed by Rhoads, Debra Page 1 of 2 Printed on 7115/2009 13 45 (Continued) 0711712009 10:35 AM Operative Report * Final Report * BILZ JR, JAMES - 7505528 course of the procedure The patient was extubated and taken to the recovery room in stable condition I was present and scrubbed for the entire procedure #776647 Signature Line Electronic Signature on File Electronically Reviewed/Signed by: Moyer, Kurtis E, MDAuthor Signature Dt/Tm: 03.07 2009 01.31 PM KEM /JJG DD 06/30/09 DT 06130/09 02.06 PM Result Type Operative Report Date of Service June 28, 200914 33 Authorization Status Final Subject Operative Report Author or Import Date Moyer, Kurtrs. E on June 30, 200914 06 Venfied By Moyer, Kurtis E on July 03, 200913 31 Encounter info 10505528, HMC, inpatient, 6128/2009 - 6130/2009 Printed by Rhoads, Debra Page 2 of 2 Printed on 7115/200913 45 (End of Report) 0711712009 10:35 AM .D/C Summary * Final Report * * Final Report * DISCHARGE SUMMARY Name: BILZ JR, JAMES HMC Number: 7505528 DOB: 02/04/2005 Date of Admission: 0612812009 Date of Discharge: 06/30/2009 Physician: Dillon, Peter W Service: Peds Surgery Discharge Diagnosis' Multiple trauma/ MVC BILZ JR, JAMES - 7505528 Other Diagnoses: Complex forehead laceration Surgical Procedures: 6/28109 Incisional debridement and irrigation of forehead laceration, plus complex closure of forehead traumatic laceration, approx 8 cm Vaccinations Received This HospNal Stay: No vaccinations were given this hospital stay Brief History of Present Illness: CHIEF COMPLAINT Head injury HISTORY OF THE PRESENT ILLNESS The patient was a four-year-old child who was apparently in the back seat There was a history of the father literally releasing the seatbelt and the car went off the road and the child was thrown into the front seat There was no reported loss of consciousness The patient was taken to the Hanover Hospital, where a CT scan showed a possible skull fracture The patient as transferred as a stable level 2 trauma response The child complains of a headache The child denies any neck pain or back pain The child denies any chest pain The child complains of pain about the umbiicus in layman's terms The child denies any pain in his arms or legs I was present with the entire Trauma Team upon his arrival PHYSICAL EXAM The patient had a cling dressing on the forehead It was gently removed There was at least a 5-cm laceration on the forehead There was no obvious hemotympanum of either eardrum The child has no obvious Battle signs or raccoon eyes The pupils are 3-4 mm and equal The entire face was nontender The nostrils were patent and dry The pharynx is pink and moist with saliva His head and neck were kept fixated, and the cervical spine showed no obvious palpable stepoff or tenderness The collar was replaced The trachea is midline The neck veins are flat The chest wall is nontender bilaterally The lungs have equal, bilateral breath sounds, and no audible wheezes, rales, nor rhonchi Heart exam revealed a regular rate and rhythm, with S1 and S2, and no audible murmurs, gallops, clicks, nor rubs that are obvious The abdomen is soft and nontender in all four quadrants, with no obvious rebound, guarding, or palpable mass effect Bowel sounds are active The only exception is minimal subjective pain about the umbilicus which is equivocal Bowel sounds are active Percussion Printed by Rhoads, Debra Page 1 of 4 Printed on 7/15/200913 46 (Continued) 0711712009 10:35 AM .D/C Summary • Final Report * BILZ JR, JAMES - 7505528 does not worsen the pain Pelvis is stable, nontender bilaterally AN four extremities showed no obvious palpable deformities When the patient was log rotted, he had no obvious palpable tenderness or stepoff of his thoracic or lumbar spine His gaze is conjugate His speech is age appropriate The tongue was midline Handgrip is full strength bilaterally He can flex and extend both ankles without difficulty Light touch was intact in all four distal limbs MEDICAL DECISION MAKING in light of the mechanism, the plan was to immediately evaluate him with a chest x-ray and pelvic films They showed no obvious acute abnormality CT scan was repeated of the brain which revealed a large, soft tissue laceration of the forehead, but no obvious skull fracture or brain abnormality In light of his vague equivocal penumbOical pain, CT scan of the abdomen and pelvis was done, but no obvious acute traumatic etiology was found He was admitted by Trauma Services for further care and treatment of his forehead laceration Hospital Course: His complex forehead laceration was repaired per PRS in the OR early in the am of 6128109 He returned to the 7th floor post op in stable condition His head of bed was elevated and he was to remain on Ancef for 2 days Topical bacitracin was applied to the area His C-spine was cleared He was started on clear liquids and advanced as tolerated Post op day one he continued his Ancef He was tolerating a regular diet He pulled his IV out in the early evening of post op day one An IV was not restarted after several tries He was placed on po antibiotics The family had no transportation as their vehicle was involved in the crash There was also not a car seat for James Social services had arranged for this on 6130/09 so he remained another day until this all could be arranged Exam on Discharge: Repaired laceration intact Neurologically appropriate CTA RRR Abdomen soft Pain controlled with Tylenol Tolerating a diet Afebrile with stable vital signs Care Instructions: laceration care - wash with soap and water and pat dry, apply bacitracin twice/day avoid sun exposure, as may burn very easily See the head injury care instructions The key to getting better after a head injury is to rest when tired allow for rest breaks during the day, and keep an early bedtime Children's Tylenol as needed for pain Follow directions on label Diet Guidelines: regular diet encourage plenty of liquids Activity Guidelines- avoid activities that may lead to falls or impact, including riding things with wheels, playground play, amusement rides, jumping or climbing, sports - for the next 2 weeks Call your doctor if: Please call 717-531-8521 (operator -ask for the pediatric surgery resident on-call) fever greater than 101F, Printed by Rhoads, Debra Page 2 of 4 Printed on 7/1 5/2009 13 46 (Continued) 07/17/2009 10:35 AM .D/C Summary J BILZ JR, JAMES - 7505528 * Final Report * increased severe pain, increased redness/drainage from wounds for routine questions during the weekdays, please call the pediatric surgery office at 717-531-8342 Other Instructions: Penn State Children's Hospital injury Prevention Tips . Prevent Falls For Life Infants and Children Keep furniture (cribs/tables) away from windows Keep windows locked when closed Remember that stairs and windows are not safe play areas Use safety gates at the top and bottom of stairs Make sure kids wear helmets every bme they nde anything with wheels Strap children into highchairs, swings, changing tables, strollers, etc Supervise your children at all times Follow up with Plastic Surgery on July 3 for suture removal If you don't hear from them please call the operator and ask to be connected to the office of Plastic Surgery so you can check on your appointment The operator number is 717 531-8521 Follow-Up Appointments. Scheduled Penn State - Hershey Appointments Within the Next 90 Days. 1. Follow-Up with PRS, UPC Nurse at Plastic Surgery - Univ Phys Ctr Suite 3200 on 07/07/2009 at 12 00 pm 776780 Signature Line Electronic Signature on File CC Stein, Thomas W, MD 1230 High Street Hanover PA 17331 Electronically Reviewed/Signed by Simmons, Lynn G, MSN, CRNPAuthor Signature Dt/Tm Printed by Rhoads, Debra Page 3 of 4 Printed on 7/15/2009 13 46 (Continued) PENNSTATE HERSHEY Milton S. Hershey Medical Center August 12, 2010 Arthur Reeher Company, Inc. 5721 Jonestown Road PO Box 6215 Harrisburg, PA 17112 RE: Patient James M. Bilz Jr. D.O.B. 02/04/05 Acct #7505528 Dear Arthur Reeher Company, Inc.: Kurtis E. Moyer, M.D. Assistant Professor of Plastic Surgery Department of Surgery, Division of Plastic Surgery This letter is in response to your request on June 30, 2010. I saw James M. Bilz Jr. for his one year post accident evaluation on August 2, 2010 in my office at the Hershey Medical Center. He is a 5- year-old who a year ago had a traumatic laceration to forehead after motor vehicle accident. I repaired this in the OR. The scar is well approximated. He has a good appearance. The eschar is thin, hypopigmented but has good contour to the forehead. The eyebrows are symmetrical in height. He does have frontalis function on the right. Overall, I am discharging him from my care. He has an excellent appearance. I stressed massaging and sunscreen. Parents will call with questions or concerns in the interim. Kurtis E. Moyer M.D. Assistant Professor of Plastic Surgery Department of Surgery, Division of Plastic Surgery Penn State Milton S. Hershey Medical Center • Penn State College of Medicine Department of Surgery, Division of Plastic Surgery, Mail Code H071, 500 University Drive, P.O. Box 850, Hershey, PA 17033-0850 Tel: 717-531-8371 • Fax: 717-531-4339 • www.pennstatebershey.org/web/Plastiesurgery M An Equal Opportunity University r? < EXHIBIT w Q r i'Ils)taa=' z4 !I; `C ?4 A P d, 3 'e1 f, Of ppj A, ?l 4r f D ,t t t: r `...... Photo- to k F "MI ? f?ii11+ , s l 1 i'l ? ,aa1• is DEC 0 2 2010 9 2 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ANNA M. BILZ, GUARDIAN OF JAMES M. BILZ, JR., a minor, Plaintiff VS. JAMES M. BILZ, SR., Defendant DOCKET NO. 10-7304 CIVIL ACTION ORDER AND NOW, this 3 r day of December 2010, based upon the Petition for Approval of Minor's Settlement, the Court approves the settlement in the amount of $29,128.00. The $5,000.00 that has not been paid to satisfy medical expenses for the minor Plaintiff, is to be placed in a restricted bank account insured by the federal government and marked "not to be withdrawn until James M. Bilz, Jr., reaches 18 years old or upon Order of this Court." Distribution: a M. Bilz, 574 Crossroad School Road, Carlisle, PA 17015 homas E. Brenner, Esquire, PO Box 1268, Harrisburg, PA 17108 ? tFES rn,X1--t LEaL !e2 3/Id n G -ra -? m co r- cn z o -C. N O r? r-n C1 W N N N CD xrn rn? ?rn -AC) =-n o-n zF om 199325.1 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ANNA M. BILZ, GUARDIAN OF JAMES M. BILZ, JR., a minor, DOCKET NO. 10-7304 Plaintiff VS. JAMES M. BILZ, SR., CIVIL ACTION Defendant a PRAECIPE TO DISCONTINUE MW z? = -OM r- r.0 MCI TO THE PROTHONOTARY: ?2 °a c-? z Please mark this action discontinued. fix- N Respectfully submitted, CD Cn By: Anna M. Bilz, Guardian of James M. Bilz, Jr., a minor Pro Se Plaintiff Dated: -3 -/S - l 204044.1