# SNF Post fall



## NJEMT12 (Dec 1, 2012)

Hi everyone I am brand new to the forms and am looking for a bit of help. I have been a practicing EMT in NJ for 2 years now working both career and volunteer. I have noticed many people do things VERY different than others and that has brought me to my question for you guys...

You are dispatched to a SNF for post fall. Upon arrival 78 y/o female seated in a wheelchair. Facility aid relates witnessed fall >30 minutes ago. 

History: Dementia, HTN.  
Vitals: Baseline
Mental Status: Confused yet pt. baseline

Pt. denies LOC and relates no pain besides small skin tear on (L) arm.
Upon examination no bleeding, no bruising, no swelling.

The facilities policy is EVERY fall victim be taken to ED. 

Do you board and collar this Pt? The patient was obviously already moved by facility staff. What do you do?


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## Clare (Dec 1, 2012)

I am not sure what you mean by SNF? Like a rest home? For a patient with a simple mechanical fall with no evidence of cervical spine injury then no, no collar is required.

Although elderly patients may have a greater risk of injury from falls, be it from natural ageing or a pre-existing condition such as osteoperosis, this does not automatically mean they are treated any differently.

I've picked up plenty of oldies, dusted them off and sat them back in their chair or infront of the telly and let them carry on watching the soapies and none of them were any worse for wear for it.


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## NomadicMedic (Dec 1, 2012)

No board. No collar. 

In my case, probably a BLS transport, if at all. 

And Clare, in the states, an SNF is a "skilled nursing facility". A rest home.


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## DesertMedic66 (Dec 1, 2012)

Same as above. No board and no collar.


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## NJEMT12 (Dec 1, 2012)

Thank you for the advise. Is there any specific way you would document not taking spinal precautions?


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## NomadicMedic (Dec 1, 2012)

NJEMT12 said:


> Thank you for the advise. Is there any specific way you would document not taking spinal precautions?



Look at this from the other direction. How would you document that you would need to take spinal precautions?

And here's a hint, saying simply "she fell" ain't going to cut it.  Unless of course, your county or service does not have any selective spinal immobilization protocol and everyone regardless of complaints who suffered a "fall" needs to be boarded… In that case, you're just out of luck.


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## VFlutter (Dec 1, 2012)

SNF = Skilled Nursing Facility. The abbreviation is pronounced "Sniff". Basically a nursing home that is certified to bill Medicare.


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## Sublime (Dec 1, 2012)

NJEMT12 said:


> Thank you for the advise. Is there any specific way you would document not taking spinal precautions?



Does the pt. complain of neck or back pain that started after the fall? Is there a significant head injury that could have caused cervical trauma as well? If not then why put your patient in further discomfort by placing them in full spinal restriction?

Just document it how was a witnessed fall with no loc, and add in there something like "pt. denies neck or back pain" and "pt. ambulatory on arrival". 

If someone is able to get up after a fall and has no cervical or back pain then do you really think you need to strap them to a board and collar them? Seems to me like if there was significant enough trauma to cause a fracture in the spinal area there would be some pain involved also.


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## DrParasite (Dec 1, 2012)

post 30 minutes?  transport her in position of comfort to ER for evaluation.  no need for board and collar.  If you get flagged by QA, ask them to explain why you would need to board and collar her.


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## 46Young (Dec 2, 2012)

n7lxi said:


> Look at this from the other direction. How would you document that you would need to take spinal precautions?
> 
> And here's a hint, saying simply "she fell" ain't going to cut it.  Unless of course, your county or service does not have any selective spinal immobilization protocol and everyone regardless of complaints who suffered a "fall" needs to be boarded… In that case, you're just out of luck.



The problem is, many services are litigation-phobic, so any fall gets SMR (spinal motion restriction) unless the pt refuses. The OP could get dinged by QA saying that the pt is elderly and may have osteoporosis or can otherwise easily fracture. The OP wants to know how to explain not doing the board and collar. I would document that the pt would not tolerate SMR due to increased pain and discomfort and anatomical reasons, or perhaps orthopnea/anxiety when being placed supine if applicable. Perhaps describing the fall as a weak collapse will work, or that the pt partially broke their fall with an outstretched arm or slowly rolled out of the chair and landed with minimal force.


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## 46Young (Dec 2, 2012)

DrParasite said:


> post 30 minutes?  transport her in position of comfort to ER for evaluation.  no need for board and collar.  If you get flagged by QA, ask them to explain why you would need to board and collar her.



When I worked for NS-LIJ, they wanted SMR unless it was > 24 hrs. They were very litigation phobic.


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## leoemt (Dec 2, 2012)

NJEMT12 said:


> Hi everyone I am brand new to the forms and am looking for a bit of help. I have been a practicing EMT in NJ for 2 years now working both career and volunteer. I have noticed many people do things VERY different than others and that has brought me to my question for you guys...
> 
> You are dispatched to a SNF for post fall. Upon arrival 78 y/o female seated in a wheelchair. Facility aid relates witnessed fall >30 minutes ago.
> 
> ...



Are the witnesses reliable? If they are reliable then no I am not going to backboard.


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## TheLocalMedic (Dec 3, 2012)

Just to throw this out there...  I HATE putting patients on long boards.  Unless I really really think it's necessary I just won't do it.  Especially with the elderly, it's painful and often unnecessary and their skin breaks down so darn fast from laying on a board.  

As an alternative to going on a board I'll often use a KED type device.  This works great for those calls where you think "I might want to put them in c-spine as a precaution due to mechanism".  It does a good job of immobilizing the c-spine and is much more comfortable than a board and allows a patient to sit up.  

For those *_sniff sniff_* SNF calls where they hit the deck unwitnessed and can't tell you what's up due to dementia and they hurt "all over" (but maybe they're always saying that, the CNA suggests) I go with a KED.


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## hogwiley (Dec 4, 2012)

I think it would be beneficial to hear some examples of EMTs and Medics NOT spineboarding someone when it turned out they SHOULD have. You hear so many examples of people being spineboarded when they probably didnt need to be, but maybe it would help to hear examples of when it SHOULD have been done and wasnt. That would go some way in helping people determine when its really needed. 

I think that would probably be a good thread, if it hasnt already been done.


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## Meursault (Dec 4, 2012)

funtimes said:


> I think it would be beneficial to hear some examples of EMTs and Medics NOT spineboarding someone when it turned out they SHOULD have. You hear so many examples of people being spineboarded when they probably didnt need to be, but maybe it would help to hear examples of when it SHOULD have been done and wasnt. That would go some way in helping people determine when its really needed.
> 
> I think that would probably be a good thread, if it hasnt already been done.



Oh, yes, what we need are more anecdotes, but in the other direction.


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## Veneficus (Dec 4, 2012)

n7lxi said:


> No board. No collar.
> 
> In my case, probably a BLS transport, if at all.
> 
> And Clare, in the states, an SNF is a "skilled nursing facility". A rest home.



Despite the fact they are neither skilled nor practice nursing. 

I prefer to think of it as death's waiting room.


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## Veneficus (Dec 4, 2012)

funtimes said:


> I think it would be beneficial to hear some examples of EMTs and Medics NOT spineboarding someone when it turned out they SHOULD have. You hear so many examples of people being spineboarded when they probably didnt need to be, but maybe it would help to hear examples of when it SHOULD have been done and wasnt. That would go some way in helping people determine when its really needed.
> 
> I think that would probably be a good thread, if it hasnt already been done.



The problem is that there may never be a time when people "should be" and that is becomming more apparent.


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## Aidey (Dec 4, 2012)

I did some research a while back on lawsuits involving spine boards. I don't think I found any when the patient wasn't backboarded. It seemed like all the cases were people who were backboarded and still had injuries/died.


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## Jon (Dec 4, 2012)

Veneficus said:


> Despite the fact they are neither skilled nor practice nursing.
> 
> I prefer to think of it as death's waiting room.



No, they practice nursing.

One of these days one of them may actually get it right!


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## Jon (Dec 4, 2012)

46Young said:


> When I worked for NS-LIJ, they wanted SMR unless it was > 24 hrs. They were very litigation phobic.



For those that talk of litigation phobia - what about the possibility of skin breakdown and further complications from being strapped to a hard board?


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## TheLocalMedic (Dec 4, 2012)

Jon said:


> For those that talk of litigation phobia - what about the possibility of skin breakdown and further complications from being strapped to a hard board?



^Right on!  One of my biggest gripes, not to mention that it's really uncomfortable!  I've ridden on a backboard after I had a snowmobile accident and broke my knee.  Turns out I didn't have any spinal injury, but by the time I got to the hospital my back was hurting worse than my knee was!  

That's again why I often prefer the KED to a long board.  More comfortable, allows you to sit up, and great for those times where you feel like you "have to" immobilize someone due to mechanism.


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## casarojo (Dec 9, 2012)

Sorry, but I have three questions (I am new to the field):

1. The OP says the "pt. denied LOC." Does he/she mean Loss of consciousness? I am only familiar with ALOC and interpret LOC as level of conc. 

2. Why does going on a backboard have to do with skin breakdown with the elderly? Is it from their skin rubbing against the spyder straps of the backboard and their more sensitive skin?

3. The OP says VS were "baseline." Does that basically mean stable? I am under the impression that baseline means the first set taken, not the quality of the VS. 

Sorry for such basic questions. I've only been out in the field for a few weeks, so I'm trying to learn as much as possible


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## Clare (Dec 9, 2012)

LOC generally means level or loss of consciousness however it is good practice (or so I am told) to write "patient responds to voice" (as an example) for level of consciousness or "denies loss of consciousness" in full words.

"Baseline" as you say, means the set against which all others are trended, so to say "vitals are baseline" is confusing and poor practice I think; which vitals? what is baseline? you don't know do you?


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## TheLocalMedic (Dec 10, 2012)

The skin breakdown is caused by them laying on the hard surface unable to shift or reposition themselves.  The pressure on their skin, which is generally weaker and has less fat cushioning causes ulceration.


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