No History, No Meds

The challenges from an elderly woman's fall just start with the broken hip

Responses to the local retirement community aren't unusual for Attack One. This morning's call is for a "woman down," but the location is somewhere between the different areas of the community. A concerned staff member finally guides the crew to the side of an elderly lady lying awkwardly in a hallway, with an obvious fracture of her right hip. It's easy to see what happened: A patch of ice formed in the unheated walkway between the buildings, leading to a slip and fall. The lady says it happened around 0700 hours, and gives a very lucid history of taking her morning walk between her apartment and the assisted-care portion of the complex.

It's cold in the hallway, so the crew quickly moves the woman onto a long backboard and wrap her in a blanket. She has suffered a ground-level fall, has no signs or symptoms of a head or neck injury, and has been moving her neck actively, so they complete their cervical spine clearance per protocol. She complains only of right hip pain, and wiggles her toes actively. The cold conditions and the fact that the patient has been lying in the hall for almost two hours suggest that everyone quickly make their way to the warmth of the ambulance. The paramedic asks facility staff for any medical records but is told there are none, because the patient lives in the "independent living" area of the complex. She will have to give her own history and provide a list of her own medications.

As the stretcher is loaded into the ambulance, the patient says she's uncomfortable on the long backboard and asks to move to a more comfortable position. The crew members agree—they just needed to get her off that cold floor quickly and into the warm ambulance. They warm the patient compartment, then unwrap the patient, checking completely for injuries. The woman's right leg is shortened and externally rotated, typical of a broken hip. She indicates that it feels best if she leaves it in that position, and the crew pads her lower back and stacks a pillow and towels to keep her leg in the position she prefers. They find no other injuries.

As crew members make her comfortable, they try to get the rest of her medical history and find out what medications she's taking. The patient is vague—she knows she has a heart problem of some kind, and has had pneumonia. She denies any prior bone injuries. She cannot remember the names of any of her medications. She denies having medicine allergies.

The paramedic notes the patient's pulse is irregular. He suspects she's in atrial fibrillation, and with that rhythm it is likely she's on some type of blood thinner. He asks if she's on a medicine where they have to draw her blood every month or so, then tell her how much of her medicine to take. She confirms that. She also knows she does not take aspirin and does not get shots.

The paramedic starts an intravenous line, and while doing so puts a drop of her blood on his gloved finger. He then rubs his finger and thumb together, and notices the blood feels slippery—it doesn't cause his finger and thumb to stick together. In a crude way, that tells him the patient is on some kind of blood thinner. "You must be on a blood thinner, and that will be important to the hospital staff," he tells the patient. "If you can't remember your medicines, they will contact your doctor to get the list. Now, how about if we give you some pain medicine to make you more comfortable?"

The patient declines that, asking only that they keep her leg supported the way it is. The crew agrees to do that, and asks that if she changes her mind to let them know, and they will give her just a little morphine to help her pain as they take her to the hospital.

Hospital Management

The patient is unchanged in transit, and arrives in the emergency department stable. The crew shares what they know with the ED staff, noting they have a poor medical history and no list of medications. They offer to return to the patient's residence and try to find her medications and get any other belongings she might want.

The woman's evaluation shows only the hip fracture, and she refuses pain medication throughout her stay. Her primary care physician has her complete history and medication list, so there is no need to return to her residence. Her surgery and recovery go well, and she ultimately returns to the assisted-living part of the facility.

Case Discussion

This case demonstrates the care of a common problem in older adults who are still ambulatory. Hip fractures can present with pain anywhere from the pelvis to the knee, but are most commonly recognized by the appearance of the patient's leg and the fact that they cannot bear weight on it. Many older patients will suffer this injury from ground-level falls. It is more common among women.

It is best to be flexible in immobilizing a patient with a possible fractured hip, and be comfortable using a variety of boards, stretchers and padding materials. Use extra padding to prevent injury to the older patient's thin skin, and to increase comfort.

This paramedic was also appropriately concerned about potential use of an anticoagulant. Many older patients are on a form of blood thinner—seek that in the history. There are common histories that go with taking Coumadin, and the prehospital provider should be able to ask the right sequence of questions to determine if the patient is taking that type of medication.

Winter Safety Education

by Chris Furstenau

Now is a great time to educate the citizens of your community about some safety concerns that are unique to the winter months. Some of them may not apply to all areas of the country namely the states where fireplaces are obsolete but the other tips shared here can be beneficial to everyone. No new information is shared here, either. These are a few reminders to share with people who come through your open houses.

Legible House Numbers

When people call the fire department, they expect a rapid response to mitigate the emergency or crisis they are facing. Now that winter is upon us, it is getting dark earlier and earlier everyday. How many times have we struggled to find a specific house because the numbers aren't legible from the street? The numbers are old and faded, they are covered by trees and shrubs, or they are located in an obscure location, all of which can cost precious time when responding to an emergency. House numbers should be large enough to read from the street, they should be in number form as opposed to word form (e.g., "2" instead of "two"), and they should be illuminated. Most hardware stores sell solar-powered landscape lights that just need to be assembled and placed; no electrical work is required. Ask residents to check out their homes from the street to see if a perfect stranger--the fire department--could locate and read the numbers quickly in the dark.

This problem can be fixed quickly. In many places around the country where snow and ice are prevalent, our response times will be a little slower just because of the slippery road conditions. If we can save some time by not having to search for hidden address numbers, we have just helped our cause.

Snow and Ice Removal

Remind residents to have their sidewalks and driveways cleared off. In our jurisdiction, it is not uncommon for snow and ice to be piled high enough so that it takes two to three minutes to get from our trucks to the front door. When people are informed that brain cells die after six minutes without oxygen, it really impresses upon them the importance of having quick access to the patient or victim we are called to help. An extra couple of minutes can go a long way in creating a positive outcome to an incident. This problem is easy and inexpensive to fix, too.

Access to Fire Hydrants

Another common obstacle in winter emergencies is the lack of access to fire hydrants. Here again, the solution costs nothing but a few minutes of residents' time. If every homeowner, tenant, and landlord would maintain the area around the fire hydrant on their property, damage to property would be drastically reduced. An all-too-common tale is the one of the house that burned to the ground because the closest fire hydrant was buried under snow, frozen solid, or--worse yet--packed with debris. Many times, this is a water department, not a fire department, issue. Ask residents who have a fire hydrant on their property to make sure they remove the snow around it. Snow plows will bury them while plowing the streets. Kidsl bury them while shoveling the snow for their parents. When urging people to maintain the fire hydrants, some will say, "There isn't a hydrant in my front yard." Politely explain that the fire department will use the hydrant nearest to the burning house and that it would be unwise to assume that the hydrant has been maintained. Ask the homeowner, "If your house were on fire, would you be comfortable with the accessibility of the nearest hydrant?"--in other words, do they trust their neighbor to clear the nearest hydrant?

If snow is not an issue in the community you serve, maybe there is another type of obstacle. We have all seen hydrants blocked with landscaping, parked cars, shoes stuck in the connections, missing caps, and so forth.

Other Hazards

If winter means fireplaces and chimneys are used regularly in your community, stress to your customers the importance of having a clean chimney. If you ask a resident the last time he had the chimney inspected and he responds, "I don't know," chances are good that it is time for a sweep. Chimney fires can be easily prevented.

Let's not forget the more common winter fire hazards, such as problems with portable space heaters, holiday decorations and lights, and poorly maintained furnaces. These emergencies can be prevented by using common sense, employing safe practice, and reading and following the manufacturer's instructions. Helping people help themselves keeps everyone safe, which is our number one job.

OSHA Issues Compliance Directive to Address Flu Prevention for Health Care Workers

For the protection of frontline health care and emergency medical workers at high risk of infection, the U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) issued a compliance directive to ensure uniform procedures when conducting inspections to identify and minimize or eliminate high to very high risk occupational exposures to the 2009 H1N1 influenza A virus.

The directive closely follows the Centers for Disease Control’s (CDC) guidance.

“OSHA has a responsibility to ensure that the more than nine million frontline health care workers in the United States are protected to the extent possible against exposure to the virus,” said acting Assistant Secretary of Labor for OSHA Jordan Barab. “OSHA will ensure health care employers use proper controls to protect all workers, particularly those who are at high or very high risk of exposure.”

In response to complaints, OSHA inspectors will ensure that health care employers implement a hierarchy of controls, and encourage vaccination and other work practices recommended by the CDC. Where respirators are required to be used, the OSHA Respiratory Protection standard must be followed, including worker training and fit testing. The directive also applies to institutional settings where some workers may have similar exposures, such as schools and correctional facilities.

The CDC recommends the use of respiratory protection that is at least as protective as a fit-tested disposable N95 respirator for health care personnel who are in close contact (within 6 feet) with patients who have suspected or confirmed 2009 H1N1 influenza.

Where respirators are not commercially available, an employer will be considered to be in compliance if the employer can show a good faith effort has been made to acquire respirators.

Where OSHA inspectors determine that a facility has not violated any OSHA requirements but that additional measures could enhance the protection of employees, OSHA may provide the employer with a hazard alert letter outlining suggested measures to further protect workers.

The 2009 H1N1 influenza is transmitted via direct or indirect person-to-person spreading of infectious droplets passed when an influenza patient coughs, sneezes, talks or breathes. Transmission occurs when expelled infectious droplets or particles make direct or indirect contact with the mucus membranes of the mouth, nose or eyes of an uninfected person. The OSHA directive and other guidelines show steps to eliminate the hazard.

Under the Occupational Safety and Health Act of 1970, OSHA’s role is to promote safe and healthful working conditions for America’s men and women by setting and enforcing standards, and providing training, outreach and education. For more information, visit http://www.osha.gov.