IMAGETREND EMS SERVICE BRIDGE Wosiiand Fire Department 37201 MARQUETTE. WESTLAND, Ml 48185 Phone: 734-437-3182 Fax: MM on A I08251 i gm I i IStaa i ?6.12939?: 10 name-1 Slate Date Stellar: Incident Nutter Exp-Mme Has to ?$130255 men 5669 Hoe I32122 I I IHemilton IPL i fl else on Numben'MBepest Ple?x Shooter Highway Sill-eel Tyne Bu??or in front of I IWayne I IMI I I48184 I Rear Of MJSu?hemoom oily slate Zip Code Adiacent lo I I Direc?clng Cruse Steel. Directions or Na?ml Grid, asapp?mhlo US National Grid Incident Type E1 Dates and Times '2 E2 Shifts and Alarms Luumpuo I3 I I 00 detector due Io maane?on Month Year Hour Min See I - - Emails": New ALARH always required sum Aid Gluen or Received i 10 I 12 I I 2016 I I 22.09.00 I . mug; 1 Mutual am received i ARRIVALreqt?redmnlessoameied oreid no'lenhle E3 5 in H. Arms! 2 . a es 2 Automatic aid received Ill 2016 22'19'00 Local . Their Fmo mar sons 5 commoner: op?mni. elm-pi ermine 3 Mutual and given 2 Controlied 2 I I I I Special smog lee smash-av Veins 4 Automatic and Their Imam Number it ms'r unrremeeo. required sleep?: immune 2:231: 5 Olhe '22:31:00 I a' give" Cleared None Actions Taken RESDUMBS 62 Estimated Dollar Losses and Values I 86 I I inues?gaie I Mimi 11:3; 311? command 1 I Apparatus Personnel Properly SL1 ression Milena] AelienTaken pp EMS Contents Ill?J Pnemcmenr VALUE: optional 5; Other ID I I I Property 5 I I wig? levelled Contains I I I Completed Modules H1 Casualties 3 None H3 Hazardous Materials Release I Hixed Use Property Fire-2 3 i 2? 0 eeiel HazMet actions re ired Mixed use. Diner Show?: ?re-3 Fire [3:th 1 NZturalgas slowieair :1 [Tree rijzzMataeti: 10 Ass mblyu :"M're :3 _5 a 2:32: 2 Propane gas - Less men a 21 to. tank a 20 Educational use Ire as as. _i 2 EMSGasoline uehlole fuel tank or pothole container I 33 Medical use t? H2 Detector I II II II 4 Kerosene Rielwhomino equipmeetiportable storage I Residential use an 3 2 5 Diesel foelia?ue! oil - vehicle fuel tenafponable i 51 Raw oi stores - .- Requh'ed For con?ned ?res. f. 1 Detector ateried occupants a Householdioi?oe mm; spill 53 Enclosed man Appara e- I 2 Detector did 319? OCCUPWIS 7 Motor oil .. sum engine or portable container 58 Business and residential use Personnel-Unknown 8 Paint-v spills less than 55 gallons 59 Oil'ioe use on- i None 3 60 Industrial use ea Military use I 65 Farm use I MN Netniixed use Page 1 of 4 Property Use 341 Cilnio. diniotype in?rmerv 539 Household goods, sales. repairs Structures 34:! Doctor, dentist or oral surgeon of?ce Service station. gas station church. mosque. synagogue. 18111913. chapel 36! Jaii. prison {not juvenile) 5T9 Motor vehlcie or boat sales. services, repair 151 Restaurant or cafeteria 419 1 or 2 family dwelling 599 Business of?ce 162 Bar or 429 Multitarniiy diveiling 515 Elecbiogenerattng plant 213 Eiementerv school. irrotuding kindergarten 439 ememgrmoming house, residentiat hotels 629 Laboratory or science iaboretorv 215 High schooliiunlor high schoolr'mtddie school 449 Hotelimotel. commercial roe Manufacturing. processing Adutt education center. College titanium" 459 Residential board and care 319 Livestock. poultry storage 31 1 24-hour care Nursing homes, 4 or more persons 46!. Barracks, dormitory 382 Parking garage, general vehicle 331 Hospital medical ?svchialric 519 Food and beverage sates. grocery store BS1 Warehouse Outside 93-6 Vacanttot 93?: Constmolion an: 124 Playground 938 Graded end cared-for plots ofland 934 Industrial plantyard - area 655 Grape or orchard 5'45 Lake. rivet, 5535?" see Forest, timhedand. woneamr 951 Railroad rename We" muggy Pmpem? use i 4.3.9.. at]? Outside material storage area 950 5599?: mam?? I Multifamily dwelling on? I ere Dump, sanitary land?ll 961 Hie?mrar or divided highway Property Use comma 931 Open tend or ?eld 962 Residential street, road or residential driveway Kt PersoniEntity Involved Local Option Bum lien-lo [iIApp?cableJ Maude Phone mother Chocklhiaboxllaamo - I I I ?112 1? Mn. no, Mrs. First Name to Last Nam Sul'i'ilr 132122 I I It-lamitton i IPL 1 Number Pre?x street or Highway Street Time Salli: lWavne Pout Ol?ce ?out ApUSultei'Room City Il'v?li I [48184 State Zipde K2 Owner ??gwmn?nmmomaom I I I I Local Option Business Name ?fhpp?oablei Area Code Phone Nu'nb? Chedtthisboxtleame addreusaulmideril (more? Mr..lrls..lrtre. ?retnleme MI Lastllame Sum: I Number Frail: Sir-net or ngtmay Street SIJllh? i Poet Oti'ice Box MUSuileFRoem City i Stale ?pCede Authorization I 47 I I Jeffery Pochron I I Captain I I Station3 2016 I Ol'?oerinchargn ID Signature Mitten or rank Assam-nerd none. Day Year I I Jeffery Pochron I I Captain I Stations 2016 I Member ?aking report ID Signaluro Posiion or rank Awgnment Month Day Year Remarks LocalOptten E3 R3 were dispatched to location for a report of a CO detector activation. On arrival FD interview with the resident had the resident stating to FD that the combination CO detector had activated for a brief moment then stopped sounding. She stated that she called 911 because she was unsure if there was any 00 present in the home. The resident also stated that the CO detector was a new unit. recently installed by the buitding's maintenance personnel. FD used its 00 monitor to check for any 00 within the structure. ?nding no 00 reading on the monitor. FD had the resident run hot water from the bath tub to get the natural gas fueled water heater to operate. When the water heater began to operate. the FD CO monitor registered a ciight CO reading of 7 white being held near the exhaust pipe on top of the water heater then the unit again zeroed out. The dwellings CO monitor did not activate. FD took its CO monitor outside into fresh air restarted the unit again to establish a zero reading in the fresh air. After restarting the unit outside, the unit was again broilgnt into the structure a check of the water heater's exhaust piping with the unit, as wet! as the rest of tho three levels. did not detect any CD presence within the structure. FD advised the residence of its ?ndings 81 that if the dwelling's CO alarm sounded again to again call 911. E3 took info for report 8r E3 8r R3 cieared from incident. Page 2 of 4 MM DD WW 103251 [Mil [101112 ?2016 1 [Sta3 l16?12089W I0 I FDID sum Incident cafe Slalion Incident Number Apparatus or Resource EDates and Times ?3?"th .ESent Number of EApparatus Use ?Ac?ons Taken People :Check ONE ban: for each ELM up in 4 actions breach apparatus and each :3 Managua rm mahn use jparucnnel. -J-..- Checkif?w same date as Nam date on the Basic Madda- (Bluck E1Dispatch xi . i 1gf'1212016 2209 ?Peps I Amva? [10:12:2016 ?2219 Clear ?2231 Suppression 1; EMS I .. {03.3 1011212016 - gx I 2 I Suppression f! TYPBI 76 1 Arrival .101122016 ?2219 i EMS Claw panama ?2231 Page 3 of 4 MM DD WW AI08251 I IMII I10 II12 II2016 I IStaaI FDED Slate Incident Date Slauon I16-12089W I In I Imklem Hunter NFIRS-1 0 Personne 8 Apparatus or Resource IDates and Times I953 .. .. . 1? TypeIIa I An'ivai Clear checkinhemdale BIN Dispatch I 101122016 I10f122?2016 I 1o;12;2016 I Rank arm dale anlhe Basic mugged: E1) II 2209 I II 2231 I Grade ?gun-rake" Midnight in now Isem II2219 I XI 2 II A??ili? Taken Number of I-Apparatus Use ONE boat fare People :Actlons Taken Ilisiup to 43mm: for each 3mm and each Mm: to Indian-l: Ha malnusni Ipemnm'l. "were Other Apparatus or Resource EDates and ?mes Arrive! Clear Lyssioti?gmmony cum lflhe same date as Alarm dale an the Beale mun {Black xIw Midnight is [mo {Semi i I I1w12rzo16 I1or1zxzo1e II2219 I ?2231 I Number 0! IApparatus Use People 3' Other I I I Suppression EMS ??ionnken . .. Action ?ak-ennui- . .. . Achon'faken .. Page 4 of 4 Wesiiand Fire Department IMAGETR END 37201 MARQUETTE, WESTLAND, Ml 43135 EMS SERVIBE Phone: ?(seem-3132 Fax: MM on I A I 08251 2016 I I Sta 3 I I 16-14287W I I0 I FDID Stole Im?enl Date station incident Number Exposure Bas '5636 I I I Hickory Hollow I I I I lntersectlm "minnows: Pre?x street or Highway Streetwise Surfs: in I I Wayne I I I 48184 I Rear of ApUSLitaJRoom my 5 an zrpoode Adjacent to I Directions Cross Street, ormorons museum! one. as Ippllahae US National Grid Incident Type E1 Dates and Times Ea sums and Alarms Carbon monoxtde Incident I 3- I?l Mh?le?2?Mutual am received a?RNanquhee. munmledordiemem eclelSturtles I I Arrival 2 Automatic eld received i 2016 50 OD mummy. Mutual aid given That! masses Con?ned CONTROLLED op?onel.exoepl lorwidlanrt?rea 2016 Automatic and Gwen Their Incident Manner Last Unit maroon CLEANEDJEIMIES empremulam ?res 0 I12 I I05 I I2016 I I2 115130 I 5 Other and given Cleared None Actions Taken 61 RESOUNES I62 Estimated Dollar Losses and Values I 86 I I tnvea?nate Ii LOSSESQ mu mam. None swam-rumor 4' Apparatus Personnel Property 81 I incident command I I SLI . I I poresslon Additional Aotlon?l'eloen t2Contents I42 I IHazMat detection. monitoring, semethg?analvsis II EMS I0 I I0 I FEE-INCIDENT VALUE: 09mm Mdismamonraroena) Other '0 I In I . Property I I Cements 5 I Completed Modules H1 Casualties None H3 Hazardous Materials Release i I Mixed Use Property :22; 3 Death injury Special Hamlet actions required or split 55 gaI_ 00 Mixed use. me, I Fire . I 0 I I I ?l Natural gas: slow teak. no eves. or HazMat actions 10 Assembly use Smitten Foe Gas-? 4 Service 2 Propane 955 Less um, I, 21 It). took 20 Eduoetional use Fire Sennce 3?"5 Cil?ilan I I I I j; a Gasoline - vehicle fuel tank or portable container I 33 Medical "?53 :thtlit Ham Detector I .. I 4 Kerosene - met-burning equipmentiportabls storage 40 Residential use iMidLand Fire-3 Ram? iormn?ned sm. 5 Diesel fuelifuel oil - vehicle fuel tankiportahle 51 Row of atoms i 1 Detector alerted occupants 5 Househotdiof?ce solvent or chemical spill 53 Enclosed mail 2 Detector did not alert occupants 1 Motor oil - from engine or portable container 53 Business and residen?a? use Personnel-10 I Unknown 3 Paint - spills less than 55 gallons 59 Of?ce ?55 mm? None so industrial use 63 M?itaryuse as Formosa NN Not mixed use Fees 1 of5 Property Use Structures 131 Church, mosque. synagogue. temple. chapel 161 Restaurant or celeien'e 162 Bar or 213 Elementary school, including kindergarten 215 High schooltjunior high school 241 Adult education center. college classroom 311 24-hour care Nursing homes, at or more persons 331 Hospital medical or Outside 124 Playground 655 Crops or orchard 669 Forest. timberland. woodland Outside material storage area 919 Demo. sanitary iand?li 931 Open land or ?eld 341 342 351 419 C?nic. oliniotype in?rmary Doctor, dentist or oral surgeon ol?ce Jail. prison {not juvenile} 1 or 2 family dwei??g 429 Mullilamily dwelling 439 449 459 I164 519 936 9138 9?16 951 960 951 962 Bosrdinghoorniog house, residential hotels Hotelintotel. commercial Residential board and care Barracks. dormitory Food and beverage sales, grocery store Vacant lot Graded end caredfor plots oftend Lake. river. stream Railroad right-ot-way Street, other Highway or divided highway Residential street. road or residential driveway 539 53"! 51nerdy "you Household goods. sales, repairs Service station. gas station Motor vehicle or boat sales. services. repair Business of?ce Beckie-generating plant Laboratory or science laboratory Manulactun'ng. processing Livestock. poultry storage Parking garage. general vehicle Warehouse Construction site industrial piant yard - area look understate Pm ?woman? Property Use 429 have nor checked 3 Property Use Box. I Mul?fam?y dwelling I Property Use Descriphon? K1 PereonlEntity Involved I Hickory Hollow Townhouses Local Option Buckie-so Nam [ll'App?oablo] Ma code Pliers} Number Mr? i?l?aii" . rs. Flrel Name to lost. mm Salli: ?m I 5636 I I I I Hickory Hollow I I I I I Him-riser Pre?x Street or Highway smrm. em 1 Wayne I Pelt! Ol?ce BOX ApuauiletRoom State Zip Code K2 Owner m?im??d?s the neat ?new I I I 'l I Local Option Bushess Name lil?pplloeb'le) Area Dede Phone memeson. ?rst Name to Last Name a TESS RE. Renter Plant Street or Highway Sheet?l'yne Suti'ix Cir Poslo?ice?ex MUSu?el'Room I State [recon Authorization I 2496 I I David Polite I I Fire?ghter I Battalion Chief 2016 I Of?ce 0mm charge In Sl?nlm Position or rank Assignment Moan Day Year 47 I I Jeffery Pochron I I Captain I I Stations 2016 I ?ember Hailing report ID Signature Position or rank Monument Month {Jay Year Page 2 of 5 Remarks Lnral Option E3 was dispatched to location for a report of a carbon monoxide detector activation without any persons experiencing CO exposure On arrival E3 spoke with the resident, who stated that her 00 detector began sounding about 20 minutes prior to her calling 911 for FD response to the location. She stated that she had opened some of the dwelting's windows when the alarm began to sound a that the windows were still open. E3 checked the residence 8. found a CO level of 9 within the structure, but that the level was slowly dropping. The resident stated that she had also salted the complex's maintenance about the CO detector activation. While E3 was the location, a private HVAC company (Buttons) showed up the location, stating that they had been contacted by the maintenance personnel asked to respond to the tocation to determine the CO problem. A check of all of the natural gas powered appliances within the structure found that the kitchen stove was giving off low levels of CO when operating. The resident did state that she had been using the oven prior to the CO detector sounding. E3 advised the resident to not use the kitchen oven until the unit could be repaired andfor replaced. which the resident stated that she would do. The private HVAC company personnel stated that he wettld call the comptex?s maintenance personnel about the CO ?ndings at if the appliance in question was to be repaired or replaced. The residence was again ventilated by opening up windows until the CO level within the dwelling was zero. E3 then took info for report 8. E3 cleared from the incident. was unable obtain any information of the makelrnodel of the kitchen range. Page 3 of 5 103251 I :12 ?05 ?2016 3 {Stats} ?6.14237?! I 10 FWD shale Incident Date Elation Incident Number Ezpomm Apparatus or Resources Apparatus or Resource We] 13 I %.Dates and Times 5 same dale an ?arm dale nnlhe Basic. Mamie [Mack 13!} 1305:2016 Am'vai [1305:2016 Clear [12105)?2016 H1945 "1950 2015 "wm-?ln ?4?anng 0000 {Sent 1 5 i i i 53ml 2 Number of LEApparatus Use People cum one box for 2 Suppression 'i EMS each g??wm In indicale its main use gnemnnei. Wider-t. . :Actlons Taken I'Liihlp I10 4 ucihm lureach awe-mm em 42 I I I Page 4 of 5 MM DD A [03251 :12 ?05 ?2016 1 [Sta3l 11644237w [0 Fun Stun Incider?Date 5m? Exposwe 8 Apparatus or Resource EDates and Times ?d"wkm iSe?tE 0? EApparatus Use EActions Taken magnum came dam ?ask: Media?s (m 511 I 5 People gum; to 1: azliona luraaeh apparalus and each Home .. .. Dispatch 1210512015 .. "194.5 .. . wpeps I Anivai :4 [12052016 ?1950 0198'" 12105I201e ?2015 a 2 .. .. .. pemonneim Name Rank oerde . 122? Page 5 of 5 Patient Name? Westiand Fire Department Prehospital Care Report 37201 MARQUETTE WESTLAND, MMBIBS Incident Date: 11(241'2016 Call 16-13844WL Patient Care 1 Unit Call Sign: Rescue 4 5.0.3: ?5 . Gander:_ SSN: Address: 5535 5. Hickory Hollow Weight- Race: Wayne, Wayne, 1111431134 Phone:? Ethnicity: Hecond?af?limpression' I Summary of Events EA534 diSpatched to listed location for InelA with? En route WLFD ?3 advised there is a carbon monoxide situation at location. Armed on scene to E?nd incident involving 4 pt?s. Listed pt is C0 reading home ranged 120-200 C0. UnknOwn how long pt's were exposed to this level. Pt to A534 without .incident. Pt VS taken. Pt transported to GCOH with ongoing pt assessments. Pt condition -Pt care to ED staff with report. 02 continued at 15LPM via NR8. GCOH staff reports that the hyperbaric chamber on premises is used only for wound care therapy. 534 clear. Description . Practitioner Name ChiefCompiains? .. Secondary Complaint: Alcohol] Drug Use: _5 Injury Cause I. I --In}IsryInterIt . Ht. of Fall a co ded atient Position Inc. Date: 11/392016 Patient Name:? Westland Fire Department Page: 1 Incident Call Date Printed: 04(09/2019 14:40 15-13844WL Patient Name? . -. . CauseFor-Change-, . I EC_G~Monitof sewage: "Comments Cal! Type: Altered Mental Status Disposition?reated, Transported gist Resp. Arr. Resp. Mode: Lights and Sirens by EMS Incident Resp- Mada: Lights and Sirens oisp. Noti?ed:05:54 Can Sign: Rescue 4 Response: 911 Response Destination:GARDEN CITY Unit Disp.: 05:54 Veh. #:Spare Rescue 3~2010 Chevy Location: HomelResldence . HOSWAL: 5245 Enroute:05:57 Start Mites: 0.0 .g Address: 5636 E. Hickory Hoilow i: INKSTER RD: At Scene: 05:04 Scene Miles: 0.0 To Scene: 0.0 Wayne Wayne Gard? .. At patient: 05:05 . 4313 '3 48184 Depart: 06:26 Best. Determ.:5pecialty Resource Arrive best: 06:35 Best. Males: 6.4 To Best: 6.4 Center In Service: 0?:04 Diverted From: Cance?ed: ?i Response Delay: None i: In Quarters: End To End:0.0 Scene Delay: None Transport Delay: None . eve! of Ce?i?cation C. i?sanT?T'lW) .. .. .iEMTrPee-e??ic octor Andrew?AP) EMT-Paramedic i :Role {Primar?erievt Caregiver .. {Primary Patient Caregiver Payment Method: Work Rekated? Not Appiicable Company?tate I neurance PoiiwnE Elite!etionshin To Insured I a Inc. Date: 11;24f2016 Patient Name:? Westiand Fire Department Page: 2 Incident Call 16-13844WL Date Printed: 04109122019 14:40 fMutual Aid Given or ED ?ef??ient Given .. - .. I - uriit?esv?tche Inc. Date: 11(241'2016 Patient Name? Westland Fire Department Page: 3 incident Cat} 16-13844WL Date Printed: alum/2019 14:40 16-13844WL Patient Nam- HospitallReceiving agent Signature Signature g? (E IE ,4 i Evy/if if! . . c" Printed Name S. Wright Date 1 1! 241'20 1606 :42 . Patient Consent Form - I I i our Notice 0 Privacy Practices prowcles informatlon about how we may use and disclose protected health Information about you. have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy. You have the right to meanest that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction but if we do, we are bound by our agreement. By signing this form, you consent to our use and disclosure of protected health information about you for Ewtreatment payment or health care operations. You have the right to revoke this consent, in writing, except where we have aiready made disciosures in reliance on your prior consent. EI Agree: DisagreeNot Applicable Mame; of [43me E1 refuse treatment andy?or transportation by the providing ambulance service. assume for my own, my child own, or many famiiyumember?s medical -- -- E.treatment I have been advised to seek the attention of a physician. I reiease the providing ambulance service, its employees, of?cers and directors from liability resulting 'from my own, _r_r_I_y child?s own, or any other family member' I of edical eatmentor transportatio Agree! Applicable uthorlzatzon EI authorize the release to the Social Security Administration and centers for Medicare and Medicaid Services, any HMOIPPO other private or public insurance, or their I Eagents, ?scai intermediaries or carriers or an independent agency performing or collection functions on behalf of the ambulance service, any personai, medical or Ebiiling information needed for this or a related claim. I understand I will be responsible for any services that are not paidlcovered by my insurance. A copy of this Eauthorizatlon shall be valid as the original and shail remain in effect until revoked in writing by the I request payment of medicai insurance benefits either'E Eto me _or to the ambulance service. E1 AgreeI DisagreeN Signature Printed Name Date I'Techniclan My signature below indicates that, at the time of service, the patIent" was physically or mentaily incapable of signing, and that none of the authorized representatIves were available ?the Paiie'i?Sbeha?f- Inc. Date: Patient Name? Westland Fire Department Page: 4 Incident Call 16-13844WL Date Printed: 04,109/2019 14:40 16-13844WL murm- Signature Date Printed NameTim Wilson Reason Pt. Un bl toSign Valuables: Other/Bess: medication bottles Belongings Left: At Destination with Patient Inc. Date: 1112442016 Patient Name_ Westland Fire Department Page: 5 Date Printed: 04(09/2019 14:40 Incident Cali 15-13844WL Westland Fire Department Prehospital Care Report 37201 MARQUETTE WESTLAND, MI43135 Incident Date: 11(24i2016 Call 16-13844WL Patient Care at: 2 of 3 Unit Call Sign: Rescue 2 Name: age: Address: 5636 E. Hickory Holiow Weight? Race? Wayne,Wayne,MI48184 Phone:? Ethnicity {Prim rv Impressron'. -. Dispatched for a C0 aiarm wwith multiple patients Arrived to find 20 ylo maIe A&0x4 ambulatory outslde.?Pt denied any ?medical Ecompialnts. Pt ambulated to our ambuiance. Pt sat on the bench seat. Pt was sleeping in the basement where ievels were 240 PPM of C0 Unknown how long the i e-?xposure was. WS obtained ?Pt transported to Beaumont Wayne sitting upright on the bench seat secured with a lap beit. Pt had no medicai complaints during transport. Contacted HEMS and gave P3 report. Upon arrival to Beaumont Wayne pt taken into the ER via wheelchair. Pt moved to ER bed report given to ER RN, pt care transferred to ER medical staff. A532 clear with no Incidents. Generic Name . - Descriptlon - - Generic Name regnancv Advanced Directives - - - . Practitioner Name Chief Compiaint: No Medicai Compiaint Minutes Secondary Complaint: Alcohol] Drug Use- Injury Onset - Injury Cause - . - . Injury Mechanism - - 1'1qu Intent - Ht. of Fall: ?os: 5411;24xzo1ai I .. iNo Signs or CG Interpretation . ize of Equipment 5 .- ?a I Gastric 'Lung Placement I Seemed. .9 '3 ?nned; Inc. Date: Patient Name:? Westiand Fire Department Page: 1 Incident Cat! Date Printed: D4IDQI2019 14:40 16-13844WL Patient Name? _Pat en_i: Moved To_.Amhulance . - 3; Call Type:CO Poisoninngazmat 'g Disposition?reated, Transported Elsi: Resp. Arr. Resp. Mode: Lights and Sirens by EMS PSAP: 05:54 Incident 16-13844WL Urgency: Immediate RBSP- Mode: N0 Lights or Slrens ?Disp. Notified: 05:54 Call Sign: Rescue 2 r' I. Response:911 Response Destination: BEAUMONT Unit Disp.:05:54 Veh. Rescue 2~2011 Cheveroiei: i Location: Home! Residence HOSPITAL E: Enroute: 05:58 Start Miles: 0.0 Address: 5636 E. Hickory Hollow 33155 ANNAPOUS I At Scene: 06:10 Scene Miles:0.0 To Scene: 0.0 Wayne, wayne, MI :zf?favne? Patient:05:11 48184 Bot Depart:06:30 3 es . erm.: uses ac i I i, ty Arrwe Best: 06:39 Best. Miles: 1.0 To Desi: 1.0 Diverted From: 5 I In Service: 07:19 a 1 Res onse Bea :None Cancelled: i . Scene Dela :None .- '5 In Quarters: End Miles: 1.0 To End: 0.0 3 Transport Delay: None i Patie?tc'aregwer Secondary Patient Caregiver Payment Method: Insurance Work Related? Not Appilcabie empanv Name - Company City - - HMGikeied inc. Date: Patient Name:? Westland Fire Department Page: 2 Incident Cat} 16-13844WL Date Printed: 04i09l2019 14:40 Patient Name? HOSpltaIIReceiving ?gentSisnatm-e - .. .. Hospitaimessirinment .. . .. 3i acknowledge that the above patient was transferred to my care.3 3 3' I A real Disa reeNot Applicable Signature Printed Name Knauer, PA Date 1 1! 24/20 1606 :44 Consent 30m Notice of Privacy Practices provides Information about how we may use and disclose protected health information about you. You" have the tight to review our notice 3before signing this consent. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy. You have the right to 3request that we restrict how protected health Information about you is used or disclosed for treatment payment or health care operations We are not required to agree 3to this restriction but If we do, we are bound by our agreement. By signing this form, you consent to our use and disciosure of protected heaith information about you for: 3,treatment payment or health care operations. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. 3313 33933333391 Okayama: Applicable .. . . . Waiver of Liability 3i refuse treatment andior transportation by the ambulance service. I assume responsubillty for thy-_- own, my child own, or any famiiy member 5 medical 3-treatment I have been advised to seek the attention of a physician. I release the providing ambulance service, its empioyees, officers and directors from liability resulting ?from 33r3n3y o3w3r3l_,3 33rr3i3y3_ child?s own, or any other 3far33n3i3iy_ member 33533 refusal _o33i3?33 medical treatment 33o3r3 transportation. 3 3 33 313 Agreei Disagree?ol: Applicabie Authorization for Billing 31 authorize the reiease to the Social Secunty Administration and Centers for" Medicare and Medicaid Services, any HMOIPPO other private or public insurance, or their 3agents, ?scal intermediaries or carriers or an independent agency performing biiling or coliection functions on behalf of the ambulance service, any personal, medical or 3billing information needed for this or a related claim. I understand I will be responsible for any services that are not paidlcovered by my insurance. A copy of this 3authorlzation shail be vaiid as the original and shali remain in effect until revoked in writing by the patientiinsured. I request payment of medical insurance bene?ts either; 3to33 3r33n33e3 or to the ambulance service 33 33 Signature Printed Nam- Date 11;24{2016 . .. . . .. . J3 that .1: have ?Wide" the 33?0? assessmem?matmem .395. PamAmbulance Crew Member Statement 313-1y signature below indicates that, at" the tirne of service, the" patient was physically or mentaliy incapable of signing, and that none Mof the authorized representatives were 333av_ai3labie or willing to sign on the patient 5 bah 3 _3 Inc. Date: 1324/2016 Patient Name:? Westland Fire Department Page: 3 Incident Caii 16-13844WL Date Printed: 04(09/2019 14:40 Patient Name:? Signature Date 11f24l2016 Printed Name Mark Nation Reason Pt Unable to Si :1 Vaiuables: Other] Desc: Phone Belongings Left: At Destination with Patient 2 Inc. Date: 1132412016 Patient Name? Westland Fire Department Page: 4 Incident Call Date Printed: D4i09;2019 14:40 15-13844WL Westland Fire Department Prehospital Care Report 37201MARQUETTE WESTLAND. M148185 Incident Date: 11(241' 2016 Cali 16-13844WL Patient Care 3 of 3 Unit Cat} Sign: Rescue 2 Name:? Age:- Conden- ssn:? . Address: 5636 E. Hickory Hoilow Weight:- Race: Wayne, Wayne, MI48184 Phone? thnicity? Closest getatweIC-iuardran .. . Mame: Brow; .. IE Address: Phone 7344698656 Prlmary I . . - Secondary Impressron -. -. - - - . - Apparent Itiness?njury Not Applicable Dispatched for a CO alarm with multiple patients. Arrived to Nod 5 we female ambulatory ootside. ?Pt denied medical complaints. Pl: ambulatect to our ambulance. Pt sat on the jump seat. Pt was sleeping in the basement where leveis were 240 PPM of C0. Unknown how long the I xposure was. WS obtained,? Pt transported to Beaumont Wayne sitting upright on the jump seat secured with a child harness. Pt had no medlcal complaints during transport. Contacted HEMS and gave P3 report. Upon arrival to Beaumont Wayne pt taken into the ER via wheelchair. Pt moved to ER bed, report given to ER RN, pt care transferred to ER medical staff. A532 clear with no incidents EGeneric Name - . . Fractitioner Name Chief Complaint: No Medical Complaint Minutes Secondary Complaint: Alcohol}r Drug Use: 'I'InjuryCa'use- I I - - Injury Mechanism . -- -. 'Ht.ofFa_lI: NotRerzorded Stroke ssessment?Aduit Inc. Date: 11f24f2016 Patient Name?erry, Dominique Westland Fire Department Page: 1 Incident Cal! 16-13844WL Date Printed: 0410912019 14:39 16-13844WL Time 'gCrew Medicatgon Patient Moved To Ambulance. fAssmtedeaik I Call Type: C0 PoisoningiHazmat Resp. Mode: Lights and Sirens Urgency: Immediate Response:911 Response Location: HomeIResldence Address: 5636 E. Hickory Hollow Wayne, Wayne, MI 48184 :Knepp. BrianUBK} i, utual Aid Gwen 03? Received Additional WLFD units dlspatched Inc. Date: 11/24f2016 Incident 16-13844WL apartmenl: Gwen or Receiving Mutual Aid .. - Tn 5.9 size Patient's Posatlon In Transport - i Disposition: Treated, Transported gist Resp. Am: i by EMS 3 95?: 05:54 Resp. Mode: No Lights or Sirens ialso. Notified: 05:54 Destination: BEAUMONT Unit nisp.: 05:54 i HOSPITAL E: Enroute: 05:58 33155 ANNAPOUS At Scene: 06:10 :zf?fayne? MI Al: Patient: 06: 11 Depart: 06:30 Best. Determ.: Closest Facility Arrive Best: 0 6: 39 1 ?mm" Fm": In Service: 07:19 Response Delay: None Cancelled: Scene Delay: None In Quarters: Level of EMT-Paramedic T~Paten1e0ic i Payment Method: Incident Call Sign: Rescue 2 Patient ?we" ?mm'anFe-i Veh. #:Rescue 2?2011 Cheverolet Start Miles:0.0 Scene Miles: 0.0 Best. Miles: 1.0 End Miles: 1.0 gPrimary PatienECeggiver labed? Not Call 16-13844WL Westland Fire Department To Scene: 0.0 To Best: 1.0 To End:0.0 Page: 2 Date Printed: 04(09/2019 14:39 Signature Printed Name Knauer, PA Date 1 1l24y?201606 :43 Authorized Representative Signature . IHIPAA Consent Eour biotice of Privacy Practices provides information about how we maym use and dIsciose protected health Information about you. You have the tight to review our-notIce I lbefore signing this consent. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy. You have the right to greenest that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree Eto this restriction, but if we do, we are bound by our agreement. By signing this form, you consent to our use and disciosure of protected health information about you for Etreatrnent, payment or heaith care operations. You have the right to revoke this consent, in writing, except where we have aiready made disclosures in reliance on your ?armDreareewotivpncabie . .. . IiNaiver of UabIlIty .. II refuse treatment andlor transportation by the providing ambulance service. I assume responsibiilty for? my own, my child?s own, or many famIiy member medIcal _i i .prior consent. 3 i i ?treatment I have been advised to seek the attention of a physician. I release the providing ambuiance service, its employees, of?cers and directors from liability resuiting hiid' wn, orany other family ember' refusal Pf. medIcal treatment or transportation. :1 authorize the release to the Social Security and Centers for Medicare and MedicaId Services, any other private or publIc insurance, or men :Iagents, ?scal intermediaries or carriers or an Independent agency performing billing or coilection functions on behaif of the ambulance service, any personal, medical or information needed for this or a reiated ciairn. I understand 1 wili be responsibie for any services that are not paid/covered by my insurance. A copy of this {authorization shali be valid as the original and shaii remain in effect until revoked in writing by the patient/insured. I request payment of medical insurance benefits either it me or to the arnbuiance servic i-r'i acknowledge that I have witnessed the patientlguardlan sign this PatIent Care Report. I I I .. i Agreel DlsagreeNOt . . . .. . . .. .. . . .. . . .. .. . Authorized RepresentatIve II am signing on behalf of the patient. I recognize that Signing on: behaif of the patient is not an acceptance of f'nanciat for the services rendered '1 AgreeI Applicable Signature Printed Name Dorothy Barnes Date 11f24f2016 Relationship Great Grandma Authorized Representative Address 3354 Turnherry Lane City Ann Arbor State MI Postal Code Inc. Date: 11!24f2016 Patient Name:? Westiand Fire Department Page: 3 Incident Call 16-13844WL . Date Printed: 04(09/2019 14:39 16-13844WL Reason Pt. Unable to Sign Minor Child Valuables: i Other/Base: None Inc. Date: 11/24[2016 Patient Namez? Wes?and Fire Department Page: 4 Incident Caii Date Printed: 04(09f2019 14:39 16-13844WL Westland Fire Department Prehospital Care Report 37201 MARQUETFE . WESTLAND, MI48185 Incident Date: 11l2412016 Call Patient Care at: 1 Unit Call Sign: Rescue 3 Life Threat: No Name" Gender:- ssn:? Address: 5636 Hickory Hollow Weight- Wayne, Wayne, MI43184 Phone: - iPrirhary Impression . econdary Impression- [Altered Level of Consciousness A533 dispatched for someone yelling help. A533 arrived states that she woke up and felt like she could not breathe. Pt states that she opened all the windows to her home and noticed that her husband would not get out of bed. Pt states she went outside yelling for help, Upon further investigation of the heme, E3 found very high levels {300+ ppm) of C0 In the home. Pt Vitals assessed. ?and Pl: transported without Incident and _pon arrival, A533 transferred pt cared to ED staff with full pt care report given. A533 returned in service. .. .. Generic Name - . atienl: Medieetiens caiercompnainu? Secondary Complaint: Alcohol] Drug Use:? Injury Onset - Injury Cause Injury Intent. - Ht. of Fall Not Inc. Date: 11(2412015 Patient Name:? Westtand Fire Department Page: 1 Incident Cell 16-13842WL Date Printed: 04f09i2019 14:38 16-13842WL Patient Name? __Cornn1_ents I 'f Comments Patient Moveti To Ambulance Patient's Position In Transport - - . gPataent Movetl From Ambulance - . . . Can Twe? Disyosition?reated, Transported Elst Resp. Arr.. Resp. Mode: Lights and Slrens I a i DY EMS 5 PSAP: 05:35 Incident i Urgency?mmedlate i RESP- Modemo Lights or Sirens EDisp. Noti?ed: 05:35 Call Sign: Rescue 3 Response: 911 ReSponse Destination: BEAUMONT Unit Disp.: 05:37 Veh. #:Rescue 3-2010 Cheverolet I Location: Home/Residence HOSPITAL WAYNE: 1 Enroute: 05:40 Start Miles: 0.0 i At Scene: 05:45 Scene Miles: 0.0 To Scene: 0.0 At Patient: 05:46 f: Depart: 06:15 Arrive Dast:06:20 Best. Miles: 1.0 To Dest:1.0 In Service: 06:45 Cancelled: In Quarters: End Miles: 1.0 To End:0.0 Address:5636 Hickory Hollow 33155 ??9055 AVE, Wayne, MI 43134 i I 3 Wayne, Wayne, MI Best. Determ.: Closest Facility 1 1 1 i 48 184 Divelted From: a Response Delay: None Scene Delay: None 1 None . Transport Delay: Ecrew Member Level of Certification EWlnrow, Nicholas(leQ__ ?ompanv Name ompany State - - .. . {None 5mm Priority or Received swoop: Given or waiving i 1_ i .. I: Inc. Date: 1112412016 Patient Name:? Westland Fire Department Page: 2 Incident Cali 16-13842WL Date Printed: 04(09/2019 14:33 Signature Printed Name Knauer Date 1 1,!24f201606 28 - Patient Consent Form Consent .. our notice of Privacy Practices provides Information about how we may use and disclose protected health information about you. Yon have the tight tow review our notice i ibefore signing this consent. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy. You have the right to irequest that we restrict how protected health Information about you is used or disclosed for treatment payment or health care operations. We are not required to agree :to this restriction, but if we do, we are bound by our agreement. By signing this form, you consent to our use and disclosure of protected health information about you for; - Etreatment, payment or health care operations. You have the right to revoke this consent, in writing, except where we have already made dlsciosures in relianca on your 5 prior consent. .waiver or mamarefuse treatment andlor transportation by the providing ambulance sew-Icen?ieteume for" my.? own, my child's own, or any family-?member medicai itreatment. I have been advised to seek the attention of a physician. I release the providing ambulance service, its employees, officers and directors from liability resulting In my own, my chiid' PWEL or any other tarnilyrnembers refusai of medical treatment or transportation. - E1 authorize the release to the Social SecurIty Administration and Centers "for Medicare and Medicaid Services, any HMOIPPO other private or public Insurance, or their Eagents, fiscai intermediaries or carriers or an Independent agency performing billing or coilection functions on behalf of the ambulance service, any personal, medical or ibiiling information needed for this or a related claim. I understand I will be responsible for any services that are not paidfcovered by my insurance. A copy of this _i jiauthorization shall be valid as the original and shall remain in effect untii revoked? In writing by the patient/insured. I request payment of medical insurance bene?ts either itlimb-i- Signature .-, ,Printed Name - Date iTechnician . . .1 'Iacknowledgethatfhave moment?s above .. .. Ambulance Crew Member Statement My signature below indicates that, at the time of service, "the patient was physically or mentaiiy Incapable of signing, and that none "of the authorized representatIves were; available or willing to sign on_ the patient?s behalf. i ?1Agree1 DisagreeNot Applicable Inc. Date: 11/242016 Patient Name? Westland Fire Department Page: 3 Incident Call 16-13342w1. Date Printed: owes/2019 14:33 16-13842WL Patient Name:- Signature Printed Name Michael Bandy Date Reason Pt. Unable to Sign Inc. Date: 11(24/2016 Incident Call 16-13842WL Westland Fire Department Page: 4 Date Printed: 04,109,4'2019 14:38 IMAGETREND EMS SEvaoE BRIDGE Westlond Fire Department 37261 WESTLAND. Ml 48185 Phone: 734-45?-3182 Fax: MM DD WYY A {03251 I IMI 11 ?24 ?2016 I sta3 I I0 I FDICI Stale incident {late Station Incident timber Exposure BaSic LucsatlI-ieol-tl 13:38 ?m'?ggmg?lg?om?g? for this Wenbap?nrgf?edmdtihaad?g?hnd Fire Census Tract I 5669 I 00 I a_ re? [5636 i i IEast Hickory Hoitow ICT I [meg-586110? mkf?l??p?? Prom: smtor Highway sum-?P? sum 5? I I IWayne I IME [48184 I Rear Of {My State Zip Code Adjacent to I I Directions Cross Street. Directions or National Grid. as applicable US National Grid 6 incident Type E1 Dates and ?mes ?mm? i Shirts and Aiarms In" Carbon monoxide incident I 8 Local Open? Gm" ?we? $352.? 11 2016 05-4011" . . .. 1 Mutuat aid received - 5 E3 3' eo?al Studies I I .. I I 5 Amval - - . 2 Automatic aid received Ill til ??201 6 05'47'00 3 Mutual aid given my mu MSW Controtied maoujnmm'emm - - 11 24 I 2016 I I 03.10.00 I sped?mwwm Automatic aid given mu Incident Nmnher Un't mar mined except torwtidland 2016 I I 08:10:00 I 5 Other and given Cleared None Actions Taken G1 Resources 62 Estimated Dollar Losses and Values I investigate I ?0?19 ?8th I?m" 63111 I a, mom?. Apparatus Personnel I DI I131 common . 3 Su resolon Additional mountain on pp EMS [2-4 I). Contents I GI Ill 1 mm? I l2_l one-moms"? VALUE: opera-e Miriam Action Taken Other ID I3 I check box it msoumescmm include aid Merino mom. Property I I Contents$ I Completed Modules Fne~2 Structure Fire-3 Civilian Fire Cos-4 Fire Senrtce Gas-5 EMSAS HazMat-T W?dtand Fire-B Apparatus-9 PereonneHl] Around 1 H1 Casualties Death injury Fire Service Lil Lq_._l Civilian I I I I Hi Detector emitted formalin: 1 R{totoctor alerted occupants 2 Detector did not alert occupants Unknown H3 Hazardous Materials Release I Mixed Use Property ti Spatial HazMat actions required or spill >2 55 gal. :1 [til Mixed use. other I 1 Natural one: stow leek. no evao. or HazMat actions I to Assembly use 2 Propane gas - Less than a 21 to. tank 20 Educational use 5 a Gasoline - vehicle fuel tank or portable container I 33 Medical! use . i I 4 Kerosene - fueHJurning equipmendportable storage 3 Residential use 5 oiesel fuel-Tue: oil vehicle rue: tnnkipurtabte 51 Row ofotores 6 Househotdlo?ioe solvent or chemical spill i 53 Enciosed mall Motor oit - from engine or portable container 58 Business and residential use 8 Paint - spits less than 55 gallons 59 Of?ce use None i 60 tnduab?ial use 63 Military use 65 Form use NN Not mixed use Page I of 4 Property use 3-H Clinic. clinic-typo in?mtary 539 Househotd goods. sates. repairs 342 Doctor. dentist or orat surgeon attics 571 Service station. gas station 131 Church. moque, synagogue. temple. chapel 361 Jail. prison (not iuvoniia) 579 Motor vehicte or boat sales. services. repair 161 Restaurant at cafeteria 419 or 2 famity dwe?ing 599 Business of?ce to: Bar or 429 Mui?fam'?y dwelling 615 Eleobiogenera?ng ptant 213 Etementarv school. tnsiudins kindergarten 439 Boardingt?rooming house. residential hotels 629 Laboratory or laboratory 215 High schoolfgunior high sohooi 449 Hototlmotoi, commercial Tut] Manufacturing. processing 241 Adult education center, colieos classroom 459 Residentiai board and care 31!: Livestock. poultry storage 311 24-hour care Nursing hom?. 4 or more persons 464 Barracks. dormitory 882 Parking garage, genera! vehicle 33? H939IIRI - medical 0? 51 9 Food and beverage sales, grocery store 591 Warehouse Outside 936 Vacant tot 931 Construction site 124 Playground 933 Graded and cared?for pints 984 industrial ptentyard - area 655 Crops or orchard 9?6 Lako.rivot. stream toot: trout-oer to Us . a I 669 Forest. timberland, woodland 951 Rallroad rigllt-tzti-waylI Prape magma? 3 429 our Outside materials storage area 960 street. other mg? I Mum?m?y Mama I 919 Dump. sanitary land?tl 951 Highway ?7 highway Property Use Oescripltan 931 Open land m?atd 962 Residential: street1 road or residential driveway K1 involved I I I I I Local Option Businm Name Area Code Phone Mutter Eitr?irt?itii?l'e?riPagg?%l??ni? Mr.. Mrs" Intro. First Norm Last Name sum i it it it it 1 Number Prefix street or Highway street Type Sum: Post Ditto: Bolt ApiJSuilel?Room 135114I State Zip God: involved .. K2 Owner m?w?fbu: and :ldp tho rest arlhle alaelrLocal Option Suit-mu Name (Humble) Area Code Phone Nlmher Checklilin box {teams mastsTingle I of. 51,13 Mn. his. Mrs. First Name Ml Last Nan-lo Suf?x dup headdress inNumber Pre?x street or Highway StreetType Su?! Post Of?ce Box AthSulteiRoom stale ?p Code Authorization 1886 I I Mitch Tokarski I I Captain I I Station 2016 I O'?icerlrl stratus ID Signature ?tn?ion or rant: Writ Month Day Year I 1220 I I Alexander Stlvestrt I I I I Station 2016 I Member Making report In Sign-shire Position onunlr Assignment Month Day Year Remarks Local. Option Dispatched to above address from second rescue was requests om spa a as me. Subsequently white searching the rest of the condo 2 more paopte were found in the basomnt aoxS. A CD monitor showed 240 PPM in the basement and 120 CO in the upstairs. Consumers energy was then contacted to respond to the scene. A third rescue was requested to evaluate the 2 patients from the basement, and Battalion 1 responded to the scene also. The condo was ventilated and the unit next door was checked with low teveis of CO found in the basement. Engine 3 crew tried to isolate the source of the CO without success. Consumers arrived on scene. The scene was left with oomptox management and Consumers energy truck23325. Manager Carrie Ward 7347297262 Page 2 of 4 I03251 I IMII FDID Slate RM DD YWY I11 II24II2016 I 100162!? Date sullen IsmsI I 16-13842 Incident Number si 8 Apparatus or Resource Type 10 I I ?33am TypaL?-ng Dates and Times Dispatch I Arrival I11I24I2016 Mummea' II 0540 II 0547 _i I (:I'Ieckll'uwuamedaie an Man-n daiaanlhe Basic Mould: [Black E1) JI I . Clear I 1024:2010 DISpatcthI-uzqzo?m II 0810 Ar?val I11I24I2016 [10547 Cheat I11f2412016 I I I I I I 180:? Number of 9001330 IApparaius Use gchmouaboxm each :a Other I I Suppfassion EMS .. other I I Ix Suppression EMS II 0810 EActions Taken list up [of ?lions Much apparalm and each Page 3 of 4 MM 09 A 103251 I IMEI I11 ?24112015 I Isma] ?5-13342 I 0 FDID stale Incident Date 51m? Imam um Exposure Personne Apparatus or Resource iDates and Times ??ka iSenti Number of i (mack :?l?the some: data as Nam: am an the Basic undue {arm s11 i i?eople 1 WEN-PEP .. .. .. I . . I Af?val [1112412016 "0547 3" f; Cigar I 11/2412016 II 0310 iActtons Taken iUltuptn?ulicns hreach ammusmdeada mm]. 5. iApparatus Use . .. Pemunnelfp Name . Ra?koremde ActionyakEn i2495 Apparatus or Resource inates and Times 1? iSenti Number of mamamdalo ?mandate onlheaa?c Mndwecm E1) People 1 i - 1D Bamimspaichxl 11:24:2013 II 0540 I ?palm I ?rivet I11r2412016 "054? I ix i 0?95"? 11f24i2016 Home I iApparatus Use incttons Taken . . Other .. 3631 1 Suppression l??Page 4 of 4