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HomeMy WebLinkAbout13-1701 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTYj PENNSYLVANIA C-3 IN THE INTEREST OF: NO. ALEX NICHOLS, a minor child. C194 PETITION FOR APPROVAL OF MINOR'S COMPROMISE SETTLEMENT TO THE HONORABLE, THE JUDGES OF THE SAID COURT: The Petition of Eleanoria Alfonso and Patrick Nichols, as the parents and/or natural guardians of Alex Nichols, a minor child,respectfully represents: 1. The minor is Alex Nicols, who resides at 234 Cape May in Bayville,New Jersey. Alex Nichols is 16 years of age and has a date of birth of February 5, 1996. He currently resides with his father, Patrick Nichols. At the time of the accident, he resided with his mother, Eleanoria Alfonso at 107 E. Keller Street in Mechanicsburg, Pennsylvania. 2. Eleanoria Alfonso is the parent and natural guardian of Alex Nichols. She resides at 389 N. 19th Street in Camp Hill, Pennsylvania. 3. Patrick Nichols is the parent and natural guardian of Alex Nichols. He resides at 234 Cape May in Bayville,New Jersey. 4. Written approval of the settlement by Alex Nichols is required as he is over the age of sixteen years. 5. No guardian has been appointed for Alex Nichols by the Orphans Court of this or by any Court in any other jurisdiction. 6. On February 18, 2011, Alex Nichols was riding his bicycle at the intersection of York Street and Coover Street in Mechanicsburg Borough at around 7:45 PM. Alex Nichols P—of 88s06 was traveling north on the sidewalk of York Street and was attempting to ride his bicycle across the intersection when Jessica Faucon who was traveling south on York Street was attempting to make a left turn onto Coover Street. Ms. Faucon struck Mr.Nichols in the intersection. A true and correct copy of the Commonwealth of Pennsylvania Police Crash Report is attached and incorporated by reference as if fully set forth herein as Exhibit A. 7. Alex Nichols was immediately transported to the Milton Hershey Medical Center in the Level 2 Pediatric Trauma Unit. He was worked up in the Orthopedic Department and was taken into the operative room where he had an IM nailing of his tibia as well as formal fasciotomies done due to concern of compartment syndrome. He had to have surgery again on February 21 for repeat I&D and possible closure. The tissue looked pink and healthy and there was no necrotic tissue found. He recovered unremarkably. 8. On February 7, 2012,Mr. Nichols was seen at the Hershey Medical Center for follow up one year post IM nail for a left tib-fib fracture with four fasciotomles as well as a skin graft. Mr.Nichols had resumed all normal activities, had no residual effects and had no knee and ankle pain. He had resumed his normal activities without any limitations. He had full flexion and full extension. Mr. Nichols' skin graft had taken 100% and he was distally neurovascularly intact. His x-rays showed excellent union of the left tibia with his tibial nail in good position. Dr. Boateng stated that, "He has gone on to about maximum medical improvement. He has no limitations in terms of his weightbearing. He has no limitations in his activities." 9. The records from Hershey Medical Center are attached hereto marked as Exhibit B and incorporated by reference as if fully set forth herein. 2 10. Attached to this Petition and incorporated by reference are the Certifications of Eleanoria Alfonso and Patrick Nichols that their son has improved and that they believe that the settlement that has been reached in this case is fair and reasonable and adequately compensates their son for his injuries. 11. Joseph R. D'Annunzio, Esquire, is the managing attorney for the GEICO Staff Counsel Office in Harrisburg, Pennsylvania. He has prepared this Petition on behalf of the parents and natural guardians of Alex Nichols. He is not charging a fee for his services and the cost of filing is being paid by GEICO General Insurance Company. 12. No additional counsel fees will be paid as a result of the representation of any party in this case. 13. Eleanoria Alfonso,the mother of Alex Nichols and Patrick Nichols,the father of Alex Nichols have reached a settlement with GEICO General Insurance Company. The terms of the settlement are that GEICO will pay the sum of$15,000.00 in full and final settlement of any and all claims for non-economic loss that can be made by Alex Nichols. Attached as Exhibit C and incorporated by reference is the Certification of Policy Limits showing that the GEICO policy had liability insurance limits of$15,000.00 per person and$30,000.00 per occurrence. WHEREFORE, Eleanoria Alfonso and Patrick Nichols, as parents and/or natural guardians of Alex Nichols, a minor child respectfully requests that this Honorable Court approve the settlement that was reached in this case and direct that they may sign on behalf of their son a General Release in Full of All Claims. Further, your petitioner requests that this Honorable Court direct distribution of the settlement funds pursuant to the attached Order of distribution. 3 Respectfully Submitted: Date: ��-� � 'ZP/3 Ai /Lt t}`A—V-� Joseph R. D'Annunzio Esquire Attorney for GEICO General Identification No. 23384 4309 Linglestown Road, Suite 211 Harrisburg, PA 17112 (717) 901-5002 Fax: (717) 901-5012 4 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN THE INTEREST OF: N0. ALEX NICHOLS, a minor child. CERTIFICATION I, Patrick Nichols, am the parent and natural guardian of Alex Nichols, a minor child. Alex Nichols lives with me at 234 Cape May in Bayville,New Jersey although at the time of the accident he lived with his mother, Eleanoria Alfonso at 107 E. Keller Street in Mechanicsburg, Cumberland County, Pennsylvania. I have seen Alex Nichols and I believe that he has substantially recovered from the injuries he sustained in the motor vehicle accident of February 18, 2011. 1 understand that GEICO General Insurance Company has offered to pay the sum of fifteen thousand dollars ($15,000) in liability benefits as a settlement of any claims that Alex Nichols can make for the injuries that he sustained in this accident. I understand that court approval of any settlement must be obtained before I can sign a general release on behalf of Alex Nichols. I understand that if the court approves this settlement, I will sign a general release on behalf of Alex Nichols and that my child can no longer bring any claim for the injuries that were sustained in this accident. I ask that the court approve the settlement that has been reached. I verify that the statements contained in the Petition and in the Certification are true and correct to the best of my knowledge, information, and belief. I understand that false statements made herein are made subject to the penalties of 18 Pa. C.S.A. Section 4904, relating to unsworn falsification to authorities. Date: Patrick Nichols I, Alex Nichols, am over the age of sixteen(16), and have read and understand the Petition for Minor's Compromise Settlement. I request that the Court approve this settlement. a Date: Alex YWchols IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN THE INTEREST OF: NO. ALEX NICHOLS,a minor child CERTIFICATION I,Eleanoria Alfonso, am the parent and natural guardian of Alex Nichols,a minor child. Alex Nichols lives with his father at 234 Cape May in Bayville,New Jersey although at the time of the accident he lived with me at 3 East Factory Street in Mechanicsburg, Cumberland County, Pennsylvania. I have seen Alex Nichols and I believe that he has substantially recovered from the injuries he sustained in the motor vehicle accident of February 18, 2011. I understand that GEICO General Insurance Company has offered to pay the sum of fifteen thousand dollars ($15,000)in liability benefits as a settlement of any claims that Alex Nichols can make for the injuries that he sustained in this accident. I understand that court approval of any settlement must be obtained before I can sign a general release on behalf of Alex Nichols. I understand that if the court approves this settlement, I will sign a general release on behalf of Alex Nichols and that my child can no longer bring any claim for the injuries that were sustained in this accident. I ask that the court approve the settlement that has been reached. I verify that the statements contained in the Petition and in the Certification are true and correct to the best of my knowledge, information, and belief. I understand that false statements 1 made herein are made subject to the penalties of 18 Pa. C.S.A. Section 4904, relating to unsworn falsification to authorities. Date: -31z, // Eleanori onso 2 EXHIBIT A Print CAS ADLI00037 Page 1 of 7 k, - - POLICE CRASH REPORTING FORM�, R PENNSYLVANIA P Crash Number Case Clod Reportable Crash R x,500 1 a Ygs 0 No 0 Yes 0 No i i AdOd0037 Incident Number Polloe Agency Patrol zone 2011020392 21404 p efty Try Precinct !nv a#wn Date%W-DD-YYYY) Mechanicsburg Borough 02 - 18 - 20l i I 3 �t941 Tune(� 1943 ��� K VINCENT 2217 umbe!r, ' Revievrer Bade Number Awroval Date (MM-DD-YYYY) TIMOTHY E DYER 2212 d2 25 2011 Coon Coun No" Municipality Municipality Name CRY pf Ntreek q 21 Cumberland 404 echanicsburg Borough O sun O Thu r Gash Rate(MM-DD-YYYY) Crash Tune(mil} No of Units People In ured Killed' *If>00 Q Man !Fri ir- ED-- 18 -L2011 1941 2 Z 1 0 Form O Wed 0 Link Form F Woriczone ©Yes N Bus Q Yes e Q Yes l TQ Yes No 29 ! Rela� Rimed — section hIrtuectlan r 4 Way Intersection Q "Y"Intersection a Muti-leg Q pN Rp Railroad Crossing GoDa 00 Midblock 0 •T-Intersecton O"affic C � O On Ramp 0 Crossover O Other Q 8 About lntefSeCttan *aee Over Route Number Segment(Optional) Travel lanes Speed Limit O North House Number (if applicable) 2013 02 25 !p- 0 South L __ 4 Street Name Street Ending O East For Mid-Work crashes only.use 6 YORK ST, O West postal H a Number and make sure O Unknown street G Fll�ed�n"rF us�tha option e © rnQ Turnpike 0 SpulkE i2tO County 0 l Q e veo No pike) (EatWest State Road Street Road Unknown $ Route Number Segment Travel � Speed 0 Nosh 02 25 o C7 South a. a Street Name Street Ending 0 W COOVER ST o` 0 Unknown O Interstate 0 Turnpike Q Tumptke 0 State Q tonnty local Road Private Other! (Not Turnpike) (EastANest) Spur Highway Road or Street Q Road d Unknown Intersecting Fit Num Or Mile post-�f Or Selimat Marker a Feet E „Q South rEnter c Or! street flame St Erin' 7 a fast Or Miles e Q West rInntter eectiin�g�-R—i—Nu-m Orr Mile Pe Po-stt I—^1 Or Se ment Mad c A ) ( ( l•` ' p O hkxth Distance From Crash t...7 Scene to landmark t Or t rk"ecll Street Name St Endin 3 0 South (�Crash between O East Landmark l and Q West Landmark 21 Degrees Minutes Seconds Minutes Seconds T � Latitude:� �; Longitude: — � Traffic Qnrml Device 0 Yield Sign 0 Police officer or S e ,e 0 Not Applicable Q Traffic Signal C?Active RR Crossing 0 OtherrTT TCD 0 No Controls (� 1Drnevice Functioning C3 Reemmpti�ve. ¢' Flashing raffic Controls Improperly Signal Q Signal g {�Stop Sign Passive RA Device Not Device Functioning 0 Unknown d Crossing Controls 0 Unknown O Functioning Q Properly e 0 s t {tf htot Appfib",shgs test of the tare Obsure sect ) O North C? East Q North and South AN {�Not Applicable O Partially 0 Fully Q Unknown O South O West Q East and West (N,S,E,W) e Zltm Yes • No 0 EEf6 2r�tre l aced Unknown 0 Q a 30 Min, U 30.60 Min. 0 1-3 hrs 0 3.6 hrs 0 6.9 hrs Q>9 hours 0 Unknown PENNOOT COPY h4://www.dot6.state.pa.us/crsapp/Printlmages/XmIFiles/20110207552011022513143114... 2/25/2011 Print CRS A0000037 Page 2 of 7 COMMONVEALYN OF PENNSYLVANIA POUM CMSH REPMING FORM Page. Crash Number AA 500 2 1'd-u*0D`I` 2 A0000037 o Motor vehicle in 0 Hit&Run Vehicle 0 illegally Parked 0 Legally Parked a Non-Moto(rzed CommercW vehicle Transport 10 Lin't Pedestrian on Skates,0 Disabled From 0 Yes a NO C:) Pedestrian 0 n Wheelchair,etc Previous Crash 0 Train 0 Phantom Vehicle (if'Pedestrr'&n•or'Pedestrian on Skates,in 4Vheekhalr,etc,CbTgee Form M,Section 28) --- Of Yes,Complete Form 0 Unit No First Name MI Date of Birth(MM-DD-" EED FALEX t__1 F0771 105 Delete? Last Name Telephone Number 0 1 NICHOLS 7175573732 Address I Cl!X./State Z* EEST FACTORY STREET MECHANICSBURG PA I 17055 J Driver license Number state Can Alcohol0rum Suvected Dd-1 Or IW-Stdf- a No 0 illegal Drugs 0 medication Apparently 0 Illegal Drug 0 Fatigue Normal Use 0 Medication CD Alcohol CD Alcohol and Drugs (D Unknown 0 MErd 0 Sick 0 Asleep (:D Unknown AkvW Test Tie 1 Pdroary Vehicle g2gk viobtion char*? 0 Test Not Given 0 Breath 0 Other 1 0 CD Blood 0 Urine o Test Unk nown if GENERAL LIGHTING REQUIREM 0 Yes No G�ven Akoliol Test Results CD Test Refused 0 Unkults nown ME Pft"— I=Driver Operated 3--Driver Fled Scene Res Test Given, Vehicle 4-Mit and Run 0 Contaminated Results El 2=Nor Driver 9--Unknown J. OwneNariver 00--Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Munidpal Police Veh 09=Federal Gov Veh 01--Private Vehicle Owned/ Owned1eased by Driver 05=PFNNDOT Vehicle 08--Other Municipal 98-Other J1 F� Leased by Driver 03--Rented Vehicle 06--Other State Gov Veh Govemment Vehicle 99=Unknown Same as Owner First Name Owner Last Name or Business Name(if Pedestrian,skip this Section) clover C) VLEX NICHOLS y I State I Zip Vehicle Make *Make Code No Entry Made VIN Model Year Vehicle Model (see overlay) I I I F- License Plate Rea.State Est Speed Vehide Towed Towed B I i = CD Yes 0 No Insurance Insurance Company Policy No -C:)Yes known ... I -- ti Fr�aiGno + T 1=Towing Pass.Veh 4-MobU~ular Home 7-SemkTraiter Tag No Tag Year Tag St Utxt No.Of 2=764ing Truck 5--Camper 8=Other Tra oing Units: 3=Towing Utility Trailer 6,-Full Trailer 9--Unknown ftectle"of 'Yehkte Position 01 'Movement 01 •See SOO-Cal tisane Overlay 12--Commercial Velikle COW Veh ido Type 05-4.arge Truck 20-Unicycle,Bicycle, FOO OS 06-Yellow 01,�Aulornobile 06-SUV Tricycle 00--Not Applicable P 0726ii,jer 02wotorcy& 07=Van --other Pedalcycle 08=Gold T-I F20 21 0}=F re Veh 13=Taxi I ' 03=8us 104nowiricibille 22=Horse&B 31=81ue 09=8rown 04--SmaH Truck 11 arm Equi U' 02aAmbulance 21=Tractor Trailer O;L.!p 2-3=Horse&Ride? D,,ce 02--Red 10=OrangLI (ff'02',Complete Form 12 QWP 24--Train 22=Twin Trailer 0-3-Whhe 11w1urple M,Sectroe;26) 13--ATV 25 08--fter Emergency Z3aTdple Trailer 04-Green 12-Other (If-20.,,-21- Complete 18--Other Type Spec Veh 9= Vehicle 31=Modified Veh 05--glad 99-Unknown All Af 27) te 19--Unk.Type So,Veh 99--Unknown 1 1=Pupl Transport 99-Unknown Initial h► NCt Point Indicator Gradient 3=Downhill Road AlAwment DO=Non-Collision 14-Undercarriage r-j--j OuNone 2=Furictonal 1 4=8ottom of Hill I=Straight 01-12=Cbd Points 15-Towed Unit Li l=Minor 34isabling �Level S-Top of HUI 2=Curved 13-Top 99=Unknown 2=Uphitl 9=Unknown 9=Unknown FORM#AA4W(12KM PE NNDOT COPY http://www.dot6.state,pa.us/ersapp/Printlmages/XmIFiles/20110207552011022513143114... 2/25/2011 Punt CkS A06''t0037 Page 3 o£7 (DUCE� �REPOMING FORM PENNSYLVANIA Page: Gash Number AA 5W 2 Pone Ilse 0Ny _ 3 A0000037 o - Motor Vehicle in O Hit&Run Vehicle I Parked O Lea Parked Q Non•Motorized Type Transport O Illegally Legally Commercial Velride 70 a unit Pedestrian on Skates, Disabled From O Yes 0 No Q Pedestrian Q Q Q Train Q phantom Vehicle in Wheeidlair,etc Prevous Crash (tf Ye;Complete Form CJ (ff'Pedestrian•or•Pedestrian on Skates;in Wheelchair,etc',Com fete Form M,Section 28 Unit No First Name MI Date of Birth(MM-DD-WM F02 JESSICA L F047 ll 1987 Delete? Last Name Tele hone Number Q FAUCON 7175577056 Address I Cltv I State ZI 60 PLEASANT VIEW DR MECHANICSBURG PA 17050 Driver License Number State Clas 28527501 A&2M2nras Suspected Driver or Pedestrian Phvskat Con&bw tt $ 0 No Q Illegal Drugs Q Medication Apparently Illegal Drug Q Alcohol Normal O Use O Fatigue Q Medication Q Alcohol and Drugs Q Unknown kad Been Drinkin 0 Sick Q Asleep Q Unknown Akoiwl Test Type p` a Test Not Given Q Breath 0 Other Primary Vehcle Coda Vro lotion Charged? z O Blood 0 Urine Q Unknown if O Yes Q No s Test Given i AkoW Test Results Q Test Refused Q Unknswn Dr6w Prrsencr T_Oriver Operated 3=Driver Fled Scene Q Test Given, Vehicle a=Hit and Run Contaminated Results 2=No Driver 9--Unknown Owner/Driver 00--Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Police Veh D9=Federal Gov Veh 01 01--Private Vehicle Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98--Other Leased by Driver 03=Rented Vehicle 06=0ther State Gov Veh Government Vehicle 99-Unknown Same as Owner first Name Owner Last Name or Business Name(if Pedestrian,skip this Section) Driver 0 �SS1CA FAUCON Address/ /State I Zip Vehlde Make •Make Code 160 PLEASANT VIEW DR MECHANICSBURG PA 17050 Ford 12 VIN Model Year Vehicle Model (see overlay) 1FAFP53U33G220946 2003 TAURUS Ucense Plate Reg.State Est.Speed Vehicle Towed Towed By FWF4279 FA 015 Q Yes a No Insurance Insurance Company Poly No o 0 Yes O No Q k p,^,r, GEICO 4077488395 T, F1,n tx a T 1=Towing Pass.Veh 4--Mobile/Modular Home 7=Semi-Trailer Tag No Tag Year Tag St o nn TNroal ro u 2=Towing Truck S=Camper 6=Other . Units 34owing Utility Trailer 6--Full Trailer g=tinkrWvm Direction of Vehide Position ITT— � e 01 Movement 12 Overlay Spedal Usarre VeNde Color Vehkfe Type 05=Large Truck 20=Unicyde,Bicycle, 00 12=Commerdal 05 06=YeRow, 01=Automobile 06=SUV Tricycle Passenger 07=Silver 0I 02=Matomyyde 07=Van 21=Other Pedakyde 00=Not Applicable Carrier 08--Gold L J 03=Bus 10--Snowmobile 22-Horse&Buggy 01=Fire Veh T3=Tazi 01=8lue 09--Brown 04=SmaN Truck 11=Farm Equip 23=Horse&Rider 02--Ambulance 21=Tractor Trailer 02=Red to=Orange (if'02,Complete Form 12=Construction Equip 24=Train 03=Police 22=Twin Trailer 03--White 11=Purple A(Section 26) 13--ATV 25=Trdfe 08=0ther Emergency 23=Triple Trailer 04=Green 12=Other p 18=Other T S V Vehicle 31=Modified Veh 05=Black yg=Unknrnm (1f'10'or It;Com Complete Type Spec eh 98:•Other 11=Pupil Transport 99=Unknown Form M,Section 27) 19=Unk.Type Spec Veh 99=Unknown lrrittal impact Paint Damage Indicator—7 Gradient 3=Downhill Road Alignment 1 1 00=Non-CoWsion 14=Undercarriage 0=Hone 2=Functional 0 4=Bottom of Hill ❑ I Straight 01-12-To Points 15=Towed Unit 1=Mirror 3=Disabling 3 1-Level 5-Top of Hill 1 2=Curved i3=Top 99=Unknown 9=Unknown 2--Uphill 9--Unknown 9-Unknown FOFM a AA300('2'0�) PENNDOT COPY http://www.dot6.state.pa.us/crsapp/PrintImages/XMIFiles/20110207552011022513143114... 2/25/2011 Print CRS A0000037 \ ' Page 4 of 7 COMMONWEALTH PENNSYLVANIA H PORTING FOItAfl POLICE Crash Number AA 500 3 A0000037 seat Position. Eection A l=Driver D 00=Not A Passenger/Occupant E 00=None Used/ Applicable G o- pl;mble I=Passenger 01=Driver-All Vehicles 01=Shoulder Belt Used 1=Not Ejected 7=Pedestnan 02=Front Seat Middle Position 02=tap Belt Used 2=Totally Ejected B--Other 03=Front Seat Right Side 03=Lap And Shoulder Belt Used 3=Partially Ejected 9=Unknown 04=Second Row•Left S'Ide Or 04=Chad Safety Seat Used 9-Unknown Motorcvde Passenger 0S=Motorcyde Helmet Used 05=Saco Row-Middle Position 06�i Helmet Used 06=Second Row-Right Side 10-Safety Belt Used Improperly H � ' Q F=Female 07=Tlwd Row Or Greater- 11=Child Safety Seat Used Improperly O=Not Ejected/Not Applicable a M=Male Left Side 12�lelrnet Used Improperly i=Thr�Side Door Opening U=Unknown 08=Third Row Or Greater- 90=Restraint Used.Type Unknown 2=through Side Window Middle Position 99-Unknown 3=Through Windshield 09=Third Row Or Greater- 4=Through Back Door e Right Side uiomenr Two: 5=Through Bade Door Tailgato Opening jn�r av t.�?rity 1 D-Sleeper Section of Truckcab F 00=None Used/Not Applicable 6=litrough Roof Opening(Sunroof/ C O=Not Injured 11�n Other Enclosed 01=Front Air Bag Deployed(For This Seat) Convertible Top Down) 1=Killed Passenger Or Cargo Area 02=Side Air Bag Deployed(For This Seat) 7=Through Roof Opening(Convertible 2=Major Injury 12=1n Open Area 03--Other Type Air Bag Deployed Top Up) a 3=Moderate (Back Of Pickup,Etc) 04=Multiple Air Bags�Ployed 9=Unknown Injury 13mirailing Unk 05=Motorcycle Eye Protection 4=Minor Injury 14-Ring On Vehicle Exterior. 06=Bicyclfst Wearing Eibow/Knee/Pe is 8=rnjury,Unk 15=Bus Passenger 10--.Air Bag Not Deployed,Switch On Extnica Severity 98=Odter f 1=Air Bag Not Deployed,Switch Off 0=Not Applicable 9=Unknown if 99=Unknown 12=Air Bag Not Deployed, 1=Not Extricated Injury Unk Switch Setting 2sExtricated By Mechanical Means 13=Air Bag Removed(Prior To Crash) 3=Freed By Non-Mechanical Means 19=Unknown N Air Bag Deployed 8-Other 99=Unknown 9=Unknown u ERAS Agency_ WEST SHORE EMS Medical Facility. HERSHEY MEDICAL CENTER Unit No Parson No Delete? Date of Birth (MM-DD-Y" A B C D E F G H 1 r, O1 O1 p 02 - OS - 1996 1� M�2� 0I 00 a0 aaa Name I Address/Phone ❑Orata NICHOLS,ALEX 3 EAST FACTORY STREET MECHANICSBURG PA 170 ERAS Transport •Yes O No Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A 8 C D E F G H I 02 01 p 04 1❑ FJ 0U O 1 03 99 1 I L L Name/Address 1 Phone ES Tra E)moto EMS r FAUCON,JESSICA L b0 PLEASANT VIEW DR MECHANICSBURG PA 1 O Yes a No Unit No Person No Date of Birth (MM_O()k_ Y) A nnB C D E F G H I 0 , E1C __ E1="=F ❑H ElName/Address/Phone Same as EARS Transport C-rotor O Yes C]No unit No Person No Delete? Date of Birth (MM-DD-YYYY) A nB C D E F G H I ~ = = O =-=-��❑FIEr- ❑� Name 1 Address/Phone Same as EMS Transport Operator O Yes C]No Unit No Person No Data of Birth (MM-DD-YYYY) A II—BB C D E F G H I Delete? ElName!Address!Phone Same as ERAS Transport Operator O Yes CD No Unit No Person No t> Date of Birth (MM-DD-YYYY) A 8 C D E F G H I C-D Q-=- ❑❑❑���❑0F] Name/Address/Phone ❑Same as EMS Transport Operator 0 Yes O No FORM•AA40o 02" PENNDOT COPY http://Www.dot6.state.pa.us/crsapp/Printlmages/XMIFiles/20110207552011022513143114... 2/25/2011 Print CAS'AO6000037 Page 5 of 7 4 JCOMMONWEALTH OF PENNSYLVANIA crash Dumber POKE CRASH REPORTING FORM AA 500 4 Page rolke use r>ny . 5 A0000037 Crash Aesaintian a Mon-Col5sion 2--Head On 4=Mgte f6-Sideswipe 8 tit PeQestriart "- ear End 3=Reflr fa Rear 5= ideswipe (OppOane Direction) a I€ (Backing) (san1 Direction) 7.Kd Fixed Object 9�oftr Unknown ion to Roadway a t_-0n Travel lanes WAdmn 5=Outside Tralfnway 7=601`13(Ramp Intersection) 2-Shoulder 4=Roadside 6=1n Parking Lane 9-Unknovm teu tlon !=O�l9t# 3=013rk-Street 5=Dawn -- Sb138t .0 Lig is 4=Dusk 6=Dark-I g x C°nditrons I 8orrse 3�41eet(Half) 5-Fog 7Sleet&Fog --9-Unknown _4=Snow 6=Rain✓k Fog 8--Other orfacti•Co0=0ry 2---acrid.Mud,Dirt. 4Sltsh mice Patches B--Other 1=Wet $=Snow Covered 5=Ice 7.W t�dig t O LlR AAost lull iqr Pao Numtsr Flerni �z tkarm Eventl 30=Fkt Fence Or Wall 01=Hit Unit'1— 3i=Hit Building o 02=Hit Unit 2 32diit Culvert 2 �" �`� 03=411 Unit 3 33=Hit Bridge Pier Or Abutment Q 04=Hf!Unit 4 34it Parapttt End 05�Ik Unit 5 35=Hi18ridge Rail ut 3 ❑ Q 06=!ik Other Traffic Unit 36=Hit Boulder Or Obstacle n 074ik Deer On Roadwaayy al 08dik Other Animal 37=Hit k7w Attentwor Order 09=Cd1ision With Other Non 38=Nit Fire Hydrant 4 = ❑ Fixed OB U 39=Hit Roadway Equipment Q 11=Struck Unit 1 40=Hk Mail Sax sa E 12=S"By Unit 2 41=Hit Traffic Island t3=Struck By Unit 3 42-Hit Snow Bank 8 Harm Event L!R AMst7 Uft Pole Number 14=5vA By Unit 4 43=Hit Temporary Contraction 15=Struck By Urtit 5 Barrier Unit No i 11 16=Struck By Oft Traffic Unit 48=Hk Other Fixed Object 21-Hit Tree Or Shrubbery 49=Hk Unknown Fixed Object W 02 22=Hit Embankment 50=0verturn/Roll Over 2 ❑ Q 23=+ik(17 Pole 5}=Struck By Thrown Or Falling (----� 24--Hit S=Hit Guarf fd Rail 52=Po Holes Or Other Events. 3 ( f ❑ Q 26-Hit Guard Rail End Pavement irregularities Events in t__� 27=Hit Curb 53=lackniie SeOrderiaa! 28=Hit Concrete Or 54-Fire In Vehicle Order 4 ❑ Q 29=Hrt�Dit'cis naI Barrier 59--Other Hon.Collision 99=Unknown Harmful Event Fast Unit No Harm Event MPost Unit No Harm Event &iverAction D 17--Care Or illegal » i�imful �rndul tsh 01 U2rrrt 02 11 OOto Contnbuting Acton Sacking On Roadway I IL t�s . 014river Was Distracted 18�riving On The Wrong c,�MWi w.Wwm iWo m n+eePk� 02-Driving Using Hand Held Phone Side Of Road 034riving Using-Hands Free Phone 1 g-hWkirg Improper Envrrroiimantal/Roadte2 04=Making IkOal U-Turn Entrance To High potanWl Factors(1JR} t 00 2 I I 3 �° operKareless Turning 20=Making Improper EExx t llL ��JJJ 06-Turning From Wrong Lane From Hi hw 00=None if=A;lpery Road Conditions(ke/5now) 07=Proceedinng Wi0 21-CarefessgParkin;&nparking DI-Windy Condkiorts 12= rice On Roadway Clearance After Stop 22=OvenUrider 02=Sudden Weather Conditions 13=Potholes 08=Running Stop.Sign Compensation At Curve 03�ther Weather Conditions 14=Brdren Or Cracked Pavement 09=Running Red Ught 2 ��� 04--Deer In Roadway 15=TCD Obstructed 10-FaPure To d To y 0:=Obstacle On Roadway 16=50ft Shoulder Or Shoulder Dr Off Other Traffe ontrol Device 2 r°°Fast For r ondiS 06=0ther Animal In Roadwa Drop . 11=Tadgatir� 25ailure 7o Maintain proper Speed to 07=GJare Y 28=Other Roadway Factor 12=Sudden Slowing21`n pmg 26--Driver Fleeing Mice(Pol Chase) s 08=Wore Zone Related 29=Otfuer Emarnnmental Factor 13=1Uegally Stopped OnpRpad 27= Pe"enced e 99=Unknown 14-Careless Passing Or lane Z8 Flb re TO Use Specialized Equip EPbssibfe Vehicle Failurrs M 12=Wipers t Sing In No Pacing Zone 98-Other Improper Driving ceActions 00=None 06 Exhaust 13�riverDeatingtCod,Etc 1f>=0r ir;A,.Wrong Way On 99=Unknown 01=Tires 07--HeadG hts 1 Odors Hood,Etc 1-Way Street 02=8rake System 084ignal tights 15=Traifer Hitch 03--Steering System 09 r Ughts 16--Wheek Unit Q 1 1 �Q 2= 3 =.4= 9 04=5uspertsion 10=Hom 17--Airbags No OS--Power Train 11=Mirrors 18-Trailer Overloaded 0--Imp oiler Tows Nthth 02 t 00 Ur'h mailer tread 1L�rJJ vo No 1 t 07 2 20--Improper Towing 21=Obstructed Windshield ppdnAction 0vi No it 02 1 00 2 99-Unknown 03=Working OD=None 04-Pushing Vehicle 01=Entering Or Crossing At 05-Approaching Or Leaving Vehice LD ine Specified Location D6=Working On Vehicle F Unit No Factor Code 02=Walki ,Runni 1`n, 07=Starrdin i'rarm mn on ni n9.m94 9 9 D p a 1 Q7 Or Plapng 998=Utiilcnown EIR Q Q ff E/R is the Prime Factor Unit No U I Unit No U2 7yPe leave Unit No Wank PEivNooT copy http://VAM.dot6.state.pa.us/ersapp/PrintImages/XMIFiles/20110207552011022513143114... 2/25/2011 Print CRS A0000037 ` Page 6 of 7 JCOMMONWEALTH PENNSYLVANIA POLICE CRASH REPORTING FORM Page trash Number AA 500 5 Wa use ony A0000037 ---i— _......i..........7 ...-. . - i� I i Witness Name Address Phone t SCOTT KEEFER 1412 SOUTH MARKET STREET MECHANICSBUR 7176917232 2 KEN&SHARI MCGRAW 1914 SHEFFIELD AVE MECHANICSBURG PA 1 7179184902 Narrative and addidonal witnesses: Accident Investigation Notification Issued7 Q Property Damage O Unit one(bike)was traveling North on South York Street. Unit two was traveling South on South York Street. Unit two began to turn onto West Coover Street when she was struck by unit one. The bike rider flipped over the car and landed in the street. The bike ended up laying on the sidewalk. Fire company and EMS arrived. EMS transported bike rider Alex Nichots to Hershey Medical Center. The bike is black in color. The bike does not have a head light or rear light. The bike also does not have any reflectors on it. The bike rider was not wearing a helmet. 0 Unit two driver stated she never saw the bike until it struck her car, a x 0 C e w w O y� wr+ra a uNSOOp.� PENNDOT COPY http://www.dot6.state.pa.us/crsapp/Printlmages/XmIFiles/20110207552011022513143114... 2/25/2011 Print CRS A06D0037 Page 7 of 7 Crash Number.A0000037 Incident Number.2011020392 gg INN nol tMa 0 `>> •ST�1t�i;T\�:>�`. CO X M I ET I Unit WEST COOVER 4 STREET WEST COOVER STREET KEEPER VEHICLE ' WITNESS F�7 n NN THIS f j4�e••�T rO L WHERE BI KE � �rt-•I' LANDED AFTER IMPACT p II RAW VEHICLE NESS http://www.dot6.state.pa.us/crsapp/Printlmages/Y,mIFiles/20110207552011022513143114... 2/25/2011 EXHIBIT B PENNSTATE HERSHEY 1401f'7j 7W610 ps 7SO9169 Of CHRJSTO XXM Mflton ;S. Hershey 8800, 'T, mooX.4 plenso 9;e 9 /1000 eX!TjDAfE. OS103/p-oll SL. FO 4W Me&cd Center., PAY TRAUMA TEAM SIGN-IN SHEET Date, TRAUMA NUMBER P"N* TRAUMA LEVEL 1 2 3 Trauma Standby paged at hrs Trauma Response paged at brs "�tfig_MM A, ED Attending Trauma Attending Trauma Team Leader(PGY Junior Trauma Resident(PGY 213) Senior Trauma Resident(PGY 415) Junior Trauma Resident(PGY 213) JuniorTra6ma Resident(PGY1) Junior Trauma Resident(PGY 1) Emiggency Med:Resident T2Y 2/3), Emergena Mad. Resident(PGY 2/3) Emergency Med. Resident ffGY 1) Trauma Physician Extender Trauma P Ician Extender Anesthes!2!M Attending 7�11 � Anesthesiologk Resident Certified Registered Nurse Anesthetist Respiratory Therapy Radiology Attending Radiology Resident Radio grap her#1 LDIagnostio) Radio,qrapper#2-(Diagnostiq) Radiographer(P Al 40 Emer gen cy Medicine EMT Chaplain OR Technician/Nurse Pediatric Critical Care Attending Pediatric Critical Care Resident 5 Child Life Specialist. vi J_jRWij1AA/ Trauma Coordinator/Case Manager Iftrdffif U 14AMEE Orthbpaedics. (Pager 2002) Neurosurgery (Pager 1001) Plastic Surgery- ENT PGY=Post Graduate Year Oe4nalCopy-Medtcal Records MR 414 Rev.1108 Page lof2 Pink Copy-Emergency Dept. 111101111111111111HOURE TRAUMA TEAM SIGN-IN SHEET Yellow C6py-Trauma Services t PENNSTA7E HERSHEY IRM Milton S.Hershey E, �75M ss VF Medical Centex' MD: DESCITpi CiiRYSTO Mx-•, 9§etee D0$: 01/01/logo YF$IF DATE. 05l03l201s 0` kY SELF , TRAUMA HISTORY AND PHYSICAL EXAMINATION ������ (���� AY Date: Time: Type of Trauma '•Brief file rp{ echansmf 1njtEry ;: Q MVC Belted? D Yes ❑lea Q Airbag l 14 r 0 Pedestrian Q MCC 0-Assault • 0 Fall 0 Bum a Electrical Ci Gsw Q Stab 1&ther_ 1516,t1�,Catr-' Airway:, 1V's: 1I.0-5. Field Vitals: P. BP: RR: Immobilization: Fluid: M Amnesia?O Yes No Loss of CorE$c` ` ness?©Yes ' Field Nutft ,Printrv,Su�ve �� ' q y. h •# 6• :3 raUl�ildHt$t�!� , ^t..�a �y� .. +t .I. 17'ri .....-a .emr"�{r}�57 '4.vr...l.�..A—•.'i ++i:° iii. ' _,t' r ssray:)iatent D ObsUucted Intubated: 0 OT © Ur CI Trach Attergies; Breathing: Breath Sounds: Meds Crrutraflon P 8P: ' RR: Sat visd6ttlty Alert ❑V=1 0 Painful Q Unresponsive PMFt: Fxpruu(e: Prmcederes:❑N&-Tube Q tJ' athater PStt: Q A-line: C3 CvP(s): Chesttuhe 91 Cl fell Last Ateei: 1]BPL: Last,Tetanus., erondarygp y ?ri VNs:Temix'—P. BP 63 R L--q2 saWwr r HEENT: tread: Eyes: l- Ears: TM's: Battle's° Face: Maxltla: ilAartdibie (,� - Ntise: t r DenITw- w Mouth: Dentures Neck: Temlemess- - mss: Trachea ML: - J Chest Wall:Tenderness: Crepltus: = Lungs: Back: Tenderness: Creprtus: Heart: ' Abdomen; Distention: Bs: Tenderness: 3 - _ t Rectal: Tone Pelvis:Stable: Tendemess: t_Ettt): L -lacerallon Vascular Exam: Radial , Femoral DP PT Chc -dosed" tractors r i t Right/Left rli'"' PX-open Residel Si re Trtle I date Time a m./p.m. fracture Ab —abrasion PIA) •z o�{( •C -contusion CO GtiT 1998 PS .. OAS-Chad MR 611 Z 8` TRAUMA HISTORY AND PHYSICAL EXAMINATION Copy-Tram=senr,= I I�I�1 11tIC I Hill III it NURSE'S NOTES INCLUDES: 1:Assessment 4. Response' 2. Plan 5.Ongo,ng Assessment ` {y t 3. Intervention 6.Disposltion/Final Assessment Ve Cj. �y`t"t L i a..., . -� ��2 n YY1a� I , r { v yak A W C i� - 3 1 ` pr,✓l •j C-- r� st - blA TEMPERATURE DOLOR r Y BRACELET LOCATION: ID . SENSATION Mavmfilfr PULSE W-Warm N-Normal .R-Rapid N-Normal A-Active S-Strong BLOOD BAND Ri t567 C-Coal P-Pallor 8-Sluggish 7-tingling W-Wed W-Weak CD-Cold F-Flushed A--Absent NEI-Numbness P-Paralysis A-Absent Documenting Ner H-Hot C-Cyanotle P-Pain and A w Absent R-Regufar Support Nurse: i-Irregular Physician Signature• G liwb64-A ABBREWA`JO S MO lCTloNS -Normal ToR w BVM = Bag Valve Bask, LCT=Left Chest Tube' NS= Strength •�� ��� ET- EndatrachealTube RUT- RighiChestTube W Weatmess B A S B 8 9 ABD =Abdomen PH--Pre-hBspnal FP= Flaccid Paralyss RL = Right Leg LOG -,Level of Consciousness R ­Rigid IN3tfRl ter"�`.: r-: ;-.�',x., LL = Left Leg PMH = Past Medical History OCB= Decerebrate Posture HEAD: - RA =Right Arm BH ;'Bair Hiner DGT= Dewticate Posture LA = Left Arm PUPIL AFACTIVITY' B,.Btsk F-Fbmd 'S-Sluggish 0:Dialed N-Now adve I?ISP£75�FfDN CHEST: ' AOMtTFEDTD ® REPORTTD TIME OR NOTIFIED OR READY TO OR _ ABD: FAMILY NOTIFIED BY RELATIONSHIP C-SPINE CLEARED- 0 YES Lf NO BY Ott. (REM C-COLLAR ON: © YES 13 NO ASPEN: © YES 13 NO VALUABLES:0 W/PATIENT❑ SAFE 0 NONE 13 WIFAMILY O BELOtdS 9GS FORM DONE © EXPIRED CORONER NOTIFIED 0' BURN: MATERIAL EVIDENCE TO POLICE: ❑YES 0 NO OFFICER BADGE f OTHER: TRANSFERRED TO VIA k a TRAUMA HISTORY AND PHYSICAL EXAMINATION, - [^^•q.-.n 7'.r(v)weevs(yyfyM..aY�.7d' - SBCOndaty:Sun,Lr,�+htsortx}Y.�.• �• .4 �• 5•. � '' r•^Y� e" i r 'M• •'✓ '.� -•4 ^.e"f• x-• � adfurafty Gram < LEGEND: f• •` 1-4aceratwn Z--fmcture 3--attraston A--contusion Y - rttltt�'t Gbsgaw Coma Scale Trauma Score Cranial Nerves: �t Opening ' Gard In jury. � .1-None 'ftP•Ram k 2-open to Pala ss? Motor. r 3-0pen commsrdNMCe 0-0 0-0 A-spontaneous 1-1-9 1-0-49 T je�o1Reewonse 2 i.3& 2-50-69 Sensory:Pinprick ' i-' t-12 2-Wwp6vAWV4m to P* G-25-35 3-70-M PrapriucepbOn A-Can=feaPain 4-10 24 4->90 D•IR'S 5-Alerr/Daentedllr4aacts GCS L t-S Motor Respmare 0-3-4 1-None 1-6-7 2-Decerebrate 3-Decorticats. 2-8-10 4'-Wdbft= 3-11-13 5-Locaes t Pam 4-14-15 t4 tt 6-0beys Tatal Total: PT: Troponin: U/A: PTT: Myoglobin: T:Bilc GPK: Drug Screen: � ALT: Amylase: i ABG' ALP: ICa: ETON: ECG: TEE: BHGG: t CSR: Pelvis: ifs.,.1 Head: ' ead: GSpine: Lat Extremffies: Abdomm: AP Other`s: ` Odontoid Angla� : T&L S`ine§: U/S=. `< I Attending Signattn Dateji-urre Urlg-Chart tR 611 Rev.5108 TRAUMA HISTORY AND PHYSICAL EXAMINATIN Copy-Trauma services lVrac,ts,kk.,r 11i�8I t� I ��I�il PENNSTMM HERSHEY WE: TRAM, 7500160 ��y� IMP: 75MG9 OOSS: 10509te9 WMAUmn.S.Hersh6y IM: OEFLIM CHRISTO MDs: 46325 � :Ot1o1f1800 VISIT 0510312011 M��Cent LW � IkS: F PAY SELF PAY ORTHOPA EDIC TRAUMA ASSESSMENT • Hisfory of Injury: Sc;, W ke, e: MvA Attending on Call: Consult Date: r �( Date,of Injury:? M t t Consult Time: c7L7 ANl4eR!y Mechartisrn bf iniury: Significant Past Medical History: ❑ unknown Addictions: ❑ motor vehicle. ❑, hypertension a hepatic disease ❑ tobacco ❑ motorcycle ❑ coronary.artery disease 10 HIV r.=keippd� ❑ pedestrian struck ❑ peripheral vscuiar disease ❑ hepatitis B B chew ❑ fall ❑ congestive heart failure ❑ cancer ❑ alcohol ❑ industrial ❑ diabetes ❑ stroke 0 narcotics ❑ farm ❑ COPT] ❑ spinal cord injury ❑ unknown ❑ assault ❑ asthma ❑ ❑ oth r ❑ gunshot ❑ artrial fibrillation ❑ -non-ambutator other ❑ renal failure ❑ amcoaguiated Orthopedic injuries Open Left Right ❑ ❑ ❑ 2 ❑ D ❑, . 3: ❑ ❑ ❑ 4. {� D ❑ D D ❑ s. a o ❑ 7. v4w D ❑ ❑ 8. 9. 10. 5. r6 ❑, ❑ ❑ 11. ❑ ❑ ❑ 12. ❑ O ❑ Resident comments: fSGa �' i Q ls�i -r TW Attending summary and plan: Expected period of non-weight bearing: right leg left leg right arm left arm 6 weeks ❑ ❑ ❑ CI 12 weeks © ❑ ❑ ❑ Expected Rerl6d of Solna bracing: ervical: ❑ 6 wks Q 12 wks *TLSO: ❑ 6 As ❑ 12 wks Resident signature: . cl-e" 'e=� T!=s Attending signature: date: time:_ AMIPM MR 874 Page iof2 5108 O � RTHOPAEDIC TRAUMA *TL O=Thdra —!unbar—sacralorthisis • 11i�[q�ilq®Il�glllgl��l • Orthopedic Trauma Physical Examination R SKELETAL INJURIES !_ SO FT TISSUE INJURIES Other Injuries: ❑ Head injury ❑ Aortic dissect. O`Pneumthorax ❑ Spienlc Injury ❑ Hepatic injury RIGHT LEFT I] Renal injury ❑ Bowel Injury I I ❑ Bladder rupture rl� � WT Y lit ' FROKT BACK PHYSICAL EXAM NL ABN NL ASN R L' R L R L R - L Neck / 0 ❑ 0 Pelvis ❑ ❑ Spine ❑ D Hip D ❑ • Clavicle I I Thigh f 13 Shoulder ❑ © Knee lP D }., X e Arm 0 O r Caw 0 ❑ Elbow ❑ ❑ Ankle J� �_ ❑ '❑ Forearm C ❑ ❑ Foot _- ❑ ❑ wrist El C ❑ ❑ Hand ❑ ❑ VAScuLAR EXAM v 'EXTREMETIES RAO ULN FEM POP OP PT R Zt— L NEUROLOGICAL EXAM ,UPPER EXTREMrry ` Motor* -R deitoW bFc ep wrist flax wrist ext tr'icep L r� r, Sensory R C5 T1 LOWER EXTREMITY Motor R psoas hip ex hants b ant ext hall long gastroc L �r �' IJ/k l,r R` k µGv Sensory LL��r L3 1-4 5 , L_ t iiecral: hyper norm 'hypo absent Bulbocaw. hyper norm hypo absent X-RAYS` Add al studies needed: THAUMA SERIES - 1• �to /717 AP I:AT " POS NEG C-Spine ❑ ❑ O odbn O O 3. T Spine O ❑ f1 ❑ 4. LS-Spine ❑ El 0 ❑ ,• Pelvis ❑ 0 © 6. .MR 874 Page 2 oft 5108 ORTHOPAEDIC TRAUMA ASSESSMENT PENNS3ATE TuuE: tTTN1URr?soar se Milton S.Hershey Medical Center VA rsD9ts9 0054; 70509168 Medicine W DEFLIT011 DMISTO AIDI: 48325 College of Medicine DOB: 01/01/1900 VISIT DATE; 05103 120 7 1 S: F37E!PAY SEX:LF AY ED TRAUMA/RESUSCiTATION FLOW SHEET/ORDER SHEET H11I��1fig Hill DATE 1 TIME RESPONSE$TAT PAGED �p RESPONSE LEVEL i 2 AGE � EX_ 1` _WT TIME PT ARRIVED '71)L43 PRE-HOSRIT'AI< EMS REPORT r— EMS MEs'DS GIVEN AMB/MEDIC# Pte_OF GCS TRAUMMAYTENOANCE HELICOPTER RR _"- BAGGED® MEMBER TIME ON-SCENE — INTERHOSPITAL y C-COLLAR�Ql01FOWEL ROLL TRAUMA ATTEND CHART_ LABS_XR_ CT_ V LONaBOARWED LOSS OF CONSCIDUSNESS�NO —UNK YES #MiN MAST --' ED ATTEND- ENTRAPPED: NO�UF�H(NOWN _YES #MiN �' SPLi l�L ANESTH.ATTEEND. ZO3g SELF EXTRICATED: YES NO I SR.TRAUMA RES. •. a MECHANISM OF INJURY = : RESPiRAT RY _MVC —CAR —ORNER —BELTED „EJECTED —WINDSHIELD —O11MA{iE SPONTANEOUS RATE: —PICKUP _PASSENGER —AIRBAG ^1#FT ' _BROKER —FRONT MW SEDATED PAAAL G A1P�f —TRUCK —FRONT —CARSFAT —ROLLOVER —SPATERED —BACK _MoD —02 MASK {/MiN _VAN —BACK —NOME X STWHEEL BENT_ —BROADSIDED ,HEAVY _02CANNULA LfMIN PEDESTRGAN _BED OF PICKUP —UNKNOWN —UNKNOWN —R —L —ASSISTED RATE `` _-_-BVM RATE MOFORCYCLE BICYCLE` ATV— HELMET— NON ! UNKNOWN ARYMAY(ORAU/NASAL) FALL FT, GSW— CAL/MM— _ETT(ORALMASAL)SIZE BURN DIVING— DROWNING_ FARM—INDUSTRIAL_ SPORT.—-STABBING_ OTHER _CR{CDisirr 00TOMY TAACH SIZE FLUID`RESUSCITATION PMWPSH - IV GAUGE SOL'N AMIJT.INF. TENT? Xi L N-S 1 ro MEDS ' LAStTETAIVtJS Imo_ G2 Y 1 N 3 Y I N ALLERG=IES GLASGOW COMA SCALE A 1° PRIMARY SURVEY BY OR Ge I gallLe " Eye Sm otanam a CHEST ABDOMEN PELVIS opening To voice RESP LABORED BREATH SOUNDS kL EARTSO _ SOFT `TENDED STABLE Response To n 2 2 `►—NO _YES PRESENT ti-, PRESENT— _ RIG=ID _ YES _NO r LWSTABLE Nmrc 1 1 PAIN ABSENT _ _ , MUFFLED_ _ DGSTENDEO WHERE Ee=l arlmtW 5 O —YES CLEAR _ _ GUARDING SCAR BLOOD 0 Ve" Contosed WHERE DIMINISHED _ _ •G 0WELSOUNDS _YES _ND MEATUS Respaase maoma date%cods 3 3 CREP{TUS PARADOXICAL —YES _NO WHERE menmwel,ensmksoands 2- z --No _YES FHEST SYMMETRICAL MOTION _ DECREASED Nona i 1 WHM _YES _N � 0 NO YES _ east emuaand s 5 EK sibwr TREN FUSS 5 PS S 1N HEAD/NECK Response wlo,draws 4 4 PARALYSIS PARATHESIA PULSES PAIN PALLOR _ X �iRWAY PATENT _PALE -HOT _YES_NO roan to 2 q {gyp CYANOTIC_COOL JVD YESN+NO Nacre t 1 =AC C COLD TSACM MIDLIE RL Total AppVft sm to GCS LL — GGS padron of Trams. C014SULTATIONS REVISED TRAUMA SCORE ° COMA� 1 4 4 SERVICE CALLED ARRIVE � A SCALE{reel s-e 2 4RTH0 t4 1.aPlrrlalcl9RE E-xla O%S , .. 2A}.iPUtA0011 A-AStuM " u {iohl Po,nts 4-S t 1 3 GURS$O woo C.COBWSION 11 �aolaoarel a - N.SURG 4.DSW= WACl MIJ - h F A PLASTICS &STAR WOW s-alu G f s�lc >82= 4 4 r BM001 7b89mm T � � �_ t - I; Pressure 50 m H 2 ENT B RpSB WOI1h7) t I-1 Sd9m H 1 1 BURN-FT No Poise OPF(TH PT Respiratory 10491m1a d 4 so Ads >29 min FIMPALEDGMT •� &9raan 2 2 1•SAetn 1 f T Total Revrsed T ire Score 0 g Original-Medical Record Yellow•Trauma Service Pink-ED MR 6.90 07/65 ED TRAUMAIRESUSCITATION FLOW SHEET/ORDER SHEET I , NEURCIE GIC EVALUATION VITAL SIGNS --.;,7 Z. RO[TtEOFTEMpi Time Pupil Pupil Time Warm "Pain Size I RSizeL RReacL RAI R LA Function LL G{S Rhythm P BP RR S t c T f Lites Sege B H'Used f _ - 5, 5-V it)q I 1b I tort Ped I tut , NM- COrt1mmicarwe Chltd ARFLkQ7F No Q. NEUROVASCULAR ASSESSMENT ptlLSEASSESSED 'E X-RAY TIME ITEMPERATURE COLOR CAPILLARY RERLL SENSATION MOVEMENT LSE Time C-SRin Lateral A/P Odontoid TOTALS Swimmers 10 CXR pelvis LABS MEDICATIONS 1 — ESQ°mities TIME TRANt tM TIME BACK TIME DRUG DOSE ROUTE INIT. CT Q TRAM-2 Td,IM j WNPN�S DP{IATE Cranial Abdomen TRAM.3m Chest TPA" Other TRAMP Angiogram TSCP U T&S LEGAL URINE DRUG VENT SETTINGS" LEGAL BLOOD ErOH E OTHER SITE CCFMML4L VASE _ FLOW PREPPED WITH POVIDONE-IODINE TH ALVOL DRAWN BY P-EE BURINARY- PEEP EY YES NO HEME + gIZE - CRYSTALLOID RESPIRATORY SIZ FR BLOODATMEATUS IV# TIME SOL'N SITE AMT. LEVEL 1 SPflNTANMt1SHATE:J11LM)II INSERTED BY TIME N _02 MASK. VPAI ,GASTBOINTESTINAL ^02 CANHllUI W114 RECTA HEME + - _ASSISTED RATE TONE X GOOD _BUM RATE • DECREASED • ABSENT _AIRWAY(aRALINASAL) PROSTATE ❑ NORMAL - +Err IoRAUNASAL'l SIZE ❑ABNORMAL TOTALS ____CRICO TRACH SIZE_ DONE BY TIME NtG(ORAUNASaI) BLOOD PRODUCTS ` SIZE ER TED BY TIME PERT- PRODUCT TIME SITE AMT.INF. INIT, LEVEL I PERT LAVAGE ` DONE$Y D TIME RETURN❑ C ❑ PINK ❑ GROSS B D' AMOUNT INFUSED CC AMOUNT RETURNED FLUID TO LAB YES NO CAROH TRORACIC SIZE FR CVP 'R L - LCT FR A-LINE R THDRACOT CUTDOWN TOTALS L THORACOTOMY PERICARDIOCENTESIS T HD DONE BY OUTPUT ❑ UAi 13 Tox SENT 12 LEAD EKG YES NO' FTOTALS URINE EMESIS RCT LC'T OTHERS NEUROLOGIC tCP INITIAL READING HALO DO R - INTAKETOTAL I' OUTPUT TOTAL .Operative Report NICHOLS, ALEX - 7509,169 *Final Report Final Report OPERATIVE REPORT Name: NICHQLS,ALEX HMC Number: 7509169 DOB: 02/05/1996 Date of Service: 2/2112011 SURGEON: HenryAidoo Baateng, M.D. ASSISTANT(s): Matthew R Wllsey, D 0. PREOPERATIVE DIAGNOSIS: Left lower extremity open fasciotomy wounds on both the medial and lateral side. POSTOPERATIVE DIAGNOSIS:Same. OPERATION PERFORMED: 1. Medial fasciotomy wound primarily closed. 2. The lateral fasciotomy wound had reapplication of a wound V.A.C': 3. Also,formal I&Ds were done in both the medial and lateral wounds. ANESTHESIA: General endotracheal. ESTIMATED BLOOD LOSS:Approximately 20 mi. IV FLUIDS:800 mI of crystalloid. COMPLICATIONS: None STATUS:The patient was stable. HPI:Alex is a 15-year.-old gentleman who was lnjufed riding a bicycle this past Saturday, on 211912011. The patient was brought to the-Hershey Medical.Center-,where he was worked up by the Orthopedic•Department and then was taken to the operating room,where he had an IM.nailing of his tibia,as well as formal fasciotomies done due,to concern of compartment syndrome. The patient since that time has donevell on-the floor. His pain has Printed by: Rhoads, Debra Page 1 of 3 Printed on: 2/271201211:52 (Continued) .Operative Report NICHOLS, ALEX - 7509169 'Final Report been well controlled arid he has had wound'V.A.C.sponges in both the medial and-lateral fasciotomy wounds. It was deerned'necessary the patient retum•to the OR today, on 2121,for repeat I&D,,and possible closure. The patient in.preop. OPERATION: On 2121/2011, Mr.Alex Nichols was taken to the Hershey Medical Center operating room. Prior to entering the operating room, the patient was identified as Alex Nichols. His left lower extremity was marked and he was then fatten to the operating room. The patient was placed in the supine position on the table and properly anesthetized. His nonoperative extremities were appropriately padded and,he was prepped and draped in a sterile fashion. The patient was given intreoperative Ancef 1 gm.before the start of surgery. A preoperative timeout was taken,'where the patient again was identified and the plan for the procedural course was discussed. The patient then underwent a repeat I&D to his,left lower extremity to both the medial and lateral wound. Approximately 3 liters of saline were used. After assessing-the wound,it was decided'that the medial wound could be closed. Using.thrde different tension sutures that were placed inifiatiy,,the wound came together nicely. The wound was closed with cutaneous vertical mattress sutures using nylon on the medial side. On the lateral side, there was still a ddcenf amount of swelling and'a wound V.A.C.was reapplied to the lateral fasciotomy,wound. Dressings on the medial wound, as well as his.closed wound'over his knee and his ankle'were then placed and wound V.A.C.was hooked up and held'suction. The patient's leg v&s•wrapped with an ACE bandage. It should also be noted during the case that his muscles were tested in both his posterior gastroc and soleus,as well as laterally, his lateral musculature, and anterior-musculature responded to bony Bovie stimulation. All tissue looked pink and healthy and there was no necrotic tissue noted,. The patient after the surgery was transferred to the gurney and taken to PACU,where'he recovered unremarkably. Plan for this patient is for Him to be on postoperative antibiotics, as well as continue his wound V.A.C.suction. The patient is to keep the'leg elevated and he is also allowed to be weightbearing as tolerated as he starts to do movement with physical therapy. The plan is to lake this patient back to the OR on Wednesday for a,repeat I&D and possible closure versus skin grafting of his left lateral fasaotomy wound. 72186• Signature Line Electronic Signature,on File Electronically Reviewed/Signed by: Matthew R Vllsey, DO Electronically Reviewed/Signed by: Henry Aidoo Boateng, MDCosigner Signature Dt/Tm: 24.02.2011 Printed by: Rhoads, Debra Page 2 of 3 Printed on: 2127/2012 11:52 (Continued) . , r Operative Report NICHOLS, ALEX - 7509169 *Final Report* 09:17 AM MRW/TLD DD: 02/21/11 DT: 02/21/1115:37 Result Type: Operative Report Date of Service: February 21;201100:00 Authorization Status: Final Subject: Operative Report Author or IMport Date, IMlsey, Matthew R on February 21, 201115:14 Verified By: Boateng, Henry Aidoo on February 24,201109:17 Encounter info: 10509169, HMC, in-patibnt, 2118/2011 -2/2712011 Printed by: Rhoads, Debra Page 3 of 3 Printed on: 2/2712012 11:52 (End of Report) .p, y 1. 1 �:%',�'{a�'`,�,�,gx��J'��•�+.iY"',Y„Pkti'i' ,�»cTi°`7 Y U1'a, K N ,p i 4 t.r7a ' ( a�vxt<�`X.tS`✓ � � � x •�.9+' '�t`'. ��: rl'vsCa 0 9i6it'a� { .� r l�T .Y �„I+....v. ayr,' ��.yyr.,,d' �...a�• Ta'S 1 S G >F1 ! 4 i r u 5 n '�8•P.ts iv..tr�.z�' y{i�! 'k�.r.��"'�`y5��r s t k r r£{ r3j..'s'� A�'�p��,iy"�Y�3+^*��R, s�.•S�tkfft ,r <r t, r � "3�'�.- {f''��t�.P •.!t �'a i7a. .t.v rt; .�.:t�S fi,sae,_ �5Y s t a 'f� .t.� ,.�h 5 Y a frd x�„. rs."yiz�.�;.;�ti!��v7:t y ; A' ,.�Y`.`,4l�•Y <;•�8..� •i;: '�%;: .F S.<?s ,4?��..� ,(: '1 n.4' ,'l,., ::4 4. •9....:,h �4 G.., „ ' -. t �4s -rte•, '{ ,�: g;'; ���r i. rvfi +liar— •,1 { J MINIMUM 7 • � a � • i Q� y NICHOLS ALE 678165 075()916 t- •, �.� :• 2/5/7996 ' Q15 RAy TIBIA&PISULA 211912 42 X 4 f LEFT_ E P D ICA z r Sf f F t.� 1 i V, wt t � N H s y a ri. TIBIA PIB { xyya9r DERIVED/PRIMARY — _....•_. 409 204 �• it wit �:ak� �y,.a 4�.T ....23^�I"•'�'i-'•. P � ,r^''a�vlr �'�u'4���.,���,&'�.�' k. r�<,.y� `���``� • elar`��}.aa�r'' r�. �y���`�.ly y, r�'r5 r�3 Kv�tji.j��pt y, r���f� � r Y � �_ • s {'� E � ,aJ.�F��?r�`t`"�t�{g+.�-S fnk•'r�Ftd�FfY 5 S P"rrf>;5+' !sn�y.it"z �'S�` '� +,fix. ,c N t� r tY. aX,.Jy �(+�St t� Jib +r k 5l.��'sr,���F � S,n Y�.2��4��yr�S t$�1-+y��•�'� � a r � �i �3 r ��<�t3h r x�,� ^Y >r�i 1 S�c �).d'u( �>f �5 L�� -KO •""T'. r'r`4L��,�if's•J r".cvr� >1 `t �x f r > u 1tr r ,rv�tzr$S �,t r 'S�q ,t��.? -s• d JK/a('l a�n v -1 r/ _ r r c �}6�a�x.."o" `}ir'.�i V'��' . ;, t t r •y t / h n ftt t t - s^-:L.JD'"s ixil5f t'�;�' sr��N A t,-�aA,{ (gyp .� 5 �y�SS�� ^��"3 v�vc�������,y'�'�+✓rl^�[' � 9 v �` `r{''r�s� .x�'�_ f �, ' - „t".� H.a`3, S,a��i�. 'vj �if�tS� �, L �> a �r 5r .:: 4 t / ✓ ,3�$� .y� h Syr 5`{z< ,II�: co co Q' ` a'e5,c�'�'�. ° ` �" �Td"� i�'`Y 1YV�✓��>; ,�. »�f�GN�`�y�'�i,�:�,. M 4 4S l� t 4.. v�•j � -�h �7 � tZ 0 • f 2 C3 - z' z Q .Outpt Note NICHOLS, ALEX - 75Q9169 Final Report* *.-Final Report* OUTPATIENT-NOTE Name: NICHOLS,ALEX HMC Number: 7509169 DOB: 02105//996 Date of Service: 02/07/2012 Reason for visit is followup status post 1M na€€for a left fib-fib fracture with 4 fasclotomles as well as a skin grafting of his left lower extremity. History of present of illness is as follows: Alex now comes-in. He is a year status post his injuries as well as fixation. He has resumed all of his normal activities. He has been riding, biking,and jumping. 'He has no residual effects. He has no knee pain. He-has no ankle pain: He has resumed his normal activities without any limitations. He is seen today for followup.. His physical examination shows full flexion,full extension. No tenderness to palpation whatsoever. No pain at the knee. His incisions have all healed quite nicely. His skin graft is taking to 100%. He is distally neurovasculariy intact His x-rays taken today show him to have excellent union of the left tibia with his tibial nail In good position. IMPRESSION: Stable status post IM nail for left tibAb fracture. PLAN:' Discussed the findings and recommendations with the patient Overall,very pleased with his status. He has gone on to about maximum medical improvement.-He has no limitations in terms of his weightbearing. He has no limitations in'his activities, l will see him back on a p.r.n. basis. 261717 Signature Line Electronic Signature on File Electronically Reviewed/Signed by: Henry Aidoo Boateng, MD Author Signature Dt/Tm:02/0912012 10:36 AM HAB/CO DD: 02/07/12 DT: 02/08112 22:07 Result Type: Outpt Note. - Date of Service: February 07,2012 00:00 Printed by: Hitz, Brenda K Page 1 of 2 Printed on: 21281201213.10 (Continued) � . k 4- .Outpt Note NICHOLS, ALEX - 7609169 *Final Report Authorization Status: Final Author or Import Date: Boateng, Henry Aidoo on February 07,20121714 - Verified By: Boateng, Henry Aidoo on February 09,2012 10:35 Encounter info: 17184517,Hospital Based Offices, Clinic,2/7/2012-21812012 4 Printed by: Hitz, Brenda K Page 2 of 2 Printed on: 2128/2012 13:10 (End of Report) EXHIBIT C Jun 26 2012 10:52:21 18666568266 -> 8320463121705340588 Geico Page 882 all 13 11% 111' Will ARM11% 11 Go4ernmera Fmployt:e.s lrrsormce.Company GEICO General Insurance Conil,uty a CTFICO ID&Mni3y CjInpa.ny m GMCO Casualty Company P_U_&ix 9505 YA Fre lcTic:ksburg.VA 22403-9504 CERTIFICATION OF L ' To Whom It May Courern; T.bis will certifythat GCICO General Insurance Company has issued an automobile policy,4077488395, to:jemics Faucotn that was in effect can.the accident date of 112118111 providing the folioAring coverage tin a 2003 Ford Taurus Se,Vefikle ldentifi+;,xtiort Ntunhar('SIN} 1 P'P3 U33G 20y4b; f3odi{y Injury Liability $15;00(1,00 per person/ $30,000.00 por&vident Pi')pe* Donage Liability $20,000.00 per aeeidew First Party Boaefits -W-dical Expenses $10,000.00 per persm. Income Loss pax pmon $5000/max Fune-ral E xpens N/A per person Accidental D=b N/A per person Extraordinary Medical Beneffis NIA per parscyn Uninsured Motorist Bodily Nary NIA per person/ Stac.kabler Vehicle per accident Uadcrijisured Motorist BodUy Injury NIA per pet's w Stackable- Vehiclo per accident Cornpreitetisive Coverage NIA. deductible Collision (;Overage N/A. dcducttbl4 Tory Option NZA ERS Dental.'.eimbarsesment N/A per day maximum N/A per aoddout maxirr UM Mit ka P Iathews Claims Manager 1 6&, Az _-- i11 PA 0703) r IN THE INTEREST OF: ALEX of NICHOLS, A minor child r"3Vk%0f2t IN THE COURT OF COMMON PLEAS OF THE NINTH JUDICIAL DISTRICT 2013-01701 CIVIL IN RE: PETITION FOR APPROVAL OF MINOR'S COMPROMISE SETTLEMENT ORDER OF COURT AND NOW, this 25th day of April 2013, upon consideration of the Petition for Approval of Minor's Compromise Settlement, a HEARING shall be held on 21 May 2013, at 1:30 p.m. in Courtroom Number Six of the Cumberland County Courthouse, One Courthouse Square, Carlisle, Pennsylvania. BY T , Thoma A Placey C.P.J. Distribution List: Joseph R. D'Annunzio, Esq. Eleanoria Alfonso C) r.4- � ./Patrick Nichols , a. ; �-o =rte P i'£s A Lt L(, q .y�q f r IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN THE INTEREST OF: : -t 13,1-)b I CiAld ALEX NICHOLS, a minor child. ORDER APPROVING COMPROMISE, SETTLEMENT AND DISTRIBUTION AND NOW, this'21 S-T day of 204, upon consideration of the Petition For Leave To CompromniselSetfttleiAn Action Involving A Minor, it is hereby ordered that Petitioner is authorized to enter into a settlement with the Defendant in a gross amount of$15,000.00 on behalf of the minor. The settlement proceeds shall be allocated as follows: A. To: Alex Nichols, a Minor, $15,000.00. Within 14-days of receipt of the settlement proceeds, COUNSEL, and not the parent(s) or guardian(s) of the minor, is hereby authorized and specifically DIRECTED to execute all documentation necessary to deposit the funds belonging to the minor into an interest bearing savings account or savings certificate in a federally insured financial institution having an office in Cumberland County, IN THE NAME OF THE MINOR ONLY. The savings account or certificate shall be marked as hereinafter directed. The savings account shall be titled and restricted as follows: Alex Nichols, a minor, not to be withdrawn before minor attains majority or upon prior Order of Court. The savings certificate shall be titled and restricted as follows: Alex Nichols, a minor, not to be redeemed except for renewal in.its entirety, nor to be withdrawn, assigned, negotiated, or otherwise alienated before the minor attains majority, except upon prior Order of Court. If no withdrawals are made from the investments authorized by this Order, the depository may pay over the balance on deposit when the minor attains majority, as defined with reference to 20 Pa.C.S.A. § 102, upon the order of the late minor, without further Order of this Court. Counsel shall file with the Prothonotary of Cumberland County within 14 days from the date of deposit of the funds proof of the establishment of the accounts as required herein, by Affidavit from counsel certifying compliance with this Order. Counsel shall attach to the Affidavit a copy of this Order as well as a copy of the Certificate of Deposit or bank account showing the amount deposited and containing the required f s restrictions. The Affidavit shall further contain a specific averment by counsel that counsel, and not the parent(s) and/or guardian(s) of the minor, established the account(s) and deposited the funds therein as directed above and that counsel has provided to the financial institution a certified copy of this Order. The Prothonotary of Cumberland County shall provide copies of this Order to Joseph R. D'Annunzio, Esquire, attorney for the Petitioner. eLAT Judge Distribution: Joseph R. D'Annunzio, Esquire, 4309 Linglestown Road, Suite 211, Harrisburg, PA 17112 Car N Q C '"Z� c) S• IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, c, PENNSYLVANIA c ? ^" Mco IN THE INTEREST OF: NO. 13-1701 M N{A co °+o ALEX NICHOLS, a minor child. Yc) G D a AFFIDAVIT OF DEPOSIT I, Joseph R. D'Annunzio, Esquire being duly sworn according to law, depose and say that pursuant to the Order of Judge Thomas Placey dated May 21, 2013, I created a savings certificate for the benefit of Alex Nichols at the PNC Bank in Carlisle, Pennsylvania. The certificate is titled Alex Nichols,Not to Be Withdrawn Until Age Eighteen or Court Ordered. A true and correct copy of the order signed by Judge Placey and a copy of the certificate of deposit are attached hereto and are incorporated by reference. I understand that false statements made herein are made subject to the penalties of 18 Pa. C.S.A. Section 4904, relating to unsworn falsifications. Date: „ LY; 1--/3 �/�� i• Joseph R. D'Annunzio,Esquire 'Certificate of Deposit (D. PNCBANK Account Verification Certificate Number Reference Number 31300367016 3300156942 Purchase Date Purchase Amount 05/21/2013 $ 15,000.00 Maturity Date Term ALEX NICHOLS 05/21/2014 12 MONTHS NTBW UNTIL AGE 18 OR COURT ORDER Annual Percentage Yield 234 CAPE MAY AVE 0.1800 BAYVILLE NJ 08721 Renewal Type AUTOMATIC Product Description FIXED RATE CD For Information, Call 1-877-BANK-PNC Interest Rate Effective Until .180 05/21/2014 Please review the Account Agreement for Certificates of Deposit, Retirement Accounts and Coverdell Education Savings Accounts: Certificates of Deposit and Money Markets for important information about this account. ©2012 The PNC Financial Services Group,Inc.All Rights Reserved. PNC Bank,National Association.Member FDIC EFORM000055-1212 040