Fall with no c-spine?

[Trickimaster]

So I am a greenstick here (just got my FL license, looking for a job) but I had a question about a call when I did a ride-along for my school clinicals. We had an elderly woman who fell in her home and had right-sided pain. She was supine on the floor when we got there. I went to grab C-spine but my preceptors said it wasn't needed since it was a "ground level fall." I would have done a rapid trauma with c-spine precautions and backboarded. They just scoop stretchered her and transported in semi-fowlers. Am I thinking over-cautiously or was treatment appropriate? Thanks!

 

[STXmedic]

To no fault of your own, you may be a little over-cautious. EMT (and medic) school is fairly good at instilling a fear or belief that every patient that even thinks about falling needs spinal motion restriction and high flow oxygen.

I was not there, so I'm just going off of what information you gave. A ground level fall really is not a significant MOI (not to get into the reliability of any MOI). If she wasn't complaining of neck/back pain, has no spinal deformities, good PMS, and apparently fell on her side, I would not be inclined to start SMR on this patient. Keep her in a position of comfort and transport.

With that said, once you get hired on with a company, follow their protocols.

 

[Trickimaster]

You're right, at school they instilled a healthy fear of c-spine precautions and high flow O2 for everybody. I think I would have been reemed out if I hadn't during one of our practice scenarios! But during the ride alongs one thing I definitely noticed is classroom rules are a lot different than real life scenarios. I remember getting laughed at for asking someone with a swollen knee what their last oral intake was - granted, I thought it was a silly thing to ask too given the circumstances, but like I said, I was going through all the steps by the book.
I can tell I'm going to learn a lot and get some great advice from these forums. Thanks!

 

[crazycajun]

You're right, at school they instilled a healthy fear of c-spine precautions and high flow O2 for everybody. I think I would have been reemed out if I hadn't during one of our practice scenarios! But during the ride alongs one thing I definitely noticed is classroom rules are a lot different than real life scenarios. I remember getting laughed at for asking someone with a swollen knee what their last oral intake was - granted, I thought it was a silly thing to ask too given the circumstances, but like I said, I was going through all the steps by the book.
I can tell I'm going to learn a lot and get some great advice from these forums. Thanks!

Not sure why someone laughed at you for asking SAMPLE questions. I don't care what the call is, I ask every PT that is CAO a complete SAMPLE survey and I have been doing this since 1985. I look at it like this, suppose that PT is Diabetic and has not had any oral intake since yesterday. The swollen knee could be from a fall when he got dizzy due to low blood sugar. Not always the case but definitely doesn't hurt to ask

 

[Trickimaster]

I guess it was because the lady had tripped over her dog but I was asking what I thought was right. That's what we were taught in class (about the diabetes/dizziness) so I always asked the Q's anyway. In fact I asked my instructor about that one and he said I was right despite the "obvious" cause of the fall - even though she could have tripped over the dog because of another cause. He said cutting corners would come back to burn me so I always made sure not to cut corners.

 

[crazycajun]

I guess it was because the lady had tripped over her dog but I was asking what I thought was right. That's what we were taught in class (about the diabetes/dizziness) so I always asked the Q's anyway. In fact I asked my instructor about that one and he said I was right despite the "obvious" cause of the fall - even though she could have tripped over the dog because of another cause. He said cutting corners would come back to burn me so I always made sure not to cut corners.

Your instructor is right. I had a partner a couple of years ago that rode a call for a regular PT. The PT called 911 weekly claiming to feel dizzy and knew his BGL was high. Upon obtaining a BGL it always came back around 120. On this call the PT had the same CC. When we arrived at the hospital I asked my partner what the BGL was. He said "I didn't take one. It is always the same!!" I told him to check it anyway to save any embarrassment in the ER. His level was 528!!!! Never get complacent in this job. It will always come back to haunt you!!!!

 

[Handsome Robb]

I usually only ask last oral intake if I think they are going to surgery or they are complaining of abdominal pain.

Don't let people give you crap for doing what you were taught. Unfortunately a lot of this job is OTJ training rather than school and real life and school tend to conflict pretty often.

As far as the c-spine thing. You were doing what you were taught, no fault in that. the medic you were with is right though.

When it comes down to it, like Poetic said, follow your protocols when you get hired somewhere.

 

[crazycajun]

I usually only ask last oral intake if I think they are going to surgery or they are complaining of abdominal pain.

Don't let people give you crap for doing what you were taught. Unfortunately a lot of this job is OTJ training rather than school and real life and school tend to conflict pretty often.

As far as the c-spine thing. You were doing what you were taught, no fault in that. the medic you were with is right though.

When it comes down to it, like Poetic said, follow your protocols when you get hired somewhere.

I guess everyone has there preference. I am sure you ask for nausea/vomiting, pregnancy,etc.... I just ask every time and I never forget.

 

[Handsome Robb]

I guess everyone has there preference. I am sure you ask for nausea/vomiting, pregnancy,etc.... I just ask every time and I never forget.

Everyone has their own style, like you said. You're correct about the other questions, my thing about last oral intake is it really isn't high on my priority list on most calls, if I have time I'll ask it unless it's a situation like I stated in my last post.

 

[mycrofft]

Health is "global" (everything affects almost everything else to some degree). I remember taking the time enroute to sort of leisurely finish asking questions and maybe doing a little more exam; a few times I developed info which either was further helpful about the current complaint, or opened entertainment of an entirely and possibly more important open. Nothing says you only have one problem at a time, or that the pt will not consider important info to be relevant, or won't try to hide something.
C spine: follow protocols.

 

[Aprz]

I know we discuss we've about the effectiveness for c-spine and how backboarding a patient, especially an eldely, may be a unneccessary harm, I'm not gonna argue that, but if this patient was elderly, I would still be suspicious. From the ground for a young guy like me (22 years), I wouldn't be so worry. I would still go through the NEXUS criterias (can be remembered using the mnemonic NSAID: neuro deficit, spinal tenderness, altered, intoxicated, distracting injury), and I think there is one that is similar to NEXUS called the Canadian Spinal Criterias, or something like that that includes age as a criteria (I think >65). I would say mechanism is an unreliable way to determine if c-spine is needed (which is another can of worm that we've discuss on this forum). In my limited experience, from falls standing up, I've had 2 patients with fractures in their spine (both were old females, like 65ish), and one young male (age 29 I think) that had a tib fib compound fracture from tripping/slipping when he stepped on a n empty monster energy drink can.

I think a fall for anyone would still warrant going through those assessments at minimum.

Now we just need to figure out what to do about it, lol.

 

[Trickimaster]

Thanks for the input everyone!!

 

[the_negro_puppy]

If your protocols allow some flexibility as others have said you need to examine further-

Any altered sensation or neurological deficits?
Any neck or back pain? where is it? does it increase on gentle palpation? did it come on suddenly?
Is the pt GCS15? Intoxicated?
Does the pt have any significant distracting injury?
Was the patient 'knocked out' or has the pt suffered a head injury?
Does the patient have osteoporosis or a hx of any spinal injuries?
Has she been mobilising/ambulatory after the fall?

As others have said I would be hesitant to immobilise this patient unless she started to tick some of those boxes. We have quite flexible protocols here and choose to initiate spinal immob or not, as long as we can justify

 

[mycrofft]

Exactly. We should not treat protocols or mechanisms of injury, we should treat assessments.

 

[TheGodfather]

Exactly. We should not treat protocols or mechanisms of injury, we should treat assessments.

I second this statement!

 

[mycrofft]

First step to being recognized as a profession: discretion.

 

[AmeriMedic21]

was she complaining of back or neck pain? Usually if I do c-spine precautions its neck and back pain, sometimes i will still do it with head pain too(fall related). Yeah your thinking straight out of class and what you would do in front of a board examiner, thats okay though. Would it be necessary? No, but would it have hurt to let you play with the equipment? Definitely not! Sometimes doing the things we didn't think were necessary pay off when you find out at the hospital they did in fact need said intervention. With time you will learn to judge your calls, but by no means would it have been a bad thing to do. Also, little side note, was it a hip fracture? Any shortening or rotation to left or right leg? Cause alot of the time when i run a hip fracture call, i will still apply a board to them even if they are not complaining of head, neck, or back pain. Its just easier to move them that way

 

[Trickimaster]

No, I don't recall her having indications of a hip fracture, just R sided pain. Playing with the equipment would have been fun though...although probably not fun for her :sad: I think everybody's right the BLS crew I was with judged appropriately and it just takes experience to know when to follow the book by the letter and when to improvise. ^_^

 

[mycrofft]

BUt be ready to justify not following the protocols. Such as citing why your exam trumps the pt's primary complaint.

 

[Handsome Robb]

Scoop stretcher over a board any day of the week for a hip or pelvic fracture.

Boards are painful without a broken hip why use one in the presence of a really painful injury? I hope for the patients sale you are padding the hell out of them.