Fallen and Can’t Get Up

I hoped I could find this address. Road drive ends in a series of 4 or five dirt lanes that wind through the woods. Picking the right one is always a crap shoot. I hoped I was on the right one as I drove down a potholed dirt lane barely wide enough for the ambulance. Finally a trailer emerged from the woods with its porch light on. We were here at 2 am for a person fallen, which could be anything from a fallen and I can’t get up call to a cardiac arrest. I turned on all of the scene lights to illuminate the front yard, walked to the front door and knocked. “Fire department!” I yelled. I didn’t hear any reply. Jeff brought the med bag and laid it on the rickety wooden front porch next to me. Kay arrived in her car. “I’ll check the back” she said. Soon I heard Kay’s voice “She’s back here!” Joe and I headed to the rear of the trailer where we found a 75 year old woman just inside the rear door lying on her left side, up against a wall. “Oh thank God! I didn’t think anyone was coming for me. I have been here for so long.” She quietly sobbed. “Its ok. We are here now. What happened?” I asked “I fell and I can’t get up. My left hip really hurts.” “How long have you been here?” “A few hours.” This means she is a candidate for compartment syndrome. When we are motionless for long periods of time, our circulation gets cut off. Kind of like when your leg falls asleep. If it stays that way for long enough, acidic metabolic wastes build up. When we move and restore circulation, those wastes can enter the circulation and send the patient into acidosis, which can be serious. I added this to my problem list, along with a possible fractured hip, and internal bleeding because of the fractured hip. The pelvis is very vascular and sharp bone ends of a fractured one can sever blood vessels. A pelvis can almost hold a persons entire blood volume which can cause hypovolemic (low blood volume) shock. I did a quick full body survey just to make sure she wasn’t hurt anywhere else. As I started my exam she quietly said “I wet myself. I just couldn’t wait any more.” obviously embarrassed. “That’s ok,” I said, “We will get you changed when we get you to the hospital.” We got a set of vital signs, and complete medical history. I asked why she fell, if she got dizzy, passed out, or tripped. She said she tripped. If she got dizzy before the fall, had chest pains, or passed out I would consider a cardiac problem, which we didn’t rule out yet. It just wasn’t a primary problem right now. Our biggest problem was stabilizing that hip and getting her into the ambulance, which wasn’t going to be pretty because of the cramped conditions in the back trailer hallway and the way she was crumpled against the wall. We decided the best way to go was to place a backboard behind her, between the patient and the wall. In order to effectively splint, we need to immobilize above and below the suspected fracture and above and below the adjacent joints, which for the hip means full body immobilization on a long back board. Her vital signs were good. We checked her blood sugar since she was a diabetic, and everything checked out normal except for her hip. We slid the board behind her, got everyone in position to do the move with as little movement to the right hip as possible, and went over the plan. “Ok Mrs Smith, we put a board between you and the wall. On the count of three we are going to slide you onto your back, and that board will be under you. We are going to try to move your right hip as little as possible. Just let us do all the work. I am going to tie your legs together to help keep your hip from moving” I placed a blanket between her legs and tied her legs together with three cravat bandages. The smell of urine was strong, and I could feel the pee seep through my pants onto my knee as I knelt beside her. On three everyone moved the board and the patient just right so that she wound up on her back, centered on the board. I was surprised at how well it went, and the patient felt instant relief once she was on her back, and the weight was off her hip. I noticed that her left foot was rotated outwardly, a sign of a hip fracture. That wasn’t a good sign since the outcome and quality of life for a 75 year old with a hip fracture are usually not good. We provided supportive care on the way to the hospital and turned her over to the emergency department staff. I wished her well, but knew that she may never make it out of the hospital.