# Elderly Fall - Board/Collar



## Simusid (Oct 3, 2009)

I'm a new EMT-B and I've only been on a small number of calls.   So far they have all been medical.  Last night we had a call for an 88 YOF that fell and hit her head at a restaurant.

We got on scene to find her seated in a chair in the small foyer entrance.   Her daughter said that she did not trip but had fallen backwards, fell behind the inner door and hit her head.  They had picked her up and seated her in the chair and we found her in that position.   Pt was notably frail and probably weighed under 100 lbs.  She was alert, moving her head and had no complaint of neck pain.  She did have a complaint of hand pain and there was a minor abrasion on one hand.  She remembered the fall and did not black out.

My medic decided to board and collar her.   We had her stand up and we did a standing takedown.   It was obvious pretty quickly that she had a pre-existing spinal issue and laying her flat caused her quite a bit of pain initially.  Luckily, this subsided in about 5 minutes and the rest of the call was routine.

Given the Pt age, frailty, potential MOI (stated she hit her head), and need for transport (family wanted her checked) I can see the need for caution.   I can see that we set the bar pretty low on board/collar usage.   My question is, would you have done the same?   For an elderly patient who has fallen from a standing position what is your criteria for not boarding for transport?

As an alternative, I'm now thinking we could have used a KED because of her pain laying flat on the board.


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## Simusid (Oct 3, 2009)

Duh... I just remembered that while the KED might work, the pt would still end up on the backboard so my idea to use it to alleviate pain from lying flat was wrong.

Ten points from Gryffindor!


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## dewd09 (Oct 3, 2009)

Absolutely. I've had one instance where a patient fell backward, while suffering from Vertigo. The patient had a C3 fracture. But the patient was walking, talking, breathing. No terrible complaints, except head pain. My partner(s) decided that since the patient was walking, there was no need for spinal precautions. Hold up! No. Don't think so. We did a similar maneuver, except I laid a folded blanket under her upper back and bottom and we padded the voids. 

I'd be more concerned of a spinal injury for the backward fall victim, than a forward fall on a level surface. Lots of bad things can happen from a blow to the high spine, back of the head. That's an area where you don't want to exacerbate an injury. You can always put a blanket on the backboard when immobilizing the patient. They make several devices for comfort in patients who may be on the board longer; or who have pressure point issues. Mats, pads, inflatable devices, I believe one is called the back raft. Expensive, yes, but if you carefully selected who to use them for, I'm sure it would pay off.


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## dewd09 (Oct 3, 2009)

You may also consider looking into con-ed courses that specifically focus on treating the Elderly trauma patient. I've attended one, I believe it was called Geriatric Education for EMS.

Yup.

http://www.gemssite.com/


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## MrBrown (Oct 3, 2009)

No.  

- She has no neck pain and no distracting injury
- She remembers the fall and does not have a neuro deficit
- There is no evidence of back or neck trauma
- Awake, alert and co-operative with no intox

I would check her motor reflexes, palpate the neck and back (incl midline) looking for pain, ask about any spinal history.

We do not even carry long boards anymore as our policy is very liberal and recognizes the lack of evidence supporting thier use; although I do conceed absence of evidences does not mean evidence of absence.


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## enjoynz (Oct 3, 2009)

Just a matter of interest. As the pt didn't pass out and remembers the fall.
Did she say why she thought she fell?
I assume there was nothing on the floor that made her slip backwards?
A spilt drink for instance...being a restaurant.
Did she feel dizzy or lightheaded before she fell? 
Did anyone take a Blood Glucose Reading?
I have to agree with Mr Brown, here in NZ we do not follow the strong C-spine protocols you have there. Given the list he stated.
As someone else did say on this thread.
That's not to say that this incident should not have been handled in this regard, C-spine can be a factor.
Also with an elderly pt falling.... you have fractures of hips and (NOF) neck of femurs to think about.
Doesn't sound like it with your pt...but there can always be a curve ball thrown into the mix at times.

Cheers Enjoynz


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## Akulahawk (Oct 3, 2009)

MrBrown said:


> No.
> 
> - She has no neck pain and no distracting injury
> - She remembers the fall and does not have a neuro deficit
> ...


Given a chance, that's about how I'd clear c-spine... and I'm looking for a mechanism that supports a potential spinal injury. If I see a positive mechanism, I'll dig much deeper into the situation.

Also, with the elderly, if their back has a very characteristic curvature... I'm going to want to use a vac mat or lots of padding to help limit both movement and pain...


enjoynz said:


> Just a matter of interest. As the pt didn't pass out and remembers the fall.
> Did she say why she thought she fell?
> I assume there was nothing on the floor that made her slip backwards?
> A spilt drink for instance...being a restaurant.
> ...


With the elderly and falls, I also wonder about hip/femoral neck fractures, especially with elderly patients with obvious osteoporosis type problems.


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## medichopeful (Oct 3, 2009)

I would.  If there is ANY chance of spinal injury, I believe it's better to immobilize.  Would you rather immobilize someone who didn't have a spinal injury or NOT immobilize someone who did?


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## dewd09 (Oct 3, 2009)

> We do not even carry long boards anymore as our policy is very liberal and recognizes the lack of evidence supporting their use.





:blink:

Must be a NZ thing, b/c I read all the EMS magazines and journals; and I've never been told that we don't need spine boards. I've been taught by the pioneers of EMS, and they are still firm on the belief that if one has a spinal fracture, you keep the head, arms, legs, and trunk firmly immobilized.


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## MrBrown (Oct 4, 2009)

dewd09 said:


> :blink:
> 
> Must be a NZ thing, b/c I read all the EMS magazines and journals; and I've never been told that we don't need spine boards. I've been taught by the pioneers of EMS, and they are still firm on the belief that if one has a spinal fracture, you keep the head, arms, legs, and trunk firmly immobilized.



I wouldn't trust EMS journals and trade magazines as far as I can throw them.  They aren't exactly the same calibre of publication as NEJM, the Lancet, JPHEC, JTrauma etc as not designed for the publication of EMS related research i.e. not a peer-reviewed scientific journal and lets face it; most in EMS have never taken a course in research methods or statistics.

As for the application of a long spine board I am mixed on it's application but I am generally in favour of not going overboard (blocks, collar, board and tape) based simply upon the emperical notion of "we need to prevent getting sued" or "this helps" (does it?).  

So much in prehospital medicine has been debunked over the several decades from MAST pants to the golden hour; we give a lot less fluid for trauma than the days gone by; intra-cardiac adrenaline has been removed etc etc

Interestingly *this study*http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum found *less* movement on the scoop stretcher than on a long back board


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## Melclin (Oct 4, 2009)

medichopeful said:


> I would.  If there is ANY chance of spinal injury, I believe it's better to immobilize.  Would you rather immobilize someone who didn't have a spinal injury or NOT immobilize someone who did?



I don't think its as simple as that. An airway, for example, becomes more difficult to manage with a collar on. Have you ever worn those bloody things in a prac or whatever? Try it out, its very illuminating. Its bloody uncomfortable. I spent 25 mins in one getting extricated from a car in the "Outdoor Simulation Centre" (Read: smashed up old bomb out the back of uni). I very nearly vomited towards the end just from the discomfort and disorientation of wearing the thing and I was imagining if I was in pain and scared s***less how much more likely I'd be to chuck. I'd certainly feel like idiot if my otherwise healthy pt suffered an iatrogenic aspiration because of the vague notion they might have a spinal injury. There are other issues too, of course, which I'm sure you're already aware of and everyone else is probably much better equipped to talk about. I just thought I'd mention that one, and to (if you haven't already) try getting realistically immobilised for a lengthy period. It makes the dangers of spinal immob much clearer.   

Something one of my lecturers mentioned (and I can certainly see how this would be true since trying it out) said that in a lot of circumstances esp if the pt is a little upset and/or non compliant, that he prefers to simply ask them to lay still and provides them with some supports to help them help themselves because they get very upset when collarded and boarded and tend to end up moving more. The thing that shocked me most when I got boarded was how much it really doesn't actually stop you from moving. And you are constantly uncomfortable and trying to squirm into a more comfy position. I reckon I'd be better off just lying still. I might add though that this is applied within reason. This is for the pt-who-maybe-should-maybe-shouldn't-technically-fits-the-criteria-but-not-really-sure-if-he-should type situation, not for bonefied spinal injuries.



MrBrown said:


> I wouldn't trust EMS journals and trade magazines as far as I can throw them.  They aren't exactly the same calibre of publication as NEJM, the Lancet, JPHEC, JTrauma etc as not designed for the publication of EMS related research i.e. not a peer-reviewed scientific journal and lets face it; most in EMS have never taken a course in research methods or statistics.
> 
> As for the application of a long spine board I am mixed on it's application but I am generally in favour of not going overboard (blocks, collar, board and tape) based simply upon the emperical notion of "we need to prevent getting sued" or "this helps" (does it?).
> 
> ...



+69395. I wouldn't bother with those trade magazines. They have pretty pics for looking at on the bus, buts that's about the extent of it. The only purpose I think they serve is to get expert opinions to put particular research in context. Like Bledsoe's columns in JEMS (and JEMS is a cut above some of those magazines I reckon) when he actually references articles and discusses them a little.


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## Luno (Oct 4, 2009)

Outstanding Mr. Brown, I wondered if the selective spinal immobilization criteria was going to make a presence in this thread.  In the US we are slowly moving in that direction, as well.  However, other selective spinal immobilization criteria specifically does not allow someone of that age to not be immobilized (Canadian).  Dewd09, there is continuing research in to this field within the US, and the accumulated data is not showing a need for the abundant use of spinal immobilization that we use in the states.  Also, if you do review the data, in the context of the stated call, you might see that the backboard may be contraindicated.


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## medichopeful (Oct 4, 2009)

Melclin said:


> I don't think its as simple as that. An airway, for example, becomes more difficult to manage with a collar on. Have you ever worn those bloody things in a prac or whatever? Try it out, its very illuminating. Its bloody uncomfortable. I spent 25 mins in one getting extricated from a car in the "Outdoor Simulation Centre" (Read: smashed up old bomb out the back of uni). I very nearly vomited towards the end just from the discomfort and disorientation of wearing the thing and I was imagining if I was in pain and scared s***less how much more likely I'd be to chuck. I'd certainly feel like idiot if my otherwise healthy pt suffered an iatrogenic aspiration because of the vague notion they might have a spinal injury. There are other issues too, of course, which I'm sure you're already aware of and everyone else is probably much better equipped to talk about. I just thought I'd mention that one, and to (if you haven't already) try getting realistically immobilised for a lengthy period. It makes the dangers of spinal immob much clearer.



A well thought out post, my friend.  Airway does take priority over basically everything else, including spinal precautions.  If one doesn't have an airway, they will fairly quickly not have a heart beat, and subsequently be in a VERY bad situation.  If there was a patient who could not wear a c-spine collar who could possibly have a spinal injury, I probably wouldn't make them wear it.  I would probably just strap them down, immobilize the head the best i could, and go from there.  But that is an absolute worse case scenario, and only if it dangerously affects their airway.  If they are just uncomfortable with it, but can still breathe fine and it is not causing them to vomit, guess what they will be wearing.  As far as I know, we don't have enough training to selectively decide whether or not somebody needs spinal precautions.  So basically what I am trying to say is, it's better for the patient to be a bit uncomfortable than potentially paralyzed, unless that discomfort directly puts their airway in danger.

I'll bring this up in class next time I see the teacher to see what his thoughts are on it.


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## dewd09 (Oct 4, 2009)

Well, the correct name for the Scoop, is the Orthopedic Stretcher. Backboard with bigger holes.


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## rescue99 (Oct 4, 2009)

MrBrown said:


> No.
> 
> - She has no neck pain and no distracting injury
> - She remembers the fall and does not have a neuro deficit
> ...



We've cleared c-spine in the field for a number of years. Makes little sense to BB some patients, especially the frail oldsters. It just isn't beneficial and even harmful to BB some folks. A good assessment and CYA collar would have sufficed nicely for the patient in question.


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## Smash (Oct 5, 2009)

dewd09 said:


> :blink:
> 
> Must be a NZ thing, b/c I read all the EMS magazines and journals; and I've never been told that we don't need spine boards. I've been taught by the pioneers of EMS, and they are still firm on the belief that if one has a spinal fracture, you keep the head, arms, legs, and trunk firmly immobilized.



I've been taught by the pioneers of EMS too.  That's why I use rotating tourniquets in pulmonary edema, slap the MAST suit on anything that looks like it might have seen some trauma in the last week, pour 3 times the suspected blood volume lost of crystalloids into penetrating trauma patients, nasally intubate head injured patients... 

No but seriously, selective C-Spine clearance protocols are well established from good research and have been shown to be effectively applied by EMS staff.

The NLC has been shown to be effective in patients regardless of age.  CCR has already been mentioned.

Try reading the actual journals where research is published, rather than the trade mags.  Even the revered publication of JEMs needs to be read with much suspicion.  The recent Bledsoe article concerning the future (or lack of) intubation in EMS for example should ring very big alarm bells as to it's impartiality.


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## Simusid (Oct 9, 2009)

Thanks for all the great info in this thread.  It has been useful and interesting for me as a brand new EMT-B.

I'm going to see if we can investigate some patient comfort products for use with the longboard.   I know we'd have to consider BSI as well as whether or not it is in our protocols (Massachusetts).


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## JPINFV (Oct 9, 2009)

medichopeful said:


> I would.  If there is ANY chance of spinal injury, I believe it's better to immobilize.  Would you rather immobilize someone who didn't have a spinal injury or NOT immobilize someone who did?




I'd rather not immobilize someone who doesn't have it indicated and immobilize people who have it indicated in. The days of just plowing along and immobilizing everyone that might have a trauma injury is over. 

Oh, and quick question for the people who want to board every trauma patient. Did you board and collar yourself last time you tripped? Yea... thought so.


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## JPINFV (Oct 9, 2009)

Simusid said:


> Given the Pt age, frailty, potential MOI (stated she hit her head), and *need for transport (family wanted her checked)* I can see the need for caution.   I can see that we set the bar pretty low on board/collar usage.   My question is, would you have done the same?   For an elderly patient who has fallen from a standing position what is your criteria for not boarding for transport?



Did anyone ask what the patient wanted or check to see if there was any reason why the patient was incompetent?


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## Akulahawk (Oct 9, 2009)

Remember... mechanism of injury is a VERY poor predictor of actual presence of injury. Trauma isn't, however, all that random. If you know what the MOI is and you have a good grasp of biomechanics, it can very much tell you where to look to find injury. For instance, if you stub your left big toe, I'm not going to check your right pinkie finger for a fracture. I'm going to check your left big toe, 1st metatarsal and associated structures... and that's it.

Oh, and if the nice little old lady is mentally competent to refuse and she wants to refuse... Even if the family wants her checked out... she doesn't get transported except by her consent.


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## Jon (Oct 10, 2009)

Here's a question - is the Pt. on any blood thinners? Plavix? Coumadin?

Around here, blood thinners + fall with any form of trauma to head = trip to trauma center.

If I'm going to a trauma center with this patient, I'm probably more likely to board and collar than otherwise.

As was said - if there is no back or neck pain, Pt. has no neuro deficits, and is CAOx4 - I don't see a reason I need to board the patient.

If i do board the patient - then I'm going to be careful to pad all void spaces with towels/blankets for comfort.


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## Sasha (Oct 10, 2009)

This is an iffy one. On one side, you need to keep in mind that the elderly have decreased pain sensitivity and though she denies pain does not necessarily mean there is no injury. Also she may be frightened of the hospital or tired of it and trying to avoid another trip. 

However I would avoid spinal immoblization as it has not been proven to be effective and may in fact worsen the problem. Geriatric bones and skin are brittle and break easily and I think a much better method would be to allow the patient to lay on the stretcher in a position of comfort.


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## Melclin (Oct 10, 2009)

Sasha said:


> However I would avoid spinal immoblization as it has not been proven to be effective and may in fact worsen the problem. Geriatric bones and skin are brittle and break easily and I think a much better method would be to allow the patient to lay on the stretcher in a position of comfort.



Exactly. As I mentioned, I think there are quite a few situations where you don't necessarily suspect a spinal injury, but the pt still meets the criteria for immobilization, where simply having them lay still in a comfortable position is the best thing for them.


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## redcrossemt (Oct 13, 2009)

Jon said:


> If I'm going to a trauma center with this patient, I'm probably more likely to board and collar than otherwise.



Why's that?


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## redcrossemt (Oct 13, 2009)

This patient would not have met my protocol for full spinal immobilization. However, as posted in another thread, I am required by protocol to place a cervical collar due to the risk of occult cervical fractures in the elderly (65+ y/o is our protocol).


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## Fox800 (Oct 14, 2009)

This is an area of contention at my agency. We are to "rule-in" spinal immobilization for any of the following four reasons:
1. Spinal pain/tenderness, referred pain, or pain to the musculature supporting the spine
2. Distracting injury (this includes ANY skeletal fracture...meaning that isolated hip fractures are supposed to be boarded...whether this happens or not is another story, depends from crew to crew)
3. Awake/calm/cooperative/sober patient...they must also have been conscious throughout the entire injury. If they don't remember what happened, they are considered to be unreliable.
4. Neurologic deficit (new or old).

I would have my partner hold manual c-spine while I evaluated the pt.'s neck/back, mental status, and neurologic function/motor strength. If all of those check out, we can clear c-spine. Keep in mind we have to balance this with the increased potential for injury in the elderly.


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## EMT.Hart (Oct 31, 2009)

Yes. Fall, no matter what from or how high... We c-collar and back board. 

"err on the side of pt. care"  and I would rather over due than cause pt to be paralized.


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## Sasha (Nov 1, 2009)

EMT.Hart said:


> Yes. Fall, no matter what from or how high... We c-collar and back board.
> 
> "err on the side of pt. care"  and I would rather over due than cause pt to be paralized.



Backboarding is NOT a harmless procedure and when considering backboarding someone you must take that into consideration. If the patient is older, you have to consider how long they might be IN that position before they can be cleared at the ER. Where did they come from? Do they have decubitus ulcers you are going to make worse forcing them to be on their back for lengths of time like that? Are you going to create some pressure ulcers? Are you going to create a fracture due to the patient's osteoperosis while you're forcing them into  a rather unanatomically correct position? 

You would promote even less movement if you allowed them to lay in a position of comfort than you would on a backboard. Backboarding is not proven to be effective.

A scenario for you. We once had an elderly gentlemen at nursing home with a stage III ulcer on his coccyx with wound vac, and two stage II ulcers on his buttocks. Patient lays on his side to promote healing and because laying on his back causes him considerable pain. Somehow the patient managed on fall on the floor( There is a  major discrepancy on how the patient got to the floor. No one wants to take responsiblity for his fall.).

Knowing this patient has bedsores and that to lay him on his back will cause considerable pain, would you back board him? Don't you think a better option would be to allow the patient to lay in a position of comfort?


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## Agent_J (Nov 19, 2009)

Standing takedown does sound best in that situation. I'd still Collar her regardless of the lack of neck pain as a precaution. I wouldn't want her to lay down or anything like that because that might cause more injury or pain for her. 

Sounds like the right move.


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## medicp94dao (Nov 21, 2009)

Ok... i am not questioning your pt care by any means... I know you said pt denied LOC, Neck/back- pain/tendernes... But did you do a HANDS ON evaluatiuon? If not remeber the elderly may have a diminished sense of pain or even an increased sense of pain. They do not feel things the way you and I do. A hands on evaluation may be the deciding factor on how your treatment goes. Maybe, she didnt feel any neck pain at the time of interview but, she may have felt pain if you physically checked for injuries with your hands.... ---> DCAP-BTLS.

 What did she hit her head on? Concrete, wood, corner of table or did she hit it on carpet or mat on floor? This is a grey area... to immobilize or not to immobilize....

 How was she feeling prior to fall? was she dizzy or SOB? Or did she simply slip? There could have been a medical reason as to why she fell.

 If pt still denies any pain and is A&OX3 and has no visible or palbable injuries. Then no I wouldn't have c-collared and backboarded the pt. especially if she was against the idea... regardless of her families wishes.. just because she is older does not mean she isnt in charge of her own care. I know someone is going to bring up the fact that maybe her family is her medical POA.... That is only in the case if she can no longer competently make her owns decisions or if she is incapacitated.

If she was c/o pain from the backboard... was it properly padded? You dont have to have a fancy backboard pad... a few strategically placed towels will work fine.

 I tell my students "Sometimes the best treatment for your pt is no treatment at all!!".... 

Primum Non Nocere


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