No History, No Meds

      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.

   James J. Augustine, MD, FACEP, is an emergency physician from Washington, DC. He is the director of clinical operations at EMP Management in Canton, OH, and serves as assistant fire chief and medical director for Washington, DC, Fire and EMS. He is a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, OH, and a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.

Initial Assessment

   An 82-year-old female with a fracture of her right hip due to a ground-level fall on a patch of ice.

   Airway: Intact and uncompromised.

   Breathing: No distress, speaking in full sentences.

   Circulation: Patient is cool, but appears to have normal capillary refill and pink skin.

   Disability: No neurologic deficits, but unable to remember all her medications and medical problems.

   Exposure of Other Major Problems: Patient has an obvious right hip fracture, with the leg shortened and externally rotated. Her skin is intact, and the distal pulses, movement and sensation are normal both before and after splinting.

   AMPLE Assessment

   Allergies: None.

   Medications: Unknown, but the paramedic suspects she takes a daily dose of Coumadin.

   Past Medical History: The patient is unable to give a complete history, but likely has a history including atrial fibrillation, congestive heart failure and pneumonia. She has no signs of prior hip injuries or surgeries, and no other orthopedic problems. She has had prior abdominal surgeries.

   Last Intake: Breakfast about 0630.

   Event: Fall on ice.

   Customer Service Tip: The elderly patient with a hip (or other bone) fracture will often need extra time and care for proper immobilization and packaging. This time is well-spent, as the patient often gets great pain relief from good fracture immobilization. The older patient is often reluctant to take pain medication; many fear if they do, they could "lose control." There are simple ways to relieve pain, including placing the patient in their position of comfort, using well-padded splints, applying cold compresses and just holding the patient's hand. If pain medication is to be used, reassure the patient that you will give small amounts at a time—"just enough for the trip to the hospital." Then titrate the pain medication, even a milligram at a time, to reduce the pain without compromising the patient's level of consciousness or breathing.

   Learning Point: Hip fracture is a common injury in the older patient. It's important to be flexible in providing immobilization of an injured extremity or pelvis, and use extra padding to increase comfort and prevent injury to an older patient's thinner skin. Many older patients are on some form of blood thinner, and that should be sought in the history.