Fall Patient - Your treatment

MedicPrincess

MedicPrincess

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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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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.

:)
 
Pt landed on a carpeted floor. No coffee table in front of couch. Fall height of about 2' to floor.
 
EMTPrincess said:
Pt landed on a carpeted floor. No coffee table in front of couch. Fall height of about 2' to floor.
Click to expand...

At 77 years of age, I don't think I'd take any risks with the guy. Better safe than sorry these days. :)
 
Full spinal immobilization-careful of placement of straps on the torso due to the hernia-O2 and transport to ER.
 
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.
 
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.
 
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.
 
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
 
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.
 
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.
 
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
 
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
Click to expand...

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

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?
 
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.
 
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.
Click to expand...

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!
 
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.
Click to expand...

So what did you find out?
 
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