When A Fall Isn't Just A Fall

We walked into the house and found the patient laying on the ground on his right side. The daughter said that her father didn't speak English but she was willing to translate. Thankfully he was a Spanish speaker so I didn't need her assistance. There always seems to be something lost in translation when using an interpreter.

It was obvious from the beginning of my assessment that the patient had a problem with his right hip. He was holding it and moaning in agony. I asked how he had fallen and he said he wasn't sure. He explained that he had more or less crumpled to the ground landing on his hip. Then he tried to curl up in the fetal position to ease the pain.

My engineer grabbed me a set of vitals, which were all WNL. I set up my IV equipment and got a line in with the intent of giving some morphine ease his pain. While I was doing this there was still that nagging feeling that I was missing something major. I asked the patient again how he had fallen. Same answer. I asked if he felt weak or dizzy before falling. Yes, and he still felt dizzy and lightheaded.

Bingo.

I had my engineer toss on the electrodes and I took a look at the monitor. In lead II there was ST segment depression (I guess I should add a 12 lead interpretation to my cardiac series). I set up and shot a 12 lead and saw what I was expecting. The patient had ST elevation in leads V1 through V3 with reciprocal ST segment depression in leads II, III and aVF.

In laymen terms, he was having a heart attack.

Thankfully by this point AMR was on scene. I gave the patient some aspirin and then some morphine. The patient denied any chest pain, pressure, or discomfort so we didn't administer nitroglycerin. After rechecking his vitals we gave him a little more morphine and then loaded him up as best we could.

Since the patients condition was serious and because I was the only one with the ability to communicate with the patient I got to ride along to the hospital. The trip was uneventful.

Once in the ER the patient met the cardiologist and from there was sent to the cath lab.

Stubborn Medics

Most of us in health care, especially emergency medicine, know that we make the worst patients. Even though we should know better we usually don't call 911 when we should. We wait until we absolutely have to. When I developed gall stones I was in so much pain I couldn't stand upright. I couldn't drive. I couldn't think straight. But did I call 911? Nope. Too stubborn. I didn't really want to ask my parents to watch the kids or ask my wife to take me to the ER.

So we got a call around 2 in the afternoon for a fall with injuries. When we arrived on scene we found a 60 year old man laying in a recliner. His wife informed us that he had fallen in the bathroom the day before and broken his hip. He had then crawled into the living room and into the recliner instead of calling for help. When she arrived home from work she found her husband pale with pain, but he refused to let her call 911.

She then told us that her husband was one of the first paramedics in Oakland some 30 years ago. He had had his picture in the paper and everything. That instantly explained his lack of interest in calling 911. She continued to explain his reluctance by relating the story of his last hip fracture 3 years ago. The medics just manhandled him onto the gurney with no pain medication. He didn't want a repeat of the performance.

I assured my patient that things would be different this time. I don't think the salty old medic believed me. I then started a line on him. His BP was borderline low so we only started him off with 3 mg of Morphine. We then used a KED to stabilize his hips. While we moved him onto the gurney (as smoothly as possible) we gave him a fluid bolus to bring up his BP with the hopes of being able to give him some more pain medication in the back of the bus.

Next time I hope that he will be a little more willing to call us.