geri-ground level fall

[mshow00]

My partner and I got called to a local SNF about 0930 to take a Pt to a hospital with a c/c of a head lac secondary to a fall around midnight. We arrived on scene to find 80's y/o female walking around with a walker. She had a 2-3 cm wide and 3-4 cm long "T" shaped lac. on the bridge of her nose mostly scabbed over. Our protocols say if it has been more than six hours the pt does not need to be trauma packaged, and seeing has how she was up and moving with no complaints of pain my partner (the medic) made the call not to package her. He continued his assessment and decided to BLS her in. Anyway we took her to the hospital and gave our report. ER nurses came and did their initial stuff. The Dr. was going to glue and release her. I later found out due to a paperwork mistake at the hospital the pt was taken and had a x-ray/CT of her head and neck. Thats when they discovered a C 2-4 fx. When I did my assessment on her she had some weakness bilat but over all PMS was WNL x4. She had no complaints of pain, tenderness, LOC, loss of sensation, pain, SOB, CP etc. Just the lac on the bridge of her nose. Did I miss something, or does anyone have any suggestions on some assessment/ question that I can do to prevent this from happening again?

[EMS49393]

Don't beat yourself or your medic up over missing this fracture. It is possible for a person to suffer cervical spine fractures and be able to function. Chances are the fracture was not displaced, as it did not seem to affect the spinal nerves. The geriatric population is special in so many unique ways. If your patient had some severe kyphosis, you might not be able to tell if there is any displacement or step-offs on assessment. As we know, and hopefully are taught, elderly caucasian/asian women are at a great risk for bone density issues, such as osteoporosis. Honestly, given the information you presented, it seems you and your medic should not think you missed something. Take it as a learning experience.

I know of a fantastic paramedic that had a similar experience, except his patient was a lot younger. Thirties year old male, moderate speed MVC, no restraints, ambulatory at scene and signed a refusal of care. His wife called 911 several hours later when the patient complained that he couldn't feel his legs. He had a cervical spine fracture went from non-displaced to greatly displaced. That medic beat himself up over that call for years. Good medic, good assessment, even the trauma doctor told him that this was just one of those "freak incidents" that rarely happen.

Honestly, you are only the second person in my 15 years in this field that I've heard this type of story from. For that I tell you, it sounds like one of those "freak incidents that rarely happen."

I hope some of the older providers chime in on this post. I'm interested to know how many times something like this has happened to other providers.

[cfaulknor]

My suggestion is to use NEXUS criteria in clearing ANY trauma patient from SMR.

You can find more information here: http://www.fieldmedics.com/articles/the_nexus_study.htm

[ccmedoc]

My suggestion is to use NEXUS criteria in clearing ANY trauma patient from SMR.

You can find more information here: http://www.fieldmedics.com/articles/the_nexus_study.htm

Sounds like they did..it is hard to tell if bilateral weakness in an 80 year old is preexisting or not. With careful transport, which I'm also sure they did with an 80 year old..I seriously doubt that packaging this patient with more than a c-coller would have provided any benefit..only potentially made things worse..

Kinda depends on the type of fracture also..doesn't sound super bad..Unless you c-collar everyone with a fall history, it will probably happen again. Just be very vigilant with the elders, give them every benefit and educate yourself on the differences due to age related changes in their body..

Keep your head up..they were going to send her home anyway.. :oops:

[fiznat]

That >6 hour rule in your protocol is garbage, but I don't think you personally did anything wrong.

AOX4 patients with no complaints of pain/tenderness and a lack of significant, glaring mechanism or distracting injury will get cleared nine times out of ten here also. We tend to err on the side of caution with that stuff, but in general if the fall is old and there aren't any complaints I don't think anyone can blame you for not subjecting the patient to a full c-spine.

Cover your bases, document well, follow your protocol, and you'll be fine. 8)

[DwayneEMTP]

I this situation you only have a couple of options...

It sounds as though you and your medic chose the mindful, thorough, intelligent, r/o approach over the mindless, spinal everyone, cover my ass approach.

Kudos.

Dwayne

[Doczilla]

NEXUS criteria do not apply to the elderly for exactly this reason. The Canadian C-Spine Rule specifically excludes patients over the age of 65, and NEXUS has not been validated in this population and therefore does not apply. They are at very high risk for fracture despite minimal mechanism of injury, have underlying bone disease such as osteoarthritis, lack much of the supporting musculature that younger patients have, and frequently perceive pain differently from younger patients. Physical exam alone in geriatric patients, for a whole variety of conditions, is notoriously unreliable.

I have had dozens of elderly patients with c-spine fractures from ground level falls. I've found several c-spine fractures on elderly folks that were days or weeks old. Even in unstable fractures from these falls, neurological symptoms have not been present in many.

This is one of those situations where you really do need to immobilize them, regardless of what your gut says. You can take the compassionate approach to c-spine with a c-collar and scoop or a c-collar and securing well to the cot, but you have to treat for this injury.

'zilla

[cfaulknor]

Thanks for that, Doczilla... Somehow my mind overlooked that, not sure what I was thinking..

[mshow00]

What about the idea of spinal immoblization being more detrimental to health for the elderly? After talking to several more experienced co-workers about this; a couple of them made the statement that they would have done the same as us, due to the fact of the question/statement above.

[CBEMT]

What about the idea of spinal immoblization being more detrimental to health for the elderly?

And a broken neck isn't?

Fiznat is right about your protocol, and the Doc, as usual, reminds me of something I should have known right off.