# fall scenario



## gposs71 (Jan 5, 2011)

partner an I got called for 69 year old female. Fall from standing height- no LOC...  Pt alert and AxO x4 on arrival- Family left her in position.  Pt also had 3 broken ribs from previous fall a few days earlier- vitals stable- only complaint was a little pain on back of head- Upon exam- No swelling/bleeding- negative neck/back pain- no complaint really.

 My partner suggested full board/collar but I was leaning toward Reeves given her rib pain and inability to roll pt.  Pt also had no neck to speak of so I thought this would have been a huge painful challenge... again- no complaint of any neck/back pain or tingling. just a bump on the head-(which was really nothing)- Pt appeared to be more comfortable on the reeves with some padding for ribs.... transported with no real issues- Thoughts on full immobilization vs not?


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## NomadicMedic (Jan 5, 2011)

I don't c-spine patients if the following conditions are met. 

&bull;Patient is CAOx3. 
&bull;Patient is not under the influence of drugs or alcohol. 
&bull;Patient has no complaints of neck pain. 
&bull;Patient had no complaints of arm or leg numbness. 
&bull;Exam reveals no px or tenderness. 
&bull;There is no distracting injury. 

Did your patient meet all these criteria? If yes, then no c-spine in indicated.


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## jjesusfreak01 (Jan 5, 2011)

Following n7lxi's post, do you not have a spinal immobilization clearance in your protocols, because this is pretty much ours too?


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## MrBrown (Jan 6, 2011)

Nah Brown would probably leave her at home .... or may consider taking her round to the GP to get a referral to the falls team it sounds like she has fallen twice in the last few days which is concerning.


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## Akulahawk (Jan 6, 2011)

Allowed full use of what I know? After evaluating her and finding nothing notable except for the rib pain from previous (and no changes with that), I'd probably have left the patient at home, with family and instructions to see her PCP soon, as well as instructions with family about what to look for in the event that she ends up having a cranial bleed of some sort.

I'm more concerned with her history of falls recently... she's at risk for more. Lots more. She'll probably need a walker and proper training how to use one to prevent falls. At this point, if she was stubborn about using her walker after the first fall, perhaps she's now more amenable to using it all the time.

Under current protocol, transport would be expected, however she could refuse care... and if I transported, I'd have probably had to immobilize. somehow.

It would have been a pain for me and for her.


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## Melclin (Jan 6, 2011)

+2 on leaving her at home + GP/falls team if available. 

Immediately adjust her environment too. Rugs are a common trip hazard in old people's houses. It takes very little effort to role up a rug and put it in a spare room. Not quite the life saving procedures you imagine when starting a paramedic degree granted, but its a bloody easy way to potentially save a life. 

A quick eye exam too. Namely visual acuity and visual fields. These things slip away easily in the olds without them noticing from things like macula degeneration. Low vision is a leading cause of falls in the elderly and falls are a notable cause of injury and health care expenditure. 

I'm considering the use of amsler grids and snellen charts in pts like this if I could stand the laughter of my partner when I pull them out.


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## clibb (Jan 6, 2011)

gposs71 said:


> partner an I got called for 69 year old female. Fall from standing height- no LOC...  Pt alert and AxO x4 on arrival- Family left her in position.  Pt also had 3 broken ribs from previous fall a few days earlier- vitals stable- only complaint was a little pain on back of head- Upon exam- No swelling/bleeding- negative neck/back pain- no complaint really.
> 
> My partner suggested full board/collar but I was leaning toward Reeves given her rib pain and inability to roll pt.  Pt also had no neck to speak of so I thought this would have been a huge painful challenge... again- no complaint of any neck/back pain or tingling. just a bump on the head-(which was really nothing)- Pt appeared to be more comfortable on the reeves with some padding for ribs.... transported with no real issues- Thoughts on full immobilization vs not?



First off do a complete evaluation. Why did she fall? From a seizure? All the sudden some numbness in a leg and she couldn't stand? Did she slip? What does the scene look like? Why did she fall the previous day? What medications is she on? Diabetic?

Patient is AAO x4? No ETOH on board? Didn't LOC. No numbness or tingling sensation anywhere? Was the pain from the previous fall or from the one present? Any bleeding from the head? Just some pain on the back of the head, nothing on the spine while palping it?
Question is; does the patient want to go to the hospital? If not, have her sign a refusal and tell her to call back if anything changes. Then you're on your way. 
No reason to c-spine this patient. You just c-spine cleared her according to my protocols.


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## boingo (Jan 6, 2011)

She fell a few days ago and fx several ribs, when was the last time you fell and did that?  I would be careful about blowing off the head pain and fall and getting a refusal.  She clearly breaks easily, and assuming her last fall was from a standing position I would NOT clear her C spine in the field.  This patient should be transported IMHO.


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## abckidsmom (Jan 6, 2011)

MrBrown said:


> Nah Brown would probably leave her at home .... or may consider taking her round to the GP to get a referral to the falls team it sounds like she has fallen twice in the last few days which is concerning.




If you took her to the GP, would you be waiting and bringing her home, too?

ITA with the PCP angle, but I worry about a 70 yo lady with two falls in a week and rib fxs.  The infection risk is high, the fall risk is high, and why the sudden change in her mobility?  70 is young-old, not terribly old, and I would be highly suspicious of underlying CVA/TIA or other neuro involvement.

Don't think I'd immobilize her, but I'd probably want her to go to the ER, to have a full workup.  Next week's falls can go to the PCP.


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## clibb (Jan 6, 2011)

boingo said:


> She fell a few days ago and fx several ribs, when was the last time you fell and did that?  I would be careful about blowing off the head pain and fall and getting a refusal.  She clearly breaks easily, and assuming her last fall was from a standing position I would NOT clear her C spine in the field.  This patient should be transported IMHO.



If she's AOX x4, no LOC, no nausea or vertigo, and she has no numbness or tingling sensation anywhere; she's c-spine cleared according to my protocols. If she broke her C1 and C2, she wouldn't be breathing or responsive. She might have a hematoma on her head, but who hasn't had in their lives? If she starts feeling nauseous she needs to call back. But she does not need a $800 ambulance bill for this case.


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## boingo (Jan 6, 2011)

You don't need to have neuro deficits w/c-spine fx.  I'm not suggesting she has a cord injury, what I am suggesting is she has had a 2nd fall in less than a week, the last resulted in multiple rib fx, having a non displaced fx of her cervical spine is not unlikely.  She also had a head strike, any chance she fx her skull?  Old lady, osteoporosis, natural decrease in brain mass gives her an above average chance of subdural hematoma.  

3 weeks ago I had a lady, fall from standing on to her face, called almost 48 hrs later.  She complained of face and head pain, no neuro deficits.  She had a small subdural and non displaced fx of c2 and c3.  Leaving her at home would have been a bad idea.


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## clibb (Jan 7, 2011)

boingo said:


> , osteoporosis,   .



I didn't see anything about that in his topic. Now if she had Osteoporosis, it would be a whole other story. She would be c-spined and taken to the hospital on a backboard.


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## vquintessence (Jan 7, 2011)

clibb said:


> I didn't see anything about that in his topic. Now if she had Osteoporosis, it would be a whole other story. She would be c-spined and taken to the hospital on a backboard.



Heh, I'd lean more towards the assumption of her having it than not, given the some sources spout a prevalence of 30%-40% geriatric women having the disease within the US.  (before anybody goes ballistic... see the reference below).

Given my gross assumption, it doesn't necessarily mean I'd prefer to backboard her however.  The OP was more of a quick run down than a full narration to make any determinant judgement.

(Melton III LJ, Chrischilles EA, Cooper C, Lane AW, Riggs BL: Perspective: How many women have osteoporosis?)


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## Veneficus (Jan 7, 2011)

clibb said:


> I didn't see anything about that in his topic. Now if she had Osteoporosis, it would be a whole other story. She would be c-spined and taken to the hospital on a backboard.



Because of the physio of aging, she does have osteoporosis. The only question is how advanced or well managed.


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## Mile High Medic (Feb 9, 2011)

I have only been a medic for three years so maybe that is the cause for my trepidation.  I don't understand any reason to put a c-spine clearing criteria into protocols.  I backboard and c-collar anybody with mechanism regardless of pain.  Now for your pt I would have used a scoop to avoid rolling and towel rolls, a pillow or even a cut up blanket.  I have even transported kyphotic pt's with there head taped to my stretcher with towel rolls.  The hospitals have better collars that can fit pt's with no necks.  My question that no one seemed to address is what if the rib pain which is extremely painful was hiding any neck or back pain?  Until medics can carry malpractice insurance I wouldn't risk it.  As a lifeguard I saw a kid break his neck diving into the water from a 1.5 meter board.  He didn't have any pain just heard a pop.  My point is he hit the water awkwardly and broke his neck.  He had no further injury because my guards boarded him but I wouldn't want to be the medic on the one call that was the exception to the rule.  Plus you would get destroyed in court.  Which is better, an $800 bill that can be written off or even reduced, or being paralyzed for the rest of your life?


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## Melclin (Feb 10, 2011)

Mile High Medic said:


> I have only been a medic for three years so maybe that is the cause for my trepidation.  I don't understand any reason to put a c-spine clearing criteria into protocols.  I backboard and c-collar anybody with mechanism regardless of pain.  Now for your pt I would have used a scoop to avoid rolling and towel rolls, a pillow or even a cut up blanket.  I have even transported kyphotic pt's with there head taped to my stretcher with towel rolls.  The hospitals have better collars that can fit pt's with no necks.  My question that no one seemed to address is what if the rib pain which is extremely painful was hiding any neck or back pain?  Until medics can carry malpractice insurance I wouldn't risk it.  As a lifeguard I saw a kid break his neck diving into the water from a 1.5 meter board.  He didn't have any pain just heard a pop.  My point is he hit the water awkwardly and broke his neck.  He had no further injury because my guards boarded him but I wouldn't want to be the medic on the one call that was the exception to the rule.  Plus you would get destroyed in court.  Which is better, an $800 bill that can be written off or even reduced, or being paralyzed for the rest of your life?



1,2 are just two papers discussing the fact that mechanism has almost not worth in predicting occult injury in general.

From (3): 





> The current practice of immobilising trauma patients before hospitalisation to prevent more damage may not always be necessary, as the likelihood of further damage is small. Means of immobilisation include holding the head in the midline, log rolling the person, the use of backboards and special mattresses, cervical collars, sandbags and straps. These can cause tissue pressure and discomfort, difficulty in swallowing and serious breathing problems.
> 
> The review authors could not find any randomised controlled trials of spinal immobilisation strategies in trauma patients. It is feasible to have trials comparing the different spinal immobilisation strategies. From studies of healthy volunteers it has been suggested that patients who are conscious, might reposition themselves to relieve the discomfort caused by immobilisation, which could theoretically worsen any existing spinal injuries.



(4) Is one example of the mistake free application of C-spine clearance.


From (5):


> Comparison of spine injury patients from 2 study populations, one with out-of-hospital spinal immobilization and the other without, showed a higher rate of neurologic injury in the immobilized group. Acute spinal immobilization may not have significant benefit for the prevention of neurologic deterioration from unstable spinal fractures.


So:
-We have decent tools (NEXUS and CCR) to inform the hx taking and physical exam. 
-The evidence clearly exists that they as well as other clinical indicators are quite safe to use.
-There is no evidence to support the use of spinal immobilisation.
-There is some evidence that it may in fact cause more harm than good, especially when misused as it often is.  
-Spinally immobilising if nothing else causes pain, anxiety and discomfort as well as costing the system quite a bit extra.

So tell me again why you're immobilising everyone who crosses your path based on mechanism?

A few other points:
-You cannot possibly know that the kids immobilisation is what prevented further injury. To suggest it as fact is absurd. 
-Aren't you covered by your covered by your agency/medical director in terms of insurance?
-The fear of being sued, often evident on this board, seems dramatically disproportionate with the actual likelihood of being sued. On top of that them winning is a whole other board game, so I'd like to think that providers wouldn't practice in some archaic and probably harmful way based on some silly fear of lawyers. 

(1)Boyle MJ, Smith EC, Archer F. Is mechanism of injury alone a useful predictor of major trauma? Injury. 2008;39(9):986-92.

(2)Domeier RM, Evans RW, Swor RA, Hancock JB, Fales W, Krohmer J, Frederiksen SM Shork MA. The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury. Prehospital Emergency Care. 1999;3(4): 332-337. 

(3)Kwan I, Bunn F, Roberts IG. Spinal immobilisation for trauma patients. Cochrane Database of Systematic Reviews 2001, Issue
2. Art. No.: CD002803. DOI: 10.1002/14651858.CD002803.

(4)Armstrong BP, Simpson HK, Crouch R, Deakin CD. Prehospital clearance of the cervical spine: does it need to be a pain in the neck? Emergency Medicine Journal. 2007;24(7):501-3.

(5)Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Academic Emergency Medicine. 1998 ;5(3):214-9.


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## Mile High Medic (Feb 10, 2011)

I think there are valid points either way.  But if done correctly c-spine doesn't cause further injury.  My point is better to cya.   It does take a lot to prove neglect but in the states if you screw up and your in the private sector your agency will cut all ties.  They claim that they will help you but the reality is there lawyers will help them not you.   There are many ways to comfortably protect c-spine I just don't see why we shouldn't err on the side of caution.


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## Aidey (Feb 10, 2011)

Mile High Medic said:


> ...But if done correctly c-spine doesn't cause further injury.



Absolutely false when talking about the use of a c-collar and long spine board. I'm not going to quote a ton of studies because all the information is available here if you search through other threads on the topic. C-collars have been shown to increase ICP when properly applied, and LSBs cause pressure points which leads to tissue breakdown.


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## Mile High Medic (Feb 10, 2011)

I have never heard of that effect on ICP but you can use towel rolls and a stretcher that will protect c-spine.  I will check out the study but 10 minutes immobilized shouldn't cause harm.  Studies are also relative.  There are many studies that support the atkin's and south beach diet. MD's and PhD's sY it works but any one with a kinesiology degree are any health field degree can tell you those diets offer false positive results.  You have to know statistics, how to read and understand if a study and its results are significant and whether the journal is a credible journal.  I am not saying it isn't and I will check it out but too many take a study as gospel.  Just because it is in a journal take it with a grain of salt.  Ultimately use your judgement.  My only point is trauma can be present w/o pain or deficits.  If further injury occurrs it's your but on the line.


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## Veneficus (Feb 10, 2011)

Aidey said:


> Absolutely false when talking about the use of a c-collar and long spine board. I'm not going to quote a ton of studies because all the information is available here if you search through other threads on the topic. C-collars have been shown to increase ICP when properly applied, and LSBs cause pressure points which leads to tissue breakdown.



and restrict ventilation.


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## reaper (Feb 10, 2011)

Mile High Medic said:


> I think there are valid points either way.  But if done correctly c-spine doesn't cause further injury.  My point is better to cya.   It does take a lot to prove neglect but in the states if you screw up and your in the private sector your agency will cut all ties.  They claim that they will help you but the reality is there lawyers will help them not you.   There are many ways to comfortably protect c-spine I just don't see why we shouldn't err on the side of caution.



I feel sorry for you, if you are going to have a career of CYA! These are not random studies. They have been proven over and over in multiple studies. NEXUS is used by almost every progressive service that wants medicine, not just cover our butts in court.

If you practice medicine with the most up to date information. You will never be successfuly sued for negligance. I know that you are new enough to be one that got caught in the scare tactics of ill informed instructors. Lawsuits are not common place in EMS. As long as you do your job and provide care to the set standard, you will not have to worry.

Immobilzation is not a new argument. These studies have been out for years. You need to push your system to catch up to 20th century medicine. You can not practice the "way it's always been" medcine forever.


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## usalsfyre (Feb 10, 2011)

Mile High Medic said:


> I have never heard of that effect on ICP but you can use towel rolls and a stretcher that will protect c-spine.  I will check out the study but 10 minutes immobilized shouldn't cause harm.  Studies are also relative.  There are many studies that support the atkin's and south beach diet. MD's and PhD's sY it works but any one with a kinesiology degree are any health field degree can tell you those diets offer false positive results.  You have to know statistics, how to read and understand if a study and its results are significant and whether the journal is a credible journal.  I am not saying it isn't and I will check it out but too many take a study as gospel.  Just because it is in a journal take it with a grain of salt.  Ultimately use your judgement.  My only point is trauma can be present w/o pain or deficits.  If further injury occurrs it's your but on the line.



Your doing the paramedic equivalent of closing your eyes, sticking your fingers in your ears and shouting "lalalalalaaaaa" when presented with evidence that doesn't fit your preconceived notions. How would you feel if your physician did the same?

NEXUS was a gargantuan study that pretty well proved physical exam is a reliable, specific and sensitive tool (more so than plain radiography)when it comes to diagnosing c-spine injury. Furthermore many systems (including the entire state of Maine) have been using this tool for years without issue. So unless your physical exam skills are so subpar that you don't trust yourself to accurately assess for pain then you'll be fine. If your assessments are that sub par then you should probably seriously question your ability to work independently.

Furthermore skin breakdowns can occur in as little as 30 minutes, which is a more realistic minimum time frame for being on a board. ICP and interference with respiration have already been noted. Not to mention it's very painful to be immobilized for any length of time.

Your unfounded fears over legal liability are getting in the way of proper patient care if you think every minor trauma needs SMR precautions.


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## Hellsbells (Feb 15, 2011)

Ive never been a large fan of immobilization when unnessesary. There is no need to cause a pt the increased pain of being strapped to a hard board if not totally warrented. In my urban area the guideline for a pt remaining on a board is 1 hour after arrival at hosp, so if the hosp is busy and has had a long tranport that can add up to well over an hour on the board. 

Furthermore, Milehigh, you state that the board and collar is harmless if done properly...but also admit that you have transported a pt with their head attached to the cot? What do you think is going to happen in the event of a sudden stop or mvc when the head but not the body is immobile?

As to the original poster, I would say transport, but not a board and collar is warranted. The potential for a brain bleed is there. Was the pt in question on warfarin?


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## Melclin (Feb 15, 2011)

http://emj.bmj.com/content/28/2/115.short?rss=1

Interesting article on risk stratification of minor head injuries in pts on warfarin.


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## Smash (Feb 20, 2011)

Mile High Medic said:


> MD's and PhD's sY it works but any one with a kinesiology degree are any health field degree can tell you those diets offer false positive results.



Sorry, off topic I know, but did I just see someone equate an MD or PhD with a Degree in Quackery?


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## Aidey (Feb 20, 2011)

I'm not sure I would call it quackery. A Kinesiology degree does have applications in the various physical fitness fields (rehab, physical therapy, professional coaches etc).


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## Veneficus (Feb 20, 2011)

Smash said:


> Sorry, off topic I know, but did I just see someone equate an MD or PhD with a Degree in Quackery?



There is a growing body of minimally educated healthcare providers who think all that advanced education obtained by MD and PhDs is just academic. That their basic textbooks show the true way because they present information as absolutes in simplified concepts. 

There is a reason most never obtain higher education themselves.

Biochemistry, it's such a wonderful thing when discussing diets.


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