Live from Prospect St: The Reluctant Tumble

It’s 9:00PM on a Wednesday, and you’re the tech on A48, a dual-EMT, transporting BLS ambulance. You are the 911 coverage for Poketown, a midsize urban area; ALS is available for intercept as needed. You carry fingerstick glucometry, activated charcoal, glucose, aspirin, and epinephrine.

You are just starting to yawn when a tone hums from the radio, and a voice declaims:

Ambulance 8, take the response to 91 Eastbrook Rd. That’s priority 1 to 9-1 Eastbrook Road in Poketown, apartment 710, for the fall.

You acknowledge, flip your lights on, and head that way. This is an apartment block in the middle of town that you know well.

You arrive to find Poketown Fire and Police already on scene. You load your bags into the stretcher, plus a backboard, and head into the elevators, which are so small you have to fold the cot to fit inside; you wonder how you’re going to fit the patient if you end up boarding them.

You arrive at the apartment to find an elderly man sitting in his wheelchair, accompanied by neighbors and friends, including a young woman who describes herself as his healthcare proxy. He greets you cheerfully, telling you that he’s Joe, 79 years old. He was walking around the apartment with his walker when he brushed against the refrigerator and fell backwards; his proxy tried to catch him but failed, and he hit the ground. He denies falling, then denies hitting his head, saying he landed on his butt, then finally agrees that he hit his butt then his head; his proxy, however, tells you he fell straight back like a board and struck the posterior of his head on the ground. She says his eyes rolled back for a few seconds and he seemed unconscious, after which he quickly came around and moved himself to his chair. She was alarmed and called 911 immediately after; the fall was about 15 minutes ago.

He presents as fluidly conversational, friendly, and fully oriented. He is slightly hard of hearing, speaks in a loud voice, and doesn’t always understand your questions the first time around, but he’s generally “with it” and remembers the full chain of events that led him here. He jokes around with you and the firefighters and offers to marry you to one of his daughters, who has “lots of money.” You tell him you wouldn’t know what to do with it.

Physically, he seems well, with no notable trauma. There is a small lump on his occiput which may or may not be baseline (hey, heads have funny shapes), but he denies any pain or tenderness there. He also denies pain or tenderness of the neck or back, and in fact denies everything, saying he’s just fine. A “lifeline” bracelet is present on his right wrist. His vitals show:

Skin: Slightly cool in the feet, some ecchymosis throughout, otherwise dry and unremarkable.
Pulse: Weak, slightly irregularly irregular radial pulses at 78
BP: 110/70
RR: 16 and unlabored
BGL: 124

Your physical exam notes no other gross trauma. His left pupil is large and abnormal in shape; he states that he has bilateral cataracts. His right pupil is round, slightly small, and somewhat reactive. His eyes track in all directions with no major nystagmus. His lungs are clear bilaterally. He demonstrates equal CSM in all extremities, and no facial droop, arm drift, or speech slurring. A full neuro exam notes no deficits. He denies chest pain, dyspnea, nausea/vomiting, general weakness or dizziness, peripheral weakness or parasthesias (numbness/tingling), or any other complaints. During your exam, he actually gets up and ambulates back and forth across the room with his walker, moving slowly but well with no major gait disturbances.

While you talk, your partner is examining the medication list provided by his proxy. It includes:

  • Digoxin
  • Metformin
  • Citalopam
  • Advair
  • Omeprazole
  • Coumadin
  • Ibuprofen

His full medical history is otherwise not readily available. He does state that he was just released from the hospital two days ago, after a 5-day stay for diverticulitis. He is allergic to morphine.

What is your general impression of this patient’s priority?
What do you think is going on? What are you worried could be going on?
What is your next step?


  1. At this point, he’s a non-emergent transport to the hospital.

    In my mind, because he is not critical, the first step is to decide whether he requires spinal immobilization. Thankfully he does not by my local protocols. His fall was not greater than standing height, he demonstrates no spinal pain or mid-line tenderness, and there is no distracting injury. He may still have a vertebral fx since older folks are very much capable of breaking things from standing height falls, and I would still agree with anyone who chooses to do so, but knowing the limited utility of immobilization (and possible harms from it), I would not want to in this case without good cause.

    The second worry on my mind, because it would actually change my management of the call (resulting in an ALS assist), is whether he truly fell or experienced syncope. Since there was a reliable witness to the fall (in this case the patient is not entirely reliable), I’d double check her account that he was knocked off balance by NFL great William Perry and make sure the patient didn’t experience any prodrome.

    So we’ve got a pleasant, well oriented, grossly neurologically intact old fellow that struck his head with a probable brief loss of consciousness. Also, he’s on warfarin. With that picture, this man will most assuredly be transported to the hospital for evaluation with a possible intracranial hemorrhage (ICH). I know we can’t kidnap patients yada-yada-yada, but he’s going. Again, we have to consider an ALS assist early if we’re going to request them, but in this case they have nothing to offer the patient in their bag except intubation if he should deteriorate and a prophylactic IV, which is not a strong enough argument to require their use at this point. The patient will receive 12 Lpm oxygen via non-rebreather per protocol, along with BLS non-emergent transport to the hospital of his choice, but diverting if conditions change.

    The single most important part of his transport will be serial neurological examinations en route. They don’t have to be fancy; simply talking to the patient throughout the transport can be enough to spot trouble brewing, occasionally throwing in tests of gross motor and (especially here) ocular function. Although he seems fine right now, older folks have a bit of extra space in their heads for blood to accumulate before they start exhibiting signs or symptoms of their injury and his risk is especially high being on warfarin.

    Of note, one pupil is not acting normally, and I am very much at a loss as to what to do with that, although it is concerning. As far as I know, a blown pupil is a sign of impending herniation and not an early finding of ICH, occurring from compression of cranial nerve III (don’t go thinking I’m smart or fancy or anything, this is pretty much the only thing I know about the cranial nerves). It is true, however, that it will usually be the first ocular sign of compression, with motor findings coming later as more nerves become affected, so it will be especially important in this patient to make sure his gaze doesn’t change and that eye continues to exhibit full range of motion. The best thing we could probably do is question his proxy, who will hopefully know him well enough to recognize if one eye was typically giant and irregular, perhaps from a surgery or condition the patient hasn’t divulged. Maybe the patient was just at the ophthalmologist recently and had his eye dilated for some reason, which could also account for why he had trouble dodging the fridge.

    Thanks for the interesting case, I look forward to seeing where things go and your discussion.

    • The point about syncope vs. mechanical fall is, as Tony the Tiger would say, “grrrrrreaat!” How could we help distinguish them with the help of our witness?

      And I feel confident it will not ruin this tale for anyone if I reveal that the pupil is secondary to cataract surgery.

    • Vince; do your protocols state to put all suspected head bleeds on NRB at 12LPM? I’m just curious. That seems a little bit overzealous for a man in no apparent distress.

      • Yessir, a requirement in our protocols is that anyone, with any complaint, not on home O2 for COPD should recieve high flow O2 via NRB mask (and if they are on home O2 but have a respiratory complaint, they get high flow). I used to make a bigger fuss about titrating O2 as needed (especially in stroke where there’s some actual evidence of harm), but due to a combination of factors didn’t in this post. Good catch though, and I’m glad to see such a great number of people looking at oxygen use with a critical eye.

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