# Fall Patient - Your treatment



## MedicPrincess (Aug 26, 2006)

At 0900 - CAOx4 77 y/o M found laying on a couch. His head is propped with pillows, turned slightly to the left. Patient reports he was startled awake by the phone ringing at about 0400. He jerked his head up, looked to the right where the phone was and fell off of the couch. Patient states he got back up and laid back down on the couch and went back to sleep.

Patient states when he woke up he could not turn his head. He reports pain laterally on the right side of his neck. Pain is constant, worse with movement. Patients states it feels muscular, like he may have slept wrong. No cervical pain. Patient denies LOC.

Patient skin pink, warm, dry to touch. Pupils PERL. Pelvis stable. No neuro deficits. Bilateral Breath sounds clear. Pulses strong, regular. ABD is significant for a massive umbilical hernia, about the size of a basketball.

Patient has a cardiac history, psych history. Meds are numerous, but unknown. Pt reports we can get the list from his daughter when she gets tot he ER.

What would your treatment have been? Specifically, would you have placed him in a collar, CID, and LSB?  Any interventions?  How about an IV?  Patient is requesting transport to the ER because he doesn't drive and his daughter lives closer to the hospital so she can meet him there instead of coming to get him.


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## fm_emt (Aug 26, 2006)

Around here, since there could be some question about the MOI (did he whack a table? Hardwood/tile floor?) protocols would have us do the whole c-spine bit, backboard included. He'd get O2 and be on his way to the ER. Being a lowly Basic, *I* wouldn't be giving him any IV, but the medic that we'd have on scene (county protocols, again) would make that determination. Being that he's 77 and possibly clonked his head on something, I might worry about some sort of intracranial bleed. That whole hernia thing would alarm me too. But he'd get a quick trip to the hospital.

Our transport times around here are pretty short. We have several hospitals and since he wanted to go to an ER, he'd have a choice:  
* Kaiser Santa Clara
* Kaiser Santa Theresa
* O'Conner Hospital
* Santa Clara Valley Medical Center
* San Jose Regional Hospital
* Good Samaritan Hospital
* Stanford Medical Center/Lucille Packards Childrens Hospital
* El Camino Hospital

He'd be off of the board pretty fast.


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## MedicPrincess (Aug 26, 2006)

Pt landed on a carpeted floor.  No coffee table in front of couch.  Fall height of about 2' to floor.


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## fm_emt (Aug 26, 2006)

EMTPrincess said:
			
		

> Pt landed on a carpeted floor.  No coffee table in front of couch.  Fall height of about 2' to floor.



At 77 years of age, I don't think I'd take any risks with the guy. Better safe than sorry these days.


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## soon2bemt (Aug 26, 2006)

Full spinal immobilization-careful of placement of straps on the torso due to the hernia-O2 and transport to ER.


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## akflightmedic (Aug 26, 2006)

I would not have done anything other than tx on stretcher. There is no indication for cspine, oxygen or IV. Simple detailed exam reveals that.

Might even recommend ibuprofin and a refusal.


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## soon2bemt (Aug 26, 2006)

Unable to move his neck-hmmmmm-that would make me think c-spine....even if it was only a two foot fall from a couch.


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## sdadam (Aug 26, 2006)

I agree with akflightmedic, the pain in the neck wasn't reported at the time of the fall, in fact pt said that they were able to get back on the couch and go back to sleep, nor was there a report of any direct injury to the neck, or head in the fall. Had he reported pain in his neck immediately after the fall, or that he hit his head/neck during the fall that would be another story. But the S&S point to muscle discomfort which was caused by the way he was sleeping.

There is no significant moi, so no c-spine would be needed, I would 02 and transport.

.adam.


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## Ridryder911 (Aug 26, 2006)

It's called a neck wry. No reason for spinal immobilization, since there is no MOI, pain on spinal area, or paresthesia. Alternated heat/cold packs with some NSAID- like Toradol for pain or muscle relaxer such as Valium if severe. 

The patient will be placed on Norflex TID, and some other NSAID's ... better get that hernia repaired before it incarcerates.

R/r 911


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## fm_emt (Aug 26, 2006)

Hmm. maybe you're right. I guess around here, c-spine has been engrained in our skulls pretty deep, especially if you didn't see it happen. 

I was thinking that since older folks tend to have a more brittle bone structure, it certainly wouldn't (or shouldn't) hurt anything to c-spine the guy for the short ride to the hospital. He'd have his x-rays and be set in probably 25 minutes.


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## MedicPrincess (Aug 26, 2006)

We cleared this patients C-spine.  As he was in such pain, we lifted him from the couch with one person supporting his head/neck/shoulders, one taking his hip, and one with his legs.  It was beautiful.  Maintained inline stablization and everything.  

BLS patient, off to the ER with him justa whining the whole way.  He's hot.  He's cold.  My partners driving is terrible (actually, it was really good for her.  She was trying hard to make it easy).  Is there anyway we can get him out of the ambulance without any bumps.

Report to nursing and the ER physician.  ER physician says He ACUTALLY called EMS for this.  YEP, we don't go looking for patients.

Our shift commander called us 2 hours later.  This patient was admitted with an unstable C-2 fracture.  THAT DOESN'T HAPPEN!!  

What I want to know is if it was an old fracture that was aggravated by this latest fall.  Our MD has said he will talk with the ER physician and see what the MRI results said.  He had no indication of a fracture at all.


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## Ridryder911 (Aug 26, 2006)

Then you received only a partial part of the history... C-2 axis fxrs, are real hard to obtain, and a fall from that height, without spinal pain and only lateral pain....something fishy...Unless he has a sever case of osteopenia, or osteoporosis.

R/r 911


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## MedicPrincess (Aug 26, 2006)

Ridryder911 said:
			
		

> Then you received only a partial part of the history... ....something fishy...Unless he has a sever case of osteopenia, or osteoporosis.
> R/r 911


 
Thats why I was wondering about it being an old Fx.  Perhaps previously undetected.  

To do it all over again, we wouldn't backboard this same type of patient.  I was just shocked when they reported back with a FX.  I need to ask next shift what the MRI showed.


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## soon2bemt (Aug 26, 2006)

That's why I said c-spine-I was taught in my EMT class that unless a fall pt-even from any height refuses treatment/transport that we immoblize them-if this guy was one of those crazy ones-he could have said ya'll were negligent when he finds out he has an unstable c2 fracture.  hmmmmm.....


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## FF894 (Aug 26, 2006)

I was agree with AKFlightMedic except I would transport.  I would take care in trying to keep him laying still and avoid gross movement on the way to hospital, but I would not board, O2 or other.   Our average transport time to 3 area hospitals is only about 7-10 minutes at most so I would just get him there quick and have hospital clear him.  In my experience, I find that by the time I talk them into not going to the hospital, I could have just transported them and gotten it over with.

The fact that it turned out to be a C-2 is a fluke.  Its one of those 1 in a million times that a situation like you described turns out to be the "worst."  It is interesting that it turned out to be that way and I would be curious about maybe some PMH he forgot about or like the others said osteoporosis or the like........:unsure:


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## fm_emt (Aug 27, 2006)

EMTPrincess said:
			
		

> Our shift commander called us 2 hours later.  This patient was admitted with an unstable C-2 fracture.  THAT DOESN'T HAPPEN!!



Wow! That's kind of what I thought (some sort of fracture) you were going to say. I guess I was kinda right.. better to be safe than sorry sometimes, eh?


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## fieldmedics (Aug 30, 2006)

Spine Imb. o2 tx.


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## jaron (Sep 2, 2006)

Our protocols say that you C-spine anyone over 65 y/o. In the case you described above I would have used a pillow or blanket with some 2 inch tape to "splint" the head and neck in the position of comfort. In route, a full trauma assessment would have been done. IV with bloods drawn, depending on BP (systolic less the 100) no fluids would have been provided secondary to the cardiac Hx. A BGL would have been obtained.

I just woke up so that’s all that I can think of right now.


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## Airwaygoddess (Oct 1, 2006)

fm_emt said:


> Hmm. maybe you're right. I guess around here, c-spine has been engrained in our skulls pretty deep, especially if you didn't see it happen.
> 
> I was thinking that since older folks tend to have a more brittle bone structure, it certainly wouldn't (or shouldn't) hurt anything to c-spine the guy for the short ride to the hospital. He'd have his x-rays and be set in probably 25 minutes.



I agree, better to do full C-spine than not.  old folks and little kids frail like fine china will break if they land just right!


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## Summit (Oct 6, 2006)

EMTPrincess said:


> Thats why I was wondering about it being an old Fx.  Perhaps previously undetected.
> 
> To do it all over again, we wouldn't backboard this same type of patient.  I was just shocked when they reported back with a FX.  I need to ask next shift what the MRI showed.



So what did you find out?


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## wolfwyndd (Oct 9, 2006)

Personally, I wouldn't have recomended a C-spine immobilization either, however, if ANYONE else on the rig would have suggested it, sure, I would.  I would actually be a bit more concerned with the abnormal abdomen (say that 5 times fast) then his neck pain.  

That's a not so nice sunday surprise that he had a c-2 fracture.


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## FF/EMT Sam (Oct 31, 2006)

C-Collar, LBB, O2, Call for ALS, Fast Transport


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## trauma1534 (Nov 17, 2006)

Come on people, let's get real.  Why LSB or C-coller?  No MOI, if it were that severe, he would not have been able to get up.  2 feet fall?  Are we not taught to only LSB if pt falls 4x's thier hight?  

I would transport him in a position of comfort.  He is A&Ox4... wonderful!  Airway is not compromized.  What is the big deal?  What about his hand grips?  Does he have good PMS present x 4?  Are there any deformities?  I wouldn't sweat it.  He would just get a routine transport to the local ER.  While this is something that needs to be treated, it is not life or limb threatening.  

Sometimes people are being immobilized when they shouldn't be.  Rememeber the saying "first do no harm".  Why try to streighten the neck and put him in a c-coller?  Are we not tought to splint them as we find them, unless there is no palpable pulse present?  THis does not even warent splenting.


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## yowzer (Nov 18, 2006)

Based on the description of the patient, I wouldn't have gone with a collar and backboard either. It doesn't sound like he meets the criteria. Well.. maybe if he had a history of brittle bones or osteoporosis. As long as you follow your protocols, and document everything, you're on pretty safe ground. 

Wouldn't be too concerned about the hernia either; if it's that big, it's been there a while. Liver problems?


If he doesn't know what medications he's on, go through his bathroom and kitchen looking for pill bottles.


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## Ridryder911 (Nov 18, 2006)

FF/EMT Sam said:


> C-Collar, LBB, O2, Call for ALS, Fast Transport



Okay ... justify the above treatment?. Collar..hmmm... maybe, okay.. LSB.. 02 for what reason? ALS again for what reason? .. and fast transport? So you are going to endanger someone with a spinal problem?.. Hmm last I read, and heard spinal precautions are supposed to be nice, smooth transport.... I don't see any urgency here... 

[QUOTE="trauma1534] Are we not taught to only LSB if pt falls 4x's thier hight?[/Quote] 
Never heard, read or seen that one.. so if they are 6' tall they have to fall 24 feet before you LSB someone.... I don't think so! 
Any MOI that suspected cervical, spinal precaution should be considered for spinal immobilization, especially those with osteoporosis and the elderly. However, this scenario does not meet those criteria (ground level fall and non-sos of cervical pain. 

R/r 911


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## jeepmedic (Nov 21, 2006)

Any Fall that Pt. complains of neck or back injury gets c-spine and LSB. I don't care about any ground level fall or fall 4x there height. I  have seen more than one pt c/o neck and back pain that fell from a sitting or lying position that resulted in some type of neck injury. It may be a 1 in a million pt. but it only takes that one to make you a former EMT!!!! Use a back board.


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## trauma1534 (Nov 22, 2006)

Let me correct myself on something.  When I posted earlier about not backboarding 4X's someone's hight, I was wrong.  I don't know what I was thinking.  That is our criterior for flying a fall patient out.  However, I still would not have backboarded this patient.  In my opinion it would have caused more harm than good.  I am not sure how I would have c-collered him.  With his neck stiff and to one side, there again, seems like I would have caused more harm than good.  I can see how that would have been a tough call for someone to make the right decision though.  In our area, there is a big thing of clearing c-spine in the field.  I don't agree with it.  But our recieving facility is not as strong on patients being backboarded for that reason.  Follow your gut in the field, and when in doubt, call med controle.


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