HomeMy WebLinkAbout06-3243
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In Re:
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
QRPHANS' COl::JFI'f DI'JISION
NO. Or., - 3 ~4 3, c) v.l 1-,-"'"'
PETITION TO AUTHORIZE SETTLEMENT
OF MINOR'S PERSONAL INJURY CLAIM
ESTATE OF BRIANNA GRIFFIN,
a Minor
Pursuant to 20 Pa.C.S.A. Section 3323(a), Petitioners Michael and Mary Griffin
respectfully petition this Honorable Court to enter a decree authorizing and approving a
compromise settlement of the personal injury claim of Brianna Griffin, a minor, and in
support thereof aver as follows:
1. Brianna Griffin is a minor child residing with her parents, Michael and Mary
Lou Griffin, the Petitioners herein, at 25 Westgate Drive, Mt. Holly Springs, Pennsylvania.
2. At all times relevant hereto, there was in full force and effect a motor vehicle
insurance policy issued by State Farm Mutual Automobile Insurance Company, in favor of
one Paul Ranck, which policy listed as an insured vehicle a 1999 Ford F150 Pickup Truck,
and which policy provided Bllimits in the amount of One Hundred Thousand ($100,000.00)
Dollars. A true and correct copy of a Certificate of Coverage for the policy at issue is
attached hereto, made part hereof, and identified as Exhibit A.
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3. At all times relevant hereto, there was in full force and effect a motor vehicle
insurance policy issued by Brotherhood Mutual Insurance Company, in favor of the Carlisle
Evangelical Free Church, which policy has a combined single limit of $1 ,000,000.
4. On June 19, 2004, Ketha Ranck, wife of Paul Ranck, was operating a 1999
Ford F150 pickup as part of a church trip sponsored by the Carlisle Evangelical Free
Church.
5. Brianna Griffin was among the passengers in the Ranck vehicle, which had
been parked on the right berm of Route 11, just south of its intersection with Fairway Drive
in West Pennsboro Township, as part of a caravan of three additional vehicles, each of
which was also stopped in a parked position on the berm of the road.
6. Thereafter, the Ranck vehicle commenced a U-turn from the berm of the
road onto Route 11.
7. As the Ranck vehicle entered back onto Route 11, it collided with a tractor
trailer, owned by Clouse Trucking and operated by one Michael J. Barrick, that had been
traveling southbound on Route 11; the collision caused the Ranck vehicle to travel across
the roadway, into the northbound lane and off the roadway, where it hit a small
embankment, and overturned. A true and correct copy of the Police Accident Report for
this accident is attached hereto, made part hereof, and identified as Exhibit B.
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8. As a result of the collision involving the Ranck vehicle, the minor Brianna
Griffin, did sustain certain personal injuries, which required medical attention, to wit:
a. Acute closed head injuries
b. Left femur fracture, requiring surgery - open reduction
with 1M nailing on 6/19/04
c. Left wrist fracture, requiring two surgeries - open
reduction on 6/19/04; closed reduction with
percutaneous pinning on 6/28/04
d. 1st and 2nd degree chemical (diesel fuel) burns on chest,
shoulders, upper arms, back and face
e. Pelvic fracture
f. Anemia, requiring series of blood transfusions
g. Infection, requiring antibiotic therapy
h. Insertion of a femoral arterial line.
9. Brianna Griffin was flown by Life Lion to Hershey Medical Center from the
scene of the accident. Due to the voluminous nature of Brianna's medical records from
her admission to Hershey Medical Center, the complete file has not been reproduced with
this Petition, although the following relevant reports and Summaries are attached hereto,
made part hereof, and identified as Exhibits C through F:
C - ED (Emergency Department) Summary
o - 6/19/04 Operative Notes
E - 6/28/04 Operative Notes
F - Radiology Reports
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The complete file will be available at the hearing, if any, for this Petition, should the
Court wish to view the same at that time.
10. Brianna Griffin was hospitalized in the Pediatric Intensive Care Unit of
Hershey Medical Center from 6/19/04 through 6/30/04 where, in addition to the surgical
procedures noted above, she underwent a series of Xrays, CT scans, and other diagnostic
tests, IV therapy, physical/occupational therapy, and consultations from orthopedics and
plastic surgery.
11. Upon her discharge from Hershey Medical Center on 6/30/04, Brianna Griffin
was transported by ambulance to her home, where she required the use of a wheelchair,
hospital bed, bedside commode, installation of a wheelchair ramp, and other rehabilitative
appliances for several months. She remained in a wheelchair until mid-September 2004;
thereafter, she utilized crutches to ambulate for several additional weeks.
12. Medical care required after her discharge from Hershey Medical Center
included: Follow up visits to Hershey Medical Center treating physicians and outpatient
physical therapy. Brianna was discharged from the Hershey Medical Center in December
2004. Medical records from 6/30/04 through 12/31/04 are also attached hereto, made part
hereof, and are identified as follows:
G - Hershey Medical Center records, post-
discharge
H - Shepardstown Family Practice records
(includes 9/24/04 Outpatient Letter from
HMC pediatric surgeon)
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13. Michael and Mary Lou Griffin anticipate that additional visits will be required
in the coming months, as Brianna continues to experience various problems related to her
left wrist and left knee. They have also been advised that additional surgery may be
required in the future to remove the plate in her left wrist.
14. On behalf of their minor daughter, Michael and Mary Lou Griffin have made
a claim under Ranck's State Farm policy, and the church's Brotherhood Mutual policy, with
respect to the personal injuries that Brianna sustained in the accident.
15. State Farm has tendered the applicable limits available under the Ranck
policy, in the amount of One Hundred Thousand ($100,000.00) Dollars to Michael and
Mary Lou Griffin in their capacity as legal guardians and parents of Brianna Griffin.
16. Brotherhood Mutual has offered the sum of One Hundred Seventy-Five
Thousand ($175,000.00) Dollars to Michael and Mary Lou Griffin in their capacity as legal
guardians and parents of Brianna Griffin.
17. Neither the Department of Public Welfare, nor any other entity, has a lien or
claim against Brianna Griffin or her parents in connection with her accident-related injuries.
18. The settlements would be in exchange for a general release, barring all
claims arising from the accident, including any claims against Michael Barrick and his
employer. Brotherhood Mutual has indicated that it may pursue a subrogation claim
against Barrick and/or his employer. As part of the settlement, Petitioners will assign to
Brotherhood Mutual any claims they may have against Barrick and/or his employer.
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19. Brianna Griffin's claim for underinsured motorist benefits against Progressive
Insurance Company is still pending. Progressive has, however, consented to the
settlement of the third party claim against Ketha Ranck.
20. Petitioners propose that the total settlement monies from the State Farm
policy be invested into a structured annuity with Hartford Life, as follows:
Payments
In consideration of the Releases to be executed in this case, Hartford Mutual Life
Insurance Company, on behalf of Defendant, agrees to pay to the Brianna Griffin, Payee,
the sums outlined below: Periodic payments will be made according to the schedule as
follows (the "Periodic Payments"):
One Hundred Fifty-Six Thousand Eight hundred Three Dollars and Forty-Two Cents
($156,803.42) guaranteed to be paid on September 8,2015; and, no further payments
beyond said date. All sums set forth herein constitute damages on account of physical
injuries and sickness, within the meaning of Section 104(a)(2) of the Internal Revenue code
of 1986, as amended.
Claimant's Riahts to Payments
Each Claimant and/or Payee acknowledges and agrees that neither the Periodic
Payments nor any rights thereto or interest therein (collectively, "Payment Rights") can be
accelerated, deferred, increased or decreased by the Claimant; nor shall the Claimant have
the power to sell, mortgage, encumber, or anticipate the Periodic Payments, or any part
thereof, by assignment or otherwise.
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Beneficiary Desianation
Any payments to be made after the death of Brianna Griffin, pursuant to the terms
of this Settlement Agreement, shall be made to the Estate of Brianna Griffin. Upon
reaching the age of majority, Brianna Griffin shall have the right to submit a request to
change the Beneficiary designation. No such designation, nor any revocation thereof, shall
be effective unless it is in writing, signed by Brianna Griffin, and delivered to Hartford Life
or its Assignee. The designation must be in a form acceptable to the Insurer or the
Insurer's Assignee before such payments are made.
Consent to Qualified Assianment
Claimant acknowledges and agree that Defendant and/or Hartford Life may make
a "Qualified Assignment," within the meaning of Section 130 ( c) of the Internal Revenue
Code of 1986, as amended, of the Defendant's and/or Hartford Life's liability to make the
Periodic Payments set forth in above to Hartford CEBSCO ("the Assignee"). The
Assignee's obligation for payment of the Periodic Payments shall be no greater than that
of the Defendant and/or Hartford Life (whether by judgment or agreement) immediately
preceding the assignment of the Periodic Payments obligation.
Any such assignment, if made, shall be accepted by the Claimant without right or
rejection and shall completely release and discharge the Defendant and Hartford Life from
the Periodic Payments obligation assigned to the Assignee. The Claimant recognizes that,
in the event of such an assignment, the Assignee shall be the sole obligor with respect to
the Periodic Payments obligation, and that all other releases with respect to the Periodic
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Payments obligation that pertain to the liability of the Defendant and Hartford Life shall
thereupon become final, irrevocable and absolute.
Riaht to Purchase an Annuitv
Hartford Life, through its Assignee, reserves the right to fund the liablity to make the
Periodic Payments through the purchase of an annuity policy from Hartford Life Insurance
Company. The Assignee shall be the sole owner of the annuity policy and shall have all
rights of ownership. The Assignee may have Hartford Life Insurance Company mail
payments directly to the Payee. The Claimant shall be responsible for maintaining a
current mailing address for Payee with Hartford Life Insurance Company
Discharae of Obliaation
The obligation of the Assignee to make each Periodic Payment shall be discharged
upon the mailing of a valid check in the amount of such payment to the designated address
of the Payee in named in this Agreement.
21. Additional information as to the proposed investment, and comparison quotes
obtained from other providers, is attached hereto, made part hereof, and identified as
Exhibit I.
22. Petitioners propose that, after payment of the fees and expenses detailed
below, the net settlement monies from the Brotherhood Mutual policy fund a trust, to be
established for the benefit of Brianna Griffin. Petitioners nominate Brianna's aunt, Mary
Metz, Vice President of Fitch Ratings, New York, New York, to serve as Trustee and
oversee the investment of the trust monies in selected mutual funds over the life of the
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trust, and request further that the trust remain in place until Brianna reaches the age of
twenty-five (25) years. A copy of Ms. Metz's curriculum vitae is attached hereto, made part
hereof, and identified as Exhibit J; her consent to act as Trustee in connection with this
matter is attached hereto, made part hereof, and identified as Exhibit K.
23. Petitioners have engaged the services of the undersigned attorneys, Stephen
Geduldig, Esquire and Thomas, Thomas & Hafer, in connection with the presentation and
settlement of the within claims, and have incurred attorneys' fees in the amount of
$5000.00.
24. Petitioners have incurred and/or will incur a total of $4,198.09 in out-of-pocket
costs and expenses, to wit:
a. Co-pay charge - Hershey Medical Center (6/19/04)
b. Co-pay charge - Physician services (6/19/04)
c. Washing tray (7/1/04)
d. Construction & materials for wheelchair access ramp
at Griffin residence (7/5/04) $143.00
Medications (7/6/04) $40.53
Co-pay charge - Physician services (7/28/04) $15.00
Co-pay charge - Radiological services (7/14/05) $20.94
Travel expenses to hospital, doctor appointments, and
physical therapy appointments (approx. 1554 miles @
$.385/mL) $598.29
$25.00
$15.00
$31.99
e.
f.
g.
h.
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IME examination (3/31/06)
Mediation fee (4/19/06)
$1,225.00
$2,083.34
$ 300.00
$4,498.09
j.
k.
Exercise bicycle (2006)
TOTAL
25. On behalf of their minor daughter, Michael and Mary Lou Griffin have
accepted the aforementioned settlement offers and have reviewed and approved this
Petition; their concurrence in the foregoing Petition is attached hereto as Exhibit L.
WHEREFORE, Petitioners respectfully request that the parties be permitted to enter
into the settlements recited above and that the Court enter an Order approving payment
of the above-referenced settlement amounts to Michael and Mary Lou Griffin, on behalf of
and as the parents and legal guardians of Brianna Griffin, a minor.
Respectfully submitted,
Date:
s-'u-t)/'
THOMAS THOMAS & HAFER
BY:~-
Stephen E. Geduldig, Esquire
305 N. Front Street
Post Office Box 999
Harrisburg, PA 17108-0999
Attorneys for Petitioners
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State Farm Insurance Companies
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State Farm InSU(Hf\(;~
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Claim Number:
38-K46le021
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Fire and Casualty
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_StateeFarm
'C'nlS c"ert.lfies t:hat pc)l..Lcy numbel 0526-742-38 GO':', c'YJe'l:l.nj ~,
1999 Ford FISO pickup, was issued to Paul Ranck and was ID Qffcc!
~).i~ th.e ,-:-<-ccidc;I~lt cL:~te of ,Tl.ln2 J.9, 20(;.0'1 The C(}''..:--PY;:.?P:~ ....,.,...,A lrr~ (""("'
of liabllity for this policy on that date were:
A 100/300/100, C2 100,000, D, G 500, H, Rl 80%/1000, U SO/lODe Ii
50/100, F 2,500, Z2
This policy provides Full Tort.
Karenere~Urv:: 'CPCi:J:>CLU, ChFC
Claim f earn fVlanager i ,
State of Pennsylvania
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County of York
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Subscribed and sworn to before me this ~
day of CO,.. I,
(Year) '2~
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Not;at~'e~ubl:;"'" e'rl.-
Sta
Commission Expires:
COMMONweAlTH OF PENNSYLVANIA
Nolar1al Seal
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Spring Gatde,' rwpe. YOfk~
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Member, Pennaylvanla Association of Notaries
Insurance Company
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EXHIBIT
1-8-
HOJ'vlE OFFICES: BLOOM!NGTOI'L ILUNOIS 61710-000-:
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COMMONWEALTH OF PENNSYLVANIA
POUCE CRASH RE:>ORTlNG FORiVl
Case Closed Reportable Crash
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AlcohoUOnJOS Suspected
. No a lIieg.1 Drugs
Chambersburg
SfP 1 (j 2004
~1~lllmlllllmm Crash Number. "I
State Class
~IA
o ME'd:catlQn
Driver or Pedutrian .~vsicaJ Condition
. App.mmtly a Illegal Drug
Normill Use
o Sid
Medication
o .:'koho;
o .t..kvhot and Drwgi
OUnkno'J'in
o ~~~,B;en
....."..."
~
!: Alcohol Te.. T...,.,
~ a Test Not Given
car _ _ .
:g I LJ ~(OO<.1
'Ii
:> i Alcohol Te.. Results
i [Q].~
o
a
fatIgue
a
a
Asieep
UIlK.nown
.a"'.th
o Unll~
/v'ON Eo
Primary V.hic:/e Code Violation
Charged?
a Ye< a No
GOther
U U.'1kno~'I.':1 If
Test Given
a unxnown
Rt'''u.t\
.1
I
Driver Presence
a
o
Tes1 RefuSE'd
Te<.t Glve_".
(ontamlnat~d RI!'\ult<;
ITJ
O!/'jn~rlDrl!ler
OO",Not Appllc<Jb!f'
01 ,.,PrNdt(' Vrhlclc Own<'dl
If''t1'ol:'"d ltj OnVC-t
01 ","P'IV,Jtf> V@1-jI('1' "'Of
Ownt~dI\ ed~f'O by Dr'vE'r
03 -Rt>..,ted Vi:'h\(.\e
Q4.-Stdtf' POilU' V('h.(]l'
O,..Pf NNDOT VPh:clp
06""Otb('( l}tdtr GO'l V~h
@EJ
1:o-Drlver Op€'rdt€'d
Vehicle
2".NoDrl'iE'T
3=Onver Fleod Scene I
4",Hlt and Ruf' .--L-
9",.lJnltnown
Ol",Mu.'1ICIPdl Pollcp Veh
u8-0thC'r Mut1;cipa)
GOVC'(f'mE"llt VChlC\e-
09-"Fed€'fdl Go... VPh
98=OthE'f
gg..:Un\trO\'ln
5~rn'" -5 JI C'.\'!r~j Xii':; '\'z. m:! C'.t:tncr Lelst I'!ilm~ or lJusiness f.J:Jm:1 (1f p;K/~strizn. s::ip ~hjs Section)
o~i~;r'a [JI-~ :C.!L.:Olll!~ ~1/<..ir-Gf&I[JJ
.f:'.t:C:r~s I Cl'~ I 5~r..t!l J I1,
I ).. 0 7 S- )...1 rt.Jc7l..
4-t &J.J.w "1
{l,1,z'-l sa;
fJ",
17()I.J
Ven!de ;\r.a~l!
II Hut c...f-
VGj,jde iViodeJ
I eH SIZ/l-lC!;
.11J~a~tl~ Cct:e
I~
("", ove11ay)
I
I
I
iiI;od.el'tear
I ~13
Rf!g. State Est. Speed' Vehide Towed
teE] ~ ,-Yos aND
. InsufiMCtf
! g! . Yes 0 No
i;:n
:r.J',
l~: Troil/nq '"""
""~'Unff NOeOfW ~
''''1- Traihnq' J!!!!!
I~! Units-
I i ~ Direction of ~ DVeh/de Position
, Tr~vel ~
t.\-
I i Vehicle Color
r " [iill 06=YeUow
I: J 07.SI!ver
i . OS-Gold
J OT =Blue 09-..:Srown
" 02..,Red 10=<)range
I O'hWhlte 11 =Purple
04=Greeil 12=Other
I OS""SltlCX 9g:..~nknown
fnstlrance Company
a ~~';"ol SII2.ILI S
A-HItIUC,I4
1 .. Towing PelSS. Ve-h
CJ 2..Towmg Truck
LLJ 3=Towrnq Utr:,fy Trat~er
4..Mobile/Modular Home
5-=:CilmpE'r
6=F ull T r elller
0IJ
'Movement [QW
Vehicle T!rDe
r:-r::::::1 01=Automobile
~ 02=Motorcycle
03=.B\.Is
04.,.SmaJl Truck
(/f "01", Comp/ere Form
M. Section 26)
(If "20" or "1''', Complete
Form lvi, Section 27)
05=Large Truck
06~SUV
07,Van
1Q:::Snowmobde
11 ",Fdrm EqU1P
12. ConstructIon EqUIp
13....ATV
19,..,Ott>pr Type Spec VE-h
1 9""U"k. TyPl' Spec Veh
InjtJallm.".~ Poilft
: '. r:-r::)l 00. Non-COI:.~:on
L." LL..Lt:J 01.12,..Cloex Po:"t.,
I ll=Top
;:CP",; ; AA'~:-:'.,;I1:va:z)
!4~:';l'1derc~rraqf>
1S;-TwJed Unit
9q=~nk"o'N(\
Dama!T~ Indicator
r;:j"l a.-None )",F,mctI0I1<l1
lA.I'=:\kno. hQt~bl'''g
9=lmk.'1o......n
:::": .::::-:-'
Policy No
II
Towed B~.
I OI-Vf.Jcl:-
loOI3'=jIlOZ-
l",Seml' Tral~l:'r
8=Oti'€,r
9=Unkrown
"See
Overla~'
20,=UniCYde, B,cycle.
Tncycle
2' =Other Pedalcycle
22...Horse & Buggy
23.."HOrse & Rider
24...TraJn
?S",froi'ey
98.:-0t/'ler
9g.,~U"known
Gradient
Ill'"'evel
2..Llphld
:af! ~o Tag Year Tag 5t
IPr~i7d-O II "?(J{)'1llhLl
Soecial Usacra
[Q1DJ
12=(omm('rClai
Passenger
OO::-Not Apphc.clbl€' Cdrr,er
01=-Fire Veh 13=Taxl
02==Ambulance 21""lractor Trailer
I 03~Poilc.e 21::>.TWlo Trdiler
08-=Other Emergency Z3=Trlple Trarler
I Ve-hrd(' 31...MocMled Vch
i 11 ",Pupil TrCl1'\s.port gg,..Unkrmwn
.1czd AJlcmmant
1 ",Strdlgl1t
}::(UfVed._ I
?~Unk.no~
3;;:DOW'lhl:1
4",Boltom of Hil:
S",Toc of H.:I
9",U'1k'1(lwn
CIJ
,. r::A-r
--l COMMONWEALTH OF PENNSYLVANIA
POLICE C;lASH REPORTING fORM
AA 5003 I ""..u~~ 2.- /40 J "l B 10
_...-
A PPrmn r vDe'
l=Onver
1. ""PaSsE>nger
7 =P~destTlan
8""Ot\'ler
9""Unk.nown
c
o
;l
.
~
~
.5
.
0.
o
:.
>f2!.
B F .Female
M...Male
U =Unknowc
/1)JJJ~r&
C O=No[ Injured
I.::KiI1ed
2=Ma/or Injury
J,Moder ate
Irjl.JrY
4.::Minor Injury
8=lnJury, Unle:
Sevedty
9=Unk~own ,f
Lp
!n!ury
-'~sn1Dfl:. =-.
D OO#Not A Passenger/Occupam
O,...Dnver - All Vehldes
02sFront Seat Middle POSitIon
03...fronl Seilt Right S:de
OA..:::5econd Row - left Side Or
Motorcycle Passenger
05=Second Row - Middle POSlt'on
06=5econd Row - Right Side
07= Third Row Or Greater -
Left SIde
OS"" Third Row Or Greater -
Middle Position
09= Third Row Or Greater'
Right Side
1O=5teeDE:'r Se<tlon of TruckLJb
1 hln Other Enclosed
PassengE'r Or Cargo Area
12=ln Open Area
(Bact.. Of Pr<"klJp, ttc.j
13",.Trillh'19 Unrt
14=~ldmg On Vehicle Exterior
15=Bu'i Passe:l9E'r
98=Other
99==Unk.nowli
Page
[iliJ
E ~i~~"~~~~;7rN~iip'~~~~~~ ~ ,'"
01=Sho,Jlder 8elt USed
02:::lap Belt Used
03:::lap And Shoulder Beit Usee
04=Chtld Safe~ Seat Used
05=Motorcycle Heime: Used
06=8lcycle Helmet Useo
10=Safety Belt Used Improperly
11=(hlld Safety Seat Used Improperly
12=Hefrnet Used Improp~rly
90=Restramt Used, r~pe Unlc.nO'Nfl
99=UnknowfI
W.tyJ~e
F OO=None Used / Not ApphCdble
o l...Frol'lt Air Baa Deoloved (For ihl, Sean
Db,S,de Air 8dg"Dep'joyed (for ThiS Se2t)
03=Otner Type Air Bag Dep1oye.j
04,..Multlp1e AIr Bags Deployed
05=Motorcyde Eye Protection
06=BICy()rst Wearing Elbow/Knee/Pads
iO=A;f 8ag Not Deployed. SWltC.~ On
11 =AIr !lag Not Deployed. SWitch Off
12=Alf 8ag Not Deployed,
'...:nk Sw:~cr. S2tW~~
i 3=AII Odq Rt;11101r'1'U If-rlU{ To (rd~i1!
19=Unknown It Air Bclg Deployed
99=U"known
Chambersburg
SEP 1 n 200~
11I111~lilllml~1 Crash Number I
p 0632393
--- ..'~',~"""""'"'~-""'"---
G O=Not Aopl'cable
1 =Not fleeted
2=Totaliy Elected
TzPartlally Ewcted
g",unknown
-1
!
H€JJ'~tl
O",Not Ejected f Not Apphcable
\ =- Ttuougn Side Door Opening
2=Through Srde Window
3;Through Wlnd:.hreld
4= Through Back Doo(
S=Througn Back Door TaIlgate Openmg
6= Through Roof Opening (Sunroof!
Con\'embte Top Dowll)
7=TI"lrough Roof Opening {(..)rl'.d:l,bie
lOP Up}
9=Unknown
e,
~
~(2!!Q!J
Q=N0f Applicable
1 =Nct txtncated
2=htrJ(ated Bv Me(h~ni(.'li M..:jn,
3=rrE'e-d B\' Non - Mect'.,mic.al Me-,'1n:,
S=Other
9=U1'lKno",;n
'I
~I
o~l,i
"
EMS Agency-Iu,,",; I.IC.'oJ / r'WN84'~~J Mod;cal Facility: 1
f!-A/Zi..d", ;.J~5pmf"'-/HcA>He'f IVLb
Unit No Person No Date: of Birth (MM.Da-YYVYl A 8 C 0 E F G H I
CQJLJ ~ D~te7 OJ-OJ -DIIJ OJ[EJ@0J]@E][:0 UJ0~
Name I Address I Phone
fiZl S.me as I
Operator
"
I EMS Transport ;'1
. Yes 0 No I
Unit No Person No D Date of Sirth (MM.DD-YYYY) ABC D E F G H I
[2JJJ [ill] ~te7 ~-lIlIJ -~ QJCEJ00iJ[iliJ [ili] []][2] W
Name I Address I Phone
OSamo.s _ 717'Z,<3- '!i'l fMSTransport I
Oporator Ie fZ 1 J I;}. F(){l.~t. eO 5(11(...,N(;. s:i .-' S p~ . Ye' 0 No II
ii-;;;; No -Porson No D .Oate-ot Birth (MMe:iibe.yyyvj"e.e ee' A '8. "c: u 6 (' e e_ r~'"-G-H-"'I=~I
0D ~ ~te7 !:l:W-0a-lI.TI.I.frn[]]0[i][ili]~~[JJ~riJ :1
Name I Address I Phone EMS Transport :'1
OSameasl!"rt(...JIJ_ .' p. 7/7" - :
Operator ",.., ~ I..,. ",,,,,- 3 (, CI./I.<..r>>" "'<- c!.s1U..< S<t: ~, 70/1 "'l 'q '70 . Ye, 0 No ;,
I!
UnitN~ Pe~on No Delete? O.ie of Birth" lMM-OO-Vyii)'
[ill] [ill] 0 GEJ-lEJlJ -~ @]ca~~[Eli] [ili] [1][E] ~
Name I Address I Phone
O Sam. .s nn
Operator f~I.1 ~ IVNIl
. Gt.IFFIA.>
A
B
c
D
G._--H"
E
F
..",i, r..J;;sr'A-ll: iI~ . ;Ire}
"".,.
EMS Transport ,'!
.Ye, ONo:1
U';-iiNo"erson No I 7 Oat. of Birth (MM:OO>iYVY), .e.eePA'e. B 'i:-' "~D""-T.__._eTe- . G H Tell
01]~ Dote WfJ-0Il-~00[]]lolS'"llol.3I~[L][EJ[i] Ii
Name I Address I Phone EMS T rt I
o ~a;:.:~~I_A/..I,:eS(J.V_:..,_~.~~~~~__~_~':::~."!::~~::_~~.::'~~_-':'_~e~7.:N~J'/, p~~. " , eYe:a~ :ojj
Unit No P"'son No D I 7 Dat. of Birth (MMeOOe YYVYI ABC D E F G HI-I
0LJGJ1J ~te CiliJ-ffiJ-~QJ0~[ill]~~ITJ~0 ;i
Name I Addr4!!5s I Phone ~
l' 7 _ EMS Transport I
o ~~~~:,_~L;~N HAM! ;:'IT~~~:'''''P (; .n._~~e__~O~'-I^,~..~___'e"~~.en_e__ . eyes ~ No I
FOAM /I AA-600 (121G2)
PENNDOT COPY
Chambersburg
FAT
CC.e,iiVjO:\r;JEA:'TE1:;: ?;:::\:J\is~;.,n\X:A
J"G;.;a: CRASH REPORTING fORM _ New
Page
AA 500 P IPoJKer~t_ 1403"18 (D I c:7 15-1 0 ~~-:~ation p 0 to 3 2 !> q
-----------~_._-._._--_.- - .-------- - ~--,---'-----_._-,
UnI1 No Person Ho Dot. of Birth (MMeDDe YYYY) ABC 0 E F G H I
14 [QID [ill] D~te7 OJ-OJ -ITTIJ OJ ~ [QJ ~ [Qli] [E0 w[El OJ
,
~ Name I Address I Phone EMS Transport ;
188'=~1 I ayes .No!
1
ABC 0 Ce -~ E 'e ~""F" G H I--j
[JDDDCIJDJDJDDD I
.;...]
IIHlllmllllllfEP Cr~2Nu~~ "I
Unit No ";;;'onNo" e Daie~ofBi;U; iMMeDDeyYYY) -., ~
CD [0 0.2)'.7 [IJ-ITJ -[]
Mantel Address! Phone EMS T _ J
sa ] rans!"". ;
kOo=a~r' a Yes a NO:
: OJ rn ~te7 rn~crrrIrD(irIDdJdJcb[5Dc5
I I A...J...J "
I Name I I'UKir8SS I Phone EMS T n 1
! Same-as I I I ranspo :'
; n Operator a Ye' a No !
Unltil:o Personi\!o Date of Birth (MM-DD-YYYY) ABC D E
OJ [IJ ~te7 [IJ-[[]-ITTIJDDDCTICD!
~ame! Address I Phone
r ,Sam... I
LJO_rl
F G H I
IDDD
EMS Transport i
~ DYes DNo
Uni'i: ~o Person ~o Date of Birth (MM-DD. YYYY)
IT] [IJ D~:e7 [lJ-[1J-IT~ I
Nam2! ~d~ssl ?:lone
'"lSi:;n:!i!S r-- - - - --
L --I O:;srator I _
ABC DE F Gr.l
i JDDDl-LJCDITJDDD
~ Ei\f.S Transport
~ OYo, ONo
Uni. j\~o
Do,e of Birtl, 1M MeDDeYYVYj ABC 0 E F G H 1
IT] [Il OC:;"'7 [IJJii-U\ -, - lr -lU... r-1iT li-Oii T -U-iD
I_~ ._LJ LL_i -L~LJ L.-JL-L---I~ LL-JU
~ame I Address I Phone
f 1 Same as I
I ~ Op:3rator ,
Person i'!o
l EN:S Trenspor'i: ,
---' aYe, 0 No '
Unit i\!o Person i\!o Date of Birth IMM.DD- YVYY) ABC D E f G H I
IT] ITJ De2j'e7 ITJ-IT1-Lj-.L~1 0 D D CD IT] [IJ DO D
~am.1 Address I Phone
l J5om... [
Operator
I EiViS Transport .
a Y., a No!
Unit ~o ?orson ~o Date of Bfrth (MM-DDe YYYYl ABC D E F G H ]
! OJ [1J O(!)'e7 LTJ-lTI -ITTIJ 0 DOLl] [l] CD DO 0
i\!oi!l::ne I Address I P;,or.e =r-;:: ,:
r ~ Same as I II ;::EM.S Transport ~
l j Operator a Yes 0 No ,
COrn D(!)te7 rOTfBl~rnrrTTIDDDdJdJcbDDD
i\!ame I Addr.ss I Phone
O=~rL
"
I EMS Trampo" '!
a Y., a No.
Unltl\!O ~ersoni\!o ll<IteofBlrth IMM-DDeVYVY) A B ( 0 E F G H I
CIJ IT] D~te7 [IJ-D~-ITIIJDDD[]JOJOJDDD
~!ame I Address I Phone
~---- ElVtSTrattSport
'JSarr.eas I ]
L o,.~ratar i 0 Yes O.:J
~O--:.- ,&_'..c:"~
:=~xx~~.: ;:::.:','
~
FAT
CO,lIjMC!\IWEAl.:rn O~ I'E!\:NSYLVAN:A
:>c:.:o: eRAS;'; ltE!'O:tTIlIlG ~!'lM
M 500 4 I """"7-WZ,-Il.fO"? <1€l"
4~
rll l",On Travel Lanes 3=M8dian
LLJ 2=Should.r 4=Roadside
IT] 1~oa~igiit ~':i~D;"- - Stre.,
2=Oa" e No lights
...~~~I Uih~~;..-.. ._~4:0_~~_~,.
fTl l=~\Il'~~~o 3=51..' (Hail)
~ 2::.Rain 4=Soow
.""'-.......... ~.-_.~...' .,~'.'_.._~...'....._. . -....,
fQl O=Ory 2=~flnde Mud, Din,
~ 1 =Wel 3=Snow CO\i~red
....-'.--__...c .-. HannEvent t'JR' MOstl Utility pore Number' -...... ..' ~ ".--
UnitNo 1 OJ!] 0 · CIIIIIIJ
[MQz [ill] [] 0 CIIIIIIJ
O~
o CIIIIIIJ
......;..
Crash Desmation
O=Non..coUision
l=Rear End
2=Head on
3=:Rear to Rear
(Blll:klng)
c e
H
oS .
15 .c 3
; .
.::J~
"!Z
~ .
~ ~
~
_lion 10 Roadway
Illumination
Weather Conditions
=:.'-,-- .~
Road Surla~ Conditions
I g
PI.,.. IV J ~O 0
Events In ~
Sequential
Order a CO 0
. ~
E
2
-=
Harm Event L/R Most? Utility Pole Number
~ Unit No 1~ 0 . CIIIIIIJ
W @0zCD 0 0
Piea.. Put 3 r-r-l 0 0
Events In LL-J
Sequential
Order 4 CD 0 0
~
eo
::>
I
I
I
CIIIIIIJ
CIIIIIIJ
CIIIIIIJ
~tul
tventm
ifii'tiiih
Unit No Harm Event
0IJ OTIJ
Most
Harmful
Event to
lliil:'iash
Unit No Harm Event I
0LJ [ill]"
::-.;~......:--
OO'l(llre,tINltll'\intO<mlllOnOl1mtA-'llIe~
.
Environmental / R~dwav
_tia/_(ElRj 1
OO=None
Ot...Windy Conditions
02=Sudden Weather Conditions
03=OtI1er Weather Conditions
04aDeer In Roadway
05=Obstacle On Roadway
06~ther Animal On Roadway
07=G~re
08=Wolt Zone Related
[Q0 2CD 30J
11=Slippery Road Conditions flcelSnow)
12=Substance On RoadwdY
13=Potholes
14:=8roken Or Cracked Pavement
15= TeD Obstructed
16=Soft Shoulder Or Shoulder Drop Oft
2g...0ther Roadway Factor
29....Qther Environmental Factor
99::::Unknown
g
0"
~
of
s
g>
~
.9
Possible Vehid~ Failures (VJ
OO=None 06=Exhaust
01=Tires 07=-Headflghts
Ol=Brake Sys1l!!T\ OS-Signallights
03=Steertng System 09..other lights
Q4-5uspension 10=Hom
05=Power Train 11=Mirfors
~it ~ 1 @:@J2 OJ
:l;:it [ill] 1 @0 2 OJ
lZ,::Wipers
13=.Ori\ler Seatmg/Control
14=8ody, Doors, Hood. Etc
15==Trairer Hitch
16.Wheels
f7=Airbags
18=Traiter Overloaded
19;Unse(urelShlfted
Trailef Load
20=Jmproper Towing
21.0bstructed Windshield
99::Unknown
"
--'- "~'''''~-----''-''-~ _.'....
Indicated Prime Factor Unit No Factor Code
:l~ ~~ll'olS IlIform.llOl1 on @]] f(jT(jl
fIR V 0 P ~
00.0
L-__ "...~..
ee,__
If EIR is the Prime Factor
Type. .!!~~~ l.!,!lt No ~/ank
FQm.1t~(1_
?=NNCOT CO?Y
Chambersburg
_New
1I1~llmlllm"llrE~ ~~. ..
P b
Page
@II]
o Chang.'
Continuation
" .... ..._' -..... - ............- -.-.
.-. ~_.. _...:"' I
S=Side'w'oe (Opposite Oil'llCllon)
(Same Direction) 7=Hit Fixed Object 9=OlhertUnfcnown
5~6u~~~~~i';;;;~;~ (Ramp"I;'~u
6:ln Parking Lane 9=Unknown
5=Dawn eo_eo ..oe S=Othe,' e ~e -----.0",
6=Oark - Unknown ~
Roadway Ughling )-
5=F~~ -'-"-~ 70SIeel &Fog.1 ;:'unknown 1
~~ ~=.~~,n.;~ Fog __,_~~~?:.~~._.. --~-J
4=Slush 6""lce Parches 8--Qlher 1
7=W.t~r: SleI1dinq !
S=lca _oe_.__..Or,i\lIO..V..!.."9 ... ;
.- - ,-- - ..--.........ill
Harmful Ellena {Harm Event} 30=Hit Fence Or Wall ~;
Ql=Hit Unit I 31=Hit Building ~.'
02=Hit Unit 2 32=Hrt Culvert ~
03=Hit UnIt 3 33=Hrt Bridge PierdOr Abutment ~.;
Q4=Hit Unit 4 34=Hit Parapet En _
05=Hit Unit 5 35=Hit Bridge Rail
06=Hit Oth@r Traffic Urit lfi=Hit Bourder Or Otmadp. ~
07zHir Opf'r On Roadwav ~l
08::Hit Other Animal 37=Hit Impact Attenuator i'.
09::Collision With Other Non 38=Hit fire Hydrant
Fixed Object 39=Hit RoadINay Equipment
11 ::Struck 8'j Uni~ 1 4O=Hit Mail Box
i2=5truck 8y Unit.2 4i=Hd f,affi(.lsi.utJ J
r 3=Struck By Uf'lt 3 42=Hit Snow Bank ,~
14=Struck By UnIt 4 43=Hit Temporary Construction n
15=StrucK By Unit 5 earrier I!
16=StruCK By Other Traffic 'Jr.it 48=Hit Other Fixed Object I
21=Hlt Tree Or Shruboery 49=Hit Unknown Fixed Olliect I
22=Hlt Embdnkment 50=Overtu~1l Over
23::Hlt Utility Pole 51::Stn..td: By Thrown Or Falling
24=Hit Traffic Sign Object
lS-Hlt Guard R.1tl 52....Pot HoIe~ Or Other
26=H,t Guard Rail End Pavemt'flt IrregulC!rities
27,..HII Curb S3=Jaanite
28..Hir Concrete 0- S4=fire In Vei1ide
longlto,;dindl Bam{;'f SB:-OtMr Non-CoUiseoo
29...Hlt Dtld' 99:><Unknown Harmful Event
Orivet' Action (OJ 17...Careless Or Illegal
OO#'No Contributing Action Backing On ROddway
01=Driver Was Distracted 18::Driving On The Wrong
02=Driving Usmg Hand Held Phone Side Of Road
{J3=Orl\ling US;f\g Hands free Phone '9=Making Improper
04:::Making Illegal U- Tum Entrance To Highway
05=lmproper/Care!ess Turning 20=Malong tmproper Exit
06= Turnmg From Wrong Lane From Highw.ay
07=Proceeding WIO 21 ",Careless Parl(lngIUnparting
Cleara~ce After StoD 22:::0ver1Under
08=-RlJnnlflg Stop Sign Compensation At Curve
cg::Runn1ng Red light 23=S~ng
lO=Fallure To Respond To 24=Driving Too Fast
Other TraffIC Control Device for Conditions
1 bTadgatmg 2S..failure To Maintain Proper Speed
12:Sudden Slowing/Stopping 26=Orive( Aeeing Police ~~ Chase)
13=lUegally Stopped On Road 27::Drive, 1neJl;per1enced
14=Careless Passing Or lane 28=failure To Use Specialized Equip
Chango 92=Affected By Physical Conalton
15=Passrng In No Passing Zone 98=Othef Improper Driving Actions
16=Drivmg The Wrong Way On 99=Unknown
l-Way Street
~lt~l
~~;tlolz..1 '
I
I
I
- 1
,
r
I,
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~
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[QE]2ITJ3ITJ{TI
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Pedestrian Action (P)
OO=None
01",Entertng Or Crossing At
SpecJf~ed locatlon
02=Wall:.\n9, Running, J09glng.
Or Play.n9
Unit No OJ
03=Wor'ting
04=P\Jshrng Vehicle
OS=Approac:hing OJ leaving Vehide
06::Workinl] On Vehide
07=Standing
98=Qther
99=:Unknown
[I] Unit ~oCD
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Chambersbur'd
FA'
~ COMMONWEALTH OF PENNSYlVANIA
POLICE CRASH REPORTING FORM
AA 500 5 1....;.~"Oz _/Uo 3 't 8"
Page
[iliJ
-.-----_._~--,-....._~.......- .----. _. ~-.....-._._---- ..--_...
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't'-():( . 2, ..1. -...,.
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SR.09.L1a. ;
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I ~ 51l11Z1.
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.6P/.I..,!0:._
Narrative and additional witnesses: Accident Investigation Notification 1S5Ued? . Property Damage 0
UNIT I: Cell Phone Present/Not in Lse UNIT 2: "io Cvlll'hollv PresclIt
m-lwlH<ehicle~Uisioo-oooor~iA the southbl/DAd I"A~ l>!SR()OII Unit-l-wa..
eJ In \.If SR60ftwitI. .. (,d. ~h dll uf llll ,=\:-additionm
.
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OIt a emp C 0
complete a V-Turn across the southbound lane into the northbound lune. Unit 2
was traveling southbound and braking to avoid a collision with the vehicles entel'ing
the roadwa . Unit 1 turned into the nth ofUnit2. Unit2 struck Unit 1 in the left
pr to rp.:Ar hpd arp:A ofthp. vphif'lp I.'nit I travele..d..a.c-ro!ii~ the roa
e
I\~ff the roaaway. Unitl hit a smaU-4!mbaakmtmt,-l1i
Irectron. VOlt
e to nnal resttln the cast berm and grasr,fm:'
lane of SROO 11.
er w s no
'OR.......<600 (1ut2}
PENNOOTCOPY
Chambersburg
~
CAr
COMMONWEALTH OF PENNSYLVAII:IA
PeWCE CRASH REPORTING FORM
AA 500 N I"""um ~ -lliD H ?t..
Page
I [Q]k]
. New
1111I1I~lmllllllm S::hlNU~~~O~
o Change'
Continuation
Narrative and additional witnesses:
22
P si
from the tanker of Unit 2. Measurements from the be 'n i
marks to point of impact were as follows:
Right rear outside; 66 Feet
Ig t rear insIde; 8 f'eet
Left rea r inside; 70 Feet
Left relU outside; 80 Feet
Unitt traveled 67 Feel across SROOII after poml 01 Impac In a
(')1Itfteast-di, ediou tll tll" ~. "~~y "...ball ""'''" I I" iv, I
igt
The distance from Fairwav Drive to Point of I m act was 179 Fcet and
10 inches. Visibility was a roximatelv three- uarter's of II mile on a
clear, sunny day.
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':IJUhrs, I mtervlewed Witness #1, Jon Patrick HA.ND,
y , 01 In prmgs, a
Irntire'Was ill lI,,, le~ftidc "ft!." 4-ve!.icle Ca,aV311
'ng;nembers 6fhi~ ehllreh g.-oil!' to a YMCA e.ent.
eUng-m.the wrollg-directioll and had
ed to the right herm on SROOIl ollllthhollnrl to ..I.....k thp .lirp..tiono
with the rear d iv r. He tated that [nit I wa . ua e behind him and
he then conducted a U-turn to travel northbound on Rt 11. He stated
that he heard the collision between the units.
it Ion thl: light bf.l m of Routl: II. She statui that t.1:1 hu.-band ..<13
I.
FOftU . AA..aco.., lIM2)
PENNOOT COPY
I FAl
.;....J COMMONWEALTH OF PE!\iNSYl.VANIA
POLICE CRASH REPORTING FORM
AA 500 N I "",..;.to z. - /'f 0 Y1.f b
. New
~I ~ ~I~ I ~ 111111~1 m
ChambersbUl 9
SEP 1 I) 20~
Crash Number
Page
[QEJ
o Changel
Continuation
Narrative and additional witnesses:
22
0930111'1>, I inten'iewea Operator #2 at tile eallisiofl se
p ~t<ltpcl that hI" was travel"
the car v two of th !-
Turn from the ri ht berm in front of him. He stated that he was
braking and Unit #1 turned onto the roadwa ' in front of him. He stated
that he collided with the driver's side of Lnit #1.
, . erviewedi)pe,alUl #
.ttHis .
ukI n!lt rllm@mbl!r anything fer this officer ts acid.
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On 7/12/04 20 5hr I i terviewed Witness #
W/N/M, 10/14/81,201 Candleliuht Drive. Carlisle Pa,201-543-8609. He
stated that he was in the last (fourth) car in the carllvan. He stated that
the group had pulled over on the Route 1 \ southbound berm to confirm
Irec Ions. estate t at e was t e Irst to turn across t 11 mto the
nor oun ane an wal or "e olhers. He staled thaI once he turned
looked back to see t1lettnlt I nrl'lltllto the path of {jnit 2. He suited
tl.., b. a~e~ uf U ..il 2 "Ill! I,"".. I,"" "ulli~iun.
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T-he ju;cnile passe.ngers Cqu:~ ~:~ provide s'lbstllntilll investigative
tlon concernmg theJ:fi s ,
'l'ansparted ta Hershey Medical eenler fay Life Lio
:r:ampo
n 6 9/04 1 30hrs Troo er HENNEMAN and the Coroner notified
the father of the deceased, Gordon Scott BEA TTI E.
1
I_e___e _ _ _ __
p:ofQ1 . AA-G:n!,:....
pa\NDOT COPY
Chambersbur9
FA.
~ COMMONWEALTH OF PENNSYLVANiA
POUeE CRASH REPORTING FORM
AASOON ~m2-140 3'l&c.,
. New
Illl~l~mlllll~lm S€!s: N~m~~O~
fPlo l!J~I3G1i]
Pogo
UIQ]
o Change'
Continuation
Narrative
,
exam was erformed on 0 erator #2 at US Hea thworks
22
:trooper
a .
lied SUJlPIemettt1t~ort.
, .' e F , NN.\ I r T~..)i' f; r. ~.r..n~..
Services Unit arrived at the collision scelle and d cum nt ~ th scene
with a di ital and film camera. See Attacbed Su lemental Re ,ort,
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~hicle Traftk-Fatality was forwa~a to th\!-DWe~r of
Rllr..".. n If, . .. . UP #R710 IA VQR9W\o1
0 !
Troop H CARS was not called at the direction of CPL MA YS. ,I
j
News Release Submitted, No NCIC, SP7001S's were mailed to the I
property ownerSe
1"0. uAYS, TRP KEEBAV(;J~lRd TPR-HENNE'\ilA~ssisted-at tbe j
.
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This is a final report.
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~,AA<<!l:I!':~
?ElIjNOOT COpy
o Chenge'
Continuation
~li~..'A98~q- -.." -_.- Patrol Zone .
~ GLIJ i
II:ei:ion Dat. (MM-DD-YYYY) ,
I "G1J-~ I
lodge Number !
Jonathan L, MAYS 7789 I LITIIJ :,
Badge Humber Approval Date (MM~OD-YYYY) ~
EEliIITJ [~EHLIIH21J~] .,1
H _, _ __ e e_._ . -eHel
/2;ULl>LWllrII ':
OSun OThu!
o Mon 0 Fri !
People 1 ~ :tilled* ~~;;pF.:\'. 0 Tue 0 Sat
LL.1.J CD Fonn C) 0 We<J 0 Un~
School Zone 0 Ves 0 No l\:m;iIY:>SI!lI:DOr 0 y", 0 No 'I
Related nr~ I:
- 1 - e. - e.' -"I
o Off R.;Imp CJ Rdi1radd Cn:1'~!.jn9 1 ~S~.;! I I' I
j l-~oft
._~...;J.;'...... I I
o C rO$'\over 0 Other i ~ Se2 CVcr:a
_ ee _de..:&
House "urn!>... (d applicable}
U '! I I
for Mid .blocJ; crashros or-y. ~
?Q!>\:dl HO'..rsc Numhtr dnd malt€! sU!e
PrInCIpal Roadw<1Y ~trPt't ;-.!a~ IS
fillrd In if ll..mq thl!> apt:on
.'
~O:IhIViOil!~ O~ nNNSYLVANIA
;>QuCE nASl-: :tE?OilTIi\lG ~ORM
Case Closed Reportable Crash
. Yes 0 No . Yes 0 No
fTI/ I
lD New
..Jf'~';:
AA 500 1
:I H 0 2
.! A,lenc.x N.me
1 i rp~nn.c:l:~'u~ni#l .c;t"~f"", Pn~it"P-
J ritch 1m., lmil) I Arrival Time (mil) Investigator
~ [L[D I Corporal
Ii. Review...
I Cf-..- Of\'llQ
Precinct
II C..rl is1..
f. CnOUI-OI
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County Name
I
Municipaiity
lITO
[II
. <:-1
. ~ 1
'"
I.. !
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0'
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1-'
4 tiI:
10.'.
v-
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.;:
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!...
,
Wor~one(lf Yes, Complere
. Form M. Section 19)
.In1fta.MtimL!~
a Mldblock
School Bu, 0 Ye' 0 No
Related
o "'(0 fnterSe(Uon 0 Mult'.LPg
Intersection
O Tratflc (,!rcle/ 0 On Ramp
Round About
o 4 Way intersection
o "r' IntersectlO'l
r-gjen'rprna, Trovel lane, Speed Umi,
e CD LLJ
a
Street Ending o~
CD ~
Chambersburg
1IIIIIIIIIIIllllllllllllrf:~h ~)~~ I
o
o
o East
OW"",
a Unknown.
North
South
O County
Road
a Pnvate
ROdd
,ou
~
II
f ~
~ -0 Inter':ottltc 0 Turnp:kp 0 Turnplke-O Stdte-
.l!!D.!ne (Not Turnplkel (Ed'ittWestl Spur HlghwdY
~ Ro:..!~ i\!um~r S~9ment (O,.tionaf) Travel L2.r:es Speecl Umlt
~ rTTTl ITTTl CO CO
! Stre.t "'om.
! 0 Interstate 0 Turnpike 0 Tump,ke
(Not Turnpike) (Ea.st/W~t) Spur
Stre>et Ending
OJ
I"
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"
t:',
'1';
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I.E,
t.
O SMe 0 County
HIghway Road
..."J
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S~ i.
1]1 i
8 @; .
1"'1I
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I
1 i reg!"'" I
.. ~'l'
7 ~ (;; la1itude:
, ,
~
-
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Pfease "g
Enter ,j
Information
for BOTH
landmarks
if Using N
This Option ~
E
l!
~
Minutes Seconds
ITJOJ.DJ
o lo<.1 Rood
or St.@€'t
o Othed
Un!mown
0 North
" 0 l-
0 South
"
J:l 0 f.d\l.t
"
. 0 West
5 0 unknown
o Local Road 0 Private 0 OtherJ ,I
or Srref?t Road Unlc.nown ; I
;;10 North
... 0 South
St l:ndlng ;:) a East
[IJ ~ 0 West
f3e1 I
U! LU;;
Of n:~{les
CC10
;;1 0 North Distance from Crash
. 0 South Scene to landmark 1
St End!ne :S 0 (For Crash between
[IJ East Landmar.( 1 and
i 0 West Landmark 2)
0:
Longitude:: -
Degrees Minut~s SeconC:s
CD []] :[TI. OJ
It!ff1kJ:ootauJJ1'JIkp, o Y'eld S'gn a PolIce Officer or ImhW!iP1lios Emerger>cy
.Hr CJ Not ApplIcable o TraffiC Slg'lal o Actwe RR Crossing Flagman 0 No Controls 0 Oevi<.e Functioning 0 Pret'mptive
Controls o Oth., Type reo Improperly Siqn.u
~ :-; o Flashing Traff,c o Stop SIgn a PassIVe RR o Unknown 0 DeVIce Not 0 Device Functioning 0 Un-mown
, ~19nd! Crosslnq Cortro,~ fUnr.tl0r':lOg Properly
! $! 1.8.tt"'t (1~d..(1f -Not Applicable-, skip rest of the Lane Closurt! section)
~
:.~ 0 I\ot APP!lCabic a Ptlrt,d';Y 0 ~u;ly a Unknown
Dl,,----
j 11 TP'';jJ: V", 0 No 0
Ll. ft-t'JJ{lp.d Unlc:nowr. a
::C:\.; :":"3:::~~
o
o
North
South
,-.~
OW<lk>n
'~~O<lOfv:e
~~'"
o 30.60 M;(1 0 1 3 tv!. a 3-6 hIS
- -0. :.:-: =::.="'
o
o
o North and South 0
o Edst and West
East
WC'it
All
(N.S,E,'A1l
o 6-.9 h,,> 0 > 9 haUl")
o UnXnown I
CI1eam't'}l;ISbUfg
f+I
--.I COilllMONWEA1.TIt OF PENNSYLVANIA
FAT POLICE CRASH REPORTING FORM
AA 500 N I """''''''''tIcz - /110 3 ~ g G
(1)1tow
IIlnl~lmllllllm S~~h :~~~'I
22
Narrative and additional ~s:
On 06/19/04, I interviewed a witness to this crash at the scene at approx, 0959 hes.
Amiee Nicole HAND, 19 Shirley Lane, Boiling Springs, PA, ,'717 ;-240-1299, related that
she lJas the OOE>rator of the third veh'ecle ~.n the group that \.1as pulled on the roadside.
She advised that thev had pulled ovee to check directions. She related that after
thev were clear On where they 'oIere ooing, her husband, who was in the first vehicle, ,
did a u-turn to 00 back north on SRll. UnitU then attempted a u-turn to follow the
first vehicle. Unit#! oulled into the path of Unit#2. HAND related that Unital should
not have nulled out and it was the oroup's fault, She also stated that her husband in the
first vehicle, should not have pulled out. I
,
On 06/19/04, T interviewed Shannon C I :i5ra r.1CGUIRE I 2"~" Ritner Hw.'V, ...... "l' , Pl''\, ,j
~ ..>..><. .....ar,;.iSJ-E, I
(717 \ -226-6031 at 1006 hes. He related that he heard the crash and "as the fir-Bt on I,
the scene. He assisted a female oassenuor out of the '-""an<'oe ~ide i-iirilo;,oJ and la.i.d her- !.
~ OM "he aide of This ""ssencer "
;: the road, 'dentified herself as Ed ca . He also 'oIoke a il
i fn=la ~saenner on the """senaer side 'n the back seat. She told him that her name II
z
'D ..-- .Ta"M. "hn -. that she was having chest cain and trouble breathinq. 'I'
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I ! ;\
.€ On 06/19/04. T met_.r')pp~At:or Jl2 at- ~he Pennsylvan'il~te Police StatioJ:LJ.~lisle. :1
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o Changel
Continuation
I;: ,
: ~I
T "8_-' _ h~Q,,"h "an~ ';Q"'~n "~ ~"sur" operritnr #2's blood alcohol content. I
.!!
'ii "'''i- i n~t'rll'mPn" \J;:\I~ ~n ~lcn-,qQon~or M~rk T\I. Thp. test \Ja~ ~onchlct:ed at 1235 hrs. The
:II
C Oee__ ,..., "'h-">.'" ~l"'~,..nr "
, q?'q R A C I,Jn~ () ()()()~ "
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PCP.M' ~ce-a
FE/lHOOT COPY
r:iT;l;p l~ I r~f~T--i-e
lll:;;i~j:l ;aj ;r~I~j;: I 0 I vi
~
t')A{}?COw.rf-1 7321 I LLL-LLJ
~ Approval Date {MM-OD-yyyy)
I ~GLJe,~-~
'U ., ..... . . .,.... '..
IMuntParty I Municipality Name aav at W""k
I OSun OThu
OMon OFri
Crash Time (mil) No of Units o(lf,. no. 0 Tue 0 Sat
Complete
fonn F) 0 Wed 0 Unk ,
N~ PE.~'IIlllT 0 Ye, 0 No
Mamtename " _
o Railn;lad Crossing . ~~~ CD
o Oth~r j 0 ~~ ~,!E!~,
House i'lumber (it appli(,ab~e)
Ii! I
Fr I county Name
11 I
2 ~ Crash Oat. (MM-DD- YYYY)
S IJl.TTl.
, W' (II Yes. Compler. 0 0 School Bus 0
i or.:zoneForm M, Section 29) Yes No 'Related YE,lS
t i~ ln1e~n.ft 04 Way lntl?isectiO;'l 0 "Y" \nt::!(s~tIon 0 '~t~:~i~gon
!I~. J'. 0 MtdbiOCK 0 or" tnter-:.ectJon 0 lraH:c L1rrJeI 0 On Ramp 0 Crosmver
~ ..;} Round Ahout
I 1 Route l\!umber Segment (Optional) lravellanes Speed limit 0 North
11: D-LU LLLL1 [I] i i i e~! 0 South
I n: j Street i\lame Street Endinrt ~ 0 East
4':ii'~ ~...
~f: LLJ I I l-L-I I i I n LD [I] s g ~::~own
;~i 8m!J:fl
Sjp..QL,,2.
r:4i'
I ::OiV;ltllOt\!lftf::Ai..t:~: 0;: ;>l:i\.Ij\!SYl.VAN1A
.-..J J>OL!C~ CMS:'; il::?OilTi;'\!G ~oai\li
C.... Closed Reportable Crash
AA 500 1 . Yes 0 No . Ye, 0 No
.i\!ew
Page
ETIJ
o Changel
Continuation
II
'I;
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CI/1UI.>/..e
PeLl cE
Arrival Time (mil)
C2I2E0
Investigator
b.Eb"r'c.l!' (!;=--cl2
Reviewer
1Cf'\.-
~lP ~ G.~.""
ChambersbUrg
1111111111111111111111111 SC~il ~:~;,O~
School Zone 0 Ve, 0 No
1telated
o Off Ra",p
~IO North
: 0 South
St Ending ::t 0 East
CD ~ 0 We~t
Degrees Minutes Seconds
IT] IT] :0]. OJ
T.PJ-IP1l<t(oning Emergency
0 No Controls 0 De\lic~ FunctIoning 0
Improperly Preemptive
S'gnal
0 DevICE> Not 0 DeVIce Functlomng 0 Un!movvn
Functlonlng Properly
0 North 0 E.a:.t o North aod Soul., 0 All
0 Sou~h 0 West a Ea!lt and West (N,S,E,\N>
o Interstclte a Turnp:k.e 0 TurnpIkE' 0 Stelt('
(Not Turnprke) (bt!lt^/Vest) Spur H:gr,wey
,; I Ql1l i"TITI ffi"ffi'
5 1:1 s DlLII[IJJI I I LrTl
o is /lmm1
.,1:".... 5igaing 0 Interstate 0 TurnOlke 0 Turnpike
1- t ! (Not Turnpike) (E.aslJ\lVestl Spur
[ I
!~i 1
lEI ...
i~15
Ij, ~
,I a! ~
hi :!l
"'i:f
i! .2
t:1, 2
lEi :)
I !
'.0 .
I .; Degrees
71 ~ ! l.1tltude: o:J
o County
ROold
Street fndlnq
CD
O Stat. 0 County
HIQhway Road
Intersecting Rt Mum Or MilePost
16 ITITJ ITIJ.O
.fi Or Intersecting Street i\5ame
S
Please
Enter
In'ormation
for BOTH
Landmarks
if Using N
This Option ~
E
...
c
~
Intersecting Rt Hum Or Mile 'ost
ITITJ ITIJ.O
Or lntersecting Street Name
Minutes Seconds
o:J:CD.CD
Longitude: -
10
8! ~" '
! .- ~
lfaffic Contrnllb"t.'tJ!:R
o Not ApplICable 0 Traffic Signal
O Fla5I1;ng Trath, 0 5 '
SIgnal top ~;g"
o Unknown
o YIeld Sign
O Active RR CrOSSI'1g
Controls
o Pa<.io!llVE RR
C rOS$lnq C D'ltrols
) ~. l7.0..stct:!rt_(If "Not Applicable", skip rest of the Lane Closure f<<tion:lJ I 1M1'~I~
. 8 0 Not App!ICdb1e- 0 Pa'1"idt1Y a F;;lly 0 Unknown QJr;t~r'irm
n j"j' .___---,.-__ ,_
j~. ;. DJ1t1/( Yo> 0 No 0 I kj(TIm,.O e e
~i, Q1f1:pp.r?f1 Un:;''''lown 0 CfAv'Ji < 30 IVI!" 0 30-60 M'1l 0: -3 !"Ir<.:. 0 3-6 hrs
- .
"Cit"~:;.\;'~::'(12iDZ)
o Pollee OH:cet or
Fla9man
o Other Type IC D
For M'd.block cra~e~ only U'il'
pili.tGI Hou!oe Number and rfIcl':c~ sure
Pnncipar Roadway StrE'et Nilme IS,
1:1'00 ;0 If usmg lhMo opton
o Lo,al Road
or Street
o Private
Road
O OtI1erl
Un~nown
0 North
~ 0 ~
.!2 South
.-
II 0 Ed~t
"
.!! 0 West
15 0 Unknown
o Loc..1 Road o PrIvate 0 Other!
or Street Road UnJ::nown
;10 North
= 0 South
St Ending " 0 Ea"
[I]~Owe"
Foet
ITIIIJi
Or Miies
ITJ.D
Distance From Crash
Scene to landmark 1
(For Crash between
Landmark 1 and
Landmark 2)
:-:.~~,:,-,":C.: ::c~~.r
a 6-9 hr';i 0;:. 9 hours
o Unlc.no1,vn I
~
NMratlve and additional witnesses:
01\,) .-v ,he /C;4 r __L ^ .,rr'" II JVJo.r.).. O"<<'~R :r N:y'f~ejl c'V' ...., IV
I J.,,.,-1I;l A'i" tl,," SO'.. .,,,r 1f"'f'>FJ 'f" r. NslcCJICN .4etQJ~7* pIJo IS 10000 99
A C r,)ly ,..,;:: "TilE'- LNSfJE:<1JJCAJ # ;"CAil, ,,,' , /l", f.//<~ IN THt<:
.4'iilkrtC"l..",. F,L.e G.lR. I"HI j INJ€.S7/c:.4rtc/'"
?):;s 's'<el) 1J't 'Tnco~d.. IIf)7Q \~ I3Rp,~I..E.'j.
I
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- ---
F~r
-.J COMIVlONWEALTH OF PENNSYLVANIA
POLIO: CRASH REPORTING FORM
M500N IPbl"",,0n'1:l0~-I</oj98b
22
FQlWO~.~
Page
I DE]
PENNCOT COpy
_Now
o Chango!
Continuation
Chambersburg
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Chambersburg
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COI\r.MONWEALtH 6F PENNSYLVANIA
POLICE CRASH RE?ORTING FORM
Case Closed Reportable Crash
. Yes 0 No . Yes 0 No
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7 ~ I Latitud., rn
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, ,
Degrees Minutes Seconds
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a Actlve RR ([ossmg
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~rossm9 Co~tro:s
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- ..~_... .
FOR" , ,lA.SOD ('2102)
PENNDOT COPY
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.;...] COMMONWEALTH OF PENII!SYLVANIA
POLlC:: CRASH REPOaTING FOaM
AA 500 5 t"'l1O'l _ 1'/0 -5 q 6"
ChambersburQ
SEP 1 0 200~
111111~lmllllllm Crash Number I
r OSOS7G7
Pofv323'13
. ...,.'-" .~-"... -~".'_";"*' ~,_.-....,""",,,,_.
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....... --,
Witness Name'
I~ress
_e_-~o~;
.
I
! 2
,
1 Narrative and additional witnesses:
,
I
;
Acddent Investigation Notification Issued? 0
Property Damage 0
On 06/19/04 at 1015
hours I was requested
a traffic accident on
by pSP Carlisle Station
2200 block of Rittner
to respond to the
Hwy.(RT 11), West
scene of
Pennsboro Twp., Cumberland Co., PA.
The Investigator is Trooper Donald CHEWNING,PSP Carlisle, Patrol Unit.
I arrived at the above location on 06/19/04 at 1045 hours and
photographed the scene using a Nikon N90s 35rnrn camera, 28 to 8?rnrn lens,
Nikon SB-28 flash unit as needed and GC400 Kodak color film (2 rolls).
A 60rnrn Macro lens was used as needed. Negatives to be retained by Troop
H, Forensic Services Unit. This officer also took 37 digital photographs
using a Nikon Coolpix885 3.2 megapixel digital camera. The digital
photographs are stored on disc and a copy was provided to Tpr. CHEWNING.
Film was forwarded with form SP4-136 to the PSP Harrisburg
Photographic lab at 1800 Elmerton Ave., Harrisburg, PA 17110, for
processing only. If photographs are needed contact Troop H, Forensic
Services Unit and refer to ID #2004-0433.
FOAM' ,M.5OQ (121021
l'ENNDOT COl'Y
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1
Chambersburg I
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o Brick or Block 0 Din SDeCial Jl)risdiction 0 Military 0 Other Federal Sites
o Concrete 0 Slag. Gravel or 0 Other . No Spedal 0 Indian Reservation 0 Other
. Blatktop Stone 0 U I. Jurisdiction .
=_ _'-,," ___ _ _ ~ .n",nown .. . _ _0, National Park _ _0 ~~1u~n1Ve1"Sity 0 Unknown
PlelSe ~omplete Un!t ~~~~~r~~ :~;r~!~:~ f~'~~~~~~~o~'~i~,~~i~e.j-n~'~~~~~~in"t~;E~;:;~~~;i:;;Qes.
UnttNo I'ri e I I
~ noD. moact Point
t.E..iU 0 NooeCollision
o Restrictions
Complied Wrth
o Restrictions Not
Complied Wit'"
O Compliance
Unknown
o ~~u~r::. -With 0 ~~~:r Pennsylvania
o Required. Non 0 Unknown
Compliance Compliance
o Required -
Compliance Unknown
o Restrictions
Complied With
a Restrictions Not
Complied With
O Compliance
Unknown
. Required ~ 0 Not a Pennsylvania
Complied Wtth Ofiver
o Requir~d ~ Non 0 Unknown
Compliance Compliance
o Required -
Compliance Unknown
o ~:~i~J~a;~~d for 0 Unk if eDL. or
COL Required
o No Valid license 0 Not a Pennsylvania
for Class OriV1i!r
_ ~~ License for 0 Unknown
..
-_s
eom_
. No Restrictionow'
Not Applicable
"
o
i Driver Endorsement
I ComDIiarn
-
.5
u
!
. None Required
Omr tiatnse
ComDIYnce
o Not Required 'for
Vehide Class
o No Valid License
for Class
. Valid Ucense for
Class
o Not Ucensed
DnHI Test TVl>8 0 Blood
~ . None 0 Urine
i Drua Test RttSults - (Uo to Four Results)
~ 0"= No Test Given 5 . Amphetamines
; ~ , = No ONg Reported 6 = pcp
I ,r 2 ... iVlariiuana 8 = Other
( 3 = Cocame 9 = Unknown Test
I 4 = Opiates Results
_1_ _ __ .e_
Unit No
~
_ Restrictions
CDmDIlance
. No Restriction51'
Not Applicable
I
1
"I
-
"E
"
= Endonement
D ,_
o None Required
Driverlicenso
ComDllimce
o Not Ucensed
DruG Test Tv'"
o None
o Blood
. Urine
DnIfl Test Results . IUD to Four Resu/rs)
0= No Test Given 5 = Amphetamines
1 = No Drug Reported 6 = pcp
2 = Mariiuana 8 . Other
3 = Cocame 9 = Unknown Test
4 ,. Opiates Results
r:=:-....J.:'.....!':':r~
o Not a Penm.ylllania
Driver
o Unknown
Compliance
o Unk if COlor
COL Required
O Not a Pennsylvan ia
-. Orivt!r .
o Unk.nown
o Other
O Unknown if Test
Given
~[QJ 0
DO
o Not a Pennsylvania
Driver
o Unknown
Compliance
o Other
O Unknown If Test
Given
~w 0
00
o Top
o Undercarriage
o Towed Unit
o Unknown
AvOidance Maneuver
. No Avoidance
Maneuver
a Braking. Skid
Marks Evident
Braking. No Skid
o Marks, Driver
Stated
Under Ride Indicator
. No Underride or
Override
Underride,
Compartment
Intrusion
o
Emeraencv Use
O Not in Emergency
Use
PrindDle ImoaCf Point
o Non-Collision
o Top
o Undercarriage
o Towed Unit
o Unknown
AtIOidance lWaMUVW
o No Avoidance
Maneuver
.. Braking - Skid
Marks Evident
Braking. No Skid
o Marks. Driver
Stated
Under Ride Indicator
000
Ol~ll 1201020
.09 030
00 040
07 06 050
o 0
O Braking. Other
Evidence
o Steering. Evidence
or Driver Stated
III
Other Avoidance I:
Maneuver il
"
I,
,
o
o
locondusive
r-l Steering and Braking
'--' Eviaence or Stated
o
Unknown
Underride, No
o Compartment
Intrusion
o OvelTide, Other
Vehide
o
Underride,
Compartment
Intrusion Unknown
Unknown it
Underride or
Override
I'
:1
II
Ii
,.
,
"
o
o
o
Lights Flashing
Siren Sounding
o
o
Both Ughts and
Siren
Unk.nown
0.0
01~11 IZ OIOZO
o 09 03 0
008 040
07 06 050
o 0
l- it
II
a Braking - Other
Evidence
o Steering. Evidence
or Driver Stated
o Other Avoidance
Maneuver
o Inconclusive
I
o Steering and Braking 0 Unknown
Evidence or Stated
No Underride or Underride, No o Override, Other
- o Compartment
Override Intrusion Vehide
Underride, Underride. Unknown if ~
0 Compartment o Compartment o Underride or
Intrusion Intrusion Unknown Override ~
\
Emeroencv Use OUghts Flashing o Both Ughrs and ~
o Not in Emergency Siren
Use a S\nm Sounding o Unknown -.J
:::t~\N~OT C~~'."
Cl1ambersburg
SfP 1 i) 200'1
Crash Numllar
FAr
I Clll'.19.~JJ:O;\l1l1iEA:'::1.; OF PE~1IiS,,{LVA\\llA
.;....J
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c.nm Bodv Time
a I\!ot AppUcoIlIo
o Van/Endosed Box
. Cargo Tank
~anIouJ Materia'
ayes eNo
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;
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U
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~
11
E
j
Carcro IIotIt1 Tvare
a Mot Applitable
a Van/Enclosed Box
o Cargo Tank
Haardoln ftAateri.l
o Yes ONo
1
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FOf',;'l at....<<::.=[1UIZ)
',=.-'u ~.
- '~~~-ofAxJes
I AI r<1 (CodtNunrblr.fAxhs
v ~ or""(aruninownJ
o Flat Bed
o Dump
o Concrete Mixer
o Auto Transport
o Garbago/Refuse
OSus
a Other/Unknown
Enter 1-digit hazardous material dass
'7 '7 "'V '7
DODD
DODD
~ ~ L'::.. ~
1 :; i\!Q Release 2 = Release Occurred 9 = Un~:nown
Number of Anles
CD (CodeNumborofAJdes
or"" f<< U1h'mcwnJ
a Flat Bed
o Dump
o Concrete Mixer
o Auto Transport
o GarbagelRofuH
o Bus
o Other/Unknown
Enter 1-c1igit hazardous material class
'7 'V" './ 'V
DODD
DODD
J"':'.... .L"',.. ~ ./"'...
, = i\!o Release 2 = Release Occurred 9 = Un~{nown
Page:
I ITm
. New
IIII~I~I m1lllm N
o Chango/
Continuation
, ""carri.r' Pho~' -
([2]]E)~-~
GVWR
~
o..r.i.. Load
o yes _No
o Unlmown
State Zip
[IE] ~ [[[0
PUO I
:1 ITIITIl
VehicJ. Confiaurat;on
o "ot Applicable
o Passenger Car . Only Record if
HazMat Placard Displayed
OUght Truck (Van. Mini-Van. Panel.
Pitkup or SUV with HazMat P\atilrd)
~Single Unit Truck (2 Axles. 6
11r..)
. Ingle Unit Truck (3 or More Axles)
o Single Unit True!( (Un!(nown
Number of Axles)
o Truc!tJTrailer{s)
f'i
o True!< Tractor lBobtaJQ j
. TractorIS.mi.TraiJer(s) ~
o MediumIHeavy Truck - Cannot II
Cassify Ij
o Smau Ikl5 (Stits ~15 Poop:.. I,
Including Driver) :1
Bus (Seats More Than 15 ~I.II
o People. Induding the Driver)
o Other 'I
o Un~nown il
Carrier Phone
(ITD~ITD"ITITI':
i,
i:
G~ i
ITIIrD I
Oversize load i
o yes 0 ~:o ~
State Zip 0 Unknown ~
IT] ITIITI [[[01
'I
fi
~
PUC'
VMid. Confiouration
a Not Applicable
o '~seng.r Car . Only Record if
HazM.t Placard Displayed
o Ugh< True. (Van. Mini-Van. Panel.
Pfaup or suv with HazMat Placard)
o Single Unit Truck (2 Axles, 6
Tires)
o Single Unit Trudt (3 or More Axles)
o SIngle Unit Truck (Un:mown
Number of Akles)
CJ TrucklTrailer(s)
o Truck Tractor (Bobtain I
d
o Tractor/Sem~Trallel'(s) :i
O Medium/Heavy Tntd . Gmnot : I
Classify , .
o Smalllkl5 (Seats ~15 .....Po". ,
Including Orivot) .
o Bus (Seats ~:"'" T11an 15
Peoplo. Indud!,,!! the Drlver)
o Other
o Unknot".1n
.J
::~;r~.;CT: =~?'..'
PENNSrATE
I!S Milton S. Hershey Medical Center
.. College of Medicine
en :i '~' t '_: -; ~_~ ~.'\Jj ~
tIer " "
J. ) '- 2110;
Patient Name: GRIFFIN, BRlANNA
PSUHMC MRN: 7000328
Emergency Department
Document
Not e
I
,
Final
ED SUMMARY
DATE OF SERVICE: 06/19/2004
CHIEF COMPLAINT: leg injurye
HISTORY OF PRESENT IllNESS: The patient was a 13-year-old rear seat passenger in an SUV that rolled after
colliding with a tractor trailer as per the Life Lion Paramedic. The patient was found to have a deformed left femur and
was tender in the pelvis. She had C!1e !V in f!!ght. Supp!ement2! oxygen was fully immobilized.
PAST MEDICAL HISTORY: Negative as per the Life Lion team along with meds and allergiese
FAMILY HISTORY: Not obtained due to the detailed trauma team response along with the social history and review of
systemse
PHYSICAL EXAM: She was a level one trauma team response in light of three simultaneous children and one adult who
were all part of the same motor vehicle crash. Her airway was patent and stable. The trauma team assessed equal
bilateral breath sounds and no obvious chest wall crepitus. She had a deformed left femure Orthopaedic surgery was
also present upon her arrivaL Dr. Meier, the Pediatric Trauma Surgery Attending was also present upon her arrivaL The
orthopaedic team and the trauma team slowly extended her left leg to be placed in the air traction splint for further
stabilization. She had pulses intact in all four distal limbs. Her left pelvis was tender. The right pelvis was not
Chest x-ray showed a normal mediastinum as per radiology with no obvious hemothorax or pneumothorax. Pelvic films
showed pelvic fractures of the left superior symphysis pubis. The left ischial tuberosity and questionable right sacroiliac
joint Plan was for CAT scanning of the brain, abdomen and pelvise Cervical spine films are also in progress. Trauma
labs were drawn e
PROCEDURE NOTE: I was present as the ED attending as the trauma surgery resident cleansed, utilized sterile
technique. Betadine preparation and cleansed the right groine He then punctured the right femoral artery withdrew blood
for blood gas and phlebotomy. He then tamponaded the areae The patienllolerated the procedure.
I deferred further management of the case to Dr. Meier of Pediatric Trauma Surgerye Please see his notes and the
trauma teams synopsis for results of her CAT scans and further films.
EXHIBIT
L
Date Printed: 9//412004
Time Printed: 1/: J I AM
I
PENNSTATE
!SI Milton S. ~ Medical Center
. College ofMediclne
(~~n_~.i(.i;:.:'; :
"::..'
no s, " 21l~'
., ee eiJ(j4
Patient Name: GRIFFIN, BRIANNA
PSUHMC MRN: 7000328
I
Operat
v e
Not e
Document
I
Modified
OPERA TrVE REPORT
DATE OF SERVICE: June 19, 2004
SURGEON: Kelly Vanderhave, MD
ASSISTANT: Thomas G, Harris, MD
PREOPERATIVE DIAGNOSIS:
1 , LefI closed femoral fracturee
2e Left closed radius fracture,
POSTOPERATIVE DIAGNOSIS:
PROCEDURES:
1 e Left intramedullary nailing of femur fracture,
2e Closed reduction left radius fracture, distal.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 200
IV FLUIDS: 700
URINE OUTPUT: 300
COMPLICATIONS: None,
DRAINS: None,
DISPOSITION: Stable to ICUe
INDICATIONS FOR PROCEDURE: Brianna Griffin is a 13-year-old who had a severe motor vehicle accident this
afternoon, She was involved in a collision with a semi. She suffered a wrist fracture, pelvis and mid-shaft femur fracture
that was amenable to an 1M nail. Her growth plates are closede Risks and benefits were explained to the parties involved,
and they agreed to proceed, This was an urgent procedure,
OPERATING ROOM COURSE: Patient was identified and correct operative site was initialed, and the lower extremity
was sterilely prepped and draped in the standard fashion, A gram of Ketzol was given prior to an incision being made,
The greater trochanter of the femoral was palpated, and a 3 cm incision was made just proximal to this, Care was taken
to bluntly dissect down to the piriformis fossa, and the guidepin was inserted into the piriformis fossa, This was over
drilled with a 13 mm reamer once it was inserted into the correct position, and a curved guidewire was advanced down the
medullary canal. The femur fracture was reduced using longitudinal traction and the curved guidewire was advanced to
the distal physeal scar. At this point, sequential reamers were used starting with an R5mm up to size 12 mm, and the
nail measured to be about 340 mm,
EXHIBIT
J~
Date Printed: 9//4/2004
Time Pn.nted: 11:11 AM
PENNSTATE
I!S Milton s. Hersb.ey Medical Center
... College of MediCine
-,
j. .....lYi'_
"
:1Cf ; ," inO/;
Patient Name: GRIFFIN, BRIANNA
PSUHMC MRN: 7000328
,
Operat
v e
Not e
Document
I
Modified
At this point, the exchange tube was used, the curved guidewire was removed. and a straight guidewire was placed, and
the intramedullary nail was advanced across the fracture site down to the physeal scare The fracture was nicely reduced
at this point. Two proximal locking screws were placede The distal locking screws were used with .freehand technique
using the perfect circles, and we chose to use one, given the fact that it was a stable transverse fracture above the
isthmuse Intraoperative xrays were obtainede
All the incisions were irrigated and closed with 2-0 Vicryl, and 4-0 PDSe Xeroform and sterile dressings were placed on
them afterwards.
Attention was then drawn to the left wrist. Longitudinal traction and closed reduction with dorsal manipulation was
performed, and the radius was found to be in good alignment. A sugar-tong splint was applied, and the fracture was
found to be in good position on both the AP and lateral fluoroscopic viewse
There were no complications encountered in the case. The patient was transferred to her leu bed, and then eventually
transferred to the ICU. DL Kelly Vanderhave was present for the entire procedure.
#475187
Review/Sign: Thomas G Harris, MD
Review/Sign: Kelly L Vanderbave, MD
Assistant Professor, Pediatric Orthopaedic Surgery
Penn State Milton Se Hershey Medical Center
PO Box 850, Hershey, P A 17033
(717) 5314653
Review/Sign: Kelly L Vanderbave, MD
Assistant Professor, Pediatric Orthopaedic Surgery
Penn State Milton Se Hershey Medical Center
PO Box 850, Hershey, P A 17033
(717) 5314653
TGH/CJK DD: 06/21/04 DT: 06/21/04 09:36
Date Pn'nted: 9/14/2004
Time Printed: 11.' II AM
PENNSTATE
IS Milton S. Hershey Medical Center
. College of Medicine
(""l~:;,ni_r'..::.\ ~,'i~'l!(g
lCl!i: 20U4
Penn State Milton S. Hershey Medical Center
Penn State College of Medicine
Health [nformation Services, HU24
500 University Drive
PeO. Box 850
Hershey. PA 17033-0850
Tel: (717) 531-8055
Patient Name:
Patient Sex:
Patient Location:
Visit Type:
GRIFFIN. BRJANNA
Female
7MBS. 7236. 01
Inpatient
PSUHMC MRN:
Date of Birth:
Visit Number:
7000328
9/8/1990
6500193
I
Operat
v e
Not e
Document
I
Modified
OPERATIVE REPORT
DATE OF SERVICE: 06/28/2004
SURGEON: David Wallach. MD
ASSISTANT: Derek Miller. MD
OPERATION PERFORMED: Closed reduction, percutaneous pinning of left distal radius fracturee
ANESTHESIA: General/Dr. Fehr.
BLOOD LOSS: MinimaL
IV FLUIDS: 800 cc lactated Ringerse
INDICATIONS: Brianna is a 13-year-old female who was involved in a motor vehicle accident and had severe diesel
burns at multiple locations and she also had a fracture of her left femur and a left pelvic fracture. It was revealed to us
that she had a displaced left distal radius fracture and ulnar styloid fracture. After a thorough discussion of the possible
risks and benefits with her family, they elected for her to go to the Operating Room to undergo a closed reduction,
percutaneous pinning of her left distal radiuse
PROCEDURE: Brianna was identified in the Intensive Care Unit by the Department of Anesthesia and by Dr. Wallach
and transferred by the Department of Anesthesia to the Operating Room. A closed reduction of her left distal radius
fracture was performed and adequate fracture alignment was obtained, using fluoroscopy. It was felt that, due to the
nature of her fracture, that she would require additional stability and underwent a percutaneous pinning of her left distal
radius fracture, utilizing two Oe062 smooth K-wires, which obtained bicortical fixation and adequate placement of the pins
and the fracture alignment was verified with fluoroscoPYe The pins were then cut and bent and a sterile dressing was
applied and a plaster sugar tong splint
The patient tolerated the procedure well and was transferred to the Recovery Room in stable condition by the Department
of Anesthesia e
EXHIBIT
\-E-
Dale Printed: 9/14/2004
Time Printed: /1:1 J A.M
PENNSTATE
IS Milton s.!Jershey Medical Center
. College of MediCine
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Patient Name: GRIFFIN, BRIANNA
PSUHMC MRN: 7000328
I
Ope rat
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Document
I
Modified
#483219
Review/Sign: Derek W Miller, MD
Review/Sign: David M \Vallach, MD
Review/Sign: David M Wallach, MD
DWM NSC DD: 06/28/04 DT: 06/28/04 17:23
Date Pn'nted: 9//4/2004
Time PnOnted; J J: 1 J AM
PENNSTATE
IS Milton S. Hershey Medical Center
.. College of Medicine
f"'-~; ~-'. ~ r', Co, {~;' ~. .....-(if 9
'lCT " i:5 2004
Patient Name: GRIFFIN, BRIANNA
PSUHMC MRN: 7000328
I
Musculoskeletal
Study
I
Final
CT UPPER EXTREMITY WITHOUT CONTRAST - PED
PATIENT NAME: GRIFFIN, BRIANNA
PATIENT MRN:07000328
PATIENT DOB: 09/08/1990
EXAM DATE OF SERVICE: 06/29/2004
EXAM NUMBER: 369693
ORDERING PHYSICIAN: MEIER, ANDREAS
CT of the distal left wTist with rc(:onstructioJLs
Clinical history: I3-year-old female status post multI-trauma with left wrist fracture or. status post ORIFe
Technique: Since the patient was in an angulated long arm cast, the original image data was acquired in the oblique plane and
reconstructed in the axial, coronal, and sagittal planese
Discussion: There is an intra-articular, connninuted, slightly impacted fracture of the distal left radius, There are two pins extending
through the radial fracture fragment without hardware complication notede The fracture extends entirely across the radius in the
coronal planee There is dorsal angulation of the distal fracture fragments with the dorsal fragment slightly overlying the posterior
radiuse There is approximately 3eO mm separation of the distal intra-articular fragments on the sagittal reconstructions (image #22145)e
The entire articular surface of the distal radius is displaced dorsally by approximately two millimeterse
Note is also made of an ulnar styloid fracturee The carpal bones are satisfactory aligned,
Impression:
I e Pinning of an intra-articular, comminuted, slightly impacted fracture of the distal left radius as described aboR
2e Ulnar styloid fracturee
Dr. Rebecca Sivarajah is the dictating resident.
Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the
interpretatione Preliminary reports may not have been reviewed as yet by the attending radiologist
DICTATED: BOAL, DANIELLE
REVIEWED AND SIGNED: BOAL, DANIELLE 1
DATE DRAFTED: 06/2912004 IO:IOAM
DATE OF FINAL SIGNATURE: 06/30/2004 04:14 PM
EXHIBIT
IJ
Date Printed: 9/11/2004
Time Printed: 11: I J AM
PENNSTATE
!.S Milton s.!IersIJey Medical Onter
. College of Medidoe
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Patient Name: GRIFFIN, BRIANNA
PSUHMC MRN: 7000328
Musculoskeletal
Study
~
Final
PORTABLE X-RAY WRIST 1-2 VIEWS LEFT - PEDS
PATIENT NAME: GRIFFIN, BRJANNA
PATIENT MRN:07000328
PATIENT DaB: 09/08/1990
EXAM DATE OF SERVICE: 06/28/2004
EXAM NUMBER: 368882
ORDERING PHYSICIAN: WALLACH, DAVID
!'.1ultiple portable matrix ;"icw:; during that reduction vf a cviiimmutcd left ~Ti5t fraaure followed by portable AP (lnd lalerai views of
the wrist at 1430 hrse
On the final radiographs two K-wires traverse the comminuted mildly impacted intra-articular fracture of the distal radiuse The radial
styloid is held in satisfactory position and aligmnent by the two crossing in K-wires. There is only minor dorsal angulation of the
articular surface with respect to the shaft. Computed tomography ofthe wrist is to be yet performed for further evaluation of the intra-
articular component of the fracture.
DICTATED: BaAL, DANIELLE
REVIEWED AND SIGNED: BaAL, DANIELLE /
DATE DRAFTED: 06/29/2004 03:23 PM
DATE OF FINAL SIGNATURE: 06/29/2004 03:23 PM
Drzte Printed: 9//4/2004
Time Printed: J J: J J AM
. PENNSTATE
IS Milton s. Hershey Medical Center
., College of Medicine
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Patient Name: GRIFFIN, BRIANNA
PSUHMCMRN: 7000328
I
Musculoskeletal
Study
I
Final
X-RAY FEMUR LEFT - PEDS
PATIENT NAME: GRIFFIN. BRIANNA
PATIENT MRN:07000328
PATIENT DaB: 09/08/1990
EXAM DATE OF SERVICE: 06/26/2004
EXAM NUMBER: 367177
ORDERING PHYSICIAN: MEIER, ANDREAS
Post tr::u.:r'~. Rudiographs of the left femur and pelvis.
AP and lateral views of the left femur following fixation. A single intramedullary rod extends the length of the shaft of the femure
Mildly comminuted transverse fracture of the proximal portion of the femur is in satisfactory position and alignment with slight lateral
displacement of a small fragment ofofbonee Two screws maintain the rod at the subtrochanteric region and a single screw traverses
the distal portion of the rod at the metadiaphysise
Impression: Satisfactory appearance following open reduction and fixation of proximal femoral fracture with intramedullary rod,
AP, inlet, and outlet views of the pelvis are compared to prior imaging studies
Mildly comminuted fractures involving the superior and inferior left pubic ramii lateral to the symphysis are in satisfactory and
Wlchanged position and alignment. There are fractures involving the right and left body of the sacrum better demonstrated on CT but
evident due to the distortion of the sacral foramina on tOllay'S radiographs. The fracture involving the superior medial aspect of the
right ilium is not appreciated radiographically but is present on the CT, The SI joints are symmetric and within nonna1limitse No
other abnonnalities appreciated,
Impression: Pelvic fractures as described
DICTATED: BaAL. DANIELLE
REVIEWED AND SIGNED: BaAL, DANIELLE /
DATE DRAFTED: 06/27/2004 01:09 PM
DATE OF FINAL SIGNATURE: 06/27/2004 01:09 PM
Dale Printed: 9/14/1004
Time Printed: 1/: I J AM
PENNSTATE
!is Milton s.!Iersbey Medical Center
.. College of Medicine
(:'h,JT;; ,;:~ ' ",'lJ'!)
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Patient Name: GRIFFIN, BRIANNA
PSUHMC MRN: 7000328
Musculoskeletal
Study
,
Final
X-RAY WRIST 1-2 VIEWS LEFT - PEDS
PATIENT NAME: GRIFFIN. BRIANNA
PATIENT MRN:07000328
PATIENT DOB: 09/08/1990
EXAM DATE OF SERVICE: 06/2612004
EXAM NUMBER: 367178
ORDERING PHYSICIAN: MEIER, ANDREAS
AP :md lateral views of the left "\-TIst and plaster. The mildly comminuted intra-artkillar fracture of the distal radiU3 ShvW3 m.ild
lateral displacement of the distal fragment and slight dorsal angulatione Overlying plaster obscures detait
Impression: Mild lateral and dorsal displacement and angulation respectively of the distal intra-articular radial fracturee
DICTATED: BOAL,DA}ijELLE
REVIEWED AND SIGNED: BOAL, DANIELLE /
DATE DRAFTED: 06/26/200412:27 PM
DATE OF FINAL SIGNATURE: 06/26/200412:27 PM
Dnte Printed: 9//4/1004
Time Printed: 11: I J AM
C he: II'; ~.: .'~~~;. S ~~,t~ r 9
PENNSTATE
IS Milton S. ~ Medical Center
. CoDege of Medicine
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Patient Name: GRIFFIN, BRlANNA
PSUHMCMRN: 7000328
I
Musculoskeletal
Study
~
Final
PORTABLE X-RAY FOREARM LEFT - PEDS
PATIENT NAME: GRIFFIN. BRlANNA
PATIENT MRN:07000328
PATIENT DOB: 09/08/1990
EXAM DATE OF SERVICE: 0611912004
EXAM NUMBER: 358917
ORDERING PHYSICIAN: MEIER, ANDREAS
Port::lblc AP and lateral views Df the left foreann pvst traW"1l<i.
There is a comminuted, mildly impacted and dorsally angulated intra-articular fracture of the distal radiuse There is a small
nondisplaced fracture of the ulnar styloid as well. The remainder of the bony and soft tissue structures are normal on the elbow
through wrist.
Impression: Fractures of the distal radius and ulna as described
DICfATED: BOAL, DANIELLE
REVIEWED AND SIGNED: BOAL. DANIELLE 1
DATE DRAFTED: 06/22/2004 09:33 AM
DATE OF FINAL SIGNATURE: 06/22/200409:33 AM
Dale Printed: 9/1412004
Time Printed: II.' 11 AM
PENNSTATE
IS Milton s.~ Medical Center
., College of Medicine
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Patient Name: GRIFFIN, BRIANNA
PSUHMC MRN: 7000328
Musculoskeletal
Study
I
Final
PORTABLE X-RAY WRIST 1-2 VIEWS RIGHT - PEDS
PATIENT NAME: GRIFFIN, RRIANNA
PATIENT MRN:070oo328
PATIENT DaB: 09/08/1990
EXAM DATE OF SERVICE: 06/21/2004
EXAM NUMBER: 359165
ORDERING PHYSICIAN: MEIER, ANDREAS
P~liabl~ radiugraph:; of the right wrist amI purtabit:: AF supine film of the chest at 0615 hrs. Trauma.
Right wrist: There is soft tissue swelling over the ulna aspect of the wrist and distal foreann. The bones are normaL I see no
evidence of fracture dislocation in the visualized structures of the wrist and distal foreanne
Portable AP supine film of the chest excludes the extreme IWlg apices. The visualized bony and soft tissue structures are normaL
Heart and mediastinum are normaL The lungs are unifonnIy at aerated and free of diseasee Visualized upper abdomen is normaL
Impression: Soft tissue swelling over ulna aspect of right wrist.
Nonnal chest
DICTATED: BaAL, DANIELLE
REVIEWED AND SIGNED: BaAL, DANIELLE /
DATE DRAFTED: 06/21/2004 10:37 AM
DATE OF FINAL SIGNATURE: 06/21/2004 10:37 AM
Date Printed: 9//4/2004
Time Printed: J J.' J J AM
PENNSTATE
IS Milton S. Ha:shey Medical Center
. College of Medicine
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Patient Name: GRIFFIN, BRIANNA
PSUHMC MRN: 7000328
I
Musculoskeletal
Study
t
Filial
PORT ABLE X-RAY WRIST 1-2 VIEWS LEFT - PEDS
PATIENT NAME: GRIFFIN, BRIANNA
PATIENT MRN:07000328
PATIENT DOB: 09/08/1990
EXAM DATE OF SERVICE: 06/19/2004
EXAM NUMBER: 358954
ORDERING PHYSICIAN: V ANDERHA VB, KELLY
X-RAY PORTABLE FEivIUR-PEDIA TRIC
Jooe 20. 2004
2005 hrs
CLINICAL HISTORY: Multiple trauma status post intramedullary nail ofIeft femur, status post femur fracture
COMPARISON STUDY: 6/19/2004
FINDINGS: Intra-operative matrix films of the lefr femur demonstrate placement of the intramedullary rod transfixing the mid left
femur fracture which is comminutede There is now good anatomic alignment The intramedullary rod is transfixed proximally by two
threaded screws, and distally by a single threaded screWe There is no complication of the orthopedic hardwaree Surgical skin staples
are seen in the medial aspect of the left thigh.
IMPRESSION: Status post intramedullary nail insertion transfixing a previously described left ferrrur fracturee There is near
anatomic aligrunent No complication is seen radiographically.
X-RAY PORT ABLE LEFT WRIST -PEDIATRIC
Jooe 20, 2004
2050 hrs
CLINICAL HISTORY: Left wrist fracture
COMPARISON STUDY: 6/19/2004
FINDINGS: AP and lateral views of the left wrist was obtained on matrix film. The patient is now in a cast, which obscures fine
bony detail. The previously described comminuted fracture of the left distal radius now demonstrates near anatomic alignment The
intra-articular component of the distal radial fracture can be seen with lucency along the poster lateral aspect of the left distal radius.
There is no significant distraction of the fracture fragments.
IMPRESSION: Status post closed reduction ofa left wrist fracture as described above.
DICTATED: HULSE, MICHAEL
REVIEWED AND SIGNED: HULSE, MICHAEL /
DATE DRAFTED: 06/20/2004 03:05 PM
DATE OF FINAL SIGNATURE: 06/20/2004 03:12 PM
Date Printed: 9/14/2004
Time Printed: J 1: /1 AM
PENNSTATE
IS Milton s.!!eJ:shey Medical Center
., College ofMediclne
Jcr ) ,~ 2Qui
Patient Name: GRIFFIN, BRIANNA
PSUHMC MRN: 7000328
Chest
Study
I
Filial
X-RAY CHEST PA AND LATERAL VIEWS - PEDS
PATIENT NAME: GRIFFIN, BRIANNA
PATIENT MRN:070oo328
PATIENT DOB: 09/08/1990
EXAM DATE OF SERVICE: 06/24/2004
EXAM NUMBER: 364830
ORDERING PHYSICIAN: MEIER, ANDREAS
X-RAY CHEST-PEDIATRIC
June 24, 2004
j400hl'S
CLINICAL HISTORY: Status post multiple trauma with decreased breath sounds and increased oxygen requirements
DISCUSSION: Comparison is made to the prior examination from 6/2I/2oo4e
An AP supine view the chest demonstrates bilateral alveolar opacities, sparing the upper lobes, The cardiac silhouette is normal in
size, There is no evidence of pleural effusione
IMPRESSION: Bilateral alveolar opacities query hydrocarbon aspiration/pneumonitis
DICTATED: HULSE, MICHAEL
REVIEWED AND SIGNED: HULSE, MICHAEL /
DATE DRAFfED: 06/24/2004 05:41 PM
DATE OF FINAL SIGNATURE: 06/24/2004 05:41 PM
Date PnOnted: 9//4/2004
Time Printed: /1: J 1 AM
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PENNSTATE
!SI Milton S. HerslJey Medical Center
. College of Medicine
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Patient Name: GRIFFIN. BRIANNA
PSUHMC MRN: 7000328
I
Chest
Study
I
Final
PORTABLE X-RAY CHEST P A OR AP VIEW- PEDS
PATIENT NAME: GRIFFIN. BRIANNA
PATIENT MRN:07000328
PATIENT DOB: 09108/1990
EXAM DATE OF SERVICE: 0612112004
EXAM NUMBER: 359264
ORDERING PHYSICIAN: MEIER, ANDREAS
Portable radiograph.5 of th~ right wrist and portable AP ~UpillC film ul the chesi ai 061.5 firs. Trauma.
Right wrist: There is soft tissue swelling over the ulna aspect of the wrist and distallorearm. The bones are normal. I see no
evidence of fracture dislocation in the visualized structures of the wrist and distal forearm
Portable AP supine film of the chest excludes the extreme lung apices. The visualized bony and soft tissue structures are normal.
Heart and mediastinum are normaL The lungs are uniformly at aerated and free of diseasee Visualized upper abdomen is normaL
Impression: Soft tissue swelling over ulna aspect of right wrist
Normal chest
DICTATED: BOAL, DANIELLE
REVIEWED AND SIGNED: BOAL, DANIELLE 1
DATE DRAFTED: 061211200410:37 AM
DATE OF FINAL SIGNATURE: 0612112004 10:37 AM
Date Printed: 9/14/2004
Time Printed: II: J J AM
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PENNSTATE .
E5I Milton S. Hershey Medical Center
., College of Medicine
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Patient Name: GRIFFIN, BRIANNA
PSUHMC MRN: 7000328
,
Pel v
s I G U
Study
,
Final
X.RA Y PELVIS 3 OR MORE VIEWS. PEDS
PATIENT NAME: GRIFFIN, BRIANNA
PATIENT MRN:07000328
PATIENT DOB: 09/08/1990
EXAM DATE OF SERVICE: 06/26/2004
EXAM NUMBER: 367176
ORDERING PHYSICIAN: MEIER, ANDREAS
Post tramna. R:ldiographs of th~ left femur and pch-is.
AP and lateral views ofth. left femur following flXatiOne A single intramedullary rod extends the length of the shaft of the femur.
Mildly connninuted transverse fracture of the proximal portion of the femur is in satisfactory position and alignment with slight lateral
displacement of a small fragment of of bone. Two screws maintain the rod at the subtrochanteric region and a single screw traverses
the distal portion of the rod at the metadiaphysise
Impression: Satisfactory appearance following open reduction and fixation of proximal femoral fracture with intramedullary rod.
AP, inlet, and outlet views of the pelvis are compared to prior imaging studies
Mildly connninuted fractures involving the superior and inferior left pubic ramii lateral to the symphysis are in satisfactory and
unchanged position and alignment There are fractures involving the right and left body of the sacrum better demonstrated on CT but
evident due to the distortion of the sacral foramina on today's radiographs. The fracture involving the superior medial aspect of the
right ilium is not appreciated radiographically but is present on the CTe The SI joints are synunetric and within normal limits. No
other abnormalities appreciated.
Impression: Pelvic fractures as described
DICTATED: BOAL, DANIELLE
REVIEWED AND SIGNED: BOAL, DANIELLE /
DATE DRAFTED: 06/27/2004 01:09 PM
DATE OF FINAL SIGNATURE: 06/27/2004 01:09 PM
Date Printed: 9//4/1004
Time Printed: 1/: // AM
..."
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PENN STATE
!is Milton S. ~ Medical Center
.. College of Medicine
;'j,_.e;
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Patient Name: GRIFFIN, BRlANNA
PSUHMC MRN: 7000328
I
Pel V
s I G U
Study
~
Final
CT PELVIS WITHOUT CONTRAST-PED
PATIENT NAME: GRIFFIN. BRlANNA
PATIENT MRN:07000328
PATIENT DOB: 0910811990
EXAM DATE OF SERVICE: 06/24/2004
EXAM NUMBER: 364990
ORDERING PHYSICIAN: MEIER, ANDREAS
CT of the pelvis.
Clinical history: 13-year-old female with multiple pelvic fractures and decreasing hematocrit
Technique: Routine unenhanced helical CT the pelvis.
Discussion: Comparison study is dated June 19 70,004.
There are comminuted fractures involving the superior and inferior pubic ramus on the left. There is moderate sized hematoma within
the anterior compartment of the proximal left thigh. The proximal aspect of the intramedullary rod is noted within the left femur:
There is buckling of the anterior cortex of the superior right side of the sacrum adjacent to the sacroiliac joint. There""s also a linear
fracture through the posterior margin of the right iliac wing extending into the posterior articular surface of the SI joint This suggests
a fracture of the sacrum extending through the SIjoint to involve the poster iliac winge There is no significant diastasis of the
sacroiliac joints and soft tissues are unremarkable in appearance. There is a fracture line extending through the sacral ala on the left
side of the sacrum There is no significant free fluid to account for the patients decreasing hematocrit There is some straightening of
the subcutaneous soft tissues likely related to the patient''''s chemical burns suffered during a traumatic incident or it
Impression: Comminuted fractures of the superior and inferior pubic ramus on the left and sacral fractures as describede
Dr. Daniel Je O'Shea is the dictating resident
Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the
interpretatione Preliminary reports may not have been reviewed as yet by the attending radiologist
DICTATED: HULSE, MICHAEL
REVIEWED AND SIGNED: HULSE, MICHAEL /
Date Printed: 9/14/2004
TimePrinted: 11:/1 AM
-I
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-~
PENNSTATE
ED Milton S. ~ Medical Carter
., Co1lege of Medicine
:lr.r ~;.'i 7011,
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Patient Name: GRIFFIN, BRlANNA
PSUHMC MRN: 7000328
I
Pelvis/GU
Study
I
Final
DATE DRAFTED: 06/24/2004 03:46 PM
DATE OF FINAL SIGNATURE: 06/2712004 12:05 PM
Dale Pn'nted: 9/14/1004
Time Printed: J J.. 11 AM
.-" ~'. c'".'~_; ~~
PENNSTATE
IS Milton S. Hershey Medical Center
., College of Medicine
il.. f dil.i~
Patient Name: GRIFFIN. BRIANNA
PSUHMC MRN: 7000328
I
H e a d
I
Nee k
Study
~
Final
CT HEAD WITHOUT CONTRAST PED
PATIENT NAME: GRIFFIN, BRIANNA
PATIENT MRN:07000328
PATIENT DOB: 09/08/1990
EXAM DATE OF SERVICE: 06/1912004
EXAM NUMBER: 358818
ORDERING PHYSICIAN: SALNESS. KYM
CT HEAD
CT OF THE CERvlCAL SPINE WITH RECONSTRUCTIONS
THORACOLUMBAR SPINE RECONSTRUCTIONS
CLINICAL HISTORY: Motor vehicle accident
TECHNIQUE: Routine, unenhanced CT of the head and cervical spine was performed, with head images digitally filmed in brain and
bone windows. Coronal and sagittal reconstructions of the thoracolumbar spine were perfonned from the existing datae
HEAD CT: Noted are nasogastric and endotracheal tubes. The brain parenchyma is unremarkable, without evidence of mass, mass
effect, hemorrhage or infarct The lateral ventricles are slightly enlarged, without evidence of hydro cephal USe The visualized orbits
and periorbital structures are nonnaL The visualized paranasal sinuses and mastoid air cells are patent
CERVICAL SPINE: The cervical vertebrae are nonnal in height and alignment, without fracture or subluxation. The prevertebral soft
tissues are unremarkable,
CERVICAL SPINE RECONSTRUCTIONS: The cervical vertebrae are again noted to be nonnal in height and alignment, without
evidence of acute fracture or subluxation. Incidentally noted are consolidated changes and loss of aeration within the right apexe
THORACOLUMBAR SPINE: There is mild straightening of the thoracic spine. Incidentally noted are bilateral fractures through the
sacral ala, with widening of the SI joints bilaterally and fracture of the left superior and inferior pubic rami. No vertebral fractures are
noted.
IMPRESSION
I e No radiographic evidence of acute traumatic injury to the cervical or thoracolwnhar spinese
2. Enlarged lateral ventricles, of unclear etiology, likely congenital, without evidence of hydro cephal uSe
3 e Incidentally noted sacral and pubic rami fractures, as noted abovee
Dr. James H. Birkholz is the dictating resident
Date Printed: 9/14/2004
Time Printed: 11:1 JAM
"~, " ,;1', 'J
PENNSTATE
I!S Milton S. ~ Medical Carter
., College of Mediclne
ilCT ;),~ ((Hi.
Patient Name: GRIFFIN, BRIANNA
PSUHMCMRN: 7000328
I
H e a d
I
Nee k
Study
I
Final
Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the
interpretarione Preliminary repor'''' may not have been reviewed as yet by the attending radiologist
DlcrATED: iviCNAivIARA, KEVIN
REVIEWED AND SIGNED: MCNAMARA, KEVIN I BIRKHOLZ, JAMES
DATE DRAFTED: 06/19/2004 02:54 PM
DATE OF FINAL SIGNAI'URE: 06/20/2004 06:36 AM
Date Printed: 9/1412004
TimePn'nted: I/:I/ AM
PENNSTATE
!S Milton S. ~ Medical Center
. College of Medi<;ne
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Patient Name: GRIFFIN, BRIANNA
PSUHMC MRN: 7000328
I
Pel V
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Document
I
Final
X-RAY PELVIS AP 1-2 VIEWS - PEDS
PATIENT NAME: GRIFFIN. BRIANA
PATIENT MRN:07000328
PATIENT DOB: 09108/1990
EXAM DATE OF SERVICE: 06/19/2004
EXAM NUMBER: 358849
ORDERING PHYSICIAN: KIMAK, MARK
CERVICAL SPINE SERIES, PORTABLE AP CGt, PORT ABLE PEL ViS FRONTAL 'v'IEW ONLY, FRONTAL AND LA TERAL
PROJECTIONS OF THE LEFT FEMUR
CLINICAL INFORivIATION: MULTIPLE TRAIJMA
COMPARISON STUDY: There are no comparison studiese
FINDINGS: Cervical spine: The alignment is intact to the level ofC7 without spondylolisthesis or radiographic evidence offraclUre.
C7 - T1 are not adequately evaluatede There is no precervical soft tissue swellinge The vertebral body height and intravertebral disc
spaces are maintained. On the odontoid view the tip of the dens and lateral masses are obscured. On the frontal projection there is
mild widening of the left C6-C7 uncovertebral joint. This may be due to rotation of the patient or lateral flexion of the neck at this
leveL This should be further evaluated with CT. A CT is reconnnendede
CXR: The lungs are cleare The mediastinum is not proment for techniquee The soft tissues and bones are unremarkable.
PELVIS: There is a comminuted fracture of the left superior and inferior pubic ramuse There is mild irregularity in the right sacrum
which may represent an associate sacral fracture. The pubic symphysis is not widened, There is associated prominence of the soft
tissues above the left superior pubic ramus consistent with a hematoma. The hips are nonnally located. No other definite fractures are
identified. Evaluation is obscured by overlying artifact from the trauma board.
PELVIS, 3 VIEWS: There has been placement ofa right femoral line with its tip at the level ofD. Inlet and outlet views
demonstrate the aforementioned left superior and inferior pubic rami fractures as well as irregularity in the bilateral sacral ala
consistent with buckle fractures. Please correlate with a CT report. On the outlet views there appears to be widening of the left
sacroiliac joint. There is contrast in the bilateral kidneys and collecting systems. There is a Foley catheter in the bladder. The
hematoma associated with the left pubic rami fractures is again appreciated. The bowel gas pattern is nonobstructed.
LEFT FEMUR: There is a comminuted fracture at the junction of the proximal and middle thirds of the left femur with one shaft
width medial and two shaft widths posterior displacement of the distal fragment. The femoral head is located and the alignment of the
knee is grossly intact. Again noted is the comminuted fracture of the inferior and superior left pubic ramie
IMPRESSION: I. Inadequate evaluation ofCI-2 and widening of the left portion of the C6-7 uncovertebraljoint a CT is
recommended to exclude a fracturee
2e There is no radiographic of acute cardiopulmonary disease.
3e Left superior and inferior pubic rami fractures with associated hematoma.
Date Printed: 9/14/1004
Time Printed: 11: J I AM
Ci~.,-t.
" .' -."", - '. '. ~-
PENNSTATE
IS Milton s.!Iersltey Medical Carter
., College of MediCine
'1p .'
" .." "J'J'
., 'e e{ l"
Patient Name: GRIFFIN, BRIANNA
PSUHMC MRN: 7000328
Pel V
s
I
G U
Document
I
Final
4, Irregularity in the bilateral sacral ala consistent with sacral fractures with widening of the left SI joint
5, Comminuted displaced proximal left femoral fracturee
Dre Edward J, Borman is the dictating resident
Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the
interpretatione Preliminary reports may not have been reviewed as yet by the attending radiologist
DICTATED: HULSE, MICHAEL
REVIEWED AND SIGNED: HULSE, MICHAEL /
DATE DRAFTED:
DATE OF FINAL SIGNATURE: 06/1912004 01:25 PM
- ~ ....
Date Printed: 9/1412004
nme Printed: 11: II AM
:.;.~
PENNSTATE
IS Milton s. Hershey Medical Center
., College of Medicine
del eO '( rt)'
'"J '0. /1 ',I
;- " .<' '--' ~.l: tJ';!
Patient Name: GRIFFIN, BRIANNA
PSUHMC MRN: 7000328
I
Pel V
s
I
G U
Document
,
Final
X-RAY PELVIS 3 OR MORE VIEWS - PEDS
PATIENT NAME: GRIFFIN, BRIANNA
PATIENT MRN:07000328
PATIENT DOB: 09/08/1990
EXAM DATE OF SERVICE: 06/2612004
EXAM NUMBER: 367176
ORDERING PHYSICIAN: MEIER, ANDREAS
Po<;;;t tr!'.lIma. Radiographs of the left femur and pelvis,
AP and lateral views of the left femur following fixatione A single intramedullary rod extends the length of the shaft of the femur.
Mildly comminuted transverse fracture of the proximal portion of the femur is in satisfactory position and aligmnent with slight lateral
displacement of a small fragment of ofbonee Two screws maintain the rod at the subtrochanteric region and a single screw traverses
the distal portion of the rod at the metadiaphysis.
Impression: Satisfactory appearance following open reduction and fixation of proximal femoral fracture with intramedullary rode
AP, inlet, and outlet views of the pelvis are compared to prior imaging studies
Mildly comminuted fractures involving the superior and inferior left pubic ramii lateral to the symphysis are in satisfactory and
unchanged position and aligmnenl. There are fractures involving the right and left body of the sacrum better demonstrated on CT but
evident due to the distortion of the sacral foramina on today's radiographs. The fracture involving the superior medial aspect of the
right ilium is not appreciated radiographically but is present on the CTe The SI joints are symmetric and within normallimils. No
other abnormalities appreciated.
Impression: Pelvic fractures as described
DICTATED: BOAL, DANIELLE
REVIEWED AND SIGNED: BOAL, DANIELLE /
DATE DRAFTED: 06/27/2004 01:09 PM
DATE OF FINAL SIGNATURE: 06/27/2004 01:09 PM
Date Printed: 9/14/1004
Time Printed: 1 I: 11 AM
r";'r
",'t",..
", ,
'.,;'
PENNSTATE
!S Milton S. ~ Medical Center
., College ofMedidne
:lr r i
,.~ 'l.'i\;
- '.t,lil..
Patient Name: GRIFFIN, BRIANNA
PSUHMC MRN: 7000328
I
Pel V
s
I
G U
Document
I
Final
CT PELVIS \\'lTHOUT CONTRAST-PED
PATIENT NAME: GRIFFIN, BRIANNA
PATIENT MRN:07000328
PATIENT DOB: 09/08/1990
EXAM DATE OF SERVICE: 06/24/2004
EXAM NUMBER: 364990
ORDERING PHYSICIAN: MEIER, ANDREAS
CT of h~e pelvis.
Clinical history: l3-year-old female with multiple pelvic fractures and decreasing hematocrit
Technique: Routine unenhanced helical CT the pelvise
Discussion: Comparison study is dated June 19 70,004.
There are comminuted fractures involving the superior and inferior pubic ramus on the left. There is moderate sized hematoma within
the anterior compartment of the proximal left thigh. The proximal aspect of the intramedullary rod is noted within the left femur:
There is buckling of the anterior cortex of the superior right side of the sacrum adjacent to the sacroiliac joint. There""s also a linear
fracture through the posterior margin of the right iliac wing extending into the posterior articular surface of the SI joint. This suggests
a fracture of the sacrum extending through the SIjoint to involve the poster iliac winge There is no significant diastasis of the
sacroiliac joints and soft tissues are unremarkable in appearance. There is a fracture line extending through the sacral ala on the left
side of the sacrum There is no significant free fluid to account for the patients decreasing hematocrit. There is some straightening of
the subcutaneous soft tissues likely related to the patient''''s chemical burns sutTered during a traumatic incident or it
Impression: Comminuted fractures of the superior and inferior pubic ramus on the left and sacral fractures as describede
Die Daniel J. O'Shea is the dictating resident.
Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the
interpretatione Preliminary reports may not have been reviewed as yet by the attending radiologist
DICTATED:HULSE,MUCHAEL
REVIEWED AND SIGNED: HULSE, MUCHAEL /
Date Printed: 9/14/2004
Time Printed: 11:11 AM
PENNSTATE
!S Milton s.!Jersbey Medical Center
., College of Medicine
(~;~ ;-,' ~'l; '.-\
,f,:CT ":,~ 2t1n4
Patient Name: GRIFFIN, BRlANNA
PSUHMC MRN: 7000328
I
Pel V
s
I
G U
Document
I
Final
DATE DRAFfED: 06/24/2004 03:46 PM
DATE OF FINAL SIGNATURE: 06/27/2004 12:05 PM
Date Pn'nted: 9/1412004
Time Printed: //:11 AM
'. .':, ':. ,~'.' ~;.;-'
PENNSTATE
IS Milton s. Hershey Medical Center
.. College of MediCine
leT; ,\ 2004
Patient Name: GRIFFIN, BRIANNA
PSUHMCMRN: 7000328
I
Abdom
n a I
I
GI
Document(s)
I
Final
CT ABDOMEN WITH CONTRAST-PED
PATIENT NAME: GRIFFIN, BRIANNA
PATIENT MRN:07000328
PATIENT DOB: 09/08/1990
EXAM DATE OF SERVICE: 06/19/2004
EXAM NUMBER: 358822
ORDERING PHYSICIAN: SALNESS. KYM
CT OF THE ABDOMEN AND PEL VTS
CLINICAL HISTORY: Motor vehicle accident.
TECHNIQUE: Routine CT of the abdomen and peh;s was perfonned utilizing oral and IV contrast. Images were digitally filmed in
soft tissue and lung windowse
DISCUSSION: Correlation is made to prior plain film exams the same daYe
ABDOMEN: The visualized lung bases are clear, without effusion or infiltrate. The visualized heart and great vessels are
unremarkablee There is a tiny sliver of right perinephric fluid, although there is no radiographic evidence of traumatic injury to right
kidney or adjacent structureSe Small hypodense region within the spleen is most consistent with a simple cyst; no acute traumatic
injury of the spleen is notede The liver, gallbladder, pancreas, adrenals and kidneys are nonna!. There is no ahnonnal intra-abdominal
fluid collection or lymphadenopathYe No acute bony injury is seen within the abdomen. Incidentally noted is a conuninuted fracture of
the distal left radius, seen somewhat obliquely with the patient""s hand resting on the abdomene
PEL VIS: There are bilateral buckle fractures involving the sacral ala, with widening of the sacroiliac joints bilaterallYe There are
slightly displaced fractured involving the left inferior and superior pubic rami. Adjacent hematoma is noted within the dependent
portion of the pelvise The remaining solid and hollow pelvis viscera are unremarkable.
IMPRESSION:
1. Small sliver of right perinephric fluid, without evidence of renal injurye
2e Bilateral sacral fractures and left pubic rami fractures as noted, with adjacent haematoma.
3. Small splenic cyst.
4 e Distal left radial fracture as noted.
Dr. James R Birkholz is the dictating resident.
Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the
interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist
Date Printed: 9//4/2004
Time Printed: 1/:11 AM
PENNSrATE
!!II Milton S. !IersIJey Medical Center
. College of Medicine
C:.;;.'~t~',-- :~.;. f':,,', _
'J/' I 'i'< 'W',
,,t, .... LuU~
Patient Name: GRIFFIN, BRlANNA
PSUHMC MRN: 7000328
Abdom
n a I
I
GI
Document(s)
I
Final
DICTATED: HULSE, MICHAEL
REVIEWED AND SIGNED: HULSE, MICHAEL /
DATE DRAFTED: 06/19/2004 10:20 PM
DATE OF FINAL SIGNATURE: 06/21/2004 01:01 PM
Date Printed: 9//4/2004
Time Prinlt'd: 11:11 AM
PENNSTATE
IS Milton S. Hershey Medical Center
., College of Medicine
'Ii',." e" ?O.
:, 'e' ,..UI!
Patient Name: GRIFFIN, BRIANNA
PSUHMCMRN: 7000328
I
D
scharge
Summary
Document
~
Modified
DISCHARGE SUMMARY
ADMIT DATE: 6/19/04
DISCHARGE DATE: 6/30/04
ADMITTING DIAGNOSIS: Multiple traumae
PRINCIPAL DIAGNOSIS: Closed head injury, left femur fracture, pelvic fracture, chemical burns to chest and face, left
distal radius fracturee
PROCEDURES: Open reduction and internal fixation of the left femur fracture, open reduction and internal fixation of the
left wrist fracture e
BRIEF COURSE: The patient is a 13-year-old white female who was involved in a motor vehicle collision on June 19,
2004 and brought to Penn State Milton S. Hershey Medical Center as a level one trauma. Orthopaedic Surgery was
consulted to evaluate the patient's bony injuries, and the patient was taken to the operating room for definitive
management of her fracturese Plastic Surgery saw the patient in reference to her chemical burns and recommended local
wound care other than surgical interventione She required transfusion for anemiae
In the patient's hospital stay, she had intermittent fevers and elevated white blood cell count but at the time of discharge
was afebrile, tolerating a regular diet, transferring with assist, and having normal bowel and bladder habits. Physical and
occupational therapy were provided by the hospital, and the family was trained to assist the patient in transfers out of bed
upon dischargee The patient was discharged to home on hospital day number 12e
DISCHARGE MEDICATIONS:
1. Colace 100 mg peO. beLde
2e Senokot 20 cc p.o. qede
3e Percocet 5/325 mg 1 peOe qe 4-6 hours peLne
4e Multivitamin 1 p.oe q.d.
Dale Printed: 9/14/2004
Time Printed: 11: I J AM
C:n~:.-;.,!' :;. ~:~;!.;: ()
PENNSTATE
!!II Milton s.!Iershey Medical OntP.t
., College of MediCine
nCT't< 2GO..
Patient Name: GRIFFIN, BRIANNA
PSUHMC MRN: 7000328
I
D
scharge
Summary
Document
,
Modified
#485574
Review/Sign: Kimberli S Cox, MD
Review/Sign: Robert E Cilley, MD
Pediatric Surgeons of Central Pennsylvania
Fl~hey: 717-531-8342
Harrisburg: 717-920-5200
York: 717-846-1980
KSC IMKS DD: 06/30/04 DT: 06/30/04 14: 13
CC: Pediatric Surgery Service
Penn State Milton Se Flershey Medical Center
P.Oe Box 850
Hershey, P A 17033
CC: Kelly L Vanderhave,MD
Penn State Milton Se Flershey Medical Center
PO Box 850
Flershey, P A 17033
Date Printed: 9/14/2004
Time Printed: J 1: 1 1 AM
PENN STATE
I!!il Milton S. Hersl Medical Center
. College of Medicine
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DAY OF DISCHARGE FORM
HMC Attending MD ~(.I
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Brief Course
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I have received and understand this written statement regarding my discharge instructions
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R 489 REV 8101
DAY OF IlI8CHAROI FORM
-
1
PENNSTATE
. ~ Milton S. Hershey Medical Center
. College of Medicme
"'
"R~ 7 a'll SSS
QO$t4)H n. : OflO"Uqo ..
iUb~~h8AUnt c .. UH~
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SURGICAL HISTORY AND PHYSICAL EXAMINATION"
..
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,
.
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(To 8e Completed In Pre-Admission Clinic; Dr in Surgical Clinic tor Healthy Track Patients Only)
Past Medical History Past Surgical History
O.MN- r"",.toJ /iJf:..t.._
~R f{ @D.'t1J ~
Any complications. f~om surgery, or anesthesia in patient or patient's ramily?
Ves (Pre-AdmiSSion Visll) No
Name
_ None (Pre-Admission Visit for more than 3 Prescription Meds)
Name Dose and
Frequency
Current Medications
Medication/Substance Anaphylaxis Hives Aeaclion Rash Wheezing Other Date
tv tal) .. ;'<>\l:jlj>jC<c..;
<- . u () 1 ?OO"
.-~, L :'-I~:" IV t: u
Does Patient take Aspirin or ~ions with aspirin in them? (Anacin. Bufferin, etce) Yes _ No ~
ALLERGIES _ None Known
,
MR 746 Rev, 4/02
SURGICAL HISTORY AND PHYSICAL EXAMINATION
Page 1 of6
.. ~0\\l'J
epAST MEDicAL HISTORYIREVIEW OF SYSTEMS
(FOR,ADPf!IONAL EXPLANATION, USE PAGES 3 AND 4)
. '
.~ #:J I. \
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; (. ~
V' N Problem/Comments V' N Problem/Comments
.....- Asthma. Wheezing (Pre.Admission Visil) ( Stroke/TIA (Pre-Admission Visil)
,/ Bronchitis Unusual Muscle Weakness (Pre-Admission Visll)
...- Emphysema (Pre-Admission Visil) r- Kidney Failure (Pre-Admission Vlsil)
./ Pneumonia .,. Kidney Stones or Urinary Disease
r' ~ough, Cold, Nasal ( Hepatitis
r' ~origestion past 2 weeks / 'Liver Disease (Pre-Admission VlslI)
~ 'eyeglasses, Contact lenses, Hearing Aid I Difficulty Swallowing or chewing
,/ h:oose Teeth .-- Unintentional weight loss
/ ~entures, Caps, or Bridges /' Persistent nausea/diarrhea
/' Stiff Neck, Jaw / Persistent Decreased appetite
~ Snoring ~ Heartbu rn
/ Home Oxygen (Pre-Admission Visil) ,/ Hiatal Hernia
Obese (Weight> 100 Kg) {Pre-Admission Visit) ( Bleeding Tendency
Rheumatic Fever ~. Sickle Cell Anemia
,-/
/" Heart Murmur (Pre-Admission Visit) /' Diabetes (Pre-Admission Visil)
,..-- Uses SBE Prophylaxis for Heart or Implanted Hardware / Thyroid Disease
(' Palpitations ("/ Steroid Therapy
~ !teart AUack (Pre-Admission Visil) (" Could you be Pregnant?
,/ Chesl Pain (Pre-Admission Visit) LMP?
./ Heart Failure (Pre-Admission Visil) CHILDREN
./ Hypertension Immunizations Up To Date
~Syncope (Pre-Admission Visil) Exposure to Contagious Diseases?
, Seizures (Pre-Admission Visit) Other:
. If 'Ves", indicate. sev.tlrity on a scale of from 1 -10 where applicable
ExercIse Tolerance: Can climb flight of stairs: Yes _ No_
What is the Most Strenuous Exercise Tolerated?
Family History:
Yes_
Yes
Yes
No_
No
No
Heart Disease:
Anesthesia Complications:
Hypertension:
Other:
Social History:
Tobacco:
Aicohol:
Other Drugs:
No _ ; packs per day for _ years
i/j'1F,ISBURG
No _; How much?
Yes
Yes_
Yes_
No _; Explain
SEP 0 1 Z005
P,ECE1VED
MR 746 Re., 4/02
SURGICAL HISTORY AND PHYSICAL EXAMINATION
Page 2 of 6
.
.
,
!
'd
PHYSICAL EXAMINATION
?~o
Wt:_ kg Ht:
em BP:
HR:
Temp: _ Sp02: _ Head Cire:
Normal Abnormal Comments/Explanation
HEENT </'
Airway /- ("Y!{\.L/) ~ ~]l f!!'Utg'FP(~on Visit It Abnormal)
Neck / '5~ ~\oe
Lungs 0/ CTft~
Heart // _ 'fL'JL {L s ~~
Abdomen /
Skin '(\vS C0lAf .,,;.,.. 5> M
Extremities ~, u, (/" " -1 .
Neurologic ---
,
Preoperative Assessment I Plan: ~'" Q ~.! RJ;M. It:
Anesthesiologist Evaluation and Proposed Anesthesia:
Prior Anesthesia' _ General _ Spinal _ E idurai _ Region~1
( w i- f,-2-. LC-t . '"
('t( C 04 2-<<
Cl-- - L M lA I~ II I\,"<:J
Premedication: oe ~ ~ / ~ ASA Physical Status:
f~~<s<- Si a~res (to be CO~P/~e~/1 Pe ons making entries on this Form)
Q ;0:-., ~
~ Signature: Discipline: Surgery
Signature: Discipline: Pre-Admissions
Signature: \.f~ Discipline: Anesthesiology
Signature: ~ Discipline: Admitting Nursing Unit
Signature: . Discipline:
Special Diagnostic Studies, Consultations, and Significant Abnormal Results
None _ No Complications
~
eMUC
L
-
DatefTime: :!151 {l1
DatefTime: -=:j;:::::j
DatefTime: ~6Xr-
DatefTime:+ ; '? -tIY
DatefTime:
Diagnostic Study/Consultation Date Result Reviewed By
/ /
/ /
/ /
/ I
/ /
/ /
/ / ;-i,/':' ,e',,",,0DoJK\.:i
/ / S -P 0 1 Z005
/ / r.'. '-e~<::",'r-."'"
.
MR 746 Rev. 4102
SURGICAL HISTORY AND PHYSICAL EXAMINATION
Page 3 of 6
PENN STATE
!Sa The Milton S. Hershey Medical Center
., The College of Medicine
SAME DAY/OUTPATIENT PROCEDURE RECORD
PRE.ADMISSION TELEPHON~ OPA
Report To: Main Entrance 1_ __ '-/
Cold Symptoms/Change in Medical Condition: Iv 0
Instructions Given To: I'Vvl tJ:b... l ->'
,
Designated 0 . ediatric Companion:
DatefTime: "7 ')-
OPER
y/ Telephone #
Arrival Time: 6730
tf1(" -'111'-1'-/
NP01/,MAJ b/:t~
Admission Time:
PRE-OPERATIVE ASSESSMENT:
o
Procedure Date:
Scheduled Operative Procedure,
/IQ~~
Of, I F- d...-.J f-e/
NPO After:
Medications Taken Today: _p t" r Q()C...j ( I)
/
<;fr "f(
Height: ~eight: i)~ I -3
Pre-op pain level (! (0 1
TPR/BP: 5b~- 7f? /t{ qz; ')~
LMP: 0 - (Cf- O~ ~t:S.f'
g~
Uj-L.-~ [y~ bc)m I e8\ -- nO tw;~ 7J
Nurse:
[)l" ( l}-<)
V
POST.OPERATIVE FOLLOW.UP:
YES
NO
1. Do/Did you have any problems at home w~h drinking, eating, voiding, or ambulating?
2e Do/Did you have any problem with pain control at home? Did you have a prescription to be filled?
3. Do you have problems with redness, swelling, excessive bleeding or discharge from the surgical s~e?
4e Do you have any questions about your discharge instructions?
5e Do you have any suggestions or comments about your admission and discharge? Is there anything
we could have done to make your hospital stay easier?
Comments:
;!:~,.~;-::.J'::8JR.G
DatefTime Of Call:
ReNe Signature:
Attempts: 1
2
MR 366 9100 pg 1 01 4
SAME DAY/OUTPATIENT PROCEDURE RECORD
SEP 0 1 2005
:-.<ECEIVED
(I .:/
,'(-'19'1'
SAME DAY/OUTPATIENT PROCEDURE h~CORD
,~ 1 -1 "
TIME "V~ "Ill l.f b-
"0
200
1811
BIl'
V 160
^
"0
,
. ./
120 V
.
100 I';. .
PULSE
0 811 .
60 1\ 1\
A "
'0
RESP 10 7"' /.~ /1.
NNJ"S ././ J --.. V
TEMP f.At 'L.~ n re\l.~
Pain SCale ! <; 'fa I.. ,
02 sal f'J\~~. I I I
02@ I~~ ~. I i I I
~ ~T~,.j-f . ORAL
.,
TIME
INTAKE L-O-.. G> IOI! <- I%-.
TUBE OTHER IV TYPE IV TYPE
FEEDING Amount Amount Amount Amount URINE
Hung Infused Hung Infused
OUTPUT
EMESIS DRAINS
OTHERS
ORDERS
k
~
~
~I"i)
O600e0700
07ooe0800
0800e0900
0900eloo0
1000elloo
llooe1200
1200e1300
130lH4oo
~
1500el600 "
1600.1700 .L L./ 0
1700-1600 "0
1800-1900 '1 !;
19!1O-2ooo ~J/ Lf -11- ,
# 2000-2100 ;.."to YJi. r.. d"'
.
2300-2400
2400-0100 .
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0200-0300
OJoo-ll4OO
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MR 366 9100 pg 2 01 4
SAME DAY/OUTPATIENT PROCEDURE RECORD
f;';C-=CEiVED
---------
s.uAE DAY/OUTPATIENT PROCEDURE RECORD
PROGRESS MOTES
~r
Ol\lt
14tH
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,
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t
SAME DAY/OUTPATIENT PROCEDURE RECORD
__.... ~ot4
MEDICATION RECORD
DATE OF
ORDER
7/5
"lis
1/s
1)
MEDICATION DOSE
ROUTE OF ADMINISTRATION
EXPIRATION DATE/TIME
p'.Q-'~~ td ir 3.2:'
--r4f c . or
~~Vlt'7 cl
SAME DAY/OUTPATIENT PROCEDURE RECORD
SCHEDULE OF ADMINISTRATION
ALLERGIES:
~ ---~~~-------- --~--~-~--------
AM
-/1) PM --.pr.-N-n-Frsn-n ___00000000_______ 00____000000__00___
AM n/J.J -
-~ -~----------- ~lfi~----------- -------------------
AM _9_~_______n 00______00______00 ~______
PM o,,~ l)~
INITIAL
SIGNATURE
DISCHARGE CRITERIAL MET:
Vital Signs Stable
PI verbilizes pain at acceptable level
Intake
Output
Bleeding Controlled
Ambulation (Pre-Op Status)
Mental Status (Pre-Op Level)
Discharge OatefTime: l' ~ - 1 f
RN: k' ~ iW
I
MR 366 9100 pg 4 of 4
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
--~~~~---------_.- ------------------ -------------------
PM
INITIAL
SIGNATURE
SIGNATURE
INITIAL
JES
~
I
./,
,},
+
0%
12" HOUR PAIN ASSESSMENT o~YQ
OOB NA
Ambulating . If ,4
Cough & deep breathing
At rest 3hJ
Activities of daily living
Pain- scale used NRS
NO
~q
AlA
~.l';.,??1::8'JRG
AFRS
SEP ()\1J~05
~-
DatelTimeJName /If:zt;J it C C i '! ~ ~O
SAME DAY/OUTPATIENT PROCEDURE RECORD
PENNSTATE
I!S:l Milton S. Hershey Medical Center
... College of Medicine
PROGRESS REPORT
N.4J,r lRIFFIN. 8RIANNA
MO, JDSPEED DAVID
MR': IOD032e
DOS: De/oe/leeo
INS: AUTO INSURANCE
LDC: ORTl
DOS': 4eoeee7
MOM: 24450
SEX: F
STANOARO
VISIT DATE: 07/20/2004
:'"
....- ~
(
Date/Tlme
PROGRESS NOTES: (Include Name, Title)
Pati nt Teaching
Tra ma
Pin Care
I
carin
Wound Care
c
are
Fracture Care
c
1, 0 ay
No Education ,cqOlrc
Pain Scale
o 1 2 J 4 5 6 7 8 9 10
No Pain Severe Pain
Worst Pain
Least PIID
,
I
MR 8 Rev, 1101
PROGRESS REPORT
n~_
">-
HARRISBURG
RE
(1 " 'iOnS
...0
PENNSTATE
I!S:l Milton S. Hershey Medical Center
... College of Medicine
PROGRESS REPORT
NAAlE' Gl!IF
"'0: GooosP~J.", BRIANNA
UR,: 700032go OAVIO
~: 09/0811990
LOC' AUro INsURANCE
: ORT.
DOs,: 4eS22S5
I
UO,: 244S()
SEX: F
STANOAAO
VISIT DATE: 09/16/2004
Date/Tlme PROGRESS NOTES: (Include Name, TItle)
I'IIti nl Tcaching
p.
l'in Cllre
Cast Cure
Fracture Care
f\
Olher
No Education Required Today
ain Today
In
I
\.
l.i
MR 6 Rev. 6/01
PROGRESS REPORT
..,j~~,RR!SBUR
:....":('~IVED
. ".t-.-...J!-
PENNSTATE
I!S:l Milton S. Hershe~ Medical Center
... College of Medicme
PROGRESS REPORT
NAME: ~RIFFIN, BRIANNA
MD: GOODSPEED DAVID
MR': 7D0032e
DOS: 09/0el1990
INS: KEYSTONE HEALTHPLA
LOC: ORT1
DOS': .eB3985
Date/Tlme
PROGRESS NOTES: (Include Name, Title)
MD': 24450
SEX: F
02 COPAY 15-361 ~
VISIT OATE: oe/03/2004
SUB~NPBRMISS M,D,iI),O,
IN ORDER FOR A BllAN!> NAME
PRODUCT TO Bll DISPENSED, THE
PRESCRIBER MUST HANDWtmE "BRAND'
NECESSARY" OR "BRANt> MEDICAlLY
NECESSARY" IN THE SPACE BELOJA R R tS
.
~l
PENNS'rATE
, pi Milton S.Il;~ey' Medical Center
Penn State Milton S. Hershey Medical Center
p,O, Box 850. M,C, H089. Hershey, PA t7033.{)8S0
(717) 531-4800
NAME: GRIFFIN, BRIANNA
PCS 22 I MO: GOOOSPEED OAVID
~ MR_: 7000328
I - 008: 09/0e/1990
NAME INS: KEYSTONE HEAL THPLA
LOC: DRTl
ADORE DOSN: 4683965
I_ PATIENT NU,
MON: 24450
SEX: F
02 COPAY 15-361
VISIT DATE: 08/03/2004
IT
AGE
DATE
_ UobelAIl ~;moris
~. Renn.. .-r;;
><
.00
fl (0\ .\ fvJJj.(]J f
{)'d5"~~~~,t~:. eVo" \-\" c~.V
< '> <0 l...vo'S\ r e\~."" ,..,~ ( .,r w,,;J~ II
David C. GoodspHd. M.D.
N~E (PIeue Print)
MD 068915 L
UCENSE
MDJD,O,
(j,E,A, REG NO,
ai;-
MR 6 Rov. 6101
PROGRESS REPORT
r~ECEIVED
PENNSTATE
!5:l Milton S. Hershey Medical Center
.. College of Medicine -.
AMBULATORY HEALTH VISIT
N~~: GRIFFIN BRIANNA
MO: OILLON PEtER W
MR': 70D032e
DOS: os/oe/1ego
INS: AUTO INSURANCE
LOC: PESU
DOS,: 4seeus
MDN: 2e1S0
SEX: F
STANDARO
VISIT DATE: 07/2e/20Q4
o Health Maintenance
Referred by/Address:
Nursing
o Consultation
o Acute Care
o Follow-up
Medications/Dosage
1.
2.
3.
4.
5.
crY
F/t-t
J-o T tCa~~
;
Subjective Signature
1./3 0 U)F sit> MVc. '-/19/0'1 c CHI, (Q{e....,0<-Y/x, R6'lu,-c -{x,
'?!hewl/'ca.{1 bu-.......s -{'e.CP/Chest, ~ dui-f-c.1 y~'us. tx -sip OR-IF
:: ~~;~ ~Cf: ~ :s1v , ~/~ 7L~~~e;;::: :lo;s~ CI O)q":J+, ~ ~ -y:.i4;;;
-1-0 Bed -.... ch... ;'..-- -> cOnny>->od e + /.(' is. SpeV'Jd.s d<'!v-j on c..J-, e.... I che.,
4. ,,",,'des, 1::...lc", cFv,'ends. rni...., pdA'r"
5. LAS"~ lococ" BL{-+f.ey oh wouj."'/cis, C1t'>c"ns,r,'j C rr>''/ct soy/i-/,z6
Objective:
Vital Signs:
Measurements: Weight
A 'e..v-+- ,ox 3,
R-t<R
l.cntID
Abdo sin, (nI:> !"A8S
~Gi-"'/!ch~s.-I-It..<~-b<--<~s h~ 1/11"7 we 1/
G u.E' .'-....., lonq <:5J,Y".., ("'""st,' ooc;l ce>op rerl/
Tone" Iv.en.- me / J I to? <-
Lab ell 0 Cc-s+
As8esament/Dlagnoel./PIan
1. 00""'1 w~ 11/ ,-ehCOl..M-O...jC' prt,-lc.,y? '~-(e>k.C
2. J<e'?1~/n,r')7 /~S~es ~re 0..- cho;:t!'c/lc
3, R TC p""" To Peds !;',...,-<$t!'J
00 RO AxO
em % Head Cire. em. %
pvob1erns
w....hY} Se.nSCl -h an I ~ j""o
Cht..(.;""6 c>bcr'uC'h OJ,
4.
ATTENDING
,-// or;
RECEIVED
MR 187 4/15
AMBULATORY HEALTH VISIT
PENN STATE
I!Sl Milton S. Hershey Medical Center
... College of Medicine
PROGRESS REPORT
NAME: GRIFFIN, BRIANNA
MD: GOODSPEEO OAVIO
MR.: 70D0:l2e
DCB: oe/oe/19BO
INS: KEYSTONE HEALrHPLA
LOC: ORT'
DCS4: 4989tl36
Date/Time PROGRESS NOTES: (Include Name, Title)
Pain Scale
hin
No Pain
Pi Care
D T Signs / Symptoms
-
W \Und Cure
W '\ to Dry Drcssmgs
-
Fr Icturc Care
M 'diC<ltinn
Pain Today
as am
MO': 244S0
SEX: F
02 COPAY lS'361
vISIT OATE: 12/09/20Oi..-.
Severe Pain
-
{
l)
MR 8 Rev, 6101
PROGRESS REPORT
..,...,".."'0 .
.,;,':_''..
'"' 0 1 2005
"'-'-'
- ,t:.:D
\ ..;... "'...r' ~,. 0" "-
'PENNSTATE
!!Sl Milton S. Hershey Medical Cente.r
... College of Medicine . -,
PROGRESS REPORT
NAME: GRIFFIN, BRIANNA M
MD: GOODSPEED OAVID
MR': 7D0032e
008: De/oe/'QQO
INS: eLUE CROSS OUT OF
LOC: ORT1
DOS': 5712565
MOM: 24450
SEX: F
80S W/ALPHA
VISIT DATE: 07/14/200P
I
Date/Tlme ' PROGRESS NOTESI PRACTICE SITE INTERDISCIPLINARY EDUCATION RECORD(IER)
Initial Assessment of Patient's Ability to Learn: 0 Emotional 0 Physical 0 CulturaURellglous None
('Explain areas thannay impact teaching) D Motivational 0 Cognitive limitations 0 Language
Learning Preferences:
~ritlen ,/C:t.....rbal 0 Demonstration 0 Group
o Audio Visual Other
Patient T chins
P n Caro
.... PIn
.J(
\,
-L4RR1SBURG
l .
)!J' 01 28BS
;~ECEIVED
MR 6 Rev, 6/01
PROGRESS REPORT
PENNSTATE
I!S Milton S. !!enfJ.e.y Medical Onter
., College of Medicine
Patient Name:
Patient Sex:
Patient Location:
Visit Type:
GRIFFIN, BRlANNA M
Female
SSS, .
Same Day Care
Penn Slate Milton S, Hershey Medical Center
Penn State College of Medicine
Health Information Services. HU24
500 University Drive
P,O, Box 850
Hershey, PA 17033-0850
PSUHMC MRN: 7000328
Date of Birth: 9/811990
Visit Number: 4594734
Tel: (717)531.8055
I
Operat
v e
Not e
Document
I
Filial
Document Electronically Signed by: Goodspeed, David C
7/12/2004 10:58:55 PM
OPERATIVE REPORT
DATE OF SERVICE: 7/5/04
SURGEON: David C, Goodspeed, MD
ASSISTANT: Michael A. Jones
PREOPERATIVE DIAGNOSIS: Left distal radius malunion,
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION PERFORMED: Takedown and repair of left distal radius malunion, intra-articular.
ANESTHESIA: General endotracheal.
INDICATIONS: The patient is a 13-year-old female involved in a motor vehicle crash, 16 days ago, in which she
sustained multiple injuries including a windswept pelvis, treated nonoperatively, a femoral shaft fracture treated with
locked intramedullary nail, and a left distal radius fracture treated with closed reduction and splinting, The patient's care
was transferred to Dr. Wallach, who then re-examined the left wrist and felt that the reduction was not adequate at its
present time. He took the patient to the OR for attempted closed reduction and percutaneous pinning with 2 radial styloid
pins. Postoperative fluorograms continued to show some lack of reduction of the wrist and a CT scan was obtained. This
showed an intra-articular dorsal shear type fracture with a large volar articular piece and two dorsal articular pieces, one
under the lunate facet and one under the scaphoid. There was continued loss of radial inclination and approximately 13
degrees of dorsal tilt There was also a bit of diastasis at the fracture between the volar and dorsal intra-articular
fragments. Because of the patient's young age and active lifestyle along with the decreased chance for remodeling given
that she was a female with near closed physis on the other side, it was felt by Dr. Wallach that this needed a revision
surgery with open plating. He had asked me to assume care of the patient and I am now bringing the patient to the
Operating Room for revision surgery of this left intra-articular distal radius fracture which is essentially a malunion at this
point, being 16 days out from the injury. The plan is for open reduction from the dorsal side in order to elevate the joint
surface and place bone graft in the bone deficit behind the elevated joint pieces. Consent was obtained preoperatively to
include this plus or minus autologous bone grafting from the pelvis.
OPERATION: The patient was brought to the Operating room and placed supine on the operating table. General
anesthesia was administered. Foley catheter was placed. Tourniquet was applied to the left arm after splint was taken
down and the radial styloid pins were moved. The pin sites were benign. We next sterilely prepped and draped the left
arm and the left iliac crest in routine fashion with Betadine scrub and paint The crest was covered and was not used
during the case.
~,!"i:,1~3BURG
Dale Printed.. 8/3012D05
TIme Printed: 7:45 AM
SI:r' 0 1 Z005
:..;:: iVED
PENNSTATE
IS Milton S. ~ Medical Center
. CoJ1ege of Medicine
Patient Name: GRIFFIN, BRIANNA M
PSUHMC MRN: 7000328
I
Operat
v e
Not e
Document
I
Final
Document Electronically Signed by: Goodspeed, David C
7/12/2004 10:58:55 PM
The arm was elevated, exsanguinated, and the tourniquet inflated, A longitudinal dorsal skin incision was made directly in
line with the third digit. The subcutaneous tissue was divided sharply with electrocautery for hemostasis. We came dovvn
through subcutaneous tissue onto the retinaculum which was divided sharply in an oblique fashion to allow later closure.
This was done carefully so as not to injure the underlying tendons including the EPL. With the retinaculum opened, the
EPL was released and allowed to fall radially. We then came down sharply in the interval between the 2M and 4th
compartments, keeping completely out of the 41h compartment. The subperiosteal dissection was then performed
underneath each of these compartments, both radially and ulnarly in order to expose the dorsal bone. Care was taken to
try to keep the tendon sheath underneath the tendons for protection between the tendons and the hardware. Again the 4th
compartment was not visualized at all. The second compartment was elevated to the radial styloid,
The dorsal bone was identified and we exposed the dorsai surface of the radius stayi~g in iine with our compartment
incision. There was a single radial styloid dorsal piece and two dorsal pieces of the level of the lunate fossa, one articular
and one more proximal. These essentially joined Lister's tubercle, We sharply divided the capsule in line with this
fracture line, entering the dorsal capsule of the wrist for just a short distance at the radial lunate interval. The dorsal
capsule was excised for a short distance at the scapholunate interval. Care was taken not to divide the capsule far
enough to injure the scapholunate ligament. The joint was identified and flushed.
We then folded back the dorsal fragments to reveal the underlying large volar articular piece. This fracture line had begun
to heal to the shaft, but could be identified. We then used an osteotome to recreate this fracture line and jack open the
fracture line with essentially a dorsal opening wedge osteotomy type technique. With axial traction on the index finger, we
could gain length and open the volar articular piece onto the scaphoid and lunate. The bone void was then created
undemeath this and this was filled with allograft. More volarly, we placed loose allograft and then more dorsally we
placed dense square allograft cubes as a structural graft in order to hold open the corrected fracture line with the opening
dorsal wedge, This bone was tamped into place and provided a good structural support. Other crushed allograft was
placed around this.
Dorsal articular pieces were then folded into place and secured provisionally with smooth K-wires. Fluorogram was
obtained which showed reasonable restoration of volar tilt. There was, however, a bit of over lengthening of the volar
aspect of the lunate facet. We then opened up the fracture site again and trimmed down the structural graft to lessen the
lengthening througn the fracture site, particularly on the volar side. The structural graft was again impacted into place and
we again folded the dorsal pieces into place and secured them provisionally with K-wires.
It was apparent that the radial styloid segment still was a bit short in terms of inclination. We attempted to pulllliis 'out to
length and hold it with a small 4-hole plate from the modular handset. This was used as a buttress plate at the proximal
end of the radial styloid piece, along the radial column. A single buttress screw was placed proximal to the fracture line
and used to hold the styloid out to length along its radial dorsal aspect. An additional buttress was obtained using a .062
smooth K-wire placed at the tip of the radial styloid and into intact bone of the radial shaft. Next, the dorsal pieces were
provisionally pinned. We then used a dorsal pie plate from the Synthes distal radius set. We trimmed ulnar and radial
holes off of the ends of the plate as we did not need extra hardware distally. The plate was then set into place,
buttressing both the ulnar and radial dorsal pieces. It was under contoured for buttress effect and was then secured
provisionally with a single screw. Its length was checked and was adjusted by loosening the screw and sliding the plate
distally. We then placed additional screws in the shaft for a total of 4 bicortical 2.7 screws. These strongly buttressed
down the distal radius from the dorsal aspect. : p C) '.: ;.~ 8 U R G
Str' 0 1 Z005
Date Printed: 8/30/2005
Time Printed: 7:45 AM
k''''~F!Vt:-D
. ._'-"-,
PENNSTATE
IS Milton s.!!eisheY Medical CMl~
., CoDege ofMedidne '
Patient Name: GRIFFIN, BRIANNA M
PSUHMC MRN: 7000328
I
Operat
v e
Not e
Document
,
Final
Document Electronically Signed by: Goodspeed, David C
7/12/2004 10:58:55 PM
For final fixation, we placed screws in the distal holes of the plate using fixed angled pins through the radial aspect and a
2.4 screw through the most ulnar hole. All screws were snugged and final fluoroscopic views showed excellent
restoration of volar tilt to an anatomic amount The volar ulnar aspect was still slightly long relative to the ulna, but this
was only mild and we felt this may settle as well. However, the dorsal aspect was anatomically out to length. All
hardware was out of the joint
The ulnar styloid had a fracture through its base which was only minimally displaced, but not displaced otherwise, It was
felt that this would not need fixation, but would heal with the arm in supination to control the DRUG and TFCC.
We then let the tourniquet down with a total time of 118 minutes. The wound was lig~tly irrigated and then closed with 0
Vicryt interrupted sutures of the retinaculum, The EPL was left outside the retinaculum. The subcutaneous closure was
with 2-0 Vicryt, skin closed with running Monocryt subcuticular suture with Steri-Strips applied. Next, we placed a sterile
dressing and sugar-tong splint with the wrist in supination for a planned 3 weeks. This was done to protect the ulnar
styloid. The patient was awakened, extubated, and taken to the Recovery Room in stable condition. There were no
complications. No specimens, Blood loss was minimal.
#498085
Review/Sign: David C Goodspeed, MD
Assistant Professor, Traumatology
Orthopaedics and Rehabilitation, H089
Penn State Milton S. Hershey Medical Center
PO Box 850, Hershey, P A 17033
(717) 531-5638
DCG /JKK DO: 07/11/04 DT: 07/12/04 08:03
CC: Michael A Jones
.~l.:\ :::: ;:\!SBURG
Dale Printed: 8/JOnOO5
Time Printed: 7:45 AM
St.r' 0 1 2005
t..;t;:CEiVED
PENNSrATE
I!S Milton s. Hershey Medical ()>.ntp.r
. College ofMedidne
Patient Name:
Patient Sex:
Patient Location:
Visit Type:
GRIFFIN, BRlANNA M
Female
7MBS, 7236, 0 I
Inpatient
Penn State Milton S. Hershey Medical Center
Penn Slate College of Medicine
Health Infonnation Services. 0024
500 University Drive
P,O, Box 850
HeBhey, PA 17033-0850
PSUHMC MRN: 7000328
Dale of Birth: 918/1990
Visit Number: 6500193
Tel: (717) 531-8055
Operat
v e
Not e
Document
I
Modijkd
Document Electronically Signed by: Wallach, David M
7/112004 9:02:50 AM
OPERATIVE REPORT
DATE OF SERVICE: 06/28/2004
SURGEON: David Wallach, MD
ASSISTANT: Derek Miller, MD
OPERATION PERFORMED: Closed reduction, percutaneous pinning of left distal radius fracture,
ANESTHESIA: General/Dr. Fehr,
BLOOD LOSS: Minimal.
IV FLUIDS: 800 cc lactated Ringers.
INDICATIONS: Brianna is a 13-year-old female who was involved in a motor vehicle accident and had severe diesel
bums at multiple locations and she also had a fracture of her left femur and a left pelvic fracture, It was revealed to us
that she had a displaced left distal radius fracture and ulnar styloid fracture. After a thorough discussion of the possible
risks and benefits with her family, they elected for her to go to the Operating Room to undergo a closed reduction,
percutaneous pinning of her left distal radius.
PROCEDURE: Brianna was identified in the Intensive Care Unit by the Department of Anesthesia and by Dr. Wallach
and transferred by the Department of Anesthesia to the Operating Room, A closed reduction of her left distal radius
fracture was perfo[fTled and adequate fracture alignment was obtained, using fluoroscopy. It was felt that, due to the
nature of her fracture, that she would require add~ional stability and underwent a percutaneous pinning of her left distal
radius fracture, utilizing two 0,062 smooth K-wires. which obtained bicortical fixation and adequate placement of the pins
and the fracture alignment was verified with fluoroscopy. The pins were then cut and bent and a sterile dressing was
applied and a plaster sugar tong splint
The patient tolerated the procedure well and was transferred to the Recovery Room in stable condition by the Department
of Anesthesia.
HAR.RISBURG
Date Printed: 8/30/1005
Time Printed: 7:47 AM
SEP 0 1 2005
RECEIVED
PENNSTATE
!S Milton s.~ Medical Carter
. CoDege of MediCine
Patient Name: GRIFFIN, BRIANNA M
PSUHMC MRN: 7000328
I
Operative
Not e
Document
I
Modified
Document Electronically Signed by: Vanderhave, Kelly L
7/5/2004 5:05:49 PM
OPERATIVE REPORT
DATE OF SERVICE: June 19, 2004
SURGEON: Kelly Vanderhave, MD
ASSISTANT: Thomas G, Harris, MD
PREOPERATIVE DIAGNOSIS:
1, Left closed femoral fracture,
2, Left closed radius fracture.
POSTOPERATIVE DIAGNOSIS:
PROCEDURES:
1. Left intramedullary nailing of femur fracture.
2. Closed reduction left radius fracture, distal.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 200
IV FLUIDS: 700
URINE OUTPUT: 300
COMPLICATIONS: None.
DRAINS: None.
DISPOSITION: Stable to ICU.
INDICATIONS FOR PROCEDURE: Brianna Griffin is a 13-year-old who had a severe motor vehicle accident this
afternoon. She was involved in a collision with a semi. She suffered a wrist fracture, pelvis and mid-shaft femur fracture
that was amenable to an 1M nail. Her growth plates are closed. Risks and benefits were explained to the parties involved,
and they agreed to proceed. This was an urgent procedure.
OPERATING ROOM COURSE: Patient was identified and correct operative site was initialed, and the lower extremity
was sterilely prepped and draped in the standard fashion. A gram of Kefzol was given prior to an incision being made.
The greater trochanter of the femoral was palpated, and a 3 cm incision was made just proximal to this. Care was taken
to bluntly dissect down to the piriformis fossa, and the guidepin was inserted into the piriformis fossa. This was over
drilled with a 13 mm reamer once it was inserted into the correct position, and a curved guidewire was advanced down the
medullary canal. The femur fracture was reduced using long~udinal traction and the curved guidewire was advanced to
the distal physeal scar. At this point, sequential reamers were used starting with an 8.5mm up to sizel12.m~~d the
nail measured to be about 340 mm, HAR.R,SBUK
SEP 0\ Z005
RECEiVED
Dare Printed: 8/30/2005
Time Printed: 7:47 AM
PENNSrATE
!S Milton S.~Medical~
. College of Medicine
Patient Name: GRIFFIN, BRIANNA M
PSUHMC MRN: 7000328
,
Operat
v e
Not e
Document
I
Modified
Document Electronically Signed by: Vanderhave, Kelly L
7/5/2004 5:05:49 PM
At this point, the exchange tube was used, the curved guidewire was removed, and a straight guidewire was placed, and
the intramedullary nail was advanced across the fracture site down to the physeal scar. The fracture was nicely reduced
at this point. Two proximal locking screws were placed, The distal locking screws were used with freehand technique
using the perfect circles, and we chose to use one, given the fact that it was a stable transverse fracture above the
isthmus. Intraoperative xrays were obtained.
All the incisions were irrigated and closed with 2-0 Vicryl, and 4-0 PDS, Xeroform and sterile dressings were placed on
them afterwards,
Attention was then drawn to the left wrist. Longitudinal traction and closed reduction with dorsal manipulation was
performed, and the radius was found to be in good alignment. A sugar-tong splint was applied, and the fracture was
found to be in good position on both the AP and lateral fluoroscopic views.
There were no complications encountered in the case. The patient was transferred to her leu bed, and then eventually
transferred to the ICU. Dr. Kelly Vanderhave was present for the entire procedure.
#475187
Review/Sign: Thomas G Harris, MD
Review/Sign: Kelly L Vanderhave, MD
Assistant Professor, Pediatric Orthopaedic Surgery
Penn State Milton S. Hershey Medical Center
PO Box 850, Hershey, P A 17033
(717) 5314653
Review/Sign: Kelly L Vanderhave, MD
Assistant Professor, Pediatric Orthopaedic Surgery
Penn State Milton S. Hershey Medical Center
PO Box 850, Hershey, P A 17033
(717) 5314653
TGH /CJK DO: 06/21/04 OT: 06/21/04 09:36
HARRiSBURG
SEP 0 1 Z005
RECEIVED
Date Printed: 8/30/2005
Time Printed: 7:47AM
PENNSrATE
!S Milton s.!JersIJey Medical Center
., Co1Iege of Mediclne
Penn State Milton S. Hershey Medical Center
Penn State College of Medicine
Health lnformation Services. HU24
500 University Drive
P ,0, Box 850
Hershey, PA 17033-0850
Tel: (717) 531.8055
Patient Name:
Patient Sex:
Patient Loc:ation:
Visit Type:
GRIFFIN, BRlANNA M
Female
ORTl..
Clinic
PSUHMC MRN:
Date of Birth:
Visit Number:
7000328
9/811990
4606887
I
Outpat
e n t
Not e
Document
I
Modified
Document Electronically Signed by: Goodspeed, David C
8/14/20045:17:51 PM
OUTPATIENT NOTE DATE OF SERVICE: July 20, 2004
.CHIEF COMPLAINT: Followup status post multi trauma.
HISTORY OF PRESENT ILLNESS: Brianna Griffin is a 13-year-old female who was in a motor
vehicle accident on June 28, 2004. She, at the time of injury, waS found to have a
lateral compression pelvis injury on the left with a crescent fracture posteriorly. She
also had a sacral buckle fracture on the right. She had closed midshaft femur fracture,
and she had a radial styloid fracture on the left. On date of surgery, she had
intramedullary nail fixation on the day of injury and she was treated conservatively for
the pelvis fracture. She had initially had surgery on her distal radius, which was found
to have residual malunion and was taken to the OR on July 5, 2004, were Dr. Goodspeed did
an ORIF of her left radial styloid and distal radius fracture. The patient reports
having no pelvis pain. She has continued bed-to-chair transfers requiring minimal
amounts of pain medicine. Her wrist has been nonpainful. She does complain today of
pain after being taken out of her splint.
On physical examination, bilateral lower extremities are neurovascularly intact. Her
motor exam 5/5. Her incisions over her left thigh were clean and dry and well healed.
The volar incision of her left wrist is clean and dry, healing well.
ASSESSMENT:
1. Two weeks ~tatus post ORIF, left radial styloid and distal radius fracture.
2. Four weeks status post intramedullary nail fixation of left femoral shaft fracture.
3. Four weeks status post lateral compression pelvis fracture. All of these injuries
are doing well.
PLAN:
1. The patient is to continue bed-to-chair transfers for an additional 2 weeks.
2. The patient to be placed in long arm cast in full supination to continue distal
radius immobilization.
3. The patient is to follow up in 2 weeks with AP pelvis, inlet and outlet views, and
PA/lateral of her distal radius and left femur 2 view films.
L.l!\Qr..~\C8l1HG
'-U".f" 'C ,/ .-
Date Printed.. 8/3012005
TIme Printed: 7:45 AM
SEP 0 1 2005
R-=.~'::j\/l=D
,,<.-\....1__1 -
PENNSrATE
!S Milton s.!!ersbeY Medical OonfiT
., College of MediCine
Patient Name: GRIFFIN, BRlANNA M
PSUHMC MRN: 7000328
I
Outpatient
Not e
Document
,
Modijied
Document ElectronicalIy Signed by: Goodspeed, David C
8/14/2004 5:17:51 PM
8279/cbt
Review/Sign: Jay T Bridgeman, MO, DDS
Department of Orthopaedic Surgery
Penn State Milton S. Hershey Medical Center
500 University Drive
Hershey, P A 17033
Review/Sign: David C Goodspeed, MD
Assistant Professor, Traumatology
Orthopaedics and Rehabilitation, H089
Penn State Milton S. Hershey Medical Center
PO Box 850, Hershey, P A 17033
(717) 531-5638
Review/Sign: David C Goodspeed, MD
Assistant Professor, Traumatology
Orthopaedics 'and Rehabilitation, H089
Penn State Milton S. Hershey Medical Center
PO Box 850, Hershey, P A 17033
(717) 531-5638
ITB /ARB DO: 07/22/04 DT: 07/22/04 13:29
HARRISBURG
Dat. Printed: 813012003
Time Printed: 7:4j AM
SEP 0 1 Z005
RECEIVED
PENNSTATE
!SI Milton S. !Iersbey Medical Center
., College of Medidne .
Patient Name:
Patient Sex:
Patient Location:
Visit Type:
GRIFFIN, BRlANNA M
Female
ORTI..
Clinic
Penn State Milton S. Hershey Medical Center
Penn State College of Medicine
Health Information Services, HUZ4
500 University Drive
P,O, Box 850
Hershey, PA 17033-0850
PSUHMC MRN: 7000328
Dale of Birth: 9/8/1990
Visil Number: 4652255
Tel: (717) 531-8055
I
Outpat
e n t
Not e
Document
I
Filial
Document Electronically Si!ll!OO by: Goodspeed, David C
10/31/2004 6:55:42 PM
OUTPATIENT NOTE
DATE OF SERVICE: 9/16/04
This is an addendum at the end of the resident's note dictated for this day.
ADDENDUM
I have seen and examined the patient and formulated the assessment and plan as detailed on the resident note above.
The patient's fractures are healing well and she will be getting gait training per the resident note,
30393931/cbt
Review/Sign: David C Goodspeed, MD
Assistant Professor, Traumatology
Orthopaedics and Rehabilitation, H089
Penn State Milton S. Hershey Medical Center
PO Box 850, Hershey, P A 17033
(717) 531-5638
DCG /1MB DD: 09/24/04 DT: 09/29/04 10:01
~'^. D--". ~B' ,
.'.-".''-'.:'' 'vRG
SLr' 0 1 2005
Date Printf!d: 8/30/2005
Time Printed: 7;45 AM
hECi::IVED
PENNSTATE
IS Milton S. Hershey Medical Center
., College of Medicine
Patient Name: GRIFFIN, BRIANNA M
PSUHMC MRN: 7000328
I
Outpat
e n t
Not e
Document
~
Final
Document Electronically Signed by: Goodspeed, David C
10/31/20047: 12:36 PM
OUTPATIENT NOTE
DATE OF SERVICE: 09/16/2004
CHIEF COMPLAINT: Multi trauma followup,
HISTORY OF PRESENT ILLNESS: The patient is a 13-year-old female who was involved in a MV A on June 19, 2004,
with the following injuries.
1. One side pelvis with bilateral tile type B posterior injuries, with internal rotation on the right and external rotation on the
left, and left-sided rami fractures, This was treated nonoperatively (lateral compression type 3 injury),
2. She had a left femur fracture that was treated with an 1M locked nail by Dr, Vanderhave,
3. She had a left distal radius articular fracture that was initially treated, closed in splint, and it had fall off dorsally, and
then it was percutaneously pinned by Dr. Wallach.
Postoperative x-rays after being pinned showed articular step-off requiring additional open reduction and internal fixation
approximately 3 to 4 weeks after her initial injury. With regard to her left femur and pelvis, she has continued to be
nonweightbearing on bilateral lower extremities and has been transferring bed to chair, She reports standing in order to
see this and sometimes stands with crutches, but does not walk, With her left wrist, she has been going on occupational
therapy and working on a range of motion, which she reports, is much beller now,
PHYSICAL EXAM: In general, she is in no acute distress. Left wrist is nontender to palpation. Her incisions are well
healed, Distally, she is neurovascularly intact. Her range of motion in extension is 80 degrees and flexion is 68 degrees,
and her pronation and supination is within normal limits, She has good strength, and there is no edema, On left lower
extremity, the incisions are well healed. The left knee has full extension and flexion to about 110 degrees, Distally, she is
neurovascularly intact bilaterally,
X-RAYS: AP pelvis, 3-views of the left wrist, and multiple views of the left femur show intact hardware in the left wrist and
left femur and a pelvis fracture and only above fractures are healing welt
PLAN:
1. She will continue to do range of motion with her left wrist and continue strengthening. She can also continue resistive
exercises with this:
2. She can start to be weightbearing as tolerated on bilateral lower extremities with gait training from physical therapy
using crutches,
3. She will follow up in 3 months in Dr. Goodspeed's clinic with all x-rays.
Dr. Goodspeed was involved with clinical decision making, as well as the care of this patient.
..!P,:-'--l,:..t,"" ,~
"'''''-.)i:J-,-,hG
Date Printed: 8/30/2005
Time Printed: 7:45 AM
SLY 0 1 2005
..,,'-;- 'co
~_....~-'~.)\, a:.
PENNSrATE
IS Milton S. !Iersbey Medical (>ntP.l'
., College ofMedidne
Patient Name: GRIFFIN, BRIANNA M
PSUHMCMRN: 7000328
I
Outpat
e n t
Not e
Document
I
Final
Document Electronically Signed by: Goodspeed, David C
10/3112004 7:12:36 PM
78429/cbt
Review/Sign: Michael P Stauff, MD
Review/Sign: David C Goodspeed, MD
Assistant Professor, Traumatology
Orthopaedics and Rehabilitation, H089
Penn State Milton S. Hershey Medical Center
PO Box 850, Hershey, P A 17033
(717) 531.5638
MPsmG DO: 09/16/04 DT: 09/20/04 21:40
HARR!SBURG
Dale Printed: 8/3012005
Time Printed: 7:45 AM
SEP 0 1 Z005
!"'I,--,,'. 'CD
~,,,:,-':":'.lVL.:
PENNSrATE
!:S Milton S. HersIJey Medical Onw
., College ofMediclne
Patient Name: GRIFFIN, BRIANNA M
PSUHMC MRN: 7000328
I
Outpat
ent ,Letter
Document
I
Final
Document Electronically Signed by: Dillon, Peter W
10/8/2004 5:33:56 PM
OUTPATIENT LETTER
September 24, 2004
Karen Campbell, MD
2140 Fisher Road
Mechanicsburg, PA 17055-0000
Dear Dr. Campbell:
I saw this 13-year-old youngster in our office on July 28,2004 for a followup evaluation, Review of our charts indicates
that she did not get a letter from this visit, and I apologies for the delay in this communication.
At the time of this visit, this infant was almost 4 weeks out from her hospitalization following a traumatic accident in which
she suffered a left femur fracture, pelvic fracture, distal radius fracture, and chemical bums to her face and chest. Her
orthopedic injuries required operative fixation at the time of her initial hospitalization. Since her discharge, she to her
mother reported that she had been doing quite well. Her activity had been restricted because of her injuries and
requirement for bed rest and wheelchair limitations, However, she reported that she had minimal discomfort, Her oral
intake was adequate, She was stooling without difficulties, She had no fevers, They were having no difficulties taking
care of her facial and chest wounds,
At the time of her visit, her facial and chest burns were superficial and healing quite nicely. The new skin was taking on
without difficulty. There was no sign of infection, Her upper extremity was in a long arm cast. Her sensation was normal
and vascular refill was adequate, Her abdomen was soft and non distended with no masses and no areas of tendemess,
Overall, she appeared to be doing quite well given her injuries, Her superficial burns were healing nicely. She had no
obvious sequelae from these injuries. Her remaining issues were, now, orthopedic, Therefore, we did not schedule a
follow up appointment with her. We will be happy to see them at anytime should the need arise,
Thank you so much for allowing us to participate in her care, Best wishes.
HAR~L3BU~G
Dat. Printed.. 8/3012003
Time Printed: 7:45 AM
SEP 0 1 Z005
RECEi\/[O
PENNSTATE
I!S Milton s. HersI1ey Medical (Ent1!r
. College ofMedidne .
Patient Name: GRIFFIN, BRIANNA M
PSUHMC MRN: 7000328
I
Outpatient
Letter
Document
~
FIlial
Document Electronically Signed by: Dillon, Peter W
10/8/2004 5:33:56 PM
88733
Sincerely,
Peter W Dillon, MD
Pediatric Surgeons of Central P A
Robert Cilley MD Peter Dillon MD Kerry Fagelman MD Andreas Meier MD
Coleen Greeeher MS RD CNSD Janet Shields MSN CRNP CS
Hershey 717-531-8342 HbgIYork 717-920-5200
PWD IBDS DD: 09/24/04 DT: 09/28/04 21 :36
CC: Karen Campbell, MD
2140 Fisher Road
Mechanicsburg, P A 17055-0000
.
h}\HP1S.8UF~G
Da.. Prlftted: 81JOIZ/)(Jj
Tim., Printed: 7:45 AM
SEP 0 1 2005
RECE-" '~D
.; 'It:
PENNSTATE
IS Milton s. Hershey Medical Center
.. College ofMedidne
Penn Slate Milton S. Hershey Medical Center
Penn State Conege of Medi~;nc
Health Information Services. HU24
500 University Drive
P,O. Box 850
Hershey. PA 17033-0850
Tel, (717) 531-8055
Patient Name:
Patient Se",:
Patient Location:
Visit Type:
GRIFFIN. BRlANNA M
Female
ORT!..
Clinic
PSUHMC MRN:
Date of Birth:
Visit Number:
7000328
9/8/1990
4683965
I
Outpatient
Not e
Document
I
Final
Document Electronically Signed by: Goodspeed, David C
811412004 5:16:12 PM
OlITPATI:J:R'r ROTE
DATE OJ' S1I:1'.V3:C!:. 08/03/04
CURRENT COMPLAINT: Multitrauma followup.
HISTORY: The patient is a 13-year-old female involved in a motor vehicle crash on 06/19/04.
She had the following injuries:
1. A windswept pelvis with bilateral B type posterior injuries, internal rotation on the
right and external rotation on the left, with left-sided rami fractures. This was
treated nonoperatively.
2. A left femur fracture treated with intramedullary locked nail by Dr. Vanderhave,
3. Left distal radius intraarticular fracture treated initially closed followed by
percutaneous pinning. She was then referred to me and we underwent osteoclasis and
corrective ORIF of an early malunion. Excellent length was restored with volar tilt,
but with slight articular stepoff. She has been in a cast, which was converted to a
long arm cast at her last clinic visit. She is having some pain at her left wrist
because the cast is getting loose and sliding on her radial styloid pin buried
underneath the cast. Otherwise, she is doing well with bed to chair transfers and
nonweightbearing bilaterally.
PHYSICAL EXAM: The cast was removed today and the underlying skin is benign. The pin site
was dry. The elbow and wrist are quite stiff coming out of the cast with minimal motion of
the wrist. The bilateral hips are not irritable. The bilateral toes have active flexion and
extension. 5/5. The left knee has full extension and excellent flexion.
AP and inlet views of the pelvis show significant bony healing with mild windswept residual
deformity, but with good ring. There is no superior migration of either hemipelvis. Two
views of the left femur show early healing with good alignment. Two views of the left wrist
show early healing with intact hardware and the mild joint stepoff on the volar aspect of the
radial styloid.
IMPRESSION: Seven weeks out fram multitrauma with above injuries and four weeks out from
corrective ORIF of left distal radius.
PLAN:
1.
Styloid pin pulled today. Dry dressing applied.
cleansing until it seals.
2. Casting discontinued. Convert to FREEDOM wrist splint.
3. Work aggressively on elbow and wrist range of motion with
4. May do pivot bed to chair transfers at this point, but no
Mother will do hydrogen peroxide
therapy consult.
gait traiil;i:i.!'l!1 R~'I : " '7'
. c. .,,~ ,_, ..,., '. '..:J
Dole Printed: 81JO/200J
nme Printed: 7:45 A.M
SEP 0 1 Z005
RECEIVED
PENNSrATE
IS Milton s.~ MedicalOntet
. College ofMedidne .
Patient Name: GRIFFIN, BRIANNA M
PSUHMC MRN: 7000328
I
Outpatient
Not e
Document
I
Filial
Document Electronically Signed by: Goodspeed, David C 8/14/2004 5:16:12 PM
5. May work on walking in a pool with chest high water.
6. Return to clinic in 4-5 weeks with AP pelvis. two views of the left femur, and PA and
lateral of the left wrist. We anticipate initiation of gait training then.
#25939
Review/Sign: David C Goodspeed, MD
Assistant Professor, Traumatology
Orthopaedics and Rehabilitation, H089
Penn State Milton S. Hershey Medical Center
PO Box 850, Hershey, P A 17033
(717) 531-5638
DCG /JLH DD: 08/04/04 DT: 08/04/04 13:30
HARRISBURG
Dote Printed; 8110/]005
Ttme Printed; 7;45 AM
SEP 0 1 Z005
pt::CErV~D
.'It..... I r::.
PENNSrATE
IS Milton s.!!ersbey Medical Center
.. College of Medicine
Penn State Milton S. Hershey Medical Center
Penn State College of Medicine
Health lnfonnation Services, HU24
SOO UniversitY Drive
P,O, Box 850
Hershey, PA 17033-0850
Tel: (717) 531-8055
Patient Name:
Patient Sex:
Patient Location:
Visit Type:
GRIFFIN, BRIANNA M
Female
ORTl"
Clinic
PSUHMC MRN: 7000328
Date of Birth: 9/8/1990
Visit Number: 4989636
Outpat
e n t
Not e
Document
I
Filial
Document Electronically Signed by: Goodspeed, David C
1/21/20058:40:41 AM
OUTPATIENT NOTE
Name: GRIFFIN, BRIANNA
HMC Number: 7000328
008: 09/08/1990
Date of Service: 12/09/2004
CURRENT COMPLAINT: Multi-trauma followup.
HISTORY: The patient is a 14-year-old female who was involved in a MVA on June 19, 2004, with the following injuries:
1, Wind swept pelvis with bilateral tile-type B posterior injuries with intemal rotation on the right and extemal rotation on
the left and left-sided rami fractures, treated nonoperatively (lateral compression type 3 injury),
2. Left femur fracture, treated with 1M nail by Dr, Vanderhave.
3. Left distal radius articular fracture, treated initially closed followed by percutaneous pinning by Dr. Wallach, followed by
malunion ORIF about 3 to 4 weeks after injury.
She is currently finished with physical therapy and is full weightbearing without assistive devices. She is somewhat sore
on the left thigh and knee and this is increased with walking a long time, However, she has been able to do some jumping
on a trampoline. She has no pelvic pain and no bowel or bladder dysfunction, The left wrist is a bit sore with swimming,
but otherwise, is doing well.
PHYSICAL EXAMINATION: All incisions are well healed. Bilateral hips have full range of motion. Quad strength is 5/5
with no lag bilaterally. Left knee motion is 0 to 140. Left wrist motion is 75 of flexion, 80 of extension, 70 of pronation, and
90 of supination. Grip strength is 5/5.
AP pelvis, left wrist. and left femur x-rays were obtained today. These all show healed fractures with good bony
alignment There is minimal articular step-off at the left wrist, as we had known intraoperatively from elevation of
impacted segments. However, overall there is good radial length and inclination,
IMPRESSION: She is 6 months out from the above noted injuries and treatments. Overall, she is doing quite well with
bony healing at all fractures.
PLAN:
H/\Ri"~~)3BURG
Dote Printed.. 8/JO/2oo5
rune Printed: 7:44 AM
SEf-' 0 1 2005
RECEiVED
PENNSTATE
!S Milton S. ~ Medical C.f'nter
. College of Medicine
Patient Name: GRIFFIN, BRlANNA M
PSUHMC MRN: 7000328
I
Outpat
e n t
Not e
Document
I
Filial
Document Electronically Signed by: Goodspeed, David C
1/21/20058:40:41 AM
1. Continue to increase activities as tolerated and reengage in sporting activities.
2. No specific fOllowup, but we would be happy to see her back on a p.r.n. basis,
33955178
Review/Sign: David C Goodspeed, MD
Assistant Professor, Traumatology
Orthopaedics and Rehabilitation, H089
Penn State Milton S. Hershey Medical Center
PO Box 850, Hershey, P A 17033
(717) 531-5638
DCG IBDS DD: 01/12/05 DT: 01/17/05 17:20
-I/~ '.,? !SBURG
Dat. Printed: 813012005
Time Printed: 7:44 AM
~::'I'; 0 1 2005
l\~._.,-. t:i\/ED
PENNSTATE
!51 Milton s.!Iershey Medical Center
.. College of MediCine
Patient Name:
Patient Sex:
Patient Location:
Visit Type:
GRIFFIN, BRlANNA M
Female
ORTl"
Clinic
Penn scate Milton S, Hershey Medical Center
Penn State Conege ofMcdictne
Health Information Services. HU24
SOO University Drive
P,O. Box 850
Hershey, PA 17033-0850
PSUHMC MRN: 7000328
Date of Birth; 9f8fl990
Visit Number: 5712565
Tel: (717)531-8055
l
Outpat
e n t
Not e
Document
,
Final
Document Electronically Signed by: Goodspeed, David C
7/30/20054:19:04 PM
OUTPATIENT NOTE
Name: GRIFFIN, BRIANNA M
HMC Number: 7000328
OOB: 09/08/1990
Date of Service: 07/14/2005
Current complaint is left hip and knee pain,
HISTORY: The patient is a 14-year-old female involved in a motor vehicle crash on June 19, 2004 with the following
injuries:
1. Windswept pelvis with bilateral Tile-type B posterior injuries with internal rotation on the right and external rotation on
the left, treated nonoperatively (lateral compression-type 3 injury),
2, Left femur fracture treated with intramedullary nail.
3. Left distal radius articular fracture treated initially closed, followed by percutaneous pinning by Dr, Wallach, followed by
malunion ORIF about 3 to 4 weeks after injury:
Currently, the patient is full weighlbearing without assisted devices, Previous x-rays have shown her to go on to heal
these injuries. She presents today with some lateral left hip pain over her abductors. She also has some left knee pain
both medial and laterally and also anteriorly over the patella. These symptoms are increased with stairs and recently after
a long trail hike. S\1e has become more active recently.
PHYSICAL EXAM: The left hip has full range of motion wUhout pain on extremes. The left greater trochanter is
nontender. There is some mild tenderness over the abductors just inferior to the iliac crest The knee itself has full range
of motion. and no laxity and no effusion. Joint line is nontender. Straight leg raise is negative on the left.
AP pelvis shows mild windswept pelvis with healed fractures. Bilateral hips are normal. There is no significant
heterotopic bone in the abductors. The 2 views of the left knee are also unremarkable, '
IMPRESSION: Healed fractures as noted above. The patient had some abductor pain on the left, probably related to
weakness and her increased activities,
PLAN:
1. Some quad strengthening, straight leg rises as shown in the clinic.
2, Abductor strengthening, at least 300 a day.
H,"R~!S8URG
SUJ 0 1 2005
f-<.t:CEiVED
Date Pri.,/'d, 8/3012005
Time Prilll~d: 7:44 AM
PENNSTATE
!S MJIton S. Hershey Medical C81ter
. College ofMedic1ne
Patient Name: GRIFFIN, BRIANNA M
PSUHMC MRN: 7000328
~
Outpat
e n t
Not e
Document
,
FIlial
Document Electronically Signed by: Goodspeed, David C
7130/20054:19:04 PM
3. Ibuprofen p.r.n.
4. Activity as tolerated.
5. Return to clinic on a p.r.n. basis.
43024788
Review/Sign: David C Goodspeed, MD
Assistant Professor, Traumatology
Orthopaedics and Rehabilitation, H089
Penn State Milton S. Hershey Medical Center
PO Box 850, Hershey, P A 17033
(717) 531-5638
DCGIMSB DD: 07/19/05 DT: 07/20/05 22:08
;.~P"'Ft::\iSE~UP.G
Dare Print<<i: 8/3012005
TIme Printed: 7;44 AM
SEP 0 1 2005
RECEIVED
PENNSTATE
B Milton S. Hershey Medical Catter
. Cotlege ofMediane
Patient Name: GRIFFIN, BRIANNA M
PSUHMC MRN: 7000328
I
Musculoskeletal
Study
I
Final
PORTABLE X-RAY WRIST 3 OR MORE VIEWS LEFf
PATIENT NAME: GRIFFIN, BRIANNA
PATIENT MRN:07000328
PATIENT DOB: 09/08/1990
EXAM DATE OF SERVICE: 07/05/2004
EXAM NUMBER: 377560
QRDERING PHYSICIAN: GOODSPEED, DAVID
Two intraoperative matrix views of the left wrist
Clinical history: l3-year-old female with ORIF of the left wrist.
Discussion: Comparison is made to prior CT scan dated June 29, 2004.
Since the prior study the two screws through the distal left wrist have been removed. There is new multiple plate and screw fixation of
the comminuted fracture of the distal left radius. There is no evidence oflooseDing, infection, or failure of the surgical hardware, A
pin also traverses the radial styloid and exists through the medial cortex of the metadiaphysis of the radius. Incidental note is again
made of an ulnar styloid fracture.
Impression: ORIF of a comminuted fracture of the distal left radius without complication noted.
Dr. Rebecca Sivarajah is the dictating resident.
Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the
intetpretation, Preliminary reports may not have been reviewed as yet by the attending radiologist.
DICTATED: BOAL, DANIELLE
REVIEWED AND SIGNED: BOAL, DANIELLE / SIV ARAJAH, REBECCA
DATE DRAFTED: 07/06/2004 11:14 AM
DATE OF FINAL SIGNATURE: 07/0612004 12:05 PM
Q!:':J'r::.r;il!'"jG
. . .'~''''''!:)-w-.d.
Dal. PrittJed: 8/J012005
nme Printed: 7:45 AM
Stt' 0 1 2005
r.c:.CE!VED
PENNSrATE
IS Milton S. Hersltey Medical Center
., CoDege of MediCine
Patient Name: GRIFFIN, BRIANNA M
PSUHMC MRN: 7000328
I
Pel V
s I G U
Study
I
Final
X-RAY PELVIS AP 1-2 VIEWS
PATlENTNAME: GRIFFiN, BRIANNA
PATIENTMRN:07000328
PATIENT DOB: 09/08/1990
EXAM DATE OF SERVICE: 09/16/2004
EXAM NUMBER: 470215
ORDERING PHYSICIAN: GOODSPEED, DAVID
AP VIEW OF PELVIS September 16, 2004
FOUR VIEWS OF LEFf FEMUR
THREE VIEWS OF LEFf WRIST
CLINICAL HISTORY: 14-year-old female with history ofleft wrist, femur, and pelvic fractures,
Comparison is made to previous studies the most recent study from August 3,2004,
Pelvis: The left superior and inferior pubic ramus fractures appear unchanged in alignment and demonstrate continued interval
periosteal reaction and callus formation, Overlying soft tissues appear normal. Again noted is an 1M rod traversing the left femur in
stable alignment and position with no radiographic evidence of complication of hardware.
Left femur: Again noted is an 1M rod with proximal and distal interlocking screws placed as treatment for a proximal left femoral
diaphyseal fracture. There is no radiographic evidence of hardware complication and the alignment is unchanged. Interval periosteal
reaction and callus formation is noted, Overlying soft tissues appear normal.
Left wrist: There has been interval removal of the K-wire fixation of the distal radial fracture, Again noted is malleable plate and
screw fIxation. There is no radiographic evidence of hardware loosening or complication. The articular surface bas undergone
remodeling, The alignment remains unchanged. Bowing of the distal ulna noted in previous studies is not appreciated today.
Overlying soft tissues appear normal. The ulnar styloid is unchanged.
IMPRESSION: Stable fixation offractures ofthe left wrist, left femur and pelvis, witb interval bealing
and in stable alignment and position.
DICTATED: HULSE, MICHAEL
REVIEWED AND SIGNED: HULSE, MICHAEL /
DATE DRAFTED: 09/17/2004 10:18 AM
DATE OF FINAL SIGNATIJRE: 09/17/2004 05:12 PM
f~t::,;~,~\jSB!)RG
StY 0 1 2005
Dote Prinled: 8/3012005
Time Printed: 7:45 AM
F{ECE\\!ED
PENNSrATE
ES Milton s.!Iershey Medical Center
. College of Medicine .
Patient Name: GRIFFIN, BRlANNA M
PSUHMC MRN: 7000328
I
Pelvls/GU
Study
~
Filial
X-RAY PELVISAP l-Z VIEWS- PEDS
PATIENT NAME: GRIFFIN, BRlANNA
PATIENT MRN:07000328
PATIENT DOB: 09/08/1990
EXAM DATE OF SERVICE: 08/03/2004
EXAM NUMBER: 413803
ORDERING PHYSICIAN: GOODSPEED, DAVID
2 VIEWS LEFT WRIST
TWO VIEWS PELVIS
AP AND LATERAL LEFT FEMUR
CLINICAL HISTORY: Left wrist fracture, femur fracture, pelvis fracture.
DISCUSSION: Comparison is to multiple prior exams, the most recent June 26, 2004,
Left wrist: There has been interval removal of casting material Again noted is the malleable plate and screw, K-wire fixation of the
distal radial fracture, There is no radiographic evidence of hardware complication and alignment is unchanged. Again noted is a
slight bowing deformity of the distal ulna. Overlying soft tissues are unremarkable,
Left femur: Only visualized on this exam is the proximal portion of the interlocking screw and intramedullary rod fixation of the
proximal left femoral diaphyseal fracture. There is no radiographic evidence of hardware complication, and alignment is unchanged.
Overlying soft tissues are remarkable only for adjacent bony fragments,
Pelvis: Again noted are the left superior and inferior pubic ramus fractures, which are unchanged in alignment and demonstrate
interval periosteal reaction and callus formation, The remaining visualized osseous structures are unchanged. Overlying soft tissues
are unremarkable.
IMPRESSION: Stable fractures of the left wrist, left femur, left superior and inferior pubic rami, with interval healing and stable
alignment
Dr. James H. Birkholz is the dictating resident
Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the
interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist
,-,-'-Cl \'.~G
H.i\H:'{\;::;'6'..~.'
Date Printed, 8/3012005
17me Printed, 7:45 AM
StY 0 1 7.005
, "0
"," "., ,
R\:.\..-t..l v 1:_
PENNSTATE
IS MDton s.!Iershey Medical CariP.r
.. College oflffMfclue
Patient Name: GRIFFIN, BRIANNA M
PSUHMC MRN: 7000328
DICTATED: BERGEY, ELIZABETH
I
Pel V
s I G U
Study
I
FIlial
REVIEWED AND SIGNED: BERGEY, ELIZABETH / BIRKHOLZ, JAMES
DATE DRAFTED: 08104/2004 02:18 PM
DATE OF FINAL SIGNATURE: 08/04/2004 05:07 PM
HA~~\"'RIIRG
. \"\ ,.... ....;,....... .~~- I "
Dale Printed: 8/3012005
Time Printed; 7:45 AM
SEP 0 1 Z005
RECEIVED
PENNSTATE
IS Milton s. HersIJey Medical Center
. Co11ege of MediCine
Patient Name: GRIFFIN, BRIANNA M
PSUHMC MRN: 7000328
r
Pelvis/GU
Study
I
Final
X-RAY PELVIS 3 OR MORE VIEWS
PATIENT NAME: GRIFFIN, BRIANNA
PATIENT MRN:07000328
PATIENTDOB: 09/08/1990
EXAM DATE OF SERVICE: 12/09/2004
EXAM NUMBER: 584527
ORDERING PHYSICIAN: GOODSPEED, DAVID
Three views of the left wrist, three views of the pelvis, four views of the left femur.
CLINICAL HISTORY: Fractures of the pelvis, left femur, left distal radius,
Discussion:
Left wrist: Comparison is made to radiographs from 9/16/2004. Malleable plate and screw fixations place for treatment of distal
radial fracture are again seen, There is no evidence ofloosening, infection, or failure of the surgical hardware, There is evidence of
bony remodeling and callus maturation consistent with interval healing. Alignment is unchanged. Irregularity of the Tadial articular
surface is seen. The radiocarpal joint is narrowed, but unchanged. A small ossification overlying the distal ulnar articular surface is
again appreciated,
Pelvis: Comparison is made to radiographs from 9/16/2004, Left superior and inferior rami fractures are again noted. There is
evidence of bony remodeling and callus maturation consistent with interval healing. Alignment is unchanged.
Left femur: Comparison is made to radiographs from 9/16/2004. The interlocking intramedullary rod transfixing the proximal
femoral shaft fracture is again noted. There is no evidence ofloosening, infection, or failure of the surgical hardware. There is
evidence of bony remodeling and callus maturation consistent with interval healing. Alignment is unchanged.
..~' ~
Impression: Healing distal left radial, left femoral midshaft and left superior and inferior rami fractures.
Dr. Mark Guelfguat is the dictating resident.
Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the
interpretation, Preliminary reports may not have been reviewed as yet by the attending radiologist
HA~~'C'B' '''G
K~,,\..' \,.1"
Date Prin,ed: 81JO/200J
Time Prin,ed: 7:44 AM
SE? 0 1 Z005
RECE.iVED
PENNSTATE
I!S Mllton s.!!ersIJey Medical CP.IItPr
.. College of lffediCfne
Patient Name: GRIFFIN, BRIANNA M
PSUHMCMRN: 7000328
I
Study
I
Pelvls/GU
Filial
DICTATED: BaAL, DANIELLE
REVIEWED AND SIGNED: BaAL, DANIELLE / GUELFGUAT, MARK
DATE DRAFTED: 12/10/2004 09:01 AM
DATE OF FINAL SIGNATURE: 12/10/2004 05:02 PM
Date Printed, 8/3012005
TiIM Printed, 7.-44 AM
HARRISBURG
SEP 0 1 2005
RECEIVED
PENNSrATE
151 Mllton S. Hershey Medical ('a1tB
., College ofMedic.ine
Patient Name: GRIFFIN, BRIANNA M
PSUHMC MRN: 7000328
I
Pel V
s I G U
S tu d y
I
Filial
X-RAY PELVIS AP 1-2 VIEWS. PEDS
PATIENT NAME: GRIFFIN, BRIANNA M
PATIENT MRN:07000328
PATIENT DOB: 09/08/1990
EXAM DATE OF SERVICE: 07/14/2005
EXAM NUMBER: 891403
ORDERING PHYSICIAN: GOODSPEED, DA VlD
EXAM TYPE: X-ray AP pelvis, single view: X-ray ofleft knee three views
CLINICAL HISTORY: Left hip and left knee pain, status post fractures of the pelvis and left femur, status post ORlF
COMP ARISION: Multiple comparisons most recent on 12/9/2004
FINDINGS:
PEL VIS: A single view of the pelvis presented for evaluation. Healing left superior and inferior rami fractures are again noted with
the fracture lines less visible with evidence of bony remodeling, consistent with healing. Alignment is unchanged, There is no joint
effusion. There are no new fractures, An interlocking intramedullary rod with screws transfIxing the proximal femoral shaft fracture
is again noted. There are no new lucencies to suggest infection, fatigue, or other hardware complication. There is .normal bowel gas
pattern, soft tissues are unremarkable.
LEFT KNEE: Three views of the left knee are presented for evaluation. The site of the prior femur fracture is not included in the
views. The interlocking intramedullary rod with a single screw transfIxing the distal femoral shaft is again noted, There is no
evidence ofloosening, infection, or failure of the surgical hardware. There are no joint effusions, The soft tissues are unremarkable,
IMPRESSION:
I, Healing left superior and inferior rami fractures.
2. Leftfemurstatus p~st ORlF without evidence of hardware complication,
Dr. Gregory J. Moore is the dictating resident.
Attending radiologist siguatuIe indicates review of both the images and the report and that the attending radiologist agrees with the
interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist.
DICfATED: MOORE, GREGORY
REVIEWED AND SIGNED: MOORE, GREGORY / SCHETTER, SUSANN
DATE DRAFTED: 07/14/2005 04:22 PM
DATE OF FINAL SIGNATURE: 07/14/2005 05:01 PM
!,.!r. :.:;~~:" ;:::-2UF~G
SEP 0 1 2005
Dole Printed; 8/30/2005
Time Printed: 7:44 AM
H.ECEIVED
l
PENNSrATE
!!!I Milton S. Hersbey Medical Center
., College ofltfediCipe
Patient Name: GRIFFIN, BRIANNA M
PSUHMC MRN: 7000328
I
D
scharge
Summary
Document
I
Modified
Document Electronically Signed by: Cmey, Robert E
7/1/2004 9:08:52 AM
DISCHARGE SUMMARY
ADMIT DATE: 6/19/04 '
DISCHARGE DATE: 6/30/04
ADMITTING DIAGNOSIS: Multiple trauma.
PRINCIPAL DIAGNOSIS: Closed head injury, left femur fracture, pelvic fracture, chemical burns to chest and face, left
distal radius fracture,
PROCEDURES: Open reduction and internal fixation of the left femur fracture, open 'reduction and internal fixation of the
left wrist fracture,
BRIEF COURSE: The patient is a 13-year-old white female who was involved in a motor vehicle collision on June 19,
2004 and brought to Penn State Milton S. Hershey Medical Center as a level one trauma. Orthopaedic Surgery was
consulted to evaluate the patient's bony injuries, and the patient was taken to the operating room for definitive
management of her fractures, Plastic Surgery saw the patient in reference to her chemical burns and recommended local
wound care other than surgical intervention. She required transfusion for anemia,
In the patient's hospital stay, she had intermittent fevers and elevated white blood cell count but at the time of discharge
was afebrile, tolerating a regular diet, transferring with assist, and having normal bowel and bladder habits, Physical and
occupational therapy were provided by the hospital, and the family was trained to assist the patient in transfers out of bed
upon discharge. The patient was discharged to home on hospital day number 12,
DISCHARGE MEDICATIONS:
1, Colace 100 mg p,o, b.Ld.
2, Senokot 20 cc p.o. q,d.
3, Percocet 5/325 mg 1 p.o. q. 4-6 hours p,r.n.
4, Multivitamin 1 p,o. q,d,
1. ~, l~. (\ ':.:; 13 U R G
Date Printed: 8/3012005
nme Printed: 7;47 AM
StY 0 1 2005
... .t::\VED
....'>-....-
PENNSrATE
IS Milton s. Hasbey Medical (P.ntf!\"
., College ofMedidne
Patient Name: GRIFFIN, BRlANNA M
PSUHMC MRN: 7000328
I
Discharge
Summary
Document
I
Modified
Document Electronically Signed by: Cilley, Robert E
7/1/2004 9:08:52 AM
#485574
Review/Sign: Kimberli S Cox, MD
Review/Sign: Robert E Cilley, MD
Pediatric Surgeons of Central Pennsylvania
Hershey: 717-531-8342
Harrisburg: 717-920-5200
York: 717-846-1980
KSC IMKS DD: 06/30/04 DT: 06/30/04 14:13
CC: Pediatric Surgery Service
Penn State Milton S, Hershey Medical Center
P.O. Box 850
Hershey, P A 17033
CC: Kelly L Vanderhave,MD
Penn State Milton S. Hershey Medical Center
PO Box 850
Hershey, PA 17033
H/~RPJSBURG
SEP 0 1 2005
RECEiVED
Dal. Printed: 8/3012005
1lme Printed: 7:47 AM
State Farm Insurance Companies
September 2, 2005
Shepherdstown Family Practice
2140 Fisher Rd
Mechanicsburg, PA 17055
RE: .Claim Number:
Date of Loss:
Our Insured:
38-K461-021
June 19, 2004
Paul Ranck
Dear Sir or Madam:
STATI 'AIM
A
INIU.ANCI
.
State Farm Insurance
11 5 Limekiln Road
New Cumberland PA 17070.0257
Our records indicate Briana Griffin is under your care for
injuries received in the above captioned automobile accident.
To assist us in the evaluation of this case, please provide us'
with copies of the medical records of your patient.
You may bill our office directly for copying services in
connection with the submission of this report. A medical
authorization is enclosed.
Thank you for your assistance.
Sincerely,
PC-.
Linda Koch
Claim Representative
(717) 774-9015
State Farm Mutual Automobile Insurance Company
Comments:
Enclosure:
AuthorizatioIO NextApp'1 Dale:
. 0 Hold for App'l
o Pt. Informed on
o Rie CI Fax
o Staff to call 10 infOll'll
Cl Pl caUod on I I by_
Cl Send: Lab Ilr/cholllrlLfLC dl3t
Cl Above mailed on I I by_
Cl Repeat in_dayS/wkslmonlhs
Cl Scheduled by
o Entered in tickler by
o R1edby_on
by
: :r{r'~{'._~~~,jC~?'7>olr':~\\ I
" : SEP - 6 2C05 !' .
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EXHIBIT
I-H-
HOME OFFICES: BLOOMINGTON. ILLINOIS 61710-0001
~
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H.'\R~8lURG
SEP 0 9 2005'
RECEIVED
f"'Iu..:a .I. I ~'OO..J
~I~( Hn ~K ' ~KL~~~-LIABILITY7 303 2290 T~ 95315068
P.e13
,
.~
r
AUTHORIZATION FOR
RELEASE OF INFORMA liON
Barcode Only
,-
i!U:Di: Property and Ca-aty Inslltance Is exeludecl from the deIlnltlon of "ll8lllll plan" In the privIcY rules developed
IlUl*UlIIlt ID lilt HeaIIIl IMlIlatlct Portability end AllCOllnIIlbility Act of 1991 (HlPAA) and Is not a _..eel entity.
H-.r, thlll autlorlzatlon meets the core elimlents criteria .. forth In the HIP," privac:y rule, Section 16.uC18 (C).
N.mt of IniInd Pelson: .MMe Grlflln (hereinafter "'~ to as the 'Injured I'er$On')
SOCial 5ea.Irity Number of Injured PertOrl:
08\e of IllI'I\'l of Injllred PeI$OI\:
ooC\ . f~ -J!.oa.
(needed to IVCOIlIII
q - r~!a
\ lid lD""" _Ills)
38-KA610G21
State Farm Claim No.:
I auUloffa:
(1) any mediCal, psycI\oIogIc8I, p$}'dlialrlc. os\eOpllhic or chIroprac:lk; phyIlcian, denlIsl. any oltIer IMdical ~ or
heaIlhcatt pRWider, hOspbI, clinic, reI1l1bll11tllon facility nuning tlome, or any other healII1C8fe faclIily to ditclose
Infonnatlon f'rom the medical and halIh;;are recMls Of the Injured Person. I undel'Itand that the I\lltCIfIC type of
Info...."tian to be disclosed lnctudes, llut Ie not Umltecl to, mealCal and heallhcllre records IIld any olher information
Including any history, treatment ~s, d1egnoel&, prognotie, narrallve tepOrts, and blIfng records. This aulhOl'iZalton
Ilso pennjW my medICal prov\del$ to dlSCU$$ In pelSOll, by telephone, eIectronk:aJfy, 0( by matl, medical options.
concluslons, ttealmenl pllI1S and other infoImatIon; and
any tlrm, employer. 0( ImllJI'ilnCe eompany to furnish Information aboUt the earnings. loss of elIrn~, 'Mll\( history,
Worlalrs' eompensatIon claim, and oIMr medical informallon in ltsIlhelr po_....n COlIeIfTIlng tile InjUred "-n, as
wen as, event Data RecolOer (EDR) illfuo ...aIlon. photographS and other Information abOullhe physical damage to the
veI1ide(s) InVlllved in the accident: and
(3) any educa\lOnal organintion to furnish the school /'ICOrlIs of the Injlll'$d Person to
State Farm MulUIIl Automobile InlllnnCll Comp;1r!Y, Its subeldlalles and afIIHate$. Its c;lajm associal8s. and legal ~
(hereinaftet referred to collecllvtlly as 'State Ferm1.
, aUthorize the use of the Ibove InformalIOn to permit stale Fllrm to investigate, proce&$. and detennln. the amount payable, if
any, for III claims made under any SllIt. Farm property and casualty Insurlnc. poliey Ihat appllet 10 the Iccident or
occurrence on 08-11?004 . I undel'Slancl as part of the daim handling proc:eu, State Farm lI1lIY disclose
medical or oIher InfornMItion obtaIn<<I by this auth~atIOn \0 physlclans, dentisls, other n1edIcal or heaIlhc:are provldenl or other
profwsslonelS for their reView and prorasional opil'lion. this Information mey also be relelled to olhet InsLranCG companies for
their UIe In connac:tlon wtlh insUl30Ce transacIIOns. Or as noquirQd or permiIIed by law. Infon'IMIIion obtained pursuant to !hIs
au\hOI1%atlOn may Ialilr be re<llsdOced and mlY nol be protected under the HII'M privacy IUIe. I Wlderstand that 111I8)' refuse to
autI10rlZv cIisc:Iosure of all or some of tile requestad IllfOtmatlon, but thall'lfJsal rrtIf polantIaIly __ a delay II p.QCli~, or reeull
In \he denIIII of, inu'ar1c:e benlIIIIs for h pertdt1g II1UIY dalm(s).
Thfa authOriZallofI may be revoked at wrt time, except to the extent thai Slale Farm has taken don in reliance on this
authortmfon prfor to notice of revocation. SUch revocaIIon muet be In wrttlng, dated. tIignad. IIlCIlndude the claim number
referenced above. I undlntand that revoeatlan of tills lulhorlutlon may po\en\ially cause a cteIay In proce8IIng, or reBlIIl In !he
denial of, InlUrance beneIIla for the pending iI1lury dalms(s). '
'!his authortza1ion 1. valIcI for the dul'8llon of the d.im referenced above. and a photocopy Is as velld IS thIl ori$1inal. ThIs
authorlZatlon SIledl\C8Uy appIiw to l'9COI'da made before. cIumg, end efter the date at signing this aUlltorlzation for as long .. the
...,U...iMdM1 lain etrect.-
I hive reed the authorlz8tion and signed this document as a ffee and volunIary aot for the purpose$ noted aboVe, I understand
that I may obtlIIn a copy of this auftMiZollion upon WIlllen request IUbmItted to Stat. Farm.
Nly ,.,.., who laIowIngIy..... wtIh InllInt eo...... any II\SuI'anC>> c.....y... oIhtr peIWOIIlIItt IIIIPf111c11tlO11 for........- ... a ~1Il of
cWnt _'''' ..., _1Iy _lnf...'llaUIHI or _caaIa iorlha \IUl1IO$9 ofmllleedlng, '''''''lI1IoIIon ~ any faCt mftIriI/lhoNlo
WI....... a t\'aUdUIent inaura_ act,....Ich,.. ~ ~~ ~r"ryo:": t!I~.,. ancI_ pona....
. d') \ r \., ~ ,\ \\. j! ,\1
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'i:' SEP - 6 200~ I: 1:\
(2)
HARRISBURG
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or penona '!tPresantallVt" BlltIIorIly or
SEP 0 1 2005
,:= :- \lED
nt
Hf-\RHlSBURG
'., '~~.'-~ .-'- ,..,.--.'" ..-
\0e3f7," 1Wv.07-20-2OO&
SEP 0 9 2005
** l:OTl'tL-~03 **
. ..__"':"'i v Ci.,:
.-
PENN STATE
!S Milton S. Hershey Medical Center
... College of Medicine
Penn Slate Milton S. Hershey Medica.! Ccnl.cr
Penn Slate College c!Medicinc
Health Information Services. HU24
500 University Drive
P.O, Box 850
Hershey. PA 17011.1ll50
Tel: (717) 531.6257
Fax (717) 531.7048
RE: GIllFFIN, BRIANNA
OUTPATIENT LETTER
September 24, 2004
Karen Campbell, MD
2140 Fisher Road
Mechanicsburg, PA 17055-0000
Dear Dr. Campbell
I saw this 13-year-<lld youngster in our office on July 2B, 2004 for a followup evaluation, Review of our charts
indicates that she did not get a letter from this visit, and I apologies for the delay in this communication,
At the time of this visit, this infant Was almost 4 weeks out from her hospitalization following a traumatic accident in
which she suffered a lell femur fracture, pelvic fracture, distal radius fracture, and chemical burns to her face and
chest. Her orthopedic injuries required operative fixation at the time of her initial hospitalization. Since her
discharge, she to her mother reported that she had been doing quite well, Her activity had been restricted because
of her injuries and requirement for bed rest and wheelchair limitations. However, she reported that she had minimal
discomfort. Her oral intake was adequate. She was stooling without difficulties. She had no fevers, They were
haVing no difficulties taking care of her facial and chest wounds,
At the time 0/ her visit. her facial and chest burns were superficial and healing quite nicely. The new skin was taking
on without difficulty. There was no sign of infection, Her upper extremity was in a long arm cast. Her sensation was
normal and vascular refill was adequate, Her abdomen was soft and nondistended with no masses and no areas of
tenderness,
Overall, she appeared to be doing quite well given her injuries, Her superficial burns were healing nicely, She had
no obvious sequelae from these injuries. Her remaining issues were, now, orthopedic, Therefore, we did not
schedule a follow up appointment with her, We will be happy to see them at anytime should the need arise,
Thank you so much for allowing us to participate in her care. Best wishes,
Patient Name: GRIFFIN. BRIANNA
HARRISBURG
Page 1 QflSEP 0 9 Z005
For ilJlormarion aboJl/ OrV" p/tysic:ifDU mad st"icu contact dw MD Network. 1-800-2]3-4081 wwwpennslatehershegom
. r-rr;-'\/Ef'
This docum.nt has ....n .Iectronically signed,
Patient Number: 7000328
88733
Sincerely,
Peter W Dillon, MD
Pediatric Surgeons of Central PA
Robert Cilley MD Peter Dillon MD Kerry Fagelman MD Andreas Meier MD
Coleen Greecher MS RD CNSD Janet Shields MSN CRNP CS
Hershey 717-531-ll342 HbglYork 717-920-5200
PWD 1808 DO: 09/24/04 DT 09128/04 21 :36
CC: Karen Campbell, MD
2140 Fisher Road
Mechanicsburg, PA 17055-0000
.
("","!;71ments:
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OCT 11 2004 !jl
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------------------------
PaliClll Name: GRIFFIN, BRlANNA
This document has been electronically signed.
PaliClll Number; 1000328
HARRISBURG
Page 20fSEP 0 9 200S
For Info.'IIIi1/ion .00"'0'" phys/dans and "'''/''''1, _ac1 tIu! MD N.twork J-I/O(}.ZJ~408Z www,pennltafllher~ FiVE. D
.. ~, ,........ ........ ....
I. U.l
.Outpt Note GRIFFIN, BRIANNA - 7000328
· Final Report ·
OUTPATIENT NOTE DATE OF SERVICE: July 20,2004
CHIEF 'COMPLAINT: Followup status post multi trauma.
HISTORY OF PRES~ ILLNESS: Brianna Gr1ffin is a l3-year-o~d female who waS 1n a
~otor ~ehicle aocident on June as, 2004. She, at the time of injury, was found to
ha~e a lateral compression pelvis injury on the left with A crescent fracture
posteriorly. She alao had a sacral buckle fracture on the right. She had closed
midshaft femur fracture, and she had a radial styloid fracture on the left. On date
of su:!'gery, she had intramedullary nail fixation on the day of injury and she was
t:reated conservatively for the pelvilil fracture. She had initially had. surgery on hel'
d.istal radius. which was found to have residual malunion and was taken to tn.. OR on
July S, 2004. were Dr. Goodspeed did an OAtf of her left radial styloid and distal
radius fracture. The patient reports haVing no pelvis pain, She hAS continued
hed-to-chair tronsfers requiring minimal amo\lnts of pain mecl1cine. Her WI"ist has
heen nonpainful. She does cOlIlplain eoday of pain after b8i,'\1 eaken out of her
splint.
On phySical examination. bilateral lower extremities ~e neurovascularly intact. Her
motor exam 5/5. Her incisions over her lefe thigh were cle.n and dry and well
healed. The volar incision of her left wrist is clean and dry, healing well.
AsseSSMENT:
1. TWo weeks seatus post ORIF. left radial seyloid and distal radius fracture.
2. Four weeks status pose intramedullary nail fixation of left femoral shaft
fracture.
3. FOUr weeks status post lateral compression pelvis fract~re_ All of these
injuries are doing well.
PLAN:
1. The patiene is to continue bed-to-chair tran&fers for an additional 2 weeks.
2. The patient to be placed in long arm cast in full supinaeion to continue distal
radius immobilization.
3. The patiene is to follow up in 2 weeks with AP pelvis, inlet and outlet views,
and fA/laeeral of her distal radius and~eft femur 2 view films.
8279/cht
Signature Line
Review/Sign: Jay T Bridgemen, MO, ODS
Department of Orthopaedic: Surgery
Penn Slate Milton S. Hershey Medical Center
500 University Drive
Hershey, PA 17033
Review/Sign: David C Goodspeed, MD
Aulstant Professor, Tnwmalology
Orthopaedics and RehebHltalion, Haa9
Printed by:
Printed on:
Perry, Lucretia
81412004 1 :01 PM
Commentn:
<0/
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SEP 0 9 Z005
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.Operative Report
GRIFFIN, BRIANNA - 7000328
OPERATIVe REPORT
.. Final Report ..
DATE OF SeRVICE: 7/5104
SURGeON: David O. Goodspeed, MD
ASSISTANT: Michael A. Jones
PREOPERATIVE DIAGNOSIS: Left distal radius malunion.
POSTopeRATIVE DIAGNOSIS: same,
OPERATION PERFORMED: Takedown and repair of left distal radius malunion, Intra-articular.
ANESTHESIA: General endotracheal,
INDICATIONS: The patient is a 13-~ar~d female involved in a motQl' vehicle crash, 16 days ago, in which she
sustained multiple injuries including a windswept peMs, treated nonoperatlvely, a femoral shaft fracture treated with
locked Intramedullary nail, and a left dloital radius fracture treated with closed reductton and splinting. The pallent's
care WIIS transferred to Dr. Wallach, who then re-examined the left wrist and felt thatlhe reduction was not
adequate at its present time. He look the patient to the OR for attempted c1Q$ed reductlon and percutaneous
pinning with 2 radial sty/old pins, PQ$loperative f1uorograms continued to show se'me lack of reductton of the wrist
and a OT scan was obtained. This showed an intra-articular dorsal shear type fracture with a large volar articular
piece and two dorsal articular piec;es, one under the lunate facet and one under lI1e scaphoid. Thero we continued
loss of rtdial inclination and approximately 13 degrees of dorsal tilt. There was al90 II bit of diastasis at the fracture
between the volar and dorsal intra-articular fragments. Because of the patient's Y':lUng age end active lifestyle along
with the deereased chance for remodeling given that she was a female with near (~osed physis on the other side, it
was felt by Dr. Wallach that this needed a revision surgery with open plating. He had asked me to assume care of
the patient and I am now bringing the pallent to the Operating Room for revision 8~rgery of this left intra-articular
distal radius fracture which is essantially a malunion at this point, being 16 days out from the Injury. The plan is for
open reductlon from the dorsel side in order to elevale the joint surface and place bone graft In the bone deficit
behind the elevated joint pieces. Consent was obtained preoperatively 10 include l11is plus or minus autologous
bone grafting from the pelvis.
OPERATION: The pallent was brought to the Operating room and placed supine on the operating table. General
anesthesia was administered. Foley catheter was placed. Tourniquet was applied to the left arm after splint was
taken down and the radial styloid pins were moved. The pin sites were benign. We next sterilely prepped and
draped the left arm and the left iliac crest in routine fashion with Betadine SCI'IJb arid paint. The crest was covered
and was not used during the case.
1l1e arm was elevsted, exsanguinated. and the toumlquetlnflated, A longitudinal dorsal skin incision was made
directly in line witl1lhe third digit. The sub<:utaneous tissue was divided sharply with electrocaulely for hemostasis.
We came down through subcutaneous tissue onto the retinaculum which was dillided sharply in an oblique fashion
to allow later closure. This was done carefully so as not to injure the underlying te ~dons including the EPL. With
the retinaculum opened, the EPL was released and aNowed to fall radially. We then came down sharply In the
Int8lV81 between the 2nd and 4th compartmente, keeping completely out of the 4th compartment. The
subperiosteal dissection was then petformed underneath each of these compartments, both redially and ulnarty in
order to elr.polle the dOl'8slllone, Care WIIS taken to try to keep the tendon sheath undemealh the tendons for
protection between the tendons and the hardware. Again the 4th compartment well not I/isuallzecl at all, The
seoond compartment was elevated to the radlalstyfold. ,-' -,.,
The dorsal bone was identified and we exposed the dorsal surface of the radius staying:ln line with our--'
f.~
,
Printed by:
Printed on:
PsTI)', Lucretia
8/412004 1 :02 PM
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SEfF~
RECEIVED
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.Operative Report
GRIFFIN. BRIANNA - 7000328
compartment incll!lion. There was a ,ingle radial styloid dorsal piece and two dOr'.ilI1 pieces of the level of the lunate
foesa, one artlcular and one mare proximal. These essentially joined Lister's tubarcle. We sharply divided the
capsule in line with this fracture line, entering the dorsal capsule of the wrist for just a short distance at tha radial
lunsle inteMI. The dorsal capsule WlI$ excised for a lIhOrt distance at the scaph.)lunate interval. Care was taken
not to divide the capsule far enough to injure the seapholunete ligament. The joint was identified and flushed.
We then folded back the dorsal fragments to reveal the undet1ying large volar artj,:Ular piece. This fracture line had
llegun to heal to the shaft, but could be identified. We then used lIn osteotome to recreate this frecture line and jack
open the fracture line ....ith essentially a dorsal opening wedge osteotomy type tec.,n!que. With axial traction on the
Index finger. we could gain lengtH and open the volar articular piece onto the'll'tSphoid and lunate. The bone void
was then created underneath this and this W86 f~led with allograft. More voIarIy. we placed 1000e alIogrefl and then
more dorsally we placed dense square allograft cubeS as a structural graft In order 10 hold open the corrected
fracture line with the opening dorsal wedge. Thill bone ....as tamped into place and provided a good structural
support. Other crushed a1log/'l1lt was placed around this.
Dorsal articular pieces were then folded into place and secured provlsionally with smooth K-wires. Fluorogram was
obtained which showed rll8Sonable restoration of volar tilt. There was. however, a bit of over lengthening of the
volar aspect of the lunate facet. We then opened up the fracture site again and trimmed down the structural graft to
leuen the lengthening through the fracture ,ite, particularly on the volar side. Tho stnJclural graft was .galn
Impacted into place and we again folded the dorsal pieces into place and secured them provisionally with K-wires,
It WlI$ apperentthat the radial styloid segment still was a bit short in terms of inclination. We attempted 10 pull this
out to l8f'lgth and hold It with a small 4-hole plate from the modular handset. This was used .s II bUttress plate at
the proximal end of the radial styloid piece. along the radial column, A single buttress screw was placed proximal to
the fracture line and usad 10 hold the styloid out to length along its radial dorsal aspect. An additional buttress was
obtained using a .062 smooth K-wire placed at the tip of the radial styloid and into intact bone of the radial shaft.
Next, the dorsal pieces were provisionally pinned. We then used a dorsal pie platl~ from the synthes distal radius
set. We trimmed ulnar 8fId radial holes off of the ends of the plate at! we did not rl8ed extra hardware distally. The
plate W88 then satlnlO piece. buttressing both the ulnllr 8fId radial dorsal pieces. It was under contoured for
buttress effect and wa& then secured proviaionlllly with a single screw. Its length was checked end walllldjusted by
loosening the screw and sliding the plate distally. Welhan placecl additional screws in the shaft for a total of 4
bicortical2.7 screws. These strongly buttressed down the dislal radius from the dorsal aspect.
For final fixation. we placed screws in the distal holes of the p1ale using fixed angllld pins through the radial aspect
and a 2.4 screw through the most ulnar hole. All screws were snugged and final fluoroscopic views showed
excellent reatoration of volar tllt to en anatomi.. amount. The volar ulnar lISpect was sUIl sl/ghUy long relative to the
ulna, but this was only mild and we felt this mey settle as well, However. the dorslllllspec;t was anatomically out to
length. All hardware was out of the joint.
The ulnar styloid had a fracture through its base whiGh was only minimally displaCEld, but not displaced otherwise. It
was felt that this would not need fi:r.ation. but would heal with the arm in supination 10 control the DRUG and TFCC.
We then let the tourniquet down with II tolaltlme of 118 minutes. The w.,..nd was lighUy iITigated and then closed
with 0 Vic:lyt interrtJpled sutures of the retinaculum. The EPL was left .,..tside the retinaculum. The subc:utaneous
closure was with 2-0 Vicryt, skin closed with running Monocryt subcutieular suture with Stari-Strips applied. Next,
we placed a sterile dressing and sugar-tong splint with the wrist in supination for a planned 3 weeks. This was done
to protect the ulnar styloid. The paUent was awakened. flXtubated, and takan 10 th.e Recovety Room in stable
condition. There were no complications. No specimens. Blood loss was minimal.
#498085
Printed by:
Printed on:
Perty. l-ucrelia
81412004 1 :02 PM
HA.R~
SEP 0 9 2005
,'~ECFIVED
-.. -.....- .--....-
{ '.' ...-.............
'f ........
.Operatlve Report
GRIFFIN, BRIANNA - 7000328
Slgnatu... Une
Review/SIgn: Oavlcl C Goodspeed, MD
AsalalBnl Professor, Traumalolcgy
OrthopaedlC$ and RIIhablIIlatlon, H089
Penn SllIte MIlton S. Hershey Medical Center
PO Sox 850, Hershey, PA 17033
(717) 531-5638
DCG IJI<I< DO: 07/11104 DT: 07/12104 08:03
CC: Michael A Jones
Result Type:
Date of Servlc:e:
A1lthorlzation Status:
Subject:
Author or Import Date:
Verified By;
Encounter Info:
.Operatlve Report
Monday, July OS, 2004 10:00 PM
Final
.Operlltlve Report
GoodlIpeed, David C on SUnday. July 11, 2004 8:03 AM
Gaodspeed, D8\tld C on Monday, July 12,2004 10:58 PM
4594734, HMC, Same Day Care, 7/512004 . 71S12OO4
Printed by: Perry, Lucretia
Printed on: 8/4/2004 1 :02 PM
~t~~~RG
(En$I.sIf ~)
=>tP 0 9 2005
i~ECEIVED
.Outpt Note
Penn State MIlton S. Hershey Mlldlc:aI Center
PO 8o>c 850, H....hey. PA 17033
(717) 531-5638
GRIFFIN. BRIANNA - 7000328
JTS IARB 00: 07120/04 DT: 07/22/04 13:29
Result Type:
Date of Selvlc:e:
AuthoriDtlon Slatus:
. Author or Import Dele:
Verltied By:
Encounter info:
.Outpt Note
Tuesday, July 20, 2004 12:00 AM
Final
8rldgemen. Jay T on Tueeday. July 20. 2004 1 :29 PM
Goodspeed, OIVic! C on Friday, July 23, 2004 3:38 PM
4606887. HMl;:, Clinic. 7/2012004 .7/2112004
HARRISBURG
SEP 0 9 2005
'i."_~. :.:.NED
Page 2 of 2
(End of Report)
Printed by: Perry, l.Uqe1ia
Ptinted on: 8/412004 1:01 PM
Benefits for Brianna Griffin
$157,374.991ump sum payment on
09/08/2015
Total
Effective Annual IRR:
Proposal - Hartford Life
Brianna Griffin
09/08/1990
Guaranteed
Expected
$157,374.99
$157,374.99
$157,374,99
$157,374.99
4.98%*
* These figures are estimates based on the assumptions slaled above and the US Annuity 2000 life eJepeelancies,
Quote Expires: 05/02/2006
EXHIBIT
I~
Cost
$100,000,00
$100,000,00
Diversified Settlements, Inc.
62 Maple Avenue
P.O, Box 507
Keene, New Hampshire 03431
(800)245-5717
Settlement Proposal for: Griffin, Brianna
Owner State: Massachusetts (0.00% tax)
Rate Series: A V041406
Rates Effective: 04/14/2006
For: Brianna Griffin Female, Date of Birth: 09/08/1990
Benefit Description
Guaranteed
Benefit
Expected
Benefit
Cost
IRR
Guaranteed Lump Sum - $157,115.14 paid as a lump
sum on 09/08/2015 guaranteed,
$157,115
$157,115
$157,115
5,04% over
$99,600,00 10 year(s)
$99,600.00
Subtotal For Brianna Griffin
$157,115
SUMMARY INFORMATION
Guaranteed
Benefit
Expected
Benefit
Cost
CONTRACT COST.".".,."..,.".".".,.",.,.",.,.."."."..,.."."
Assignment Fee .".,.".".,..".,.."."".",."."."."..".,.."."..,
(A viva Assignment Corporation)
TOTAL CONTRACT COST W/ FEES ........................
$157,115
$99,600.00
$400,00
$157,115 $100,000.00
This quote is subject to approval by the life company providing the contract. Actual rates will be those in effect on the date the premium is
received.
For Life Contingent quotes. the expected benefit is based on life expectancy.
Quote ID : Griffin, Brianna
Prepared by : - - DSI
Apr 25, 2006
Page 1 of 1
Diversified Settlements, Inc.
Version 2.10
Life Insurer Financial Profile
Company
Ratings
A.M, Best Company (Best's Rating, 15 ratings)
Standard & Poo~s (Financial Strength, 20 ratings)
Moody's (Financial Strength, 21 ratings)
Fitch Ratings{Financial Strength, 24 ratings)
Weiss Ratings (Safety Rating, 16 ratings)
Comdex (Percentile in Rated Companies)
Assets & Liabilities
Total Admitted Assets
Total Liabilities
Separate Accounts
Total Surplus & AVR
As % of General Account Assets
Invested Asset Distribution & Yield
Aviva
Life
A+ (2)
A+ (5)
B (5)
86
5,210,560
4,863,564
o
369,339
7,1%
T otallnvested Assets
Bonds (%)
Stocks (%)
Mortgages (%)
Real Estate (%)
Policy Loans (%)
Cash & Short-Term (%)
Other Invested Assets (%)
Net Yield on Mean Invested Assets
2004 (Industry Average 5.50%)
5 Year Average (Industry Average 6,39%)
Non-Performing Assets as % of Surplus & AVR
Bonds In or Near Default
Problem Mortgages
Real Estate Acquired by Foreclosure
Total Non-Performing Assets
As a Percent of Invested Assets
Bond Quality
Total Vaiue of Bonds
Class 1-2: Highest Quality
Class 3-5: Lower Quality
Class 6: In or Near Default
Weighted Bond Class
Income & Earnings
Total Income
Net Premiums Written
Eamings Before Dividends and Taxes
Net Operating Eamings
5,093,541
94,2%
1,1%
0.4%
0,0%
3,2%
1,2%
0,0%
5,83%
6,58%
0,0%
0,0%
M%
0,0%
0,0%
4,814,912
96,7%
3.3%
0.0%
1,6
780,175
619,020
-19,164
-13,675
Hartford
Life
A+ (2)
AA- (4)
Aa3 (4)
AA (3)
B+ (4)
91
112,861,252
109,669,355
85,963,789
3,426,575
12,7%
26,101,041
64,1%
5,8%
1,7%
0,0%
3,6%
3,2%
1,6%
5,51%
6,16%
0,7%
0,0%
M%
0,7%
0,1%
22,279,340
96,6%
3,3%
0,1%
1.4
14,075,539
11,507,751
481 ,435
498,322
Data for Year-End 2004 from the life insurance companies' statutory annual statements. AU dollar amounts are in thousands. All ratings shown are
current as of April 01, 2006.
Presented by: Usa Tusveld, Diversified Setuements, Inc.. 62 Maple Avenue, P. O. Box 507, Keene, NH 03431 Phone: 800~245-5717 Fax:
603-357-8926 Emsil: lisa.tusveld@dlversifiedsetUements.com
Page 1 of 1
MARY GRIFFIN METZ
447 Eighth Street
Brooklyn, NY 11215
(212) 908-0537 (office)
(718) 369-3071 (home)
megmetz@earthlink.net
SUMMARY OF QUALIFICATIONS
Proven ability to develop new business and maintain strong client relationships tied to the delivery of
complex financial services. Manage business to satisfy clients while maintaining integrity and tough credit
standards, Compete for business on quality of product, expert knowledge, excellent service, and timeliness,
not low cost.
PROFESSIONAL EXPERIENCE
FITCH RATINGS
1989- Present
Managing Director and Head of Structured Finance Investor Development (2004 - present)
Created structured finance investor development unit. Identify, create, and implement business strategies
to enhance Fitch's visibility with US investor community,
. Established group from existing relationship managers with sector focus, Created unified group with
clear direction. Organized effort to focus on investor as client with one relationship manager per
investor rather than four relationship managers each representing separate structured finance
business unit.
. Identified need for separate strategy for short term (commercial paper) product, created, and
implemented strategy, Fitch ratings now added to investment guidelines for short term investors,
.
Managing Director and Co-Head. Commercial Mortgage Structured Finance (1993 - 2004)
Established and now manage one of the leading commercial mortgage ratings businesses, Manage staff
of 55 in NY and Chicago,
. Identified conduit ratings as business opportunity and established Fitch as dominant in business.
. Secured and managed key accounts, Personally obtained business from several clients, who have
retained the organization because of my strong relationship with them and excellent service,
. Market to investors to expand demand for Fitch ratings,
. Recruited to department as Senior Director and rated numerous commercial mortgage backed
transactions supported by all property types, Promoted to Managing Director 1997, Promoted to Co-
Head 2001,
Senior Director. Asset.Sacked Finance (1989 - 1993)
Co-managed and developed both consumer and commercial asset-backed business, Supervised and
trained seven analysts,
. Developed and implemented criteria for rating securitizations of auto loans, trade receivables,
corporate bonds, home equity loans, student loans, and lease receivables,
. Rated $27 billion of securities.
. Authored numerous reports, including timely publication of complex student loan analysis that resulted
in Fitch's initial contact with international investor and significant additional business,
. Hired by previous manager at S&P when he moved to the company.
. Hired as Director and promoted to Senior Director.
STANDARD AND POOR'S CORP.
Assistant VIce President. Commercial Asset-Sacked Finance
1987-1989
EXHIBIT
j J
Rated both cash flow and market value commercial asset-backed transactions including certificates,
notes, and commercial paper. Evaluated credit, financial, and legal structures of transactions. Reviewed
and negotiated legal documents with client's attorneys.
. Developed rating criteria for securitizing high yield bonds and senior bank LBO loans on cash flow
basis,
. Implemented deal tracking system to monitor performance of rated transactions.
. Rated several unique deals including first securitization of a bank's non-performing loans "Grant Street
National Bank (in Liquidation) bonds" and first securitization of bank loans,
. Responsible for rating all student loan revenue bonds including review of guaranty agencies and
servicers. Identified that at the time student loans were not a government risk as all previous S&P
analysts had indicated.
MARY GRIFFIN METZ
-2-
EUROPEAN AMERICAN BANK 1982 -1987
Assistant Vice President" Loan Workout
Negotiated, restructured, and collected problem loans for middle market and national accounts,
Consistent success in recovery of funds from diverse industries including oil and gas limited partnerships,
manufacturing, construction, real estate, and asset-based finance loans,
Chief of Staff - International Department
Assistant to Executive Vice PresidenV Division Head. Responsible for budgeting, expense control,
personnel administration, customer service, and loan processing, Managed stafl of thirteen.
Project Leader" Special Assignment
Managed customer service operations project and supervised team of seven to reduce funds transfer
inquiries backlog, Reduced 2,000 outstanding problems by 40% within two months and established
program to improve customer service,
Account Officer" International Department
Managed portfolio of $110 million for Yugoslavia, Eastern Europe, and Israel. Conducted credit analyses,
restructured problem loans, developed new business, and provided trade financing.
AMERICAN EXPRESS INTERNATIONAL BANKING CORP. 1978 -1982
Assistant Loan Examiner
Management Trainee
Supervisor" American Express Management Services
Completed credit training program with superior performance rating, One of three BAs selected to
participate in program with 21 MBAs. Initially hired as expatriate counselor and promoted to supervisor of
three within one year, and subsequently selected for credit training program,
EDUCATION
NEW YORK UNIVERSITY, Stern School of Business Administration
MBA in Finance - October 1985,
MOUNT HOLYOKE COLLEGE -1978
BA in Mathematics, Minor in German
Wrote chapter "Evaluating Credit Risk of Asset-Backed Securities" for The Handbook of Fixed Income
Securities, Fourth Edition, Editor Frank J, Fabbozi, Irwin 1994
Spoken at several conferences including those sponsored by the Commercial Mortgage Securities
Association, Mortgage Bankers Association, American Banker, and Frank J. Fabozzi/lnformation
Management Network, Institute for International Research.
.
Mary Griffin Metz
447 8th St.
Brooklyn, NY 11215
May 25, 2006
Court of Common Pleas
Cumberland County, Pennsylvania
Orphans Court Division
To Whom It May Concern:
Re: Petition to Authorize Settlement of Minor, Brianna Griffin's, Personal Injury
Claim
I, Mary Griffin Metz, aunt of Brianna Griffin, agree to act as trustee and oversee
the investments of a trust created as a result of the settlement of the personal
injury claim on behalf of and for the benefit of Brianna Griffin.
~
EXHIBIT
I--'L-
.
.
.
CONSENT AND APPROVAL
BY MINOR=S PARENT AND LEGAL GUARDIAN
We, Michael Griffin and Mary Lou Griffin, do hereby state that we are the parents
and legal guardians of Brianna Griffin, a minor, that we have reviewed the terms and
conditions of the foregoing Petition and agree to the same.
Date: 5- J- 5'"' -c/f,
~~
Michael Griffin
Date: ,F)r~t:;: ~ DC.
~~xL.I{__ ~
Mary Lou riffin
~
EXHIBIT
IL
,
CERTIFICATE OF SERVICE
I do hereby certify that I have served a true and correct copy of the foregoing
Petition to Authorize Settlement of Minor's Personal Injury Claim by placing the same in
the United States Mail, first class, postage prepaid, at Harrisburg, Pennsylvania,
addressed as follows:
Brigid Q. Alford, Esquire
Boswell, Tintner, Piccola & Alford
315 N. Front St. P.O. Box 741
Harrisburg, PA 17108-0741
John Gerard Devlin, Esquire
Devlin Associates, P.C.
1515 Market Street
Suite 2010
Philadelphia, PA 19102
By:
Stephen E. Geduldig, Esquire
Date:
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In Re:
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY,
--QFWHAN&' SQURT Dr9~ISIj)N . I
NO. O~~ 31-43 ~I
PENNSYLVANIA
ESTATE OF BRIANNA GRIFFIN,
a Minor
ORDER
~
NOW, this \ 'i day of June, 2006, upon consideration of the Petition to Settle
Minor's Claim, it is hereby ordered that the Petitioners are authorized to enter into a
settlement in the gross sum of $275,000.00. Petitioners are authorized to sign a Release
and to mark the matter settled, discontinued and ended.
The settlement proceeds shall be distributed as follows:
TO: Thomas, Thomas & Hafer, $5,000.00 for counsel fees;
TO: Michael Griffin, $4,498.09 for reimbursement of costs;
The balance of the settlement monies are to be distributed and invested as per the
structured settlement and trust provisions set forth in the within the Petition.
BY THE COURT:
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InRe:
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
ESTATE OF BRIANNA
. GRIFFIN, a Minor
: NO. 06-3243 CIVIL
AMENDED ORDER
AND NOW, this 5"'" day of ~t4\I.."'\\J" ,2006, upon consideration of the
Petition to Settle Minor's Claim, it is hereby ordered that the Petitioners are authorized to
enter into a settlement in the gross sum of $275,000.00. Petitioners are authorized to sign
a Release and to mark the matter settled, discontinued and ended.
The settlement proceeds shall be distributed as follows: .
TO: Thomas, Thomas & Hafer, $5,000.00 for counsel fees;
TO: Michael Griffin, $4,498.09 for reimbursement of costs;
The balance of the settlement monies from the State Farm policy shall be
distributed and invested in accordance with the structured settlement provisions set forth
in the Petition.
The balance of the settlement monies from the Brotherhood Mutual policy shall
be distributed to an irrevocable trust that restricts distributions from the trust to the
payment ofBrianna Griffm's future medical expenses. Said irrevocable trust shall be
administered in accordance with the provisions set forth in the Petition,
By the Court:
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Stepher E. C;eduldig, Esquire
Attorney I 0 ~Jo. 43530
THOMAS, THOMAS & HAFER, LLP
305 North Front Street
Post Office Box 999
Harrisburg. Pennsylvania 17108-0999
(717)237-7119
FAX (717) 237-7105
E-Mail ~jL.idia(ciltthlawcom
Attorneys for PE!titioners
InRe:
ESTATE OF BRIANNA GRIFFIN"
a Minor
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PEN'\TA
: ORPHANS' COURT DIVISION
: NO. 06-3243 CML
PETITION TO AUTHORIZE FURTH:ER
SETfLEMENT OF MINOR'S PERSONAL INJURY CLAI~I~
Pursuant to 20 Pa.C.S.A. Section 3323(a), Petitioners:. Michael and :\1ary
Griffin, respectfully petition this Honorable Court to enter a decree authorizing and
approving a further compromise settlement of the personal injury claim of Brianna
Griffin, a minor, and in support thereof aver as fo11o\,\Ts:
1. Brianna Griffin is a rninor child residing v"ith her parents, Michael and Mary
Lou Griffin, the Petitioners herein, at 25 Westgate Driye, Mt. Holly Springs, Pennsylvania.
2. At all times relevant hereto, there \,vas in hIll force and effect, a rrlotor vehicle
insurance policy issued to Petitioners by Progressive Insurance Conlpany, which provided
underinsured motorist benefits (UIM) in the amount of $200,000.00. A tnle and correct
copy of the declarations page evidencing these UIlVI limits is attached hereto, made a part
hereof and identified as Exhibit "A".
3. This matter has previously been brought before this Honorable Court by
way of Petition to authorize Settlement of Minor's Personal Injury Clain1,\yhich \'\'as
... '. ~
filed on or about June 7, 2006. Said Petition is attached hereto, made a part hereof
and identified as Exhibit "B".
4. The averments of the prior Petition are incorporated herein as if fully set
forth at length.
5. By Order dated June 14, 2006, this Honorable Court authorized
Petitioners to settle claims on behalf of the minor, arising frorn the .June 19, :2004,
accident, against State Farm Mutual Automobile Insurance Company in the amount of
8100,000.00, and against Brotherhood Mutual Insurance Company in the amount of
8175,000.00, as well as counsel fees to Thomas, Thomas & Hafer, LLP, in the arnount
or 85:,000.00, and reimbursement of costs advanced by Michael Griffin in the amount
of $4:498 .0c).
6. A claim was made upon Progressive Insurance Company for payrrlent of
the policy lilnits of 8200,000.00.
7. After substantial negotiation, Progressive agreed to pay, su~ject to this
Court approval, the sum of $195,000.00, which represents a 97.5% recove':'y of
available UI M benefits.
8. Your Petitioners submit that it is reasonable to compromise the n1ioor's
claim for a 2.5% discount of available limits on the basis that:
a. Progressive's insurance policy provides that suit must be
filed against Progressive in UIM cases. The filing of su it and
attendant costs of litigation could well exceed, at a ver:,/ early stage
of the litigation, the $5,000.00 difference between the actual
recoverv and the limits.
2
-
b. The value of the $195,000.00, properly invested, likely
would exceed the value of the full policy limits if such poliCY limits
'were recovered after the deduction of costs and attorney fees, 'were
said moneys to be received at a later date.
c. The uncertainty of valuing a bodily injury claim is such that
it would not be in the minor's best interest to roll the dice for only
$5,000.00 ITlOre dollars.
9. Petitioners propose that after the payment of fees and expenses detailed
below, the net settlement monies from Progressive Insurance Company's policy fund a
trust, established for the benefit of the minor, Brianna JV1ary Griffin. This Court has
already' approved Brianna's aunt, Mary Metz, Managing Director of Fitch Ratings,
New York, N e\v York, to serve as Trustee and oversee the investment of the trust
monies in selected mutual funds over the life of the trust, and request further that the
trust remain in place until Brianna reaches the age of twenty-five (25) years.
10. Petitioners have engaged the serviees of the undersigned attorneys, Stephen
E. Geduldig, Esquire, and Thomas, Thomas & Hafer, LLP, in connection of the
presentation and settlement of the vvithin claims~ and have incurred attorneys' fees, still to
be calculated, but not in excess of the amount of $15,000.00, \".'hich Petitioners feel IS
extremely reasonable and appropriate given the total net recovery on behalf of Brianna
Mary Griffin in the amount of $470,000.00.
11. Petitioners have incurred or \'\-ill incur a total of $1,664.60 in out-of-pocket
costs, to \\1t::
Susan E. Lederer, Esquire-- Legal fees in
connection with establishing the Trust
$1,~~:00.00
Gerstemeier Court Reporting -- fee for
Brianna's SUO
S 264.60
3
..
Robert R. Dahn1us, M.D.jOrthopedic
Institute of Pennsylvania-Special report
for records review
$ 100.00
12:. On behalf of their minor daughter, Petitioners, Michael and Mary Lou
Griffin. lw\'e accepted the aforerrlentioned settlement offer and have revie\yed and
approved this Petition, and their concurrence in the foregoing Petition is attached as
Exhibit "e".
13. The Release which Progressive proposes that Petitioners sign on behalf of
the minor child is attached as Exhibit "D".
vVHEREFORE, Petitioners respectfully request that the parties be permitted to
enter into the settlement recited above and that the Court enter an Order appro\ing
payment of the above-referenced settlement amounts to Michael and Mary Lou Griffin, on
behalf of and as the parents and legal guardians of Brianna Griffin, a TIlinor, and
appro\'ing execution of the attacbed Release in favor of Progressive.
Respectfully submitted,
THOMAS~ THOMAS & HAFER~ LLP'
" /
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4719:27.1
By:
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Attorney I.D. No. 43530 //
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Policy number: 5~i518956u3
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SHINER INS AGENCY PC
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Auto Insurance
Coverage Summary
This is your Rene'vval
Declarations Page
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SOO-PROGRESSIVE (800-7i'6-4737)
POIII\
::4 r,Ciurs
11~lts and policy period shewn apply onlY If YOJ pay fer tnlS poley te reie>!J
i~~ JF r'(j ge
on Apllll, 7004a\ 1:701 cJ.'TI. 1rl"
or Octooer 11, 2004 cit 12 1
)J lSLJilnCe illd ilny policy endorsements contain a fJll of yow CCJ!'rage "'h~
'10: be combined with the lirTlts for the samE coverage or arlOtr or vehcle, Jrliess
~jflrnits. He :Jolley contract form 9608 DA (JSi01) The_:nlrar..t I~ iilUJi:lec bv fcwr:,
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Drivers and household residents
p.,CO :onJllliorl1Jtlcr
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Outline of CiOverage
1990 Pontiac Grand AM LE 40
" 383
11111iS
I'r"nliurr
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S' 00,000 2cJr..r IC:ldent
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each
$ ,:;CiO eac.h
$' ,iOO ea,=h
C!C!( rnaXlill m
9
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r\~O:OI')t - Stacked
$'(IO,OOC
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42
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$266
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'fIU':I. 55':' 2'05'13
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PJg2 ; ot 4
1999 Dodge Caravan
3~~~2S39XR4749S2
je rita' Death
Moto!';: - Stacked
$' (JO,(tOJ each ;~e',on,'$3()UI~)O
accijell
JI" Pr~,'rTllurn
!~ 129
'{3
7
2
20
1',2
28
~! =~g
$391
$657
-73
$584
LI:T1 '~
$ , C!C! (toe eace
$' eacr lC: de",
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r
$ ,
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Ins.nee Mute'lsl - Stacked
$' (:0,00(1
iJeSO'I,'S 30C),O(IO
aCUJelt
:;e'TII U IT br "999 Dodge
Total 6 month policy premium
J:lt f full
Total 6 month policy premium if paid in full
Premium discounts
. ~9S6-3
mUITI-elr "r,d hlJme owner
l~gO Por,ta', GralC .6Jv1 LE 4D
I_aravan
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cntl-tner devce ard
Tort Option
lliS policy prOVides full tort insurance,
COLLISION COVERAGE FOR RENTAL VEHICLES
IF THIS POLICY PROVIDES COLLISION COVERAGE, IT WILL APPLY TO VEHICLES YOU RENT, BUT NOT TO
VEHICLES RENTED FOR 6 MONTHS OR MORE.
Penalty for Insurance Fraud
: ny :)erson who knowingly and witl intent to injure or defraud any irsLlrer files an application or (:all! containing
incomplete 0' misleading information shall, upon conviction, lJP suhjpct to irnprisonnwlll fOI Ip t : ',(',rn years
of a fine of up to $1 S,OOO
Notice of Available Premium Discounts
nay be eligihle tor discoLlnts mandated by /\et S ofl 990
heneflts coverage if YOL/l cal is cOlllppC'd with Cl pClssive 'estraint
(Ill coverage if YOLlr car '5 cqulpr:>d '-'liTh a passive anti-theft de/Ice
i ,dlkl!ned insureds dre SS or older cJnd ;,ave suw'Js;ully completed il motor.'ehicle driv?r IlT1prl ,iCIT ell1 course
(lplJved hv PennDOT,
have dny questions dDI)Ut j0U elllJl~';lty, f-l:2Cise l":IIJo:,, v Services 01 (OIltac! your [lgel1t
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Page 5 Of 4
Driving history
, ll11 d"ivllg
use~ YOllr drivir19 historj trOll' the past ~5 months to determine )lOll I late. Vie obtalf
fr Dm the follD\^Ji ng sources
',iUI appllcatiDn (!\PP)
claims histor)l (PROG)
fv10tur Vehicle fiJ'pDrts - provided JY state
ComprehenSive Loss U ldervJrltlng Exchange
CholcePoint, Inc (GUl)
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prCI\,iJel~ t,
()(Jillce
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(rlO poi fits
non-chalgeal:!e at;ault
(nJ pOints
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MG1AEL P GRIFFN
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Notice To Nclmed Insureds
Ti,e 1_ VI'S of the Cornmor1Vvealth of Pennsy\';ania, as dldcted by the Gewral !\sst'rnbly, only require Ih,r \'OU purchase
and first-party rnedical bene'it coverages additional cove'ages or co'_rrages irl eice", O[ tv limits
bv lavv are provided only a your request as enhancements to basic coverages
Tie I ;'1:5 of the Cornrnonwealth of Pennsylvania give ynu the right to choose eltner of the tort o[1tions
"[ 'Illiti'd Tort' Uptlon - This form of j'lsurance limits )'OUI rght and the lights of Ii'lernbers of your !i'Juselluid!o seek
fi"anclal compensation for injuries caused by other driver~1 Under this form of IlIsurance, Y:Ju dnd uth -" hOLsehold
Irelll! ers covered under this polrcy lTlay seek recovery for allllledlcal end other out-nf-pocket "/[';:'!IS[":- but not for
dnd suffering or other nonmonetary damages unless the irlJuries sutierf"d fall within th:, dcfi:rit on lf IIOUS injury"
,l' se: forth in the policy or unless one of :;everal other e<ceptions noted in the policy applies
ull OIt' Option - This form of insurance allows you to IllJintal1i al urrestrlcted right for vOL: ,me: [[. rH:,rnbers of/our
h IUS hold TO seek financial compeIl';ation for IIljurie(, caused b'i other Jrivers. L nder thiS form 01 IISli'H1Ce, you and
lher household members covered under this poliCY may seek rccover,! for all m(:dicCJI CJnd other
ses and may iJlso seek financial compensation for pCJin all(: suffeing and other nOI-lrT1:Jne1ar iJn iJqc' iJS a resuit
caused by other drivers.
)ieu wish to change the tort option coverages, or Irnits that currentl'l iJpply to your polic/.lou 1'lllSt your iJgent
(nd i i'q uest an d com plete the appropriate form.
"j - 2
Cancellation Fee Waiver Endorsemlsmt
The following IS added to your policy:
When you renew this policy, we waive any cancellation fees that may apply to thl3 renewal Dolley.
Form 0101 (0802)
PMNEIEO~: 18032E:05L01 01 PA
1\,
Motor Vehicle Policy Endorsement
Your policy is amended as follows:
1, General Definitions
The definition of "vehicle" and "vehicles" is deleted and replacE~d by the followlI'g:
"Vehicle" and "vehides" mean a land motor vehicle:
a. of the private passenger, pickup body, or cargo van type;
b, designed for operation principally upon public roads;
c. with at least four wheels; and
d, with a gross vehicle weight rating of 12,000 pounds or less, according 10 the
manufacturer's specifications.
However, "vehicle" and "vehicles" do not include step-vans, parcel delivery \/3ns, or
cargo cutaway vans or other vans with cabs separate from the cargo area,
2, Part I - Liability To Others
(8) The Additional Definition of "trailer" in Part I IS deleted and"eplaced by thE!foliowing:
"Trailer" means a non-motorized trailer, including a farm wagon or farm implernent,
designed to be towed on public roads by a vehicle.
(b) The following exclusior is added to Part I:
Coverage under this Part I, including our duty to defend, dm~s not apply to bodily injury
or property damage arising out of the ownership, maintenance or use of a. vehicle or
trailer while it is parked and being used:
a. for commercial or business purposes;
b. as a residence or premises; or
c. as a premises for office, store 01 display purposes.
3. Part II - First Party Benefits Coverage
(8) The Additional Definition of "motor vehicle" in Part II is deleted and replaced c'y th'3
following:
"Motor vehicle" means a self-propelled vehicle, operated or designed for U3e upon public
roads. However, motor vehicle does not include a vehicle operated:
a. by muscular power; or
b. on rails or tracks.
(b) The Additional Definition of "your covered auto" in Part II is deleted and replaced by the
following:
"Your covered auto" means a motor vehicle for which you have purchased
a. Part I - Liability To Others CoveragE~ if the motor vehicle is:
(i) owned by you; or
(il) shown on th!3 Declarations Page; and
b. First Party Benefits Coverage as required under the Pennsylvania Motor \lf~hic1e
Financial Responsibility Law.
4. Part IV - Damage To A Vehicle
(Ell The following provision is added to the Collision Coverage Insuring Aoreemwlt ill Part IV:
Subject to any deductiule al'pl,c8ole t(, a collision loss, we will replace. or rf~rnbursl3 the
reasonable cost to repl;?,;e, "lny child ~afl3ty seat or restraint damagec in an accident to
which this Collision COl/erage applies.
(tl I The following exclusions are added to Part IV:
Form 7951 PA ICl1/0T: PMN"P:03 0032605L7951PA
Form 7951 P A (01lC13
Coverage under Part IV - Damage To A Vehicle dons not apply for loss to CL cover,ed
vehicle, non-owned vehicle, or trailer, caused directly or Indirectly by mold, '1111d13W or
fungus, including any type or form of:
a. decomposing or disintegrating organic material or microorganism;
b. organic surface growth on moist, damp, or decaying matter;
c. yeast or spore-bE!aring plant-like organism; or
d. spores, scents, toxins, bacteria, viruses, or an,! other by-products produced or
released by any mold, mildew, fungus, or othw microb,as.
However, this exclusion does not apply to loss caused by rnold, mildew or funqus, if such
loss is caused by any other loss covered under thi3 Part IV.
Coverage under Part IV - Damage To A Vehicle dops not apply for loss to EI cCivened
vehicle, non-owned vehicle, or trailer, caused directly or indirectly by:
a. war (declared or undeclared), including civil war;
b, warlike action by any military force of any govmnment, sovereign or otl181' authority
using military personnel or agents. This includes any action taken to hlnck~r at
defend against an actual or expected attack;
c. insurrection, rebellion, revolution, usurped power, or ar,y action taken by ,j
governmental authority to hinder or defend age,inst any of these acts; C I'
d. any intentional discharge, dispersal or release ::>f radi02:ctive, nuclear, pathogenic,
poisonous biological, chemical or hazardous material for any pUl'pose 01:h13r than its
safe and useful purpose,
(e) The following provision is added to the Limits of Liability in Part IV:
Payments for loss covered under Collision Coverage, Comprehensive Covwa03, Custom
Parts or Equipment Coverage and Additional Custor') Parts or Equipment CCV8tage are
also subject to the follCJwin~l provisions:
To determine the amount necessary to mpair the damaged property to its pt8-{JSS
condition as referred to in paragraph 1.c., the total cost of m~cessary repair will be
reduced by:
(i) the cost of labor, parts and materials necessar'y' to repair or replace dalllaqe,
deterioration, defE)cts, or wear and tear on exterior bod',! parts, windshields ancl other
glass, wheels, and paint, that existed prior to the accident and that is nlirrinated as
a result of the repair or replacement of propert'l damaged in the loss. Thl~
adjustment for physical condition includes, but is not limited to. broken, cracked or
missing parts, rust, dents, scrapes, gouges and peeling paint;
(ii) an amount for depreciation (also referred to as betterm.::mt) that represEnts a portion
of the cost of mechanical parts (parts that weal' out ovm time and have a useful life
typically shorter than the life of the vehicle as El whole) that are Installed a~;
replacements for existing mechanical parts that were dt3fective, inoperablE~ or
nonfunctional prior to the accident, which we deem necessary to replece in tre
course of repair; and
(iii) an amount for depreci?tion 'als0 referred to as betterment) that I'epresents a pJrtion
of the cost for repbcel'"1en+ tiref, batteries, 13ngine or transmission, deturmned by
the proportional increase in the useful life of th(~ replacement part wher~ compared to
the replaced part. For example. if we replace a twentYhfour (24) month ole battery
that had a ,no(luracture,'s ratad life of sUy (601 months with a new sixt,\, (ElO)
PMNEIE03' D032605L7951 PA
JF ;
month rated battElry, our payment for the battE~ry is reduced by forty percnnt (40%)
and you are responsible to pay that forty percsnt (40'ic:)) portion of the cost of the
battery. Howevel', the reduction of the amount we will pay for a new or rebuilt
engine or transmission will be determined by Lsing the proportion the clctual rniles
used before replacement, after reducing the rriles used by 80,000, bears ':0 1!50,000
miles (or any other measure of useful engine I fe as reasonably determined by us).
If we replace an an engine or transmission that has less than 80,000 milps of use,
no reduction shall be taken.
5. Part V - Roadside Assistance Coverage
The Additional Definition of "covered disabled vehicle" in Part V is deleted and replaced by
the following:
"Covered disabled vehich~" means a disabled covered vehicll~ for which this CO'J9rage has
been purchased.
6, General Provisions - Cancellation
The following paragraph is added to the Cancellation pro'Jision:
With respect to cancellation, this policy is neither severable nor divisible. .Any ccncellation will
be effective for all persons, all vehicles, and all trailers.
7, General Provisions - Our IRights To Recover Payment
Trle following paragraph is added to the Our Rights To Recover Payment provision:
If we elect to exercise our rights of recovery against a msponsible person, entity, 01'
organization, you authorize us, at our option, to recover any deductible incurred C)y you for
property damage covered by this policy. We have no obligation to seek repayme(lt of thl3
deductible if we pursue recovery through Inter-company .Arbitration. We have no obligation to
pursue recovery against a msponsible person, entity, or organization for anything other Ulan
the deductible incurred by you and the amount we have paid for property damag,,~.f you or
an insured person have other claims to pursue against the responsible person, Bellity or
organization for recovery of damages not paid by us, the1:
1 a separate or independent legal action may be filed by you or that insured p,,~rs)n; or
2 the claims may be joined with our action if that person notifi.3s us and secures separate
counsel to protect those other interests.
We reserve the right to compromise or settle the deductible and property damage claims
against the liable parties for less than the full amount. We reserve the right to inc ur 'easonable
expenses and attorney fees in pursuit of the mcovery. You are entitled to reimbursement of
your proportionate share of any recovery, subject to a reduction for your proportionate share
of expenses and attorney fees incurred in connection with these collection efforts
All other terms, limits and provisions of this policy remain unchanged.
Form 7951 PA (01/02 I
PMNEIE03.. 003L~605L7951 PA
-
~'0\'bi* :e,
In Rc:
IN THE COURT OF COMMON PLEAS
CUlv1BERLAND C01JNTY, PENNSYL 1\1\)11"
EST/\TF~ ()F BRIANNA
GRIFFll'-J, it Tv1inor
NO. 06-3243 C [Vll
:~MENDED ORDE.B
v~\
AND NO \;V, this~~__ day
"
tJ"
2006, upon consi c1c;-ation :)f the
PClit:on Settle tAinor's ClaiIl1, it is hereby ordered that the Petitioners an:~ authlri,:ed to
entcr ir:t~J a settlement in the gross sum of $275,000.00 Petitioner::; arc authorized sign
a Release and to mark the matter s.ettled, discontinued and ended.
The settlement proceeds shall be distributed as follows:
TO: Thomas, Thomas & Hafer, $5,000.00 for :::ounsel fees;
TO, IvIichael Griffin, $4,498.09 for reimbursement of costs;
The balance of the settlement monies from the State Fann poiicy shall
di:,lribUed imd invested in accordance with the structured settlement provision~ ,,:::t 'orth
in the Pe'ciUun.
The balance of the settlement monies Hum the Brotherhood lVlutual pobe
be di,:trihuted to an irrevocable trust that restricts distributicns rnml the trust tu
paY11'1ent of Brianna Griffin's future medical expenses., Said irrevocable tmst sh:;!] he
administered in accordancc\vith the provisions set forth in 1he PeliLion.
By the COllrt:
r '>(lUE (..;OPY F F~CH'li R E(~OAD
~ ~'~OOfOOI. ! h\(e untOS9'lrmy~.
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In Re:
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
NO.
ESTATE OF BRIANNA GRIFFIN,
a Minor
PETITION TO AUTHORIZE SETTLEMENT
OF MINOR'S PERSONAL INJURY CLAIM
Pursuant to 20 Pa.C.S.A. Section 3323(a), Petitioners Michael and 1\J1.:!ry (;riffin
respectfullv petition this Honorabl13 Court to enter a decme auttlorizing and approving a
compromise settlement of the personal injury claim of E\rianna, Griffin, a min=ir, and in
support thereof aver as follows:
1. Brianna Griffin is a minor child residing with her parents, rvlicha';31 and Mary
Lou Griffin the Petitioners herein, at 25 WestgatE3 DriVE!, Mt. Holly SprinQs. Ppn!isylvania,
2, At all times relevant hereto, there was in full force and effect a motor vehicle
insurance policy issued by State Farm Mutual Automobile Insurance Compan:,I, i'l favor of
one Pal1ll=1anck. which policy listed as an insured vehicle a 1999 Ford F-150 P ckup Truck.
and which policy provided Bllimits in the amount of One Hundred Thousand ($ 'I O'lOOO.OO)
Dollars, 1'-\ true and correct copy of a Certificate of Cow::;rage for the policy a' is~~ue is
attached hc;rcto. made part hereof and identified as Exhibit A.
3. At all times relevant hereto, there was in full force and effect a motor vehicle
insurance policy issued by Brotherhood Mutual Insurance Company, in favor of the Carlisle
Evangelical Free Church, which policy has a combined single limit of $1,000,000.
4. On June 19, 2004, K,etha Ranck, wife of Paul Ranck, was operating 2, 1999
Ford F150 pickup as part of a church trip sponsored by the Carlisle EvanqElical Free
Church
5. Brianna Griffin was among the passengers in the Fianck vehicle, 'l/hich had
been parked on the right berm of F:oute 11, just south of its intersection with F:a.invay Drive
in West F'ennsboro Township, as part of a caravan of three additional vehlcle~, each of
which was also stopped in a parked position on the berm of the road.
6. Thereafter, the Ranck vehicle commenced a U-turn from the IJenl of the
road onto f=ioute 11 ,
I , As the Ranck vehicle entered back onto Route 11, it collided \~ith a tractor
trailer, owned by Clouse Trucking and operated by one Michael,J. Barrick, that had been
traveling southbound on Route 11; the collision caused the Ranck vehicle to tl3.\/81 across
the roadway, into the northbound lane and off the roadway. where itli"t a small
enlbankmEnt, and overturned. A true and correct copy of the Police Accident Feport for
this aCCident is attached hereto, made part hereof, and identified as Exnibit E~.
-/-
8. As a result of the collision involving the Ranck vehicle, the minor Brianna
Griffin, did sustain certain personal injuries, which required medical attention, to wit:
a. Acute closed head injuries
b. Left femur fracture, requiring surgery - open reduction
with 1M nailin~l on 6/19/04
c. Left wrist fracture, requiring two surgeries - open
reduction on 6/19/04; closed reduction with
percutaneous pinning on 6/~28/04
d. 1 st and 2nd de~Jree chemical (diesel fUl?I) burns on chest,
shoulders, upper arms, back and face
e. Pelvic fracture
f. Anemia, requiring series of blood transfusions
g. Infection, requiring antibiotic therapy
h. Insertion of a femoral arterial line.
9. Brianna Griffin was flown by Life Lion to Hershey Medical Center frcm the
scene of the accident. Due to the voluminous nature of Brianna.'s medical rl:;cords from
her admission to Hershey Medical Center, the completE; file has not been reproduced with
this Petition, although the followin~j relevant reports and Summaries are attach:.d r'ereto,
made part hereof, and identified as Exhibits C through F:
C - ED (Emergency Department) Summary
o - 6/19/04 Operative Notes
E - 6/28/04 Operative Notes
F - Radiology Reports
--,
- -~-
The complete file will be available at the hE~aring, if any, for this Petition should the
Court wish to view the same at that time.
10, Brianna Griffin was hospitalized in the PEdiatric Intensive Care Unit of
Hershey Medical Center from 6/19/04 through 6/30/04 where, in addition to the surgical
procedure~; noted above, she underwent a series of Xrays, CT scans, and other diagnostic
tests, IV therapy, physical/occupational therapy, and con~;ultations from orthop~'dics and
plastic surgery.
11 . Upon her discharge from Hershey Medical Center on 6/30/04, Branna Griffin
was transported by ambulance to her home, where she rEquired the use of a vvheelchair,
hospital bed, bedside commode, installation of a wheelchc.ir ramp, and other r,:~h3.bilitative
appliances for' several months. She remained in a wheelchair until mid-September 2004:
thereafter, she utilized crutches to ambulate for several additional weeks.
12, Medical care requirE~d after her dischar~je from Hershey Medical Center
included: Follow up visits to Hers1ey Medical Center treating physicians an::j=lutr=atient
physical therapy. Brianna was discharged from the Hershey Medical Center 11-1 December
2004. Medical records from 6/30/04 through 12/31/04 are also attached hereto, made part
hereof, and are identified as folloVJs:
G - Hershey Medical Center records, post-
dischal'ge
H - Shepardstown Family Practice records
(includes 9/24/04 Outpatient !_etter!rom
HMC pediatric surgeon)
--+-
13. Michael and Mary Lou Griffin anticipate that additional visits will be required
in the corning months, as Brianna continues to experience various problems related to her
left wrist End left knee. They have also been advised that additional sur~Jer'y may be
required in thE~ future to remove th'3 plate in her left wrist.
14. On behalf of their minor daughter, Michael and Mal'y Lou Griffin have made
a claim under Ranck's State Farm policy, and the church's3rothel'hood Mutual policy, with
respect to the personal injuries that Brianna sustained in the accident.
15. State Farm has tendered the applicable limits available under the F~anck
policy, in the amount of One Hundred Thousand ($100,000.00) Dollars to r./1ichaE~1 and
Mary Lou C;riffin in their capacity as legal guardians and parents of Brianna Griffin,
16, Brotherhood Mutual has offered the sum of One Hundred S(~\!'3ntv-Five
Thousand ($175,000.00) Dollars to Michael and Mary L.ou Griffin in their capacity as legal
guardians and parents of Brianna Griffin.
17 Neither the Department of Public Welfare, nor any other entity,-las a lien or
claim against Brianna Griffin or her parents in connection v/ith her accident-relatEld injuries.
18, The settlements would be in exchange for a general release, L arring all
claims ar~;inD from the accident, including any claims against Michael Barric;1< and his
employer, Elrotherhood Mutual has indicated that it may pursue a subroqatlon claim
against Barrick and/or his emploY'3r. As part of the settlement, Petitioners v,lill assign to
Brotherhood Mutual any claims they may have against Barrick and/or his err.pioyer.
-)-
19. Brianna Griffin's claim for underinsured motorist benefits against I:)rogmssive
Insurance Company is still pending. Progressive has, however, consentE~d to the
settlement of the third party claim against Ketha Ranck.
20. Petitioners propose that the total settlement monies from the :State Farm
policy be invested into a structured annuity with Hartford Ufe, as follows:
Payments
In consideration of the Releases to be executed in this case, Hartford MJtual Life
InsUranCE! Company, on behalf of Defendant, agrees to pay to the Brianna Griffin, F'ayee,
the sums outlined below: Periodic payments will be made according to the ~;chedule as
follows (thl3 "Periodic Payments"):
One Hundred Fifty-Six Thousand Eight hundred Three Dollars and Forty-Two Cents
($ 156,803.42) guaranteed to be paid on September 8, 2015; and, no fu rthE'r payments
beyond said date. All sums set forth herein constitute damages on accoun' U physical
injuries and sickness, within the meaning of Section 1 04(a)I:2) of the Internal Revenue code
of 1986. as amended.
Claimant's Riqhts to Payments
Each Claimant and/or Payee acknowled~les and agrees that neitherlht: Periodic
PaymEmts nor any rights thereto or intl::rest therein (collectively, "Payment Rights") can be
acceler3t(~d, deferred, increased or decreased by the Claimant; nor shall the Cla.irilant have
the power to sell, mortgage, encumber, or anticipate the Periodic Payments or ar'y part
thereof. by assignment or otherwise.
6
Beneficiarv Desiqnation
Any payments to be made after the death of Brianna Griffin, pursuant 10 the terms
of this Settlement Agreement, shall be made to the E~tate ot Brianna Griffin. Upon
reaching the age of majority, Brianna Griffin shall have the right to submit a request to
change the Beneficiary designation. No such designation, nor any revocation thereof, shall
be effectiv'3 unless it is in writing, signed by Brianna Griffin, and delivered to Hartford Life
or its i\ssignee. The designation must be in a. form acceptable to the In~:;urer or the
Insurer's ~,ssignee before such payments are made.
Consent to Qualified Assiiqnment
Cia mant acknowledges and agree that Defendant and/or' Hartford Life may make
a "Qualified Assignment," within the meaning of Section 130 ( c) of the Internai Revenue
Code of 1 ~j86, as amended, of the Defendant's and/or H2.rtford Ufe's liabilit)1 to make the
Periodic Flayments set forth in above to Hartford CEBSCO ("the lLl.ssigne!3"). The
Assignee's obligation for payment of the Periodic Payments shall be no greater than that
of the Defendant and/or Hartford Life (whether by judgment or agreement) nVllediately
precedin~J thE! assignment of the F)eriodic Payments obli~lation.
Ary such assignment, if made, shall be accepted by the Claimant wiH10Jt right or
rejection and shall completely release and discharge the Defendant and HartforcJ Life from
Hle PeriOdiC f::Jayments obligation assi~lned to the Assignee. The Claimant recognizes that,
in the event of such an assignment, the Assigne(:; shall bE~ the sole obligor with "espect to
the Periodic F:Jayments obligation, and that all other releases with respE3ct to tho Periodic
Payments Dbligation that pertain to the liability of the Defendant and Hartford Ufe shall
thereupon become final, irrevocable and absolute.
.Riqht to Purchase an Annuity
Haliford Life, through its Assignee, reserves the right to fund the liablity tOllake the
Periodic Payments through the purchase of an annuity poliCY from Hartford Liff3 l'lsurance
Company. The Assignee shall be the sole owner of the annuity policy and 81"lail have all
rights of ownership. The Assigm:le may have Hartford Life Insurance Ccynl=any mail
payments directly to the Payee. The Claimant shall be responsible for m:tirtaining a
current mailinl;] address for Payee with Hartford Life Insurance Company
Dischar~e of Obliqation
The obligation of the Assignee to make each Periodic Payment shall bE discharged
upon the mailing of a valid check in the amount of such payment to the designated address
of the Payee in named in this Agreement.
21, Additional information as to the proposed invE~stment, and comparison quotes
obtained from other providers, is attached hereto, madE! part hereof, and ijentified as
Exhibit I,
22. Petitioners propose that, after payment of the fees and expen::;es detailed
below, the net settlement monies from the Brotherhood Mutual policy fund .:' trust. to be
establistlE3Cl for the benefit of Brianna Griffin. Petitioners nominate Brianna's aunt Mary
Metz, Vice President of Fitch Ratings, New York, New York, to serVE:? as "TrL stee and
oversee the investment of the trust monies in s(:llected mutual funds over the [ife of the
8
trust, and ~equest further that the trust remain in place u ltil Brianna reache~:; the age of
twenty-five (25) years. A copy of Ms. Metz's curriculum vitae is attached hereto, nlade part
hereof, and identified as Exhibit J: her consent to act as Trustee in connection with this
matter is attached hereto, made part hereof, and identified as Exhibit K..
23. Petitioners have engaged the services of the undersigned attorneys Stl3phen
Geduldig Esquire and Thomas, Thomas & Hafer, in conn3ction with the presGntation and
settlemen1 of the within claims, and have incurred attorneys' fees in the amOJnt of
$5000.00,
24. Petitioners have incurred and/or will incur a total of S4, 198.09 in out,.of-pocket
costs and expenses, to wit:
a. Co-pay charge - Hershey Medical Center (6/19/04) S~~5 00
b, Co-pay charge - Physician services (6/19/04) S', 5 00
c. Washing tray (7/1/04) $31 99
d. Construction & materials for wheelchair access ramp
at Griffin residence (7/5/04) $"143.00
e, Medications (7/6/04) $40.53
f. Co-pay char~le - Physician services (7/28/04) :315.00
g. Co-pay charge - Radiological services (7/14/05) $;20.94
h. Travel expenses to hospital, doctor 3.ppointments, and
physical therapy appointments (approx. 1554 miles @
$.385/mi.) $5~J8.29
l)
1M E examination (3/31/06)
S1.2':25.00
i
J'
Mediation fee (4/19/06)
$~: ,0,133.34
'<.,
Exercise bicycle (2006)
~__~~!0.02
TOTAL
S.4,498.09
25 On behalf of their minor daughter, Micha'31 and Mary Lou C; riffin have
accepted the aforementioned settlement offers and have reviewed and approved this
Petition: their' concurrence in the foregoing Petition is attached hereto as Exhib!t L.
\^JHEREFORE, Petitioners respectfully request that the parties be permittej tc enter
into the s(jttlements recited above and that the Court entEn an Order approvi"~l payment
of the above-referenced settlement amounts to Michael and Mary Lou Griffin, on be1alf of
and as the parents and legal guardians of Brianna Griffin, a minor.
Respectfully ~;ubmitted,
Date:
3--- -:?/- {)t
THOMJ\S THOMAS & HAFER
(-------~.-;.~ .~
By: --~ <- ---
Stephen E. Geduldig, Esquir.;j
305 N. Front Street
Post Office Box 999
Harrisburl;:J, PA '17108-0999
Attorneys for Petitioners
14- !f~?J-j; 0
10
i:-xn\blt' C-
CONSENT AND APPB-OVAL
BY MINOR'S PARENT .A.ND .LEGAL GT;ARDIA.'{
'vVe, ?v1ichael Griffin and l\l~lTY Lou Griffin, do hereby state that we arc tle
p;1fents and legal guardians of Brianna J\1ary Griffin, a minor, flat \v'C have re\~e\\2d
the term::; and conditions of the foregoing Petition anci 8gree to the same.
.._1~~(A'IL~~;~.....
::vlich3cl Griffin tr
/ _ (.)_~~r-D~
D3te
_ I .;~'l- _ 0.7
Date
L j' v1.l1
---fYb~9~:.~j/~~__________
NI3.I)! L' u Gnthn L/
,',71);0--' J
-
S~\l\'o.\t D
PARENTS' UNDERINSURED l~OTORIST RELEASE ~'- INDEMNITY AGREEMENT
Page 1 of 2
Kl'--fO\V ALL BY THESE PRESENTS: Th(lt the undersigned, individually and as kg(,l
parents lnd guardians of Brianna Griffin. a minor (hereinafter "Releasors"), for the sok
consideration of One Hundred and j'iinery five Thousand and 00/100 Dollars($195,OOO.OO).
receipt of 'cvhich is hereby acknowledged, have remised, released, .:l:1d forever discharged and
(;OVen~mt to hold harmless Progressive Casualry Insurance Company, i':s agents, employee$,
.stlbSld'iarie~ and affiliates (hereinafrer "Releasee") and Rele<'Jsee's successors and assigns, from
:.tr.y 2.n:1 all claims, action!), and causes of action, demands, COS1:S, and expenses ansing under the
policy number 55518956-3, for bodily injury or damages of any kind sustained or that may be
hereJ.frer sustained by the said mjnor, or on behalf of said m1nor. Or by the undersigncc:, on
accounr Df or in any way arising out of ac1 accident caused by an underinsured motorisr 81' or near
Route 1 , Carlisle, PA, on or about the 19th dd.Y of June, 2UO,4-.
To Drocure :.he payment of the st.3~ed consideration. the Rdea:-;ors hereby declare: that :':.0
representations about the nature and extent of the said injuries. clis3.bilit:es or damages :rnaje by
any physlcian. attorney or agent of RelcJ..see, nor any representa-:.ions regarding the nature and
extent of Jegul liability or financiCil responsibility, have induced the Releasors to make !.hi~
RdeJse &: Indemnity Agreement; the.t this Release is entered intJ in considej"ation of al I kno\\in
and unknO\,l"n injuries, disabilities and damages, and also Lhc po~,~ibility that the injuric~<.
SUGl1ne:c nlJY be pefm3-flcnL and progressive and recovery therefrom uncertain 3Jld indd'ir.ite, so
tha[ conS:jqu.:nce5 nOL now anticjpated may result from the said accidcnL
I~eleasors 8.gr~e to indemnify and hold harmless said Rdeasel~ fr,)In any additional sum of money
that Rel':;:E2f: may hereafter be compelled to pay on account of the injuries to s3icJ rmoor b'~cause
of said c:ccident.
The Releasee is hereby authorized 1.0 take any action which may be desirable or necessary ,n I~lw
or in equity, cith~r in the name of the Releasee or in the name of the Relcasors, 8gainst an:y
person Of organizalion who may be liable for such injuries or danages who has not been
heretofotc released with our wrirren consent. The Re]e:3.sors covenant 3nd agree ro tooperate
fUlly WiI:! Ine Releilsee in che pres~ntation of such cbims and to furnish ~Ill papers and
documents n;;ce.ss3.ry in such proceedings, submit to such physlcl:ll or testimonjal CXal11LJtalions as
may be equirc:d in such proceedings. and to at.teTld coun and LC;SL[y j[ tht' ReIease.e deem,; It to
be nece5:;ary.
PARENTS' UNDERINSUREDMOTORIST RELEASE & INDEMNITY AGREKM.ENT
Page 2 of 2
I nave read this release 3J1d understand it.
Signed: , J'Jd. j.~~ ~ ,/ .J),/''7 ."> ~
- /., ) ' /1 -7'. f 11.''(,''''<':01 / .. ,."1........, ?l /......
----1-A:k.w. v,f., (. ;"1/" ~ I ~, (, . /, / .._._
\Vime.s'; date Michael Glifrln, as parent and J/g31 guardi2J..:t of
'Rri':1,..,r" GrH,., 'l '-";n"f .1.,~.~ ,) ./.' 7
....... o:....I'.,:L.. .-../.... 1.;'1 ;..... JkA, V '-..l(.L..l,......
I>; . (h \
~~~
Wilnes:;
.. \,....... -
(I ; t{" .'lrtL't
date
.1. -1 J' '..\.' i
~:ry ~~u2rk;~n~';; p~r~I:~~\l:;~1 gu~;~di~n (If
Brianna Griffin, a minor date
I'
S tale of : \2v""'1~~ ~H':-_
County of: l .....vwdxl. io.{~ ~
On rhis, l2~,_ day of i:: h , 2...cJil, before illt:; p(jrsonally appeared ~~.~ ": I', \' I \ II'-
ih 1\ "'1 I. {" (~.~ ~ It"t \ J'- , to me known to be the person(s) who eXC-Cu[eJ the
fOJeg~ing inslTl.lrnenc, and acknowledged this 3.sa free act and deed.
N TFSTIMONY WHEREOF, I have hereto subscribed my n3..me and a1'fixed my seal chi:.;
, l._.,_dayof f - t:':. I'? ,,_,_~I 2 C (,7' .
',. .. <.
My cClI1lmiss ion expires'}, ~;}.,i - c \ ", '-, ..~~.,~ 2..~ '-\'..:'.~~
N P , I' "
. ocary 1.1:) Ie '.
(~lJ.i.,!-n r\i(J.
O<i 197541
FEe ! 8 2007
)
In Re:
ESTATE OF BRIANNA GRIFFIN,
a Minor
: IN THE COURT OF COMMON PLEAS
: OF CUMBERLAND COUNTY, PENNA
. J:)RPHAN~' rnnRT DIVISION_
: NO. 06-3243 CML
ORDER
i~ ~
AND NOW, this 5 day of _t'\ ~"'L.o , 2007, upon consideration of
the Petition to Authorize Further Settlement of Minor's Personal Injury Claims, it is
hereby ordered that the Petitioners are authorized to enter into a settlement in the gross
sum of $195,000.00. Petitioners are authorized to sign a Release in favor of Progressive
Insurance Company.
Further, Petitioners are authorized to distribute the settlement proceeds shall be
distributed as follows:
1. Thomas, Thomas & Hafer, LLP, counsel fees still to be calculated, but not
to exceed $15,000.00;
2. Michael Griffin, $1,664.60 for reimbursement of costs.
The balance of the settlement monies from Progressive Insurance Company shall
be distributed to a previously established irrevocable trust, to which the Honorable
Court by its Order of June 14, 2006 and Amended Order of September 5, 2006,
approved the distribution of settlement moneys from Brotherhood Mutual Insurance
Company, which distribution was restricted under the trust to the payment of Brianna
Griffin's future medical expenses until the trust's termination. Said irrevocable trust
shall be administered in accordance with the provisions set forth in the Petition.
By the Court:
''l
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