HomeMy WebLinkAbout12-01-06
"
IN RE: KRISTIN BROWN,
MINOR
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PA
ORPHANS COURt DNISION
: No. 21- OlD - IOl.o2.
PETITION FOR APPROVAL OF SETTLEMENT
COME NOW, Tanya Brown and Eric Brown, through their attorneys, Saidis,
Flower & Lindsay, pursuant to 20 Pa.C.S.A. Section 5103, and in support oftheir petition
aver the following:
1. Petitioners are adult individuals who reside at 188 Conodoguinet Estate,
Newville, Cumberland County, P A 17241.
2. Petitioners are the parents and natural guardians of Kristin Brown, a
mmor.
(")
3.
years old.
4.
Kristin Brown was struck by a motor vehicle operated by Allen Lee Baker, also a minor,
whose date of birth is February 19, 1989. The State Police accident report relating to the
incident is attached hereto as Exhibit "A."
5. At the time Kristin Brown was struck, she was in a school zone, where
yellow school-zone lights were then flashing; consequently, the speed limit was 15 miles
per hour.
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6. According to the accident report, a witness told the State Police that the
vehicle operated by Baker was traveling at a high rate of speed at the time it struck
Kristin Brown.
7. Allen Baker himself acknowledged traveling at a speed which exceeded
the applicable speed limit.
8. Allen Baker was charged with failing to operate his vehicle at a safe
speed.
9. As a result of having been struck by the Baker vehicle, Kristin suffered a
fracture to her left elbow (displaced olecranon fracture) and a deep gash in her left lower
leg.
10. Kristin Brown's elbow was surgically repaired with a metal plate. Copies
of medical records relating to Kristin's treatment are attached hereto as Exhibit "B."
11. Kristin has been released from treatment, has made a very good recovery,
but will retain some residual scarring.
12. At the time of the accident, Allen Baker was covered by SafeAuto
Insurance Co., through a policy held by his mother, Anita Defibaugh.
13. The liability limit on the Defibaugh policy was $15,000.00. See SafeAuto
declaration page, attached hereto as Exhibit "c."
14. SafeAuto has offered to pay its entire liability limit of$15,000.00 to settle
the claim against Allen Baker. See letter from SafeAuto adjuster dated March 3, 2006,
attached hereto as Exhibit "D."
15. At the time of the accident, a total of$50,000.00 in underinsured motorist
coverage was available to Kristin Brown through policies held by the petitioners with
2
.
State Farm Insurance Company. See declaration pages, attached hereto as Exhibits "E"
and "F." Petitioners each elected stacking on their policies.
16. Petitioners and State Farm have agreed to settle petitioners' and Kristin
Brown's underinsured motorist claim for $45,000.00. See letter of State Farm adjuster
dated October 2,2006, attached hereto as Exhibit "G."
17. Petitioners and their counsel believe the proposed settlements with
SafeAuto and State Farm are reasonable and in Kristin's best interests. The $15,000.00
offered by SafeAuto is its policy limit. Petitioners and their counsel believe it is unlikely
that Allen Baker, a seventeen-year-old covered by a discount insurer, would have
additional assets that could be reached to satisfy petitioners' and Kristin's claims. The
$45,000.00 settlement upon which petitioners have agreed with State Farm constitutes 90
% of the available coverage. If petitioners were to take their claim through arbitration
proceedings pursuant to their policies with State Farm, their counsel predict they would
expend a substantial part of the $5,000.00 difference between the $50,000.00 policy limit
and the $45,000.00 proposed settlement in expert and arbitrator fees. Additionally,
settling now for $45,000.00 has the advantages of certainty and expediting the realization
of the settlement proceeds. Under the settlements reached by petitioners with SafeAuto
and State Farm, the gross settlement for Kristin will be $60,000.00.
18. Petitioners have a written fee agreement with their counsel, which
provides for an attorneys' fee of one-third of the amount recovered, which in this case
would amount to $20,000.00. See Exhibit "H" attached hereto.
19. Petitioners and counsel submit that the fee upon which they have agreed is
reasonable and appropriate.
3
.
20. Petitioners propose that distribution be made in accordance with the
Statement of Proposed Distribution attached hereto as Exhibit "I."
WHEREFORE, Petitioners respectfully request the Court to approve the proposed
settlements with SafeAuto and State Farm; to approve counsel's attorneys' fees; the
approve the Statement of Proposed Distribution; and to order that the net settlement
proceeds be deposited in one or more federally insured bank accounts, providing that no
withdrawal may be made from any such account until Kristin Brown has attained her
majority, except as authorized by a prior order of the Court.
Respectfully submitted,
Saidis, Flower & Lindsay
James . Flower, Jr., Esquire
Atto ey ill #27742
Brian C. Caffrey, Esquire
Attorney ill #42667
26 West High Street
Carlisle, Pennsylvania 17013
Phone: 717.243.6222
Fax: 717.243.6510
Attorneys for Plaintiff
November $, 2006
4
.
VERIFICATION
I hereby verify that the facts set forth in the foregoing motion are true and correct
to the best of my knowledge, information and belief. I understand that false statements
herein are subject to the penalties of 18 Pa.C.S.A. Section 4904 relating to unsworn
falsification to authorities.
~-.--~.~
Eric Brown
~J~ 7JCi-t~r-
Ttyi Brown
November 2-7 , 2006
5
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.- SP7-OO1i (3-2002)
PENNSYLVANIA STATE POUCE
NOTICE OF CRASH INVESTIGA liON
AS REPORTED ON A COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM, FORM AA-45, THE CRASH INWHICH
YOU WERE INVOLVED HAS BEEN REPORTED TO THE PENNSYLVANIA STATE POLICE AND WILL BE INVESTIGATED IN ACCORDANCE
WITH SECTION 3746(C) OF THE PENNSYLVANIA VEHICLE CODE.
CERTIFIED COPIES OF THE COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM (EXCLUDING APPENDED
DOCUMENTS AND PHOTOGRAPHS) FOR CRASHES REPORTED TO THE PENNSYLVANIA STATE POLICE ARE AVAILABLE TO
AUTHORIZED PERSONS UPON COMPLETION OF THE REVERSE SIDE OF THIS FORM AND ACCc*PANIED BY A CHECK OR MONEY
ORDER IN THE AMOUNT OF $8.00. THE CHECK OR MONEY ORDER SHALL BE MADE PAYAdLE TO THE COMMONWEALTH OF
PENNSYLVANIA. GOVERNMENT AGENCIES ARE EXEMPT FROM PAYMENT OF THIS FEE.
A POLICE CRASH REPORTING FORM MAY BE VIEWED OR PHOTOGRAPHED (WITH PERSONAL EQU,aMENT) BY ANY PERSON INVOLVED
(NOT WITNESSES), THEIR ATTORNEY, INSURER, AND CERTAIN GOVERNMENT OFFICIALS ONLY AT tHE PENNSYLVANIA STATE POLICE
STATION LISTED BELOW. \-\-O?'-- 'S; O~c::>~
DATE AND TIME OF CRASH INCIDENT NUMBEIt
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LOCATION OF CRASH COUNTY
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INVESTIGATING OFFICER'S SIGNATURE BADGE NUMBER ,
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PENNSYLVANIA STATE POLICE STATION STATION TELEPHONE NUMBER
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IT IS RECOMMENDED THAT YOU OBTAIN, AT A MINIMUM, THE FOllOWING INFORMATION FROM THE OTHER INVOLVED
PERSON(S) BEFORE LEAVING THE SCENE OF THE CRASH. THIS INFORMATION CAN BE OBTAINED FROM THE DRIVER'S
LICENSE, VEHICLE REGISTRATION CARD, AND ANY PROOF OF FINANCIAL RESPONSIBILITY.
DRIVER(S)JPEDESTRIAN(S)IPROPERTY OWNER(S) INFORMATION
VEHICLE OWNER(S) INFORMATION
NAME NAME
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ADDRESS ADDRESS
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CITY STATE ZIP CODE CITY STATE ZIP CODE
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TELEPHONE NUMBER .. TELEPHONE NUMBER .
Ill:.
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DRlVER'S/OPERATOR'S UCENSE NUMBER
YEAR, MAKE, AND MODEL OF VEHICLE
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STATE OF ISSUANCE
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REGISTRATION/LICENSE PLATE NUMBER
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VEHICLE REGISTRATION EXPIRATION DATE
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DRIVER'S/OPERATOR'S LICENSE EXPIRATION DATE
NAME OF VEHICLE INSURANCE COMPANY
POLICY NUMBER
POLICY EXPIRATION DATE
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REMARKSINOTES
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,r~ . ~MONWEALTH OF PENN~YlVANIA
--.J POLICE CRASH REPORTING FORM
Case Closed Reportable Crash
AA 500 1 . Yes 0 No _ Yes 0 No
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P0748103
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Precinct
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Agency Name
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Dispatch Time (mil) Arrival Time (ml1) Investigator
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Crash Date (MM-DD-YYYY) Crash Time (mil) No of Units People Injured Kilied* *If > 00
r:-r-I r:-rTI::"l ~ r::l::::I r=-r::;"l3 C"'T;'I complete 0 TUI; 0 Sat
-~-t"'2,!o IC>P I ~ ~ ~ eJ.lJ (0. C> FormF OWed aU;')k
Workzone (If Yes. Complete 0 Yes ..... No School Bus 0 Yes I:Oi& No School Zone. Yes ~ No No~fy PENNDOTO Yes 0 No
Form M. SectIon 29) ~ Related - Related ~ Marntenance
Intersection TyDe 04 Way Intersection 0 'Y' Intersection 0 Multi-Leg 0 Off Ramp 0 Railroad Crossing ~
Intersection ~
O "1' Intersection 0 Traffic Circle} 0 On Ramp 0 Crossover 0 Other
Round About
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For Mld.block crashes only. Use
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filled In If uSing thiS option
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Route Number Segment (Optional) lravellanes Speed Umit
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o North
o South
o East
o Wert
o Unknown
o Interstate 0 Turnpike 0 Tumpike 0 State .. County 0 local Road 0 PrivatI; 0 Other/
(Not Turnpike) (Eas1/West) Spur Highway Road or Street Road Unknown
1] Route Number Segment (OptIonal) Travel Lanes Speed Limit
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Intersecting Rt Num Or Mile Post
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~~ 0 North Feet
~ 0 South CTIJTI
St Ending ;:) 0 East
LL[]J[I]~IOWest m.D
i 0 North Distance .From .( rash
Qj 0 S th Scene to Landmark 1
St Ending :J 0 EOU (For Crash between
OJ ast Landmark 1 and
~ 0 West Landmark 2)
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Degrees Minutes Seconds
Latitude: GIQI [10:1"2-1 c:; l.lS l~ I
Degrees Minutes Seconds
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Longitude: -
Traffic Conrrol Device o Yield Sign o Police Officer or rrQ Functioning
.. Not Applicable o Traffic Signal o Active RR Crossing Flagman - No Controls 0 DeVICe Functioning 0 Emergency
Q o Other Type TeD Improperly Preemptive
8 u D Flashing TraffiC Controls Signal
t- O Stop Sign Device Not Device Functioning
o Passive RR o Unknown 0 0 0 Unknown
Signal Crossing Controls Functioning Properly
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Lane aasu~ .. North
Q.imujgn 0 South
o East
o West
o North and South 0 All
o East and West (N.S.t.W)
Lane aosed (If "Not Applicable', skip resr of the Lane closure section)
o Not Applicable . Partially 0 fully 0 Unknown
ruttk yes 0 No.
Detoured unknown 0
f~ 0 < 30 Min. .30-60 Min. 0 '-3 hrs 03-6 hrs
o 6-9 hrs 0 > 9 hours
o Unknown
FORM' AA.5D1l (12!D21
PENNDOT COPY
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COMMONWEALTH OF PENNSYLVANIA
. POLICE CRASH REPORTING FORM
IPoli~~':.. l~ "2.0~ 09
Page:
IDIi-1
1111111111111111I1111111111
P0748103
Crash Number
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AA 500 2
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.. Motor Vehicle in 0 Hit & Run Vehicle 0 Illegally Parked
~ Transport
!!!!1! 0 Pedestrian 0 Pedestrian on Skates, 0 Disabled From
in Wheelchair, etc Previous Crash
(If 'Pedestr;~n. or 'Pedestrian on Skates, in Wheelchair, etc., Complete Form M, Section 28)
First Name \'AI Date of Binh (MM-DD-YYYY)
[g Eli] [IT5J [ili[iliJ
Telephone Number
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o Legally Parked 0 Non - Motorized
o Train 0 Phantom Vehicle
Commercial Vehicle
DYes (jI No
(If Yes, Complete Form C)
Unit No
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State Class
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Driver or Pedestrian Phvsical Condition
... ~gf;;alntly 0 ~~al Drug
O Had Been 0 Sick
Drinking .
AlcohollDruas Suspeded
.. No 0 l1Iegal Drugs
o Alcohol 0 Alcohol and Drugs
Medication
o Medication
o Unknown
o Fatigue
o Asleep
o
o
Unknown
Alcohol Test Type
.. Test Not Given
o Blood
Primary Vehicle Code Violation
133G.1
Charged?
. Yes 0 No
o Other
o Unknown if
Test Given
O Unknown
Results
o Breath
DUnne
o Test Refused
O Test Given,
Contaminated Results
Driver Presence
1 =:Driver Operated
Vehicle
2::No Driver
3=Driver Fled Scene I
4=Hit and Run --l-
s,.Unknown
Alcohol Test Results
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Owner/Driver OO=Not Applicable
cr::;l 01=:Pril/ate Vehicle Owned/
Q..J..Jd Lea~ed by Driver
02=Private Vehicle Not
Owned/leased by Driver
03=Rented Vehicle
04=State Police Vehicle
05=PENNDOT Vehicle
06=Other State Gov Veh
07::Municipa/ Police Veh
OB::Other Municipal
Government Vehicle
09=Federal Gov Veh
98::0ther
99=Unknown
Same 85
Driver 0
Address I City I State I Zip
I \~'1S ",",~""V-r
Vehicle Make
r-rti111 ~ \,"'~ \'-\
Vehicle Model
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· Make Code
I~
(~ee O'Ierlay)
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Model Year
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License Plate Reg. State Est. Speed Vehicle Towed Towed By
mcrn "Ye~ 0 No I \..f.s.~(-'~~'(1S"~
Policy No
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Insurance Insurance Company
~ .. Yes 0 No 0 ~:wn I $" ~r:"~ ~'-J n:.
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Tag Year
II
Tag No
I
Tag St
ID
Tra!ling ~. 1=::Towi~g Pass. Veh 4=MobileJModular Home 7=Semi-Trailer
Unit No. of n Unit 0 2=:Tqwlng Truck S=Camper 8=Other
III - li;,i~~g~ - 1QJ 3-Towing Utility Trail!!r 6-Full Trailer 9=Unknown
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Diredion of ~ .Vehicle Position [Q]J] *Movement rn *See Spedal Usaqe
Travel Overlay 10 It,) I
Vehicle Color Vehicle Tvpe 05=Large Truck 20=UnICycle, Bicycle, 12=:Commercial
[01'31 06",Yellow ~ 01=Automobile 06=SUV Tncycle Passenger
07=Silver 2' 02=:Motorcycle 07=Van 21 =Other Pedalcyde OO=Not Applicable Carrier
08=Gold 03=:Bus 10=Snowmobile 22=Horse & Buggy 01 =Fire Veh 13=Taxi
01=Blue 09",Brown 04=:Small Truck 11 =Farm Equip 23=Horse & Rider 02=Ambulance 21=Trador Trailer
02=Red 10=Orange (If .or, Complete Form 12=Construdion Equip 74= Train 03=Police 22=Twin Trailer
03=White 11 =Purple M, Section 26) 13=AiV 25= lrolley 08=Other Emergency 23=Triple Trailer
04=Green 12.::Other 18=Other Type Spec Veh 98=Other Ve hide 31 =Modified Veh
05=Black 99=Unknown (If .20- or -21-, Complete 19=Unk.. Type Spec Veh 99=Unknown 11 =Pupil Transport 99=:Unknown
Form M, Section 27)
Inltiallmpad point
CTlll OO:Non-(olllslon
~ 01-12=C10c\o; POints
13=Top
Damaae Indicator
r-:::;l O=Non~ 2::Functional
~ 1=Minor 3=Dlsabling
9=Unknown
3=Downhill
4=Bottom of Hill
5=Top of Hill
9:Unknown
Road Afianment
I"fl ' =)tralght
L!..J 2=Curved
9=Unknown
Gradient
],-!'=Level
2=Uphill
14=Undercarnage
15=Towed Unit
99=Unknown
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COMMONWEALTH OF PENNSYLVANIA
POLICE CRASH REPORTING FORM
AA 5002 Ipol\~~~_ \ S'"2.0~ 09
Page:
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111II111~ IIIIII~IIIIIIII
P0748103
Crash Number
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o Motor Vehicle in 0 Hit & Run Vehicle 0 Illegally Parked
Transport
<<I Pedestrian 0 pedestrian on Skates, 0 Disabled From
in Wheelchair, etc Previous Crash
(If .Pedestrian. or .pedestrian on Skates, in Wheelchair, etc., Compiete Form M, Section 28)
First Name Date of Birth {MM-DD-YVY )
ITIlJ EWJ ~
Telephone Number
1,\'1-'I~-/1?\Y I
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o legally Parked 0 Non' Motorized
o Train 0 Phantam Vehide
Commercial Vehicle
o Yes 0 No
(If Yes, Complete Form ()
Unit No
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Address I City f State
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Driver or Pedestrian Physical Con~ition
....., APparently 0 Illegal Drug
- Normal Use
O Had Been 0 S' k
Drinking IC
A1cohollDruos Suspected
4ii No 0 tIIegal Drugs
o Alcohol 0 Alcohol and Drugs
o Medication
o Unknown
Medication
o Fatigue
o Asleep
o
o
Unknown
Primary Vehicle Code Violation
Charged?
DYes 0 No
o Other
o Unknown if
Test Given
O Unknown
Results
o Breath
o Urine
o Test Refused
O Test Given,
Contaminated Results
'104. ~\l 'J!t.
Driver Presence
1 =Driver Operated
Vehicle
2=No Driver
3=Dnver Fled Scene ,
4=Hit and Run -.L..
9=Unknown
A/cohol Test Results
[ill. ITJ
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OwnerlDriver OO=Not Applicable
r.::::T:l 01=Private Vehicle Owned!
~ Lea~ed by Driver
02=Private Vehicle Not
OWnedlleased by Driver
03=Rented VehIcle
04=State PolICe Vehicle
05=PENNDOT Vehicle
06=Other State (,o~ Veh
07=Municipal Police Veh
OB=Other MuniCIpal
Government Vehicle
09=Federal Gov Veh
98=Other
99=Un\<nown
Same as
Driver 0
Addren I City / State / Zip
I
Vehicle Make
II
Vehicle Model
I
Towed By
I
*Make Code
1m
(see overlay)
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Insurance Insurance Company
o Yes 0 No 0 I
~~~wn
Model Year
[Ill]
Reg. State Est. Speed Vehide Towed
OJ D=:IJ 0 Yes 0 No
Policy No
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Trailino T
Unit No. of D ~
- 1railing !l!Y!
Units:
I=Towing Pass.Veh 4=MobilelModular Home 7=Serni-Trailer
D 2=Towing Truck 5=Camper 8=Other
3=Towing Utility Trailer 6=Full Trailer 9=Un\;.nown
Tag 5t
10
Tag No
I
Tag Year
II
Direct/on of 0 .Vehide Position IT] "Movement IT] *See Special Usaqe
Travel Overlay IT]
Vehic/e Color Vehicle Type 05=Large Truck 20=Unicyde, BIC)'cle, 12=Commercial
CD 06= Yellow IT] 01=Automobile 06=SUV 1 ncyde OQ=Not Applicable Passenger
07=Silver 02=Motorcycle 07=Van 21 =Other Pedalcycle Carrier
08=Gold 03=Bus 10=5nowmobile 22=Horse & Buggy 01 =Fire Veh 1 3= Taxi
01=Blue 09=Brown 04=Small Truck 11=Farm Equip 23=Horse & Rider 02=Ambulance 21=Tractor Trailer
02=Red 10=Orange (If -DZ-, Complete Form 12=Constructlon EqUIp 24.= Train 03=Police 22= Twin Trailer
03=White 11 =Purple M, Section 26) 13=A "TV 25=Trolley 08=Other Emergency 23=Triple Trailer
04=Green 12=Other (If 120. or -21., Complete 18=Other Type Spec Veh 98=Other Vehide 31 =Modified Veh
05=Black 99=Unknown Form M, Section 27) 19=Unk. Type Spec Veh 99=Unknown 11 ;:Pupil Transport 99=Unknovvn
Initial Impact Point
CD OO=Non-Collislon
01-12=(lock Poin~
13=Top
Damaqe Indicator
O O=None 2=Functional
1 =Minor 3=Disabling
9=Unknown
(iradient
O 1 =Level
2=Uphlll
3=Downhi/1
4=Bottom of Hill
5=10p 01 Hill
9=Unknown
Road AIianment
D 1 ;:Straight
2=Curved
9=Unknown
14=Undercarriage
1~=Towed Unit
99=Unknown
FORM. AA~ (12102)
PENNDOT COpy
'<to
~J COMMONWEALTH OF PENNSYLVANIA
'POLlCE CRASH REPORTING FORM
AA 500 3 I PO~(~~'2..._ I S "'2, '0 ~ D9
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A Person Tvof':
1 =Driver
2=Passen~er
7 =Pedestnan
8:=Other
9=Unknown
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B F :Female
M:Male
U =Unknown
Iniurv Sewri\)!:
C O=Not Injured
l=Killed
2=Major Injury
3=Moderate
Injury
4=Minor Injury
8=lnjury, Unk
Severity
9=Unknown if
InjUry
Seat Position:
D DD=Not A Passenger/Occupant
01:Driver - All Venicles
02=Front Seat Middle Position
03-Front Seat Right Side
04-Second Row - Left Side Or
Motorcycle Passenger
Os=Second Row - Middle Position
06=Second Row - Right Side
07=Third Row Dr Greater -
Left Side
OB=Third Row Dr Greater -
Middle Position
09= Third Row Dr Greater -
Right Side
lO"Sleeper Section of Truckcab
11 ",In Other Enclosed
Passenger Or Cargo Area
12=ln Open Area
(Back Of Pickup. Etc.)
13=Trailing Unit
14=Riding On Vehicle E>.1erior
Is=Bus Passenger
98=Other
99-Unknown
Page
I rn
Safetv Eauioment One:
E OD=None Used I Not Applicable
01=Shoulder Belt Used
02=Lap Belt Used
03=Lap And ShOU\~r Belt Used
04=Child Safety Sea Used
05=MotorCYCI~1 et Used
06-Bicycle Hel et ,Used
10=Safety Be B~d Improperly
11 -Child Safety Seat Used Improperly
12=Helmet Used Improperly
gO-Restraint Used, lype Unknown
99=Unknown
Safety FauiDment Two:
F DO=None Used I Not Applicable
o 1 -Front Air Bag Deployed (For This Seat)
D2",Side Air Bag Deployed (For This Seat)
D3=Other lype Air Bag Deployed
04=Multiple Air Bags Deployed
OS",Motorcycle Eye Protection
06",SicycJist Wearing ElbowiKneelPads
lO-Air Bag Not Deployed. Switch On
11 =Air Bag Not Deployed, Switch Off
'2=Alr Bag Not Deployed.
Unk SWitch Setting
13=Air Bag Removed (Prior To Crash)
19=Unknown If Air Bag Deployed
99=Unknown
m m lUll ~ 11111I1111111
P0748103
Crash Number
--,
~:
GO-Not Applicable
I=Not Ejected
~=Totally Ejected
3=Partially Ejeded
9=Unknown
H tiroion Parh:
o,;Not Ejected I Not AJJPlicable
t=Through Side Door Opening
~= Through Side WlOdow
]= Through Windshield
4= Through Back Door
$- Through Back Door Tailgate Opening
,= Through Roof Opening (Sunroofl
Convertible Top Down)
1= Through Roof Opening (Convertible
.. Top Up)
i-Unknown ~
I Extricarion: I
Cl=Not Applicable
l=Not Extricated
2=Extricated By Mechanical Means
~=Freed By Non - Mechanical Means
ll=Other
9=Unknown
1
EM!. Agency: I ~~~;s:u..< ~~~~L~..~ I Medical Facility: I c...~n...l.-..s:: S- L~ ~~~ "~~L
Unit No Person No I , Date of Birth (MM-DD-YYYY) ABC D... E F G H I
~ rn Dote. 10 b-l-DEJ - LliJWJ D ~ [QJ[;]]filiJ 10 Ie> I OJ ~ OJ
Name / Address / Phone
o Same as I
Operator
4
I EMS Transport
DYes eNO
Unit No Person No I Date of Birth (MM-DD-YYYY) ABC D . E F G H I
ETIJ 10 I'Ll Dote7\c \51-[[[O-~~[f]@]mlb \3Irn[!]~[]
Name I Address / Phone _ ~k.. _ i:. ") 'Y EMS Transport
O Same a5 Inn ^- \\ \ ~
Operator ~C\....cf"'~G'{ ('t."c;...\-\ \'1.\"-6'~ ('l.<:', c::.~.):'~lrf' \"'0\3 DYes _No
'"'
r~tt~ l~srINl'pC;te71~tr;BI:I~I-~'-~~)141~IDIr~ II~II~ Irnrnrnl: II~ II~ I
Name / Address / Phone
o Same a5 I
Operator
I EMS Transport
DYes DNa
IUnit.NlIPe~~[.Nr D~te7 EDi~m-:EtrTIDDDdJdJcbDDD
Name 1 Address / Phone
o Same as I
Operator
I EMS Transport
DYes ONo
ED ED D~te1 EDi:[jJ-1J=rrJoDodJdJdJoDD
Name / Address / Phone EMS T
I I ran sport
Same a5
o Operator 0 Ye~ 0 No
ED ED D~te7 ED~cfI1J=rrJDoDdJdJcbDDD
Name / Address / Phone EM
I I S Transport
Same as
o Operator 0 Yes 0 No
FORM' AA-~(1:lJ021
PENNDOT COPY
(('to
...J. COMMOI-lWEAlTH OF PENNSYLVANIA
POLICE CRASH REPORTING FORM
AA 500 4 r Police U\~6 "2..- \ S "2.. => ~":> c::;
Page
I rn
~11111UlllllllmlUI m
P0748103
Crash Number
-"1
18
Crash Description rill O=Non-Collision 2=Head On 4=Angle 6=Sid'eswlpe 8=Hit Pedestrian
0; 1=Rear End 3=Rear to Rear 5=Sideswi~ (Opposite Direction)
c: 8 (Backing) (Same irecllon) 7..Hit Fixed Object 9=OtherlUnknown
0
';:J I
III Relation to Roadway OJ 1=00 lravel Lanes 3=Median 5=Dutside Trafficway 7=Gote (Ramp Intersection)
e
.2 2=Shoulder 4..Roadside 6..ln Parking Lane 9..Unknown
c: ~
5 - 6 Illumination OJ 1 =Daylight 3=Darl<. - Street S..Dawn 8=Other
;~ 2=Dark - No Lights &=~arX - Unknown
.J~ Street Lights 4=Dusk oadway UOhting
- " 1 =No Adverse
e ~ Weather Conditions [I] 3=Sleel (Hail) 5:=Fog 7:51tet & Fog 9=Unknov/O
III .. Conditions
; ~ 2=Rain 4=Snow &=Rain & Fog B..Other
1:'_
'" Road Surlare Conditions ~ G=Dry 2=Sand, Mud, Dirt, 6:108 Patches
4..Slush 8:Other
1=Wat 011 5=:108 7::Wtr : Standing
3=Snow Covered or oVlng
Harm Event LIR Most? Utility Pole Number Harmful Events (Harm Event) 30::Hit Fence Or Wall
1 10 f'2-l 0 cg CIIIIIIJ 01=Hit Unit 1 31..Hit Building
Unit l~o 02o:Hit Unit 2 32..Hit Culvert
GJJJ 2 rn 0 CIIIIIIJ 03=Hit Unit 3 33,=Hit Bridge PiEr Or Abutme:1t
0 04::Hit Unoll 4 34..Hit Parapet End
05=Hit Unit 5 3S..Hit Bridrce Rail
06::Hlt Other Traffic Unit 36::Hit Bou der Or Obstacle
Please Put 3 rn 0 CIIIIIIJ 07=Hit Deer On Roadw~
Events in 0 08=Hlt Other Animal 37::Hlt Impact ttenuator
Sequential 09=Colllsion With Other Non o 38::Hit Fire Hydrant
s:: Order rn 0 CIIIIIIJ Fixed Object 39::Hlt Roadway Equ:pment
0 4 0 11 =Struck. By Unit , 40::Hit Mall Box
';l 12o:Struck By Unit 2 41 ::Hit1raffic Island
...
E 13=Struck By Unit 3 42",Hit Snow Bank
0 Harm Event L1R Most? Utility Pole Number 14=Struck By Unit 4 43",Hit Temporary Construction
] [ill 0 CIIIIIIJ 15=Slruck By Unit S Barrier
... 1 8 16=Struck. By Other Traffic Unit 48=Hlt Other Fixed o~ect
a::: Unit No 21 =Hlt Tree Or Shrubbery 49",Hit Unknown Fixe Object
QI
> 22=Hlt Embankment SO=OverturrYRoU Over
... 10 F92 OJ D CIIIIIIJ
~ 0 23=Hit Utility Pole 51..Struck By Thrown Or Falling
... 24=Hit TraffiC Sign ObJect
"E 25=Hlt Guard Rail S2=Pot Holes Or Other
:;) Please Put 3 OJ 0 CIIIIIIJ 26:Hit Guard Rail End Pavement Irregularities
Events in 0 27=Hit Curb S3=Jacknife
Sequential 28=Hit Concrete Or S4=Flre in Vehicle
Order IT] 0 CIIIIIIJ Longitudinal Barrier 58=Other Non-Collision
4 0 29=Hit Ditch 99=UnknoWl1 Harmful Event
First Unit No Ham Event Most Unit No Harm Event Driver Action rD) 17=Care\ess Or \l\ega\
RMmful ~ 101'2.1 Harmful ill [IT[] OO=No Contributing Action Backing On Roadway
Event In Event in
the Crash the Crash 01 =Dnver Was Distracted 1 B=Drivmg On The Wrong
02=Dnvmg U~ing Hand Held Phone Side Of Road
po ~l 'ePNI thl~ "'orl'TUlhon 011 ~tiPP JWge:i 03=Drlvmg Usmg Hands Free Phone 19=Mabng Improper
Environmental I Roadwav rn 2m 3U] 04=MaKlOg IIlegai U-Turn Entrance To Highway
Potential Fat1o~ (fIR) , OS=lmproper/Careless Turmng 20=Making Improper EXIt
06=lurning from Wrong lane Flom HIghway
OO::None 11=Shppery Road Conditions (Ice/Snow) 07=Proceedrng W/O 21 =Careless Parkmg/Unparklng
Ot=Windy CondltlOn~ 12=5ubstance On ROCldway Clearance After Stop 22=OverlUnder
02=Sl.ldcien We.ther (conditions 13=Potho\e~ 08::Runnlng Stop Sl~n C~",,,,,,oo A1 Co", -1
03=Other Weather Cond,tions 14=Broken Or C r ack.ed Pavement i)9=Runn:n~ R"a Llg t 23=5peedlng
04=Deer In Roadway 1 S= reo Obstructed 10;fClilure 0 R8Stond To 24=Dnvlng Too fast For Conditions
Other TraffiC ontrol Devjce
OS=Obstacle On Roadway 16=Soft Shoulder Or Shoulder Drop Off 1 1: T ai~atln~ 2S=fallure 10 Mamtarn Proper Speed
06=Other Ammalln Roadway 28=Other Roadway Factor 12=5u den 10wlnglStop~in~ 26;Dnver Fleeing PolIce {Pol Cha>el
07=Glare 29=Other EnVironmental factor 13=llIegally Stopped On oa 27 =Drlver Inexpenenced
r:: OB=Work Zone Related 99=Unknown 14;Careless Passing Or Lane 2B=Failure To Use Specialized EqUip
0 Change 92=Affected By Physical Condition
':0
.. Possible Vehicle Failures (V) 12=Wlpers 15::Passing In No passlnJ,. Zone 98=Dther Improper Dnvlng Actions
E OO=None 06=ExhClust 13=Dnver Seating/Control 16=Dnvmg The Wron9 ay On 99=Unknown
.e 01= Tires 07=Headlrghts 14;BOd~. Doors. Hood. Etc I-Way Street
.5 .02=Brake System 08=Slgna\ lights 1S=lraier HItch ~~tt ~ 1'~141 12-/-21
0\ 03=Steenng System 09=Other Lights 16=Wheels 1 2 IT] 40]
r:: 3
-g 04=Suspension 1 D=Horn 17=Alrbags
:g OS=Power Train 1 1 =Mrrrors 18=Trailer Overloaded
19=Un~ecurelShifted Unit [D J"-I ~ DJ
E ~~~ 0IJ 1 101012DJ T railer Load 1 2 3 IT] 40]
8 20=lmproper Towing No
21 ",Obstructed WindshIeld Pedestrian Action (P) 03=Working
Unit OJ 1 IT]2DJ 99=Unknown
No DO:None 04=Pushlng Vehicle
01=Entering Or Crossing At OS=Approachlng Or leaving Vehicle
Indicated Prime Factor Unit No Factor Code )peEiill'd LOtatlon Q6=WOlklng On Vehicle
02=Walldnfij. Running. Jogging, 07=Standing
Do not repeat lhl\ t1iformalJOl" 0I"l rem rn Or PlaY11lf 9BzOther
,,"Iup'" pall"' 99=Unknown
fiR V D P UnItNo~ ~ Unit No IT] rn
0 0 ~ 0 If fiR is the Prime Factor
Type, leave Unit No blank
FORM . .AA~S 12102
19
1&
17
DO(
PENNDOT COPY
J
. (( 'Go
COMMONWEALTH OF PENNSYLVANIA
POLICE CRASH REPORTING FORM
AA 5005 I Po.ceUse~d1-_ \ S1-D~'?~
Page
I rn
~lllll~m 111~mtm
P0748103
Crash Number
I
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Phone
'j \,- "2....HS -onY
1 \1- \.j ~ 'i? - ~ 3.9
Witness Name
Narrative and additional witnesses:
Accident Investigation Notlficatlon Issued? . Property Damage 0
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Narrative and additional witnesses:
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---l COMMONWEALTH OF PENNSYlVANIA
P\)UCE CRASH REPORTING FORM
AA 500 N IPoIice~~~,-_ I S~9~9
22
FORM' M.500N (12111Z)
Iii
1m 1I1~ln 111111111 U
Crash Number
I
New
Page
[9]=;1 0
ChangeJ
Continuation
PENN[}OT COPY
DAVID C. BAKER, M.D.
19 BROOKWOOD AVENUE, SUITE 104
CARLISLE, P A 17013
II :00 Avrt
J D - ~Lf.- oS-
,1((/5 -Ii N 1'. r3 f iJ t1J ()
ADDRESS 11> 6 C~" . '" NtlAf\) l Ue, @.
PHONE (HOME) 7 7 ~ - 7 f 1 <l.
INSURANCE ~ I Or! I~s.
I J
FAMILYDOCTOR (kIi4n4VV\. t'V\en, REFERREDBY
NAME
AGE
~-'
TODAV'SDATE
: -,';: .,,'~
.. ~ -".
".
..JiATE OF BIRTH
J/'eJ I~ t}D
P~~~t-~f-ArlY.4 --'
PLACE OF EMPLOYMENT
5.$.:1- Cf-/ g.::J.
FAMIL Y /REFERRED DOCTOR ADDRESS
ALLERGIES
SMOKER.
YES__NO
MEDICATIONS
PREVIOUS SURGERIES
HAVE YOU EVER BEEN TREATED FOR DRUG OR ALCOHOL ABUSE?
lTES_NO
PROBLEM (L) e, ~o vJ ,I f) le?j
1 b-J../- 0 S- ":Dr!-" ''g4 j(r:;;e .- ..sUf r
PREVIOUS X-RAYS
J D- J-IJ- D!::.
C!.H
JeT 24 2005 tt o?j
[I /:DO) ~d~
Q:m
,r::;>>:"
6/-P (SctJ...;,\=>\oco d D~~ ~1' ·
'j (p ~ ~ \J..::)C>~
\t- 2-cb
~ HISTORY: Four days status post left olecranon fractur&, treated by ORIF.
vi Left knee irregular laceration. SUBJECTIVE: She feels pretty good. She
:,states she has minimal pain. She is not taking Percocet. OBJECTIVE: Wound
clean and dry..on the leg. Neurovascularly intact in the upper extremity.
ASSESSMENT: Olecranon fracture, status post. Status post irregular laceratioJ
of leg. PLAN: Dressing changes every other day. Follow-up next week for
suture removal and x-ray of the elbow, AP and lateral with the cast off. DCB
. . vP\)
NOV 0 Z ztfti I ~ o'-lf 5lf' Cb b"-'-~ ~, ~
rq~DO) ~.~~)~~~
\. ~~~ ~r
y)ft
ri) (I) \29tU
~ ?-~ )
~
KRISTIN BROWN
cc:
Graham Medtcal
HISTORY: 13 days status post ORIF left elbow. SUBJECTIVE: OK.
OBJECTIVE: Wound clean and dry. No evidence of infection or DVT.
The elbow moves comfortably. X-rays good. ASSESSMENT: Status post
ORIF olecranon fracture. Status post calf wound. Both doing well.
PLAN: Start gentle range of motion exercises. I will see her back in
2-3 weeks. DeB
---------------
NO~ 18 lOl5_;- ~~\r.. S\ P Ci) ol.<L~c(\ W-. ~ b"-'.~
d'IO' ~~ ':/~d~~ ~ ~ ~
~.~ \2.-\)\- l;}-\;}~o;
v ~~~ HISTORY: 3 1/2 weeks status post ORIF olecranon fracture.
l'~ SUBJECTIVE: Doing better. OBJECTIVE: Wound clean and dry.
~ No evidence of infection. She flexes to 1300. lacks the last
10-150 of extension. Pronation and supination coming along nicely.
X-rays show good early healing of the olecranon fract';lre. ,
ASSESS:MENT: Healing olecranon fracture. PLAN: ContJ_nue adaptJ_ve
gym. She can run, lift 5 lbs and dribble. I will see her back tn
one month. If everything looks good, she can probably st:att~::.pl.aying
basketball. DCB
---------------
DAVID C. BAKER, M.D.
19 Brookwood Avenue, Suite 104
Carlisle, P A 17013
(717) 243-9010
Insurance:
Pre Cert Authorization
Patient Name: \<'f \ S-n (L~'(()U.'lYl
Date of Birth: ~ \ ~ 1--\- C10
Area to be x-rayed: Lt ~\ la:>V\J - 2\1
-T xy\~~\9 D\2-\F Fx
Radiographic Findings:
Date: \ \ -llo- 05
X-ray#: ~
Or/?
j)/~ ~
() Ie G- /'~ ~ '~
Initials:
L--
DAVID C. BAKER, M.D.
19 Brookwood Avenue, Suite 104
Carlisle, P A 17013
(717) 243-9010
Insurance:
Pre Cert Authorization
Patient Name: ~r\stiY\ hnxpD
Date of Birth: \ \ - 2\ -0\0
Area to be x-rayed: _\ -+ ~\ bOL0- 2\/
Date: \ \ - 1-- DS-
X-ray#: ~ ,0/
Radiographic Findings:
~~
i u'');/ (" J
Dc c. /b I"t 0.......
17-
Initials:
;J /~
P.B2
CARLISLE REGIONAL MEDICAL CENTER
RADIOLOGICAL INTERPRETATION
PATIENT NAME: BROWN KRISTIN L
X-RAY#: 359984
EXAM DATE: 18/28/2885
ORDERING: LAURA E CRIM.MD 245-5588
ATTENDING: DAVID C BAKER.MD 717 243-9818
CONSULTING JAY A TOWNSEND,MD MED 776-3114
HISTORY: MVA--MINOR INJURY
MVA--MINOR INJURY
MED REC #: 359984
ACCOUNT U: 9323518
D.O.B.: 11/21/1998
ROOM: 8385
TWO VIEWS OF THE LEFT TIBIA AND FIBULA
REASON FOR STUDY: Motor vehicle accident.
DIAGNOSIS: Probable laceration.
COMMENT: There is some soft tissue gas lateral to the proximal
fibula probably due to a laceration.
There is no evidence for fracture or bony destruction.
REVIEWED AND SIGNED
ROBERT F HALL II.MD
INTERPRETING PHYSICIAN
DATE DICTATED:
DATE TRANSCRIBED:
TRANSCRIPTIONIST:
5735888
18/24/2885
18/24/2885 18:27
JND
ATTENDING FAX
PAGE 1 0 F 1
P.82
CARLISLE REGIONAL MEDICAL CENTER
RADIOLOGICAL INTERPRETATION
PATIENT NAME: BROWN KRISTIN L
X-RAY#: 359984
EXAM DATE: 18/28/2885
ORDERING: LAURA E CRIM.MD 245-5588
ATTENDING: DAVID C BAKER.MD 717 243-9818
CONSULTING JAY A TOWNSEND,MD MED 776-3114
HISTORY: MVA--MINOR INJURY
MVA--MINOR INJURY
MED REC U: 359984
ACCOUNT U: 9323518
D.O.B.: 11/21/1998
ROOM: 8385
LEFT ELBOW -ONE VIEW
HISTORY: Elbow fracture.
There is a displaced olecranon fracture. The proximal fragment
has been displaced cephalad by 1 or 2 em. Otherwise no
additional bony finding based on this single view.
IMPRESSION:
Displaced olecranon fracture.
REVIEWED AND SIGNED
CHRISTOPHER LADD.MD
INTERPRETING PHYSICIAN
DATE DICTATED:
DATE TRANSCRIBED:
TRANSCRIPtIONIST:
5735087
18/21/2005
18/21/2005 9:59
JND
ATTENDING FAX
PAGE 1 OF 1
P.82
CARLISLE REGIONAL MEDICAL CENTER
RADIOLOGICAL INTERPRETATION
PATIENT NAME:
X-RAYf!:
EXAM DATE:
ORDERING:
ATTENDING:
CONSULTING JAY A TOWNSEND,MD MED 776-3114
HISTORY: MVA--MINOR INJURY
OR LT ELBOW 2 FILMS FROM C ARM
BROWN KRISTIN L
359984
18/28/2885
DAVID C BAKER,MD 717 243-9818
MED REC #: 359984
ACCOUNT #: 9323518
D.O.B.: 11/21/1998
ROOM: 8385
LEFT ELBOW - TWO VIEWS
HISTORY: Olecranon fracture.
Comparison is made to an elbow film of earlier the same day.
Internal fixation has been performed which reduces the displaced
olecranon fracture to anatomic alignment based on the views
obtained.
REVIEWED AND SIGNED
CHRISTOPHER LADD,MD
INTERPRETING PHYSICIAN
DATE DICTATED:
DATE TRANSCRIBED:
TRANSCRIPTIONIST:
5734724
18/21/2885
18/21/2885 18:22
JND
ORDERING FAX
PAGE 1 OF 1
18/22/85 15:22:48
.
H 9 htFAX - >
Ri
'AX
Page 881
BROWN, KRISTIN L
MS3 0305 D
10/21/2005
359904
DATE OF OPERATION: 10/21/2005
SURGEON: David C. Baker, M.D.
ASSISTANT SURGEON:
PREOPERATIVE DIAGNOSIS:
,. Displaoed fraoture oleoranon, left.
2. Irreguiar laoerations, left oalf - 8 x 6 om, skin, suboutaneous tissue and musole.
POSTOPERATIVE DIAGNOSIS:
,. Displaoed fraoture oleoranon, left.
2. Irrigular lacirations, lift calf - 8 x 6 cm, skin, subcutanious tissui and musoli
PROCEDURE:
1. Opin riduction and intirnal fixation, left olecranon with Accumid olecranon plate.
2. Irrigation, debridement and olosure of left leg wound.
OPERATION IN DETAIL: The patient was sterilely prepped and draped in the usual sterile fashion
after being identified by myself. She was positioned in the lateral deoubitus position and the left leg
was doni firlit. This wali a stellate crush tYPi laceration. Devitalized tissui was debridid. Wound
was irrigated. There was no growth oontamination. Any devitalized skin and fat were sharply
disseoted. The suboutaneous fat was debrided of any devitalized tissue. At the base of the wound,
it was seen that thi wound extinded to and through thi fascia of thi lateral compartment of the
knee. This was debrided. The fasoia was not olosed. The skin was olosed with 3-0 Nylon.
Then our attention was directed to the left elbo w which was placed at 90 degrees flexion over a
large roll of blankets. Then a midline inoision was made, skin and suboutaneous tissues were
disseoted to expose the fraoture subperiosteally. The oleoranon plate was plaoed on and a 2-0 K-
wire was placed through the proximal hole holding the fracture in place. Then the liliding hole distal
to the fracture was seoured with a 3.5 sorew. Two proximal 2.7 sorews were then plaoed. The
additional two distal sorews were placed in compression. Image intensifioation was used to verify
accuracy of the reduction and placement of hardware. Then thi distal to proximal 2.7 licrew was
placed where the Guidewire was.
The elbow wali taken through a range of mction. There wali no block to motion of either
flexion/extension or pronation/supination. Image intensification was used to verify placement of the
hardware and aoouraoy of the reduction.
Subcutaneous was closed with 2-0 Vicryl. Skin was closed with staples and a posterior splint was
applied.
DCB/le
D: 10/21/200509:10:25
T: 10/2212005 15:18:02
9323518
BROWN, KRISTIN L
MS3 0305 D 359904
10/20/2005 11/21/1990
BAKER, DAVID C
Page 1 of 2
DICTATING PHYSICIAN COPY
CARLISLE REGIONAL MEDICAL CENTER
OPERATIVE REPORT
18/22/B5 15:22:57
RilIhtFAX->
BROWN, KRISTIN L
MS3 0305 0
c: David C. Baker, M.D.
Page 2 of 2
DICTATING PHYSICIAN COPY
CARLISLE REGIONAL MEDICAL CENTER
OPERA TIVE REPORT
R f-::i\AX
PalIe BB2
10/21/2005
359904
David C. Baker, M.D.
9323518
BROWN, KRISTIN L
MS3 0305 D 359904
10/20/2005 11/21/1990
BAKER, DAVID C
.~I'-."
ADMISSION
RECORD
:".,;....... ..,,-'-'"
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~I~
246 ParkcrSl, CarllAlc,PA 11013 PIl;717.~49.1212
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CUMBERLAND
'1:-.;:'
dtf':i JaP_OWN, ERI C M
i/tf:E 188 CONODOGUINE:T
::x1A:~~:
:!ia~: NEWV!LLE PA 17241
:"';:'~:""': US
EMERGENCY CONT ACT NAME
OVER TRANSPORT
ME:CAN!CSBURG
PA 17055
T~ IPT
FATHER
IIE\.A TIONSHIP TO PATIENT
II
(717)776-7874
eMERGeNCY CONTACT pHONE
~MER(]ENCY etA
HILL, MADELYN
(717)486-3789
GRANDMA
AMB DAR
PilI\' A Y
;'~'~i~~ ~ 5 0 ~
'::"", CAMil HILL
Pl.', (600) 753 -1276
G
pA 17110
"N.'
::~0:~{i::~!,'::j:;ji:::i!D;,:/~:ii:\)i!.:'::;:[:::):i; "
::,j!:~:i!ji;ii;!~ij;':~!:~~
..'.....
I
:.,~":"',:. DR, END 11'0 TTIN
:i;m,;:,':CRIM, LAURA E MD
i~~i;j MVA- -MINOR INJURY
PRINCIPAL DIAGNOSIS rt'ho con~llia1'l 8Bt.b1~ned "'tIlr Blu~v 10 lJe ~iB!1V rllSponBlblo lor
oceBJlorung ttle odmiSSlon of ~ne p.tiBnt to the HOSPIT A~ 10/ carel.
JAY A
NO FAULT
COMP~ICATIONS
COMCABIO'TY(lE51
PRINCIPAL pp.OCEDUP.&
\ ~,\\\\ ~~ ~~ ,,\\\ \\1\1 ~\\\\ \11 \\\\
I \\ll~ l\lt ~~ ~'" ~~ '~'I mil 1\11 1\\1
MEDICAL RECORDS COpy
ll~ 11m 11m 'll~ \118 11m ~Ilt ~I\IIII\ UIIIIII ~ll
0000369904
"D001/1.
8323'18
. .-.-' .-- .._~- .--'.--- "
In, ,...".,...,..." .,,..,,, ",...".., L,
'^^
..----..
.-" ,..----,
( rlisle Regie' 'jl Medical t .j1\er
Instructions: circle ositive. backslash tle ative rovide sddillonal ertinent information.
Pt#: 9323518 DATE OF .seRVICE: 10i2012005 .
MR#: 0000359904 pr05Tlma: 1'5:59
.Trlage Time; 15:59
T: 98.5 T
P: 92 Regular
R: 20 Unlabored
BP: 132/077
Sa02: 100 ,% Non:nal/.HYPOXIa
Pain SCilla: 5"
.,....~.
NAME; BROWN. KRISTIN L
006: '11/21/1990 Age: 14 Yrs
Sex: F we 68.2 KG
Chief complahit: MVA-MINOR INJURY
Medicines: NoNE
o Mo& 0 Wkg
Ht: !' "
Allergies: NKDA
eDP: CRIM. LAURA E MD .
. PCP: TOWNSEND, JAY A
Arrival ModEl: ALS
Exad1'T1m8':~ Iv.!) (~ Iiidiy';
C I C I HPI: (Narrative): e!5
/4 ~/o- AA.7~ ~ ~&~ ~
Vt [Je...<.. ~ ;:L-r ~ ~ ~
-?l~ e: ~ 4 G'4/~;{!;J~
~. ~ rr.--'~.-::A~.. ~ ~
~/~
I gradually ~ I hrs. I d k a €?~~ntermltlsnt
ml hrs. I days I wks. at a time . prese sent
L~~t1Q!I,:oflnJury: head face neck chest back abd ~~~
Quality:.. cannot describe fall I height ft MV A crush Injury punched kicked GSW stab wound
~r"" ~"'16 ...,"" --:;:;-0 ",,16 _ ,.."".Ieo., ~.-<7 M/L
conte~a~ assaulted ~VA ~abuse found unresponsive e
ExaCtl.tb ,d:b~: ...nothlng ~.!!'.!,_.~ Raluivcid y: nothing' r $t Ice OTCmed$
ASsoc,. Slgns&,.Symptom.s: none . ~ ab In' eBdlng
Llmlted"oue::r:o'; ALoe
COnl!tJtutlorial: fever chills weakness diaphoresis
Em~. sore throat ear pain facial pain
Eyal:. pain visual changes
9~~dlovasc~lar: C.P. palpitations DOE PND
~llsplratoty: S.O,B. cough conge$Uon
~I:.:' N / V diarrhea I constipation pain melena hemalemesls
131../:: flank pain dysuria hematuria' freClUency
Nitis9uloskeletal;: joint pain eel< I back pain exL pain
ther Systems Reviewed And Are Negative
Intoxication Severity Unreliable
Ne.urol!),gleal::: HA seizures weakness
paycholog1c;3i: anxioUS depre5sed
EI'I,~.ocldne:: polyuria polydipsia
l~tegliriI8nt: rashes prurltis lesions
H~Il1~~ID9Ici: anemia bleedIng disorders
AlI,n:ily(i~;i, frequent Infections allergle5
9t~8f:
confusion
transfusion
hlv~
Mild!~Hx, nona IDDM I NIDDM asthma
P,as't:Med: Hx: NONE
MElds: NONE
o ReYlewed
o Reviewed
AIl~rgIGs:' NKDA
o Reviewed
~U,~B" ~~y Tonsillectomy
F~!nl!y " .
S.oclal H~:: ~:~:;:c:~~::~a~;=- Years
Immu,,!,zlitlons: Up-to- : Y ~
Reproductlvl/l,bt:: LMP: G
R I L Handed Lives Alone: y I N
ETOH: Y I N Drinks/Wi<. Drugs: Y I N
Tet,mus: uncler 5 ya
p
AB
Prl:)-MED Maximus
OCoPlnght 2001 "nr~D CUnlcal SY.llllTI>. LLC,
Pediatric.. Trauma. Page 1 of 2
Roy, lWll5I\l4
""''''''1''\'''''1 I'.U'^T 1"1"'" 111' ""f'. "" 111'\r1 ,.."'".,
:......, 'A"
.. ...
'PHV~Ir:IAN.""'nr.IIl,,1S:~TATlnll.l S:.
...
Carlisle ~nal Medical cCr
NAME: BROWN, KRISTINL
('d\ s990
csitlve - bact..-1 ne ative rovlde addl............1
dI5tre$S~ !~~p:;~
sys I dys
bowel sounds Nll ABN
guarding rebound
cubing cyanosis edema
Ii\KiW: warm. dry diaphoretic rashes
NEURO:, <?N 2-12 in~ct DTRs eq~all symmetrIc
PSY,CH: AAO X3 playful I appropriate for age
LYtJl\;)Hl adenopathy
~~' NL I deferred
Otti. r:
C~
I' '1
" !fo,~13
~..:.&
, /'iM
1'/0' .
REsp:~~ual bilateral resp. effort NL I distress
rates rhonchi wheezes
IVF:
NL I ABN
NL/ABN
DIFF
__..,MO_
B~
B
L_
RBGs waCs
pelvIc;
FOL.EY:
-,' . " .
C.T.: head I abd I pelvIs
,_.. - -
EKG: NSR no acute disease
NG:
UA: SG Prot
UCG: + / -
Other: ABG: pH 02
Q~~': concussion cervical strain Fx laceration hematoma skull Fx
pneumothorax shock spleen Injury contusion child abuse other:
Pulse 0,,:
% NL I hypoxIa
RE-EVAL:
Time:
C02
Improved Slime Wor.e
Crltlaal Care: 20-74/75-90 /91.104/105-120
121-134/135-164 Minutes
o Excl. billable proe.
. .
Olscharged to: Home NUY$lng Home Family
Follow-up with Patlent's Dr. In days.
Other Instructions;
1. ~ __L .-...~,
2.~~-~
3. ./_....
4.~~' ~
5.
i CONSULTATION DISPOSITION
Y/N
DllIcharg, Time Out:
Admit: OBS leu PCU Floor Tele. OR PrelOcrlptlcns GIven:
Transfer:
AMA;
DOA:
Condition: RE:TURN TO ER IF CONDITION WORSENS.
~ P\ ~cedureformattaChed 0
PNA~--C Mo)o.cord Complete 0
Pedl' . rauma ~ Page 2 of 2
"tv. DIIDG104
Signatures:
Pro- MED Maximus
CCO~T)gI1l2001 JIl'ro-MEtl cnnll:a15YGlDlT1a.I..I,.,C.
,....n'l'''....~''I, ..,".....Tn....." ,'" ('\1..,"'(,\ \1"'1 "'""..., 1.-' If'\A
CJRDER.EP<>CEDURE FORM,
ORTMOPL;. . Ie EMERGENCII:.-
/~""'-J'
,-....
. "
isle Reglont~fedical Center
1-.....9323518
Sex: F MR#;0000359904
PCP: TOWNSEND. JAY A
Date In' 10120/2005 TIme'
'ilTllliil"'"'''' ':rJ'<liI""'-..'~.:r.j<<!II"''':l!W'..
:.~~~~~q:"'};~...,~~!;!..,~ }I~'~;'~:~""!!':::
o~&e,11tlltia
1\. ,d;BROWN, KRIS.TI~ ... .
Age: 14YRS 00B:11121/1990
EDP' CRIM, LAURA E MD
'1'4 'r
CXRrpb/LAT. Porta.~J~)
,. C-Splne (X~table) (Compl~te),
CBC
aMP
Sed Rate
Uric Acid
RA Fact~r
CMP
-'
-,..
Drug screen (serum), (urine)
eTOH
Tyye 8< Screen or Cross #
Tl.M~ ~ 61.~. .fl) ~ -;A ~ -" t t~~~
._ I"',~___ ~ ~ ~ - "2.--L:l~ /. ~ "\'(-"',,~~
....,.... -v',4 l.:/' It::
\t:.U
,V:)
Units
~
, ~ ~ . ". "l\l'lI
-
EKG
ABG ,
02 LPM
UA
Beta HCG
M
'Ii"
M~!8tI' 1tl/~ifIl!1.ll'I'"
j'<,l .,:\~,,;,Ij;~lI"W' :.:, r;ij;;lu""I",:lJIlP.~rot..l;:'\~I'::a"t~n;t
Previous Medical RecordS
Physioal Therapy - eval & Tx
....li.
:/!~~,
'Ii,:" : ~A~~~r;lli,~,ijmt!l"~'~i. .'
lij ill~
~.-;:;- ..-"L ~ ..# - d 0
,- !/,~. ;$\../ CJ
I !...tI'?- /J ... // I 0l-r'1 /,,0
7- ~ .... 0
o Improved 0 Worse CI Unchanged
-
o [J Improved [J Worse 0 Unchanged
~<!MlIlm~1f=~:;:~_~~~~~~:~~~~_lIOifl-
_, ,_ _ r-
OIVFluld:
"1--~ I ~Z; St \J j V
11.c26 .sl\! \ V
Cllmproved CJ Worse 0 Unchanged
o Improved 0 Worse 0 Unchanged
.
o Improved 0 Worse 0 Unohanged
:a<<KCiilijD't.....~:f.lUi;IJ'iI':'.."'Ii.1tllw.\lilt~pt;~mi.U"lr.flliR111;~j;.ifl':n!UtfJltlpll>>ll~iIlill:l:aj~i"I~~~;~11~1~:'~i1W'!"~il,jj1[~;'iijl~
~h~i:r.! .. ""~'I~ll~..""...,t'!loI.~li'.!~\~\.."".~,"~IIII~IIIY.iI<<H,,,I",r,II!~...iUIi>J;/;,j1:';ni"i~lf,I',,:iP.fJ~:;I!:'i1:p,";.~;n;n;,~mI,II:"~
Cl Cardiac Monitor Rate Rhythm_ 0 Splint Application CJ (Local). (Regional) Anesthesia
o NIB? Monitor
o Pulse Oximetry
o ACfJ Bandage Application
o Sling Application
D C.Splne Immoblll~Uon
o Foreign Body Removal
o Conscious Sedation
o laceration Repair
o (Cold), (Heat) Application
CJ Wound Irrigation
. :P1",'~t1.r.gliiiJ):i~~~pl;lp~j;:i:' i:i:~;~!~::;i;,~f:::~:i~11:!j:mI;'i'ilf!;i'inni]~:iifi~1iii i, 1:!iliWRili~!f!!lin.ilt\!iiii'Pl!.'i'~~1i!iH!::j!;;:iU}~ii!iii#~!!Wii!1~!~;i8n~!li~:rI.;!'.'llI:Hn;,I:r:!fIi;"iil,i~1.~(;;iim!jri;;liafiw!)i!m!~irililmmliiWW:iWi;1~:)j,'lilr:;~i:lf#w"mk'~"~t~il!j~Wlml~
o Dressings
CJ Cast Applloatlon
t:l Frecture Care (open), (clOSed)
PNARNP;
V~I~~15/~~~re: Inltlals/s~ua..ture:l ) Initials/Signature:
~(J.::J \C),J:) Q'l.mQJl .~ K 57:.[ ~_y~"-, ~ N - ~ I
," Phye~'rs~~. ........
....-c - ('
J
Rav, 09114104
Initials/Signature:
..........~'...."~'" "'"'"...." ...,..,." In, ".1-............
"..~"M.'
'1"11 ,....('\1'......, ,L.-' 'f'\^
Date: 10/20/2005
'''''-'''' /-::'''4irlls/e Regionr',edical Center
Nalll~;aROWNI KRISTIN L. Ptfr:9323518
Age: 14YRS D06:11/21/1990 Sex; F MR#;0000359904
EDP:CRIM, LAURA E MD PCP: TOWNSEND, JAY A
~MERG~Y DEPARTMEN
9NGOIN.... NURSING ASSE~-.JMENT
_\Y!'Ji~~~I,:t.~lJ',9.;f1iP.'tl'!!~t1.J;'/!i. IIpU.. ..:..l'l ,jlt~~~~~l},Tl
.1. , . .. .'" .1".: I .~ ". ,..f ./." ~ I ~. .: .. ') I ,t.' . Ii', .." '". ,i: . ,..' ..1 ,.'. , ~l ...
AIrway Clearance, Ineffective CommunIcation Impaired Infection, potential Self Care Deficit
-Anxiety --Coping, Ineffeotlve InJuly, Potential ---Skin Integrity Impairment
-areaihlng patterns, Ineffective -r=luld Volume. AlteraUon in :=Knowledge Deficit -'hought processes, Impaired
Cardiac Output, Decreased Gas Exchange, Imp;lred ~obllily Impaired Thought Proceslle6, Alteration in
Comfort, Alterallon in _ Hyperthermls (Fever) _Non-Compliance _Tissue Perfusion. Alteration In
-Other Other .
-
littf.i'i}!trs't.:\I}IIt,~i'Jiilff:1r~>>l~ ,"":'1 " ,:fiIft'l)lH<;l:;'''I~~Ull/ili " , '~Il ,. in'. ...'" I 8m~ltIitiirf.jfii~lifilrdi ' , "'~r:IfA'~~:i1ni~i~ff1iffJjn!!!l1J~~I' .' ;iiUHrnUHf.im~YI~liIIlll1lbJmlr~iii~ilL~.
, .
N~I Not Not
M&l MAt Inl Met Mtl Inl Milt Met Int
o FB REMOVAL o IMMOBILIZATION I PRoPER ALIGNMENT e IMPROVEMENt OF BREATHING
o BLEEDING CONTROL t:l OECREASE ll>RSVENT SWELLING CI STABILIZE PATIENT IN DISTRESS
C PAIN CONTROL o MAI~TAlN STABLE HOMEOSTASIS o mBet ENVIRONMENTAL NEEDS
o ALLEVIATE NN o MAINTAIN SKIN I TISSUli INTEGRITY o meet PSycHOSOCIAL NEEDS
o FEVER CONTROL o PREVENt FURTHER INJURY IJ meet SELF ~E ABILITY NEEDS
o DECREASI: ANXIETY C MAINTAIN I IMPROVE CIRCULATION Cl lneGI EDUCATIONAL NEEDS
o SAFETY IN THE eo t:lINFECTION coNTROL o othsf
Iflt: N" doCl,lmenta~on In IIl.1riBB note!;, other 'COdS6' p8f HDspltal Policy.
I~OO b.... . C\(\YV'\ o.J:.., 'cst.dSl6.~. ~?- re{Y'lC ~Q,~ ('l ~ r \r \r.v.- /'\oN Ad., c..-c oHI r,
\'(1 lY
LL.E eiSp \Ol-ed. . Sf..L --
J..~a -. f="~ a.J::... ~cl. '" A -81. ~
-
\<.025 . (Y1edl.c.o..~ as: CJ r<::LQ..A.J d, Tb '\(......, f-O-. .....a .8/(1 ..
(J ...
..lVi;C Bn..~L -h:> -eJl( 0J"'t..... L - SN
... ~
nos l)y-- . en "''I St?o k_L -k> .[: I' Re \co.x - SI-J
!, is TY. t-o.-\uLr VlQ.!\...JL- -\-c ~ <e/v ". Jt'1A n n t~ ,- \^ I
'- -
n45 -ro ~ -+0 ~e - s~ ~ \ )()\. r\ \ :v O-L Qv \11.-*
,. 0
A(1^~ ~ (") ~ y"\bD^ u...... 1\ ~ lA n 0 \1'"'\ \o..c c\ ()n ./ - -'SP I
l~28 .O~ c.~~. J( e.a.e:t \...t ~Yo( p-\-. .s L1 --- -.
.C -
-' .
. Discharged In care of: tJ Amb 0 WIC tJ Stret c Carried
Discharge Inslructlons given 10 _ eVerball%ed understanding
Admit: Room #; O~to Dr. 1S0.~-V'" Ready for Room Time:_
~eport called at and given 10
Transfered to C Transfer Verified
- . Report called at and given to
ol.ef! without treatment cl.eft Against Medical AdvIse
~. Condition al Disposition: Dlmproved ~ble OSerlou& CExplred
Pain Scale: ~ Pllin Location:
Patient reports that p~proved o Unchanged OWors8.
Disposition Vlt.I$: T ~, . p ~ R2Q....sP II '8"~ L02~
Disposition Dali:!; lo!ZQ Time: I~~rse~ -......
RdV. OJIOW4
nf"'. I'
1111'\1('\1\"''' "l,,,Tn..,ll '",I T-I-olOn \If''\TI ~()nJ -h-:J 11\(,\
Date In: 1 0/2012005
subjective Notes:
Time: j (.,
/-...... -".,iirlis/e Reglorr\fedlcal Center
No, .BROWN, KRISTIN __ Ph. ....323518
Age; 14YRS DOB: 11121/1990 Sex: F MR#: 0000359904
eDP; CRIM, LAURA E MD PCP; TOWNSEND, JAY A
.
EMERGEr-....y DEPARTMEN7
--
PlED/A TRt.., NURSING ASSc~~MENT
i'i') jij,.p~ ....n~Uf
Locallon: (t)o..U711. LL E Quality:. harp 0 Dull [l Cramping I:] Sumlng
Mocle of Onset -Q'Sudden D Gradual 0 Intermittent
Onset; Date: Time: DuraUon:
Onset> 24 hr$. medical attention was sought? oNo [lYes Date:
Radiating: oNo eVes (Specify)
Rating Scale:
WONG/BAKER FACES RATING SCALE
@~~@OO@
o 2 4 6 e 10
Caregiver: DParents,zrMother DFather cather:
Accompanied by:
Appllarance: Dele..n
Activity level: oAwake
oOther
C Unkempt
o Playful
o Other
oSmlles / Laughs
Environment n No eteps C Few steps [l Many steps
Nutritional status: 0 Normal 0 Cachetlc lJ ObB5e
Religious I Cultural preferenoe: [l None (sPeQfy\
Besl leam by: (pt / C<lrllglver) oVerbal cWrltten oRetum demo
Learning Barriers;
o HellVYO Pulsating
Language: Derles Often OSmlles OCoos / Gurgles DBabbles
Born at Term: DYes ONo Delivery; DVaglnal DC-Section
Diet: 0 Breast Feed OFcrmula type:
E.llmlnation: 03 - a stools a day Other.
Activity: Lifts HeOld: ClYes ONo Sits up: Dwllh help 0 without help Crawls: Cl Yes 0 No Teething: 1:1 Yes 0 No
Observation of Interactloh with caregiver Is 0 Appropriate OSee Nursing AS6el>smenl
OTIDDDLER Ag~ 1.2 Years 0 Pre-School Age a. ~ Years language: OFew Words OSenleneel> 0 Easily Understood
Cllet: OFlngsr Foods ORegular Diet OFeeds Self Uses: OBottle C Cup Teething: DYes 0 No
Elimination: 01 _ 2 Stools per day ODlapers OTollet trained OWets bed: 0 Rarely D Oecaslonally
Activity: Walks: 0 Yes 0 No owalks with assistance C1Walks Independently
Obsllrvatlon of Interaction with caraglver IS 0 Appropriate OSee Nursing Assessment
DSCHOOL AGE Ago 8 -InsB" OOLESCENT Ag.1~ -18YUrlI Reached Puberty" Yes ONo
[llel: DEats 3 meals/day DEaling disorder: (specify)
Elimination: CI No problem reported 0 Wets bed: ORarely OQccaslonally
Soolal Habits: Smokes 0 Yes 0 No Us Alcohol: Cl Yes DNo
ObservatIon of Interaction with caregiver Is Appropriate OSee NUr5lng Assessment
Uses: ClBottle
DSpoon
OCup
OFrequently
Learning disability: CI Yes
Wears Braces
DFrequenlly
Uses Drugs: 0 Yes DNo
Sctlool grade:
DYes DNa
Vil:al Signs: 15:59 T: 98.5 P: 92 Regular R: 20 BP: 132/0T1
Nurse Signatur
eJJ... .
R.v. 03105104
1NITIAL A''"-~'ESSMENT FORr--
3
,... ~ . ....
"'-;~;'cirlisle Regior<-'Wedical Center
Pt#: 9323518
14YRS Sex: F MR#; 0000359904
Urgent
Patient
008:
eDP:
PCP:
BROWN, KRISTIN L
11121/1990 AGE:
CRIM, LAURA E MD
TOWNSEND, JAY A
Worker's Camp;
Emp. Referred:
PRIORITY:
DATE: 10/20/2005
Pre&entatlon Time: 15:59
Triage Time; 15;59
Arrival Mode: Al.S
Height:
Chief
Complaint:
. Weight: 150.0 lbs. 68.2 kg&. LMP:
MVA-MINOR INJURY
Last Tetanus: under 5 ye
Aoo By: Mother
Vital Signs
T: 98.5 T
P: 92 Regular
R: 20 Unlabored
BP: 1321077
02: 100 %RA
Patn Intensity Scale: 5 I 10
Pain Location: Multiple Areas
Brief STRUCK BY CAR. ON L sloe. PAlN IN L ELaOW, LLE AND ABRAISION TO R KNEE
Assessment;
NIGHT SWE;ATS
WEIGHT LOSS
ANOREXIA
SArETY
RESTRAlNEO
DRIVER
AIRBAG DEPLOYED
NO
NO
NO
HEMOPTYSIS
FeVER
NO
NO
NO
NO
NO
NO
Sudden Onset:
Pre-Hospital
Treatment
Ped~tric G&O App. for Age - N/A, Immunization UrD . N/A, Height ft. In.. Head Clre. - Grade - , with Mother
A.\lsessment:
POlst Medical NONE.
History:
Allergies: NKDA
Medicines; NONe
Nurse Signature:
Additional Notes;
~t-.l .----
To ~ f"V\ IS l.41 - .s l'-l .----
-
SEN
Rev 05/16104
^'....,'^.....~.., ""','^""""" '''' "'L.('\A It^11 ('In"'" J,., tl\"
"
~8 Auto Insurance
'~i
1/_..J/Z006 11:31 AM PAGE
2/0(,
Fax Server
AUTO INSURANCE POLICY DECLARATIONS
SAFE
AUTO
11~~:t!Da~~E I
Policy No. PA00315655A-OO
Policy Period From 09/20/2005 10:23 AM
To 03120/2006 00:0' :00
standard lime 81 the addrC5:S of thr: named Il\$ured Bli &tatecl I1r:rein.
This Amended Declaration P~ge Supersede:s prior \:)..d~rllliorl PSlle h,lOIJed on
NAIlII;D INSURED:
AN IT". D DEFIBAUGH
1845 WALNUT BOTTOM AD
NEWVILLE PA 17241
Endorsement Reason:s:
Added Exd/U:sl Driver!s)
Endors..ment Effective 10/0gl2005 00:01 :00
IF YOU CARRY COLLISION COVERAGE FOre DAMAGE TO YOUA Al1T~ THIS POLICY
PROVIDES cOLLISION CO\lERAQE fOR RENTAL AUTOMOBILEs.. HUT Q.flI.LY If' -rHE
RENTAL VEHICLE IS RENl"fD AS A RESUn OF A COVERI'!D LOSS. PLEA~ T~AT
THE DEDUc-rIBLE AND ALL APPLICABLE PoliCY TERMS AND LIMITATIONS APPLY.
Thl:; De<:larations P:tge alOn9 with the Policy Jacket (Form PA1010/1298), your signed spplic;llion (Form PA1000/0991l) and ::lny lIndorsementslform" lilit..d
below complete the Ilbove Pclicy.
Th.. in:;urance afforded is only with respect 10 liuch .;and so many aI tile fallowing coveJ89~ illi are> indicated with respect to each described vehicle wtlere
apprcprj;,ta.
The limit of tile compaI1Y.'S liability 019:1il15t such coverage shall be :1~ :;tatad herein, subjecl to all the termli at this: poIicV having reference thereto.
VEH,. YEAR MAKE MODEL
_ ... ..!fON
BODY TYPE SERIAL NUMBER
-- - y.
SYM TERR DRIVER PTS
... _ 1..
COVERAGE
SOOIL Y INJURY
LIMIT OF LIABILITY
$ 115,000 EACH PERSONt
$ 30,000 EACH ACCIDENT
~W P'-'" ---
* * *. 6 MONTHS PREMIUM .. ~ * *
~
I:
I....
..
..
TOWING AND LABOR
VEH 1
~ DISCOUNTS PER VEHICLE:
VIOLATION SURCHARGE PEA vEHICLE
OlliE!R SURCHARG~ PER VEHICLE
TOTAL PREMIUM PER vEHICLE
TOTAL POLICY PRI:MIUM:
-
:r
o
,.,
...
ADDITIONAL DRIIiERS: ALLEN BAKER
_ J 11 w
~L - ~-=~~".=u~_.~;' _r'~:~'~
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In witness whereof, we have caused this policy 10 be executed and attested by our President and Secretary and countersigned by our
Iit::ansed agent on 112912006
ii.~id
Presiden1
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Secretary
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Countersignature of Licenssd Agent
Date Issued: 1/2g12000 By 5423 F=orm PA102010202
CLAIMS CENTER
PO Box 182384
Columbus, OH 43272-5507
1-614/231-0200
1-800/SAFE-AUTO
1-800/723-3288
MAR 1~1 2OC6
March 3, 2006
Brian C. Caffrey
Attorney at Law
26 High Street
Carlisle, PA 17013
RE:
Claim Number:
DOL:
Nil:
Your Clients:
234851
10/20/05
Anita Defibaugh
Kristin Brown
Dear Attorney Caffrey:
I am the new Claims Specialist assigned to handle the above pending qlaim. I have reviewed the
information you presented to Safe Auto with your demand for policy limits.
Our offer is $15000, which represents our policy limits. We have already forwarded a copy of the
declarations page previously.
Safe Auto requires probate court approval for the settlement of a minor. Please begin the proceedings for
the judge to approve our settlement.
Please let me know as soon as you have permission to sign our release and I will forward settlement
documents as soon as possible.
"
uri K. Sellers
Claims Specialist
740-965-8876
1-800-723-3288 extension 6034
fax 614-559-5436
. m Mutual Automobile Insurance Company
.itate Farm Dr
tlcordvil/e PA 19339
R 52022-5-E
MUTL VOL
NAMED INSURED
38-6278-552E
DECLARATIONS PAGE
NAIC# 25178
POLICY NUMBER 686 3461-C05-38M
POLICY PERIOD MAY 12 2003 to SEP 05 2003
.,l
BROWN, ERIC M & TANYA L
188 CONODOGUINET EST
NEWVILLE PA 17241
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STATE FARM PAYMENT PLAN NUMBER
004551'7313
AGENT
MIKE SHOPE
812 WEST HIGH STREET
CARLISLE, PA 17013-2706
DO NOT PA V PREMIUMS SHOWN ON THIS PAGE.
SEPARATE STATEMENT ENCLOSED IF AMOUNT DUE.
PHONE:(717)241-3029
1997
DODGE
RAM 1 500
PICKUP
1B7HF16Z9VJ545483
1 B3H502
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1997
DODGE
details.
i-.
Each Accident
C2
Medical
$17.23
Each Person
D
Comprehensive .
U
Uninsured Motor Vehicle
$34.89
';55
$2.56
Each Each Accident
&. ~
~
State Farm Mutual Automobile Insurance Company
One State Farm Dr
.conoDordville PA 19339
07925-5-E
MUTl VOL
NAMED INSURED
38-6278-552E
DECLARATIONS PAGE
NAIC# 25178
POLICY NUMBER 671 0453-D18-38J
POLICY PERIOD DEC 17 2004 to APR 18 2005
BROWN, TANYA L & ERIC
188 CONODOGUINET EST
NEWVILLE PA 17241
STATE FA1=lM PAYMENT PLAN NUMBER
0045517313
AGENT
MIKE SHOPE
812 WEST HIGH STREET
CARLISLE, PA 17013-2706
~ fa) fP ,W
DO NOT PAY PREMIUMS SHOWN ON THIS PAGE.
SEPARATE STATEMENT ENCLOSED IF AMOUNT DUE.
PHONE: (7\ 7)241-3029
2002
CHEVROLET
TRAilBLAZE
SPORT WG
1 GNDT13S222140657
1 D3H502
C2
Medical
.26
Each Person
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State Farm Insurance Companies
STAn fARM
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INSURANCE
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October 2, 2006
State Farm Insurance Companies
555 Southpointe Blvd, 4th Floor
Canonsburg, PA 15317
Attorney Brian Caffrey
Saidis, Flower & Lindsay
23 West High St
Carlisle, PA 17013
RE: Claim Number:
Date of Loss:
Our Insured:
Your Client:
38~K769-581 F&~ AND REGULAR MAIL
October 20, 2005
Tanya Brown
Kristin Brown, a minor
Dear Mr. Caffrey:
Per our phone conversation today, we have reached a settlement
agreement for Ms. Brown's underinsured motorist claim in the
amount of $45,000. I will await a copy of the court approval to
issue the settlement.
SincerelY>ll) I
Cf!~ ~
Karen Kardos
Claim Representative
(724) 743-4972
State Farm Mutual Automobile Insurance Company
HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001
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"I .
i. ..'1 i . LAW OFFICES (I r ...!
SAIDlS,SHUFF, FLOWER & LI1"-1D::fAY
A PROFESSIONAL CORPORATION
26 WEST HIGH STREET
CARLISLE, PENNSYLVANIA 17013
TELEPHONE: (717) 243-6222 - FACSIMILE: (717) 243-6486
EMAIL: attorney@ssfl-Iaw.com
www.ssfl-Iaw.com
CAMP HILL OFFICE:
2109 MARKET STREET
CAMP I-llLL, P A 17011
TELEPHONE: (717)737-3405
FACSIMILE: (717)737-3407
J6HN E. SUKE
ROBERT C SAIDIS
GEOFFREY S. SHUFF
JAMES D. FLOWER, JR
CAROLJ. LINDSAY
BRIAN c. CAFFREY
GEORGE F. DOUGLAS, III
MATTHEW J. ESHELMANt
THOMAS E. FLOWER
MARYLOU MATAS
SUZANNEC.I-llXENBAUGH
tBo.rd Cenifled Creditors'
Righls Represcnllltioll
REPLY TO CARLISLE
CONTINGENT FEE AGREEMENT
THIS AGREEMENT, entered into this 11.- day 01 December, 2005, by and between
Saidis, Shuff, Flower & Lindsay (hereinafter "Attorney"), and Eric Brown and Tanya Brown,
parents and guardians of Kristin Brown, a minor (hereinafter "Clients").
WITNESSETH: That Attorney, for the consideration hereinafter stipulated, has
undertaken and does hereby undertake and agree with Client to act as legal counsel in
negotiating a settlement, and if the same is not effected, in bringing, conducting and prosecuting
an action against Allen L. Baker to recover damages on behalf of Kristin Brown for personal
injuries suffered by Kristin Brown resulting from a motor vehicle accident which OCCUlTed on or
about October 20,2005.
1. ATTORNEY FEES
In consideration for services so rendered by Attorney, it is hereby agreed by and between
the parties hereto that Attorney shall be compensated as follows:
(a) Thi1iy-Three and One-Third (33-1/3%) percent of the gross recovery.
(b) If the Attomey-Client relationship ends prior to the resolution of the case, the
Attorney shall be entitled, in additlOll to the compensation provided herein, reimbursement of
costs and expenses advanced by the Attorney.
"Gross recovery" shall mean the full amount of settlement proceeds or the full amount of
verdict, including any pre-judgment interest, without reduction for costs advanced or incurred.
Attomey shall have a lien on any sum or sums recovered, whether by settlement or
judgment, for services rendered, costs advanced and incurred under this Agreement.
, .
2. COSTS:
Costs will be reimbursed to the Attorney from proceeds of any settlement or verdict.
Costs include, but are not limited to, investigation fees, fees for court reporters, deposition and
transcript costs, witness fees, filing fees, long distance phone calls, travel expenses, photocopy
costs and other costs deemed necessary by the Attorney in order to properly pursue the action.
Costs shall be paid in addition to payment of Attorney fees as above.
3. SETTLEMENT PROVISIONS:
All offers to settle, adjust or compromise the above claim shall be reviewed between
Clients and Attorney before any such offer is either accepted or rejected. Clients further agree to
consider seriously any recommendation for settlement made by Attorney and not to unreasonably
withhold consent to such settlement recommendation.
4. DISCHARGE OR WITHDRAWAL:
In the event that Attorney subsequently detennines that the claim or suit lacks merit, or
Clients unreasonably withhold consent to any bona fide settlement recommendation made by
Attorney, or Clients refuse or fail to cooperate with Attorney, or Clients conceal or misrepresent
facts regarding their claims, or Clients commit a breach of this Agreement, Attorney shall have
the right to terminate Attorney's services by giving reasonable notice to Clients.
5. PRIVACY POLICY:
During this finn's representation of you, we may receive nonpublic, personal information
fi'om you or from other sources about you. It is our policy and practice that our attomeys and staff
do not at any time reveal information relating to our representation of you lmless you consent after
consultation, c:xcept for disclosures that arc; irilpliedly authorized tc can] out the representation, and
except for disclosures required or authorized by the Pennsylvania Rules of Professional Conduct.
6. MISCELLANEOUS:
Clients understand, acknowledge and agree that Attorney does not guarantee the outcome
or eventual result of the above claim.
2
, .
\,
IN WITNESS WHEREOF, the parties intend to be legally bound and have hereunto set
their hands and seals to this Agreement, in execution thereof, the day and year first above
written.
[:~~~~^
Eric Brown
.I'''~~ / P J
''''''f O.I..kli;C.f;;1 jC<{Lvr--./'
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Talt,cyBrown
SAIDIS, SHUFF, FLOWER & LINDSAY
By:
Ta.
G rian C. Caffrey
3
. (J ~ .
STATEMENT OF PROPOSED DISTRIBUTION
Gross settlement
Less Expenses
$60,000.00
30.00
$59,970.00
Less Attorneys' fees af(one-third)
Net to client
$19,990.00
$39,980.00