# Flying a fall Victim



## CPRinProgress (Aug 18, 2013)

I recently went a on a call for a 60 y/o male that fell down the stairs.  We are a bls squad and als and a helicopter were also dispatched.  When we got there the pt was intoxicated but his speech was not slurred and I couldn't smell it on his breath .  We did a rapid trauma and he didn't complain of any pain.  We ended up canceling medics and the helicopter.  We back boarded and brought him to the local hospital.  A couple days later we found out that he had broken a vertebrae in his neck and back and that the local hospital had flown him to a trauma center.  
My question is should we have flown him or driven him to the trauma center even though he didn't complain but solely on the mechanism?  Vitals were normal and pupils were PEARRL.  Did we do the right thing.


----------



## NomadicMedic (Aug 18, 2013)

As long as you're confident in your assessment skills, and you can verify that you did a thorough assessment and the patient didn't complain of any pain, it seems like you did the right thing to me. 

Until they start putting imaging devices on ambulances and training EMTs to use them, this type of triage will continue to happen.  

Patient falls down, patient doesn't hurt, patient was transported to hospital. Hospital discovers injury not immediately evident, hospital transports patient to specialized care facility. That's the way it's supposed to work.


----------



## ZombieEMT (Aug 18, 2013)

CPRinProgress said:


> I recently went a on a call for a 60 y/o male that fell down the stairs.  We are a bls squad and als and a helicopter were also dispatched.  *When we got there the pt was intoxicated *but his speech was not slurred and I couldn't smell it on his breath .  We did a rapid trauma and he didn't complain of any pain.  We ended up canceling medics and the helicopter.  We back boarded and brought him to the local hospital.  A couple days later we found out that he had broken a vertebrae in his neck and back and that the local hospital had flown him to a trauma center.
> My question is should we have flown him or driven him to the trauma center even though he didn't complain but solely on the mechanism?  Vitals were normal and pupils were PEARRL.  Did we do the right thing.



In my opinion this patient should have at least received and ALS assessment and trauma center if assessed to be serious enough. You state the patient was intoxicated, which means his pain threshold can be different and he might have hidden injury that due to alcohol he was not feeling. Can I ask, did he admit to alcohol, or it was assumed? Also, the mechanism alone is enough to at least warrant the ALS assessment.


----------



## CPRinProgress (Aug 18, 2013)

The only thing was he was drunk and he had a small laceration to his head.  But he said he only fell from a couple steps up.  Even if he did fall from the top'it was only 10 ft and significant mechanism is 15 ft so that was out thinking.


----------



## CPRinProgress (Aug 18, 2013)

HaleEMT said:


> In my opinion this patient should have at least received and ALS assessment and trauma center if assessed to be serious enough. You state the patient was intoxicated, which means his pain threshold can be different and he might have hidden injury that due to alcohol he was not feeling. Can I ask, did he admit to alcohol, or it was assumed? Also, the mechanism alone is enough to at least warrant the ALS assessment.



I agree that we should have let the medics come in but I talked to a paramedic and he said they might not have been able to detect the fractures.  I also agree that we should have went to the trauma center.  His wife said he was drunk but i can't remember if he admitted it himself.  Originally he didn't even want to go but his wife made him so I think that affected our decision, although it probably shouldn't have.


----------



## ZombieEMT (Aug 18, 2013)

Ok thanks for the additional info. By the way you worded the OP I thought you were refering to an entire flight of steps vs just several steps at minimal height. I think there are other factors that should play into the consideration of ALS/Helicopter. For example, what surface did he land on? Is the patient on blood thiners? Did the patient hit his head or lose consciousness? How intoxicated is "intoxicated', does the patient have an altered mental status? Other medical conditions.

Not saying necessary wrong but more to the story. Like previously said, we do not have an xray machine on hand and can not do anything to be for sure in the field, ALS or not.


----------



## CPRinProgress (Aug 18, 2013)

HaleEMT said:


> Ok thanks for the additional info. By the way you worded the OP I thought you were refering to an entire flight of steps vs just several steps at minimal height. I think there are other factors that should play into the consideration of ALS/Helicopter. For example, what surface did he land on? Is the patient on blood thiners? Did the patient hit his head or lose consciousness? How intoxicated is "intoxicated', does the patient have an altered mental status? Other medical conditions.
> 
> Not saying necessary wrong but more to the story. Like previously said, we do not have an xray machine on hand and can not do anything to be for sure in the field, ALS or not.



Well we don't exactly know how far he fell. Sorry about the confusion.  He said he was almost at the bottom but the wife said she heard him fall pretty far but she could have been exaggerating.  He had a history of a brain bleed after a fall but it was 10 years ago. he was allergic to coedine.  The wife stated he was intoxicated but I didn't smell any thing and his speech wasn't slurred.  He was aox4. No loc. He landed on a carpeted floor.  he was sitting up when we got there


----------



## NomadicMedic (Aug 18, 2013)

This is one of those scenarios that everyone can over-think And get Monday morning quarterbacked to death. From the scenario that the OP posted, the patient is conscious, alert and oriented. He tripped and fell a couple of steps onto a carpeted floor. Not complaining of pain. Doesn't have any distracting injuries. Sitting up, and probably got up and walked around? He admitted to alcohol, but that's it. Put them on a backboard, put a collar around his neck and take him to the hospital.

If I were the paramedic, after assessing him, taking a set of vitals and ascertaining he wasn't altered in any way and wasn't taking any medications that would cause me to think he might have some issues (like Coumadin) I would send him BLS

Is a paramedic going to palpate his neck or spine any differently than an EMT is? Were his vital signs stable? How long was the transport to the hospital? Do you frequently transport BLS patients from motor vehicle accidents complaining of neck or back pain without a paramedic?

I mean, really guys. At some point we have to let BLS patient be BLS patients.


----------



## DesertMedic66 (Aug 18, 2013)

DEmedic said:


> This is one of those scenarios that everyone can over-think And get Monday morning quarterbacked to death. From the scenario that the OP posted, the patient is conscious, alert and oriented. He tripped and fell a couple of steps onto a carpeted floor. Not complaining of pain. Doesn't have any distracting injuries. Sitting up, and probably got up and walked around? He admitted to alcohol, but that's it. Put them on a backboard, put a collar around his neck and take him to the hospital.
> 
> If I were the paramedic, after assessing him, taking a set of vitals and ascertaining he wasn't altered in any way and wasn't taking any medications that would cause me to think he might have some issues (like Coumadin) I would send him BLS
> 
> ...



This is what I was thinking. I was just too lazy to type it all out lol. ALS isn't going to do anything for this patient that BLS can not do.


----------



## CPRinProgress (Aug 18, 2013)

Transport time to closest hospital is 10 minutes and to the trauma center it is 40.  We transport most trauma bls.  Medics come along when there is loc  or ams and life threatening injuries but if the injuries are that bad we usually fly.  We very rarely transport with medics all the way to the trauma center.


----------



## DesertMedic66 (Aug 18, 2013)

CPRinProgress said:


> Transport time to closest hospital is 10 minutes and to the trauma center it is 40.  We transport most trauma bls.  Medics come along when there is loc  or ams and life threatening injuries but if the injuries are that bad we usually fly.  We very rarely transport with medics all the way to the trauma center.



In all honesty, as an EMT if I responded to call, I would have done the assessment followed by backboarding followed by a nice smooth ride to the closest hospital.


----------



## CPRinProgress (Aug 18, 2013)

DesertEMT66 said:


> In all honesty, as an EMT if I responded to call, I would have done the assessment followed by backboarding followed by a nice smooth ride to the closest hospital.



That's exactly what we did.  Some people said we should've flown him but I don't think that would have helped him to much a couple broken vertebra are not very time sensitive.


----------



## CPRinProgress (Aug 18, 2013)

DesertEMT66 said:


> In all honesty, as an EMT if I responded to call, I would have done the assessment followed by backboarding followed by a nice smooth ride to the closest hospital.



That's exactly what we did.  Some people said we should've flown him but I don't think that would have helped him to much a couple broken vertebra are not very time sensitive.  Plus, if he didn't have a broken back, we would have been under fire about why we flew for no reason.


----------



## DrParasite (Aug 19, 2013)

There are 9 helicopters in NJ... just fly him, got to justify their existance.

What would the paramedics have done that you wouldn't have?  even if he had the fx.... good call cancelling them.

depending on how far the trauma center is, I might have made the drive (dependng on how far and my mood at the time), but I'll be honest, I probably would have done the exact same thing you did.


----------



## CPRinProgress (Aug 19, 2013)

DrParasite said:


> There are 9 helicopters in NJ... just fly him, got to justify their existance.
> 
> What would the paramedics have done that you wouldn't have?  even if he had the fx.... good call cancelling them.
> 
> depending on how far the trauma center is, I might have made the drive (dependng on how far and my mood at the time), but I'll be honest, I probably would have done the exact same thing you did.


We use Atlantic.  We probably should have at least drove to the trauma center but it was kind of late and we were tired.


----------



## Rialaigh (Aug 19, 2013)

No need for medics, no need for chopper.

Lets say you got on scene and knew (somehow) that he had a fractured back and everything else is the same....still

No need for medics, no need for chopper. 


what is a medic or a chopper going to do for this patient that you can't (Even knowing about the fracture). Other then a smoother ride in a chopper (maybe) making transport marginally faster does nothing for this guy. 

I take him to the closest hospital not knowing, every time.


----------



## gw812 (Aug 27, 2013)

If you palpated back/neck and he didn't go 'ow' and you didn't see deformity/stair stepping you had no reason to suspect a fracture. Trauma center not indicated, unless you wanna rethink the fall height since nobody will give you a clear story, but I dunno if I would have even done that. Transport BLS, enjoy a Mountain Dew afterwards.


----------



## mycrofft (Aug 27, 2013)

"People said", "his wife said"...a new category of "SUBJECTIVE is needed "Bystander Subjective".

Good replies up there!

Never presume someone is "intoxicated" as in drunk; intracranial injury, diabetic ketoacidosis,  atypical baseline presentation (status post brain injury recovery, multiple sclerosis, etc), other toxins, or just plain being a jackass can all present like that.


----------



## Rockies (Sep 20, 2013)

Intoxication could be mistaken for DKA, so helicopter was not a bad call.


----------



## NomadicMedic (Sep 20, 2013)

Rockies said:


> Intoxication could be mistaken for DKA, so helicopter was not a bad call.



Oh, c'mon. Seriously?


----------



## Aidey (Sep 20, 2013)

Rockies said:


> Intoxication could be mistaken for DKA, so helicopter was not a bad call.



And what good is a helicopter going to be for DKA?


----------



## DesertMedic66 (Sep 20, 2013)

DEmedic said:


> Oh, c'mon. Seriously?



Zebras?


----------



## DrankTheKoolaid (Sep 20, 2013)

*re*

If there was no spinal tract tenderness to palpation and no neuro deficits there would have been no reason to even backboard this patient. 

Over the years I have come across many many patients who complain of spinal tenderness to palpation and maybe 0.5% actually had an injury.

On the other hand, I have never encountered a spinal injury that was not tender to palpation. 

And what's with your EMD process that launched a Helicopter with a hospital 10 minutes from the residence.  It takes 10 minutes just to round the crew up and get airborn in most cases unless they happen to be on the pad or already in the air. (actually I guess you cant fault the EMD process for whatever code response it came up with, Garbage in and garbage out and if the caller said the wrong things they are just following protocols)

And by the time the flight crew arrived at scene and shut down and took over the patient (remember hot loading is not the safest practice and is frowned upon in most air services, unless a truly time sensitive patient) which they would have ruled out during your report to them while they were en route to you.  They would then have to restart the helo which also takes time.  The patient would have been in the skilled hands of a ED doc with lab/Xray/CT etc etc long before the bird could have arrived and left with the packaged patient by grounding this seemingly uninjured patient, by your OP account.  

You made the right call.


----------



## unleashedfury (Sep 27, 2013)

You did everything correct in my book, I would have did the same thing. the patient didn't complain of any pain during your assessment. he landed on carpeted stairs and was hemodynamically, neurologically stable upon assessment. 

I'm not a strong believer in aeromedical based on mechanism of injury. There have been horrific motor vehicle accidents with pts who rolled their car 2 or 3 times with intrusion and walked away, where people who have struck a small tree at a slow speed have serious injuries. 

I have a trauma center less than an hour away on a good day. so if I really wanted to I could ground pound it to a trauma center. Based on the situation you described I would have taken him local to find out he has a fracture in the vertebrae. If the ED team gave you grief. I'd say well if he offered no complaints of pain, and had no noted deformity what would you do. When a portable xray becomes part of my assessment then we'll make that call.


----------



## CentralCalEMT (Sep 27, 2013)

I agree with most of the posters here. You made the correct call. Until they start giving EMS Xray vision, these types of things will happen rarely. Assuming the patient is alert, has no neuro deficits, and no indication of a fracture, then you made the right call. Did you find out how bad the fracture was anyway? It's possible it was just a hairline fracture. 

Also, if we used helicopters for every patient like this, then the helicopter would not be available for more serious calls. If I had flown a patient out presenting like that in my system, it's possible I would get a QI flag and have to explain myself.


----------

