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July 16, 2008

Trauma and You: Final Exam Pt. One
Posted by Jim Macdonald at 05:38 PM * 68 comments

Teresa, don’t look.

A simple scene. Skateboard accident.

What the video shows: A skateboarder tries to do a trick and fails. He falls, catching himself with his hand. His left forearm shows obvious deformity and he is in pain. No bleeding.

You are a witness to this event. Okay, what do you do?

Discussion below the cut.

First, fast, get help rolling. Instruct a bystander to call 9-1-1. If no bystander, do it yourself.

The scene is safe (unless it looks like the patient’s friends are going to get ugly on you). Approach the patient, introduce yourself, and ask if he wants help.

Assuming he says “yes.” Instruct a bystander to take and hold normal inline stabilization of the patient’s c-spine. (That is, hold his head steady. All trauma patients have broken necks until proved otherwise.)

ABCs. Patient is talking; airway and breathing are okay. No obvious bleeding, and patient’s skin color is normal. Circulation appears okay.

The patient has an isolated injury of the left forearm. Check motion, sensation, and pulse in his left hand/wrist. Check for pain, tenderness, swelling in left wrist, elbow, and shoulder.

Splint the left forearm in normal anatomical position, from wrist to elbow, with the hand in position of function (i.e. curled partly closed).

Apply sling and swathe.

Check circulation, motion, and sensation in the left hand. There should be no change from your earlier check.

While you’re doing all this keep up a flow of light banter, during which you hope to learn the if the patient has any allergies, whether he takes any medication, what his medical history is, the last time he had anything to eat or drink, whether he hit his head or lost consciousness. Remember, you may be the last person who can get coherent answers out of the patient, so ask, and write the answers down. Count his pulse and respirations. Write them down (with the time when you checked them).

Check for other injuries, then reassess the ones you’ve already found. When professional help arrives report to the senior person; request further assignment.


Trauma and You: Final Exam Pt. Two

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Comments on Trauma and You: Final Exam Pt. One:
#1 ::: Sica ::: (view all by) ::: July 16, 2008, 06:20 PM:

I'll bite. Although it's been a while since I read through the skeletal injuries post. I'm not 'cheating' and doing a refresher since in an actual incident I probably couldn't do that. Although the magic of my 3g phone is great and that's in an urban area where I might have reception.

I'd dial 911 (or 112 or 999 depending on where we are)

He seems to be breathing ok (can talk), he's not bleeding and the injury is to an extremity, clearly a broken arm. There's of course shock to worry about though.

However I got queasy just seeing that in a video and in the past I've come very close to passing out myself from being around injuries on other people so I'd probably turn away from the injured person and try to stay conscious myself.

If he went completely quiet and the EMP's hadn't shown up yet I'd get worried and check if he was breathing, i.e go through the airway, breathing and circulation check list.

Mostly I'd hope for the professionals to show up soon.

#2 ::: Backpacking Dad ::: (view all by) ::: July 16, 2008, 06:22 PM:

See. That's why you wear a helmet when you skateboard.

#3 ::: Stefan Jones ::: (view all by) ::: July 16, 2008, 06:30 PM:

Shout "What ya trying to get yourself killed ya crazy kid?!?" several times.

#4 ::: gdr ::: (view all by) ::: July 16, 2008, 06:35 PM:

Possibly a stupid question.

Can you explain the reason why you recommend phoning for an ambulance? It's a nasty break but it doesn't appear to be immediately life-threatening, so why not take the casualty directly to the hospital once you've put the arm in a sling?

The last couple of times I broke my arm I made my own way to hospital: did I make a mistake?

#5 ::: James D. Macdonald ::: (view all by) ::: July 16, 2008, 06:39 PM:

Call 9-1-1 first, because if things turn out to be worse than you originally thought you already have help rolling.

If you load the kid into your car, call 9-1-1 back and tell them that you're going to the hospital by private vehicle. The nice ambulance guys will return to their game of cribbage and all will be well.

#6 ::: John Hall ::: (view all by) ::: July 16, 2008, 06:51 PM:

Watch for symptoms of shock?
Pre-emptively treat for assumed shock? - (lie him down, elevate his feet, keep him warm)

#7 ::: Ben Engelsberg ::: (view all by) ::: July 16, 2008, 06:56 PM:

Jim,

Should someone who is only first-aid trained try to splint that injury, or should the first responder RICE (Rest, Ice, Compress, Elevate) the injury and wait for professional assistance?

That's some pretty nasty deformity... how do you make the call between RICE and wait, and Splint?

#8 ::: James D. Macdonald ::: (view all by) ::: July 16, 2008, 06:56 PM:

Yes, treat for shock. If he isn't already in shock he's headed there.

#9 ::: James D. Macdonald ::: (view all by) ::: July 16, 2008, 07:02 PM:

I would totally splint that injury--if it's waving around unsplinted there's a good chance that the closed fracture will turn into an open fracture. A rolled newspaper, an umbrella, a stick wrapped in cloth, whatever you have.

And splinting will help with the pain, which will help with the shock.

Until proved otherwise, assume injuries to the entire upper extremity from the shoulder down, plus the neck. (The head is big and heavy, the neck is thin and weak--sudden motion can snap that neck. The demo I like to do involves an apple stuck on a pencil. Hold the pencil in your fist with the apple sticking up, punch the palm of your other hand, and watch the pencil break and the apple go flying.)

#10 ::: Lance Weber ::: (view all by) ::: July 16, 2008, 07:10 PM:

A quick note on methodology: I watched the video once, started to google search on the other trauma series then stopped myself with a light slap on the wrist, shut down my browser, opened Textmate and began typing this. I'm going to post it without looking at any other comments first.

First Impressions: Patient is conscious, breathing, able to move their head, speak and respond to others. Appears to have broken both bones in left forearm (err ulna and radius?), no apparent skin punctures. He has just slumped over, hopefully in pain but maybe going into shock soon.

Step #1: Look around, assuming no other more qualified first responders magically appear, I take charge of the situation.* Walk up to the kid and explain "I'm here to help, okay?". Lie him back, prop his feet up on the pallet. Look at Friend #1: "You, stay right there, get your phone out and get ready to dial 911 as soon as I tell you to. Keep everyone else back unless they've got medical training". Look at Friend #2: "Figure out whose car we're going to use to get him to the hospital and get it over here. Come back and tell me when it's here."
Spawning background thread: "Okay, I'm gonna need to make an ambulance vs ambulatory call here pretty soon."

Step #2: Start assessing the kid. Where to start? Right, ABC. Which stands for... ...Fuck. Is it Artery, Breathing and...Fuck it, gotta focus. Check him and the ground again for blood. Make sure he's still breathing. Ask him his name, age, etc to gauge responsiveness. Let him keep his arm held over his stomach for now, but don't let him touch/hold/pull it with the other hand. If he's getting clammy/pale, "shocky", prop his legs higher on the pallet with something/someone, get an extra sweatshirt or two over him. If he checks out okay for everything besides the break, go the ambulatory route, otherwise pull the trigger on the ambulance.

Step #3: Explain "You've broken your arm, pretty badly it looks like. You're going to be fine, but you need to get to a hospital and we need to immobilize your arm so your friends can take you, okay?". Look around for good splint material. If all else fails, break off a board from the pallet, use a size 12 shoe, something. Belt, shoelaces, extension cord from my briefcase to bind. Definitely gonna splint the forearm and wrist, probably not the elbow. Wrap the arm in a t-shirt, slide the splint between his stomach and arm, then bind snug but not tight.

Step #4: With Friend #1 to help, stand the victim up slowly, have him keep his arm up as much as possible, then give him an assisted walk to Friend #2's car. Put him in the back right seat, tell Friend #1 to sit next to him in the back, make sure the driver is calm and knows where they are going. Tell Friend #1 his job is to keep his friend calm, talk to him and help him keep his arm as still and elevated as possible, then send them on their way.

Step #5: Look around to see if any young nubile maidens were duly impressed then remember I'm married. Head home, have a beer, then scan the news/obits for the next couple of days while thinking of ways to spend all those nice shiny karma points.

So, did I pass?

-------
* I don't know how else to describe this and I hate how pompous it sounds, but I'm one of those people who can Assume a Command Aspect complete with Voice powers. My kids hate when I break it out on them, they call it the Daddy Bear Voice...

#11 ::: James D. Macdonald ::: (view all by) ::: July 16, 2008, 07:31 PM:

ABC is Airway, Breathing, Circulation.

I'm still concerned about his neck (probably okay, but I can't clear it in the field).

When asking questions to determine level of consciousness, ask questions to which you know the answer. If you don't know the kid's name and age -- well, someone will want to know later, but for right now "What day is it" and "Where are you?" are great questions.

Splinting is in this guy's future. Immobilize the entire arm: sling and swathe.

If I started care, I'm going to continue care until I hand him over to someone with an equal or higher level of training to mine, whether on scene or in an ED somewhere.

#12 ::: Calluna V. ::: (view all by) ::: July 16, 2008, 07:34 PM:

Interesting. As of 1999 (as in, things have presumably changed several times since then), when I was teaching first aid for the ARC, we were instructed to downplay or skip the splinting section of the manual and advise students only to splint if they believed they were going to have to move the patient before the ambulance arrived.

This didn't seem entirely satisfactory; I like skills, and the default assumption for all skills, as far as I'm concerned, is that they're not always appropriate to the occasion and one must assess. Unfortunately, the Red Cross isn't big on people who have just taken an afternoon's First Aid class making assessments or applying judgment - or wasn't when and where I was teaching.

::makes mental note to consider splinting a viable option, depending on circumstances::

#13 ::: James D. Macdonald ::: (view all by) ::: July 16, 2008, 07:39 PM:

In My Opinion, a first aid class designed for Average Guy/Gal on the Street should run 16+ hours and have a ton of hands-on.

#14 ::: Lance Weber ::: (view all by) ::: July 16, 2008, 07:45 PM:

I am sooo going back and re-reading the series, especially before I even think about Exam Pt 2. You never said anything about a test!! :)

In regards to his neck, at the end of the video he's turning his head all over, so I figured it was fine, but now I know better.

And if I take him to the hospital, I can't stick around to impress the young maidens...oh never mind, I'd probably take him.

This was a really great think-about-it exercise, I definitely appreciated it!

#15 ::: James D. Macdonald ::: (view all by) ::: July 16, 2008, 07:51 PM:

And if I take him to the hospital, I can't stick around to impress the young maidens...oh never mind, I'd probably take him.

His girlfriend, and all of her friends, are going to show up at the hospital (possibly before you do) where they will be scooted out to the waiting room to ... wait. You can go there, offer to get them cups of water, and (since Someone Else now has the bubble and you aren't Terribly Busy) show them the attention they deserve. They will know that you helped the Young Man; they will press you for details (which, since you have not taken the EMT Oath you can give them), to their great wide-eyed admiration.

#16 ::: Joyce Reynolds-Ward ::: (view all by) ::: July 16, 2008, 07:59 PM:

Interesting. When DH broke his humerus skiing, as part of a dislocation as well, once the Ski Patrol got there (I'm figuring Ski Patrol has Major First Aid Training Fu--I've been skiing during Ski Patrol training camp), they didn't work on immobilizing his neck. On the other hand, he was moving around, moving the head, grasping his upper arm and moaning in pain. They seemed to be more concerned about additional injury to his chest.

What I did? I was uphill and didn't see the accident myself, looked downhill and saw him rolling in pain. Carefully skied down, assessed the situation, then stripped off my parka and tossed it over him and got him situated so his feet were uphill(okay, it was early season, the day after Thanksgiving, so I wasn't at risk but I was worried about him and shock) and told the young snowboarders clustered around to find me the Ski Patrol (one of them rode down to the bottom of the lift so the liftie could radio up for help, the others cast around until they found a Timberline employee with a radio). Patrol arrived, did quick assessment, and hauled him out upright in a small toboggan. We had the choice of ambulance/personal transport and he took the ambulance, just in case he needed pain meds.

I have seen the Patrol haul others out with backboard and immobilized neck in the honkin' huge toboggan. I think those were also the Life Flight candidates, not the ambulance candidates. I'm suspecting, however, that a crash and burn on snow and ice may be somewhat different from road rash on concrete.

#17 ::: Edward Oleander ::: (view all by) ::: July 16, 2008, 08:05 PM:

#12 - I think your instructions to downplay the splinting must have been a personal decision by someone in the chapter itself. Out here in the Twin Cities chapter we do teach the splinting, and even stress it.

The difference might be that most of us who teach here are also on the 1st Aid Team. I think we're the only chapter left that has one.

Jim, I totally agree about the 16 hour course... but I don't think many would sign up for them... Even our Instructor Cert course is only 16 hours (although you have to be 1st Resp or higher to take it of course)...

And once again, thanks for the ongoing med posts... I've showed my file of them to my co-instructors and the response has been uniformly positive... even though we can't use them formally in class because the ARC has an over-active bureaucracy gland...

#18 ::: Calluna V. ::: (view all by) ::: July 16, 2008, 08:05 PM:

Jim, #13:

In My Opinion, a first aid class designed for Average Guy/Gal on the Street should run 16+ hours and have a ton of hands-on.

God, I would have loved to have had permission to teach that class. I would have loved to have been trained to teach that class. ARC classes are (or were) generally 7-8 hours: 4 hours in the morning for CPR, 3-4 hours in the afternoon for First Aid, multiple choice test, boom, you're certified, we'll see you again next year for CPR and three years from now for First Aid. Happy Helping.

There was, at least, about as much hands-on as the time would allow. That was definitely the emphasis. But...it's not enough. It's flat-out not enough.

#19 ::: Greg London ::: (view all by) ::: July 16, 2008, 09:29 PM:

I'm rusty with my slings and splints, damn it.

also, OW!

Lastly, random unicorn chaser is here.

#20 ::: Carol ::: (view all by) ::: July 16, 2008, 09:38 PM:

I read "16+ hours" as "164 hours" and thought, wow, that's a LOT of hours. If Jim thinks that's what we need...

#21 ::: P J Evans ::: (view all by) ::: July 16, 2008, 09:39 PM:

I remember getting first aid, complete with artificial respiration and bandaging, lo these very many years ago in HS.
It was at least a 4-hour course - I can't, now, remember if it was one week or two, because two would make it at least 8 hours. We practiced on each other, on the stage in the auditorium (that being where the class was held). (The other thing I remember was us making jokes about possible monsters in the orchestra pit.)

#22 ::: James D. Macdonald ::: (view all by) ::: July 16, 2008, 09:53 PM:

In regards to his neck, at the end of the video he's turning his head all over, so I figured it was fine, but now I know better.

He's got what we in the trade call a "distracting injury."

I've seen people walk on broken legs.

#23 ::: Wirelizard ::: (view all by) ::: July 17, 2008, 12:44 AM:

I've got the Canadian Red Cross' Standard First Aid/CPR "C" ticket, renewed once already, and due for a renewal sometime this fall. Never had to use it, thank Dog.

Canuck RC's Standard is 16hrs, two full days (very full days) and the renewal is a full day by itself. Not sure if this is the same as the "ARC" folks are talking about - I think CRC does a short course as well, "First Responder" or something w/o the full CPR C ticket.

I gather that CPR procedure has changed recently - no breathing, all chest compresses all the time now? Adult standard 2.5yrs ago when I renewed was still 15 compresses/3 breathes/repeat, IIRC...

#24 ::: Anne KG Murphy ::: (view all by) ::: July 17, 2008, 01:17 AM:

Before the days when cell phones were so common I was in the second car behind a car that rolled off the road in heavy snow on highway 80 in Iowa. After a quick conversation the driver of the first car behind it (we both stopped) drove on to get help from the next town and we stayed to offer help onsite. The car had rolled onto the passenger side and then upside down; the driver and the passenger both got out of the car and were walking away from it by the time we got to it (it was behind where we'd managed to stop, and down in a ditch). The driver showed no signs of impact but the passenger had clearly hit the side of her head against the window of the car, which had broken either from that or impact with the ground. Luckily she was protecting her face with her hand at the time, so the hand was more badly cut and her face was relatively fine, but I was very concerned about her neck.

The driver and the other two guys with me stood outside our car and chatted (the driver wanted to smoke to settle his nerves) while I sat the girl in the back seat of our car, made her keep her head perfectly still, looking forward, put my coat over her lap as the nearest thing I had to a blanket (we may have put an additional coat over her shoulders, I don't remember), and had her raise her arm so her hand didn't bleed as fast (it wasn't badly cut, but still), and then proceeded with the making of small talk to find out about her and help keep her conscious and distracted/less shocky if possible.

When the EMT got there and decided she really did need an ambulance, she then made me hold the girl's head in the position I already had her maintaining, which was really really awkward and hard for me to do without introducing motion to her head and neck, until the ambulance got there. I don't know how long that took but it was one of the loooongest waiting periods of my life. Then they put a neck brace on her and took her out of the car. Because I wasn't related the hospital wouldn't give me details about them the next day, but said they were all right.

It really seemed to me that it was easier for the girl to immobilize her own head than for me to do so, though it would have been different if I'd had her lie down, I suppose, but that would have been tactically difficult in a small car. When a person is conscious and calm (unlike the patient in the video), is it really more effective for another person to try to hold their neck still (inline) than for them to do so themselves?

#25 ::: Cynthia Wood ::: (view all by) ::: July 17, 2008, 02:22 AM:

My 1st first aid course was actually a semester long credit course in college. Highly informative, and has made recertification since then a bit of a letdown.

I'd decidedly go for ambulance rather than transporting him myself. No way to hold a c-spine in transit in my car that I would trust.

We had a kid in my class in HS do something remarkably similar to that to his arm on Field Day. He tried to slide into base and it didn't go well. By the time the ambulance showed up, he was losing circulation to the hand, which exceeded the knowledge level of the available adults.

#26 ::: Bruce Arthurs ::: (view all by) ::: July 17, 2008, 04:24 AM:

A couple of years ago I was at home, mid-morning, when there was a knock on the door. Answered it to find two teenage girls, about 13-14, standing there.

"I think I broke my arm" one of them says, in a slightly shaky voice. I look down and see there's an extra bend in her right arm, about four inches behind the wrist.

"Wow, you sure did," I replied, and reached for my cell phone with one hand. With the other, I reached for a chair, and told the girl to sit down. (I was afraid she might start ot wooze out on me.) While speaking to the 911 operator and getting an ambulance dispatched, a handy basket of laundry provided a towel that, folded, put some padding underneath the arm.

With the ambulance on the way, the other girl gave me the first's home number, so I called the first girl's parents and let them know what had happened.

(I'd learned that from the two girls while getting the chair and towel, and talking to the 911 lady: The two girls had been trying to visit the teenage girl next door, but had no response when they knocked, so the first girl climbed on top of the 90-gallon trash can, with the rounded lid, to look over the fence to see if the neighbors were in the back yard. Slip, fall, bang, break, and they ended up at my door.)

Several minutes later, ambulance, parents, and a police car all arrive within seconds of each other. I let the EMTs take over.

(Yes, with hindsight I recognize that I should probably have had the girl lay down and elevate her feet, but considering my first aid training was over thirty years past, and that it had emphasized bullet and shrapnel wounds, I thought I managed a fair response to an unexpected situation.)

The policeman asked me what had happened, so I told him what the girls had told me, and partway through that telling I noticed that he was looking very closely at my face as I spoke, and that he was listening very closely to what I was saying, and I realized...

...that he was trying to determine if I was feeding him a line of bullshit, and whether or not I might have had something to do with breaking the girl's arm.

He must have seen that realization cross my face, because he told me it was routine to investigate closely whenever a child or minor was injured. Which reduced the sudden case of goosebumps I'd gotten by a bit, but still... sheesh!

#27 ::: aphrael ::: (view all by) ::: July 17, 2008, 04:29 AM:

Yikes. I was on a bicycle at the time, but I've had that injury, through a very similar poor choice of using my hand to break a fall. I'm cringing inside, now.

#28 ::: Connie H. ::: (view all by) ::: July 17, 2008, 06:41 AM:

Note to #27 -- trying to break your fall with an arm can be pretty instinctual, as the lizard-portion of the brain can take over, rather unhelpfully, in emergencies. So don't blame yourself too much!

#29 ::: Johan Larson ::: (view all by) ::: July 17, 2008, 08:14 AM:

@27, Daily Planet (a Canadian science show) had a segment about researchers trying to prevent broken hips in the elderly resulting from sudden falls. One idea they tested was teaching them Judo breakfalls. So they brought in a bunch of judokas and subjected them to unprepared falls. It turned out not one of them was able to use his training when he wasn't expecting trouble, even after years of training. Our response to falling is hardwired *deep*.

#30 ::: Arete ::: (view all by) ::: July 17, 2008, 08:57 AM:

Johan@29, I think it might depend on when the training was given - I've had that situation. At a live action roleplaying event, I was in a 'battle' when I tripped, hard. The 'sword' (pvc wrapped in padding) stayed in my hand as I did a somersault fall - not really it's name, but the judo fall where you use your arm to create an arc that you guide your roll with, till your shoulder rolls on the ground, and then point of contact goes diagonally on the back to the opposite leg, and you stand up. Which I did, to a massive double-take from onlookers and myself (impressing 15-yr olds boys for the win!). I was twenty at the time, with the judo training beginning when I was fifteen till I was eighteen.

#31 ::: R. M. Koske ::: (view all by) ::: July 17, 2008, 09:32 AM:

#29, Johan Larson -

That's interesting (and discouraging)! I'm really curious about the "subjected them to unprepared falls." Do you have any idea how they did that? I'm not sure how one would both surprise someone with a fall and protect them from, well, breaking their arm catching themselves or somesuch.

#32 ::: Johan Larson ::: (view all by) ::: July 17, 2008, 09:48 AM:

R.M. Koske@31: The device used to make people fall was a thin rug on a powerful motorized roller. When activated, it literally pulled the rug out from under the test subject. They ran their tests with a padded floor under the rug.

To catch people unawares, I suspect they just activated the machine while telling folks they were still setting up the cameras and whatnot. "OK, please stand in that spot over here. It will take me a few minutes to set up the cameras, and verify the motion-capture equipment is registering all the reference points. Please raise your right arm. Good. And the left. Good. Now turn around." WHAM!

#33 ::: Ginger ::: (view all by) ::: July 17, 2008, 09:49 AM:

Johan @ 29: That's odd. I studied a Korean martial art that emphasized throwing, and we began each class with warm-up falls, so I collected thousands of falls in the course of a year. This was more than ten years ago, and I don't study any martial art now. Yet everytime I have an unexpected fall (like stepping in a pothole while going downhill and falling flat forward), I end up on my elbows*, in proper landing position. It has saved me from several breaks, and it is totally unconscious on my part.

I wonder about the set up for those judokas. I would have expected them to react just as I have.

*Technically, I land on the flat part of the ulnas, not the pointy part down. It's a strong, thick bone, and can be used to break boards with, so landing on it is pretty safe. The next day, your shoulders and lats will ache, and your back muscles may punish you with muscle spasms, but hey -- nothing was broken.

#34 ::: R. M. Koske ::: (view all by) ::: July 17, 2008, 09:55 AM:

#32, Johan -

Okay, I can see how that would work. Thanks!

#33, Ginger -

Maybe that fall is closer to the instinctive movement than the rolling fall? (I never got any good at that fall in my Aikido classes. I was too frightened of it.)

#35 ::: Greg Morrow ::: (view all by) ::: July 17, 2008, 10:45 AM:

Jim:

Why get someone holding c-spine before you ABC? I thought the only thing that had more priority than ABC was getting help rolling.

#36 ::: Carol Maltby ::: (view all by) ::: July 17, 2008, 11:28 AM:

#29 Johan One problem with trying to teach the elderly to fall better would be that they couldn't afford much of a learning curve. If you break something while learning how not to break something, it doesn't do you much good.

What about making some videos that they could watch and absorb on a subconscious level? Some studies have shown that visualising physical acts can be almost as useful as physically practicing.

I'm middle-aged and stout and not very flexible, with no martial arts training. Yet a few years ago, when I slipped on some black ice in the dark, I somehow managed to not only roll with the fall but come up out of it in one smooth motion and land upright on my feet again. I quite astonished myself. I can only assume that all those years of watching Emma Peel came into play, as it happened too fast for conscious reaction.

#37 ::: James D. Macdonald ::: (view all by) ::: July 17, 2008, 11:31 AM:

Why get someone holding c-spine before you ABC?

That's because of the potentially devastating effects of spinal-cord injury. And you can't go back to fix it if you mess it up. Holding c-spine doesn't delay you in getting to the ABCs, but it may make a big difference in the outcome.

#38 ::: Joyce Reynolds-Ward ::: (view all by) ::: July 17, 2008, 11:35 AM:

John @ 29, that's interesting about the reaction to unprepared falls.

As a horseperson and skier, I've been subjected to unprepared falling. With the horse, the reflex is pretty much conditioned--tuck, roll, hands behind neck and take the fall on the right side (usually you have enough time when falling from horseback to do that, and yes, I usually do fall on my right side).

Skiing is a different story, depending upon whether I feel myself going out of balance and deliberately fall in a controlled manner, fall because it's the only way I can stop in a situation going to pieces, or if I get startled. Even then, I try to control the fall.

When I've fallen on my own two feet, though, it all goes to pieces as far as trying to control what is happening in the fall. The conclusion I've come to is that an unexpected fall from your own two feet simply doesn't give you enough reaction time to prepare a protective stance. If you're engaged in an athletic activity where falling is likely (such as martial arts or skiing), the likelihood of falling is already in your backbrain and you've got the initial reaction prep set up in your body. On skis, at least, I know that the momentum gained from moving forward buys me just enough time to set myself up to protect myself--at least, it has so far. On horseback, you're high enough that you have just enough time to set yourself up for protection (my falls have included the classic horse spooking out from under me--that one really made me feel like Wil E. Coyote, plowing through a jump sending standards and rails flying--but I had the time to pick my fall spot, and getting bucked off).

Tripping and falling, though, just happens far too fast. At least that's what it seems like to me when I review the falls on my own feet as compared to riding or skiing.

#39 ::: Carol Kimball ::: (view all by) ::: July 17, 2008, 12:06 PM:

Re: fractured wrists

Better not to break anything, but if I've got two bad choices, I'd rather crack my wrist than my skull.

#40 ::: B. Durbin ::: (view all by) ::: July 17, 2008, 12:30 PM:

#29: The only falls I've ever had have been from a bike; one was a full-on car encounter, low speed, and I rolled quite properly. This was before I started using a backpack instead of strapping a bookbag to my bike, so there was nothing to impede the roll. Good thing: I wasn't wearing a helmet. (I refused to use my bike again until I got one.) End result: piece of glass in my leg and whiplash.

Another one was a slow-motion stupid where I managed to wrench the wheel sideways and went over the front. That one I caught myself on my hands and just touched my chin to the pavement. I had a bruise on the inside of my thigh from the seat that didn't fade for a good six weeks or more; now that I've read the soft-tissue trauma thread, I'm a little concerned that all I did was accept some Advil from a friend, four hours later. But hey, all's well that ends well, so they say.

On c-spine immobilization: what if you know for a fact that the trauma is localized? I'm thinking of one injury we had a summer camp where a scout tried to draw his scoutmaster's compound bow and managed to break his arm from the strain. When he came back from the hospital, I asked him how he was and he said, "This doesn't hurt as much as when I broke my collarbone." Calcium deficiency, perhaps?

#41 ::: Lila ::: (view all by) ::: July 17, 2008, 12:38 PM:

Arete @ #30, I learned that breakfall in taekwondo in my early 40's, and did it instinctively when my 2 medium-sized dogs yanked me off my feet chasing a deer. I also did a good front breakfall (slap the floor with both forearms and palms) when my 2 dachshunds wrapped their leashes around my ankles in opposite directions and I tripped down the step into my garage.

Sometimes it works. (Also: although pets are good for your blood pressure and as a mood-lifter, dogs and cats are a risk factor for falls for elderly owners.)

#42 ::: R. M. Koske ::: (view all by) ::: July 17, 2008, 12:49 PM:

The anecdotes popping up here make me think the mental difference between "I'm doing something physical from which I might take a tumble" and "I'm walking across a carpeted floor with an active dog nearby" is more significant that I'd realized. It seems unfortunately impossible to use this as a solution for falls for the elderly, and probably cruel to try. ("You're *old* now, so you break easy. Think of the rest of your life as a bone-breaking obstacle course, and be careful. Have a nice day.")

#43 ::: P J Evans ::: (view all by) ::: July 17, 2008, 12:50 PM:

Falls:
The one bad fall I had from a bike (low-speed encounter with a stationary object), I landed, judging by the damage, on palm, side of arm below elbow, and knee, all on the left side. The knee was the one that was worst, but the skin wasn't broken there. The others were scrapes. The nearest patch of lawn had just been watered, so I used that to clean off the scraped spots. (No infections, thank Ghu.)

#44 ::: James D. Macdonald ::: (view all by) ::: July 17, 2008, 02:00 PM:

You always pay attention go mechanism of injury (MOI). Someone who broke an arm bone pulling a bow isn't in danger of a c-spine injury. Someone who broke an arm in a fall might be. You err on the side of caution.

Any altered mental status buys you full c-spine stabilization.

#45 ::: Ginger ::: (view all by) ::: July 17, 2008, 02:46 PM:

RM@ 42: Besides being the answer to Everything..for elderly people, one of the most effective ways to prevent falls is to have them do some exercise. Seated exercises like leg raises to strengthen leg muscles, seated arm exercises like bicep curls, and some basic yoga-type stretches -- all of these help rebuild some proprioception and the strength to resist falling.

Proper falling techniques need to be taught before you get to that stage in order to be incorporated as "second nature", but there's no harm in showing them proper falling and using a nice soft big pillow to fall into. It's a form of exercise, after all.

"OK, everyone got their pillows ready? On a count of three, we're going to fall on our faces.."

I have to say, after reading Johan's response, that it was a bit of an unfair situation: rolling the carpet out from under someone imparts a bit of extra momentum that translates to higher speed towards the ground. It isn't the same thing as stepping into a pothole while walking downhill (while not looking where I was going) and ending up on my front fall stance without even thinking. If I'd been walking on a roller carpet, I would have face-planted before I could even move my arms. And then I'd have been royally pissed off at the jerks who performed that maneuver, and I would have demonstrated why we don't play practical jokes on judokas, but that's probably just me.

#46 ::: joann ::: (view all by) ::: July 17, 2008, 03:54 PM:

Ginger #45:

I'll go along with the recommendation for strength training as anti-falling, and add in another thought: bio-feedback for balance. About a month ago, because it looked like a neat toy, we got the Wii Fit add-on, on the theory that anything to get me to exercise even a bit more than the 20 minutes of treadmill every day would be useful. Turns out to have a really big emphasis on balance (well, with a subtitle like Balance Board, what did you expect?) and also takes you through a bunch of strength training exercises and yoga. My balance has improved visibly, as has my posture; I can stand on one leg for more than half a second for the first time since puberty; I'm learning to do better about seeing things coming at me out of the corner of my eye and reacting appropriately; and I'm losing weight.

OTOH, I might not recommend it for really old people, as it involves stepping on and off the thing, which is about two inches high. I mention this because an old friend of my mother's has spent much time in rehab after breaking his hip when he fell off the bathroom scales.

#47 ::: Cynthia Wood ::: (view all by) ::: July 17, 2008, 07:03 PM:

Tai Chi is frequently recommended as a fall preventative in the elderly. I believe there's at least one study showing some effectiveness.

There's a huge difference between a situation where you can reasonably expect to take a tumble (fighting, dancing), and just walking around minding your own business. I did a nice backward rollout in the middle of a karate bout a couple of weeks ago (It is very impressive to the 15-year-old boys, isn't it?), but I'm pretty sure I wouldn't have saved myself from my broken wrist several years ago from tripping backwards and catching myself with my hand. Not to mention the tight quarters indoors. There's a good chance that a back shoulder-roll would have put me through the plate-glass door behind me.

#48 ::: joann ::: (view all by) ::: July 17, 2008, 07:20 PM:

Cynthia #47:

Yes, walking around on poorly maintained streets in the dark is a sure way to have an entirely unexpected fall. Foot goes into declivity, or finds treeroot-caused unevenness in sidewalk, and boom. Somewhere--after I froze my shoulder--I learned to roll with those falls, too. Start falling forward, do *some*thing in midair (if I thought about it consciously, I'm sure it wouldn't happen), end up on my plumpest part. The really hard part is getting back up.

#49 ::: David Dyer-Bennet ::: (view all by) ::: July 18, 2008, 12:24 AM:

Jim@#13: I've watched the course length dwindle over the years I've been taking the basic civilian bottom-level training. CPR and first aid used to be separate, and CPR covered two-person and babies as well as the most basic version. First aid included fun bondage techniques using triangular bandages :-). Now they've got it down to half a day for both. We actually got taught tourniquets in the first course I took.

#50 ::: Marilee ::: (view all by) ::: July 18, 2008, 01:50 AM:

Johan, #29, I've been taught how to fall, and although nobody ever pulled a rug out from under me, the training has worked well. In all the falls I've had since the stroke, none has broken bones. I was taught to drop what I'm holding, no matter how important, cover my face with my hands, and pull my elbows in over my chest. This way the face is protected, and I'm not landing on an extended elbow or arm. We're supposed to just go with the fall, become loose, and evaluate when we land.

Joyce, #38, that's true. When I walk, I think about falling. I think about opening my hands to drop what I'm carrying, I think about where I'd fall, every step. But falls are still fairly unexpected.

Ginger, #45, Kaiser does a not-falling class for the elderly (I think they'd let me in), but it's at 8am in Arlington! What the heck are they thinking!?

#51 ::: Johan Larson ::: (view all by) ::: July 18, 2008, 07:23 AM:

Marilee@50: "I was taught to drop what I'm holding, no matter how important..."

That's an important bit, I think. An acquaintance of mine slipped on ice and tried to protect the laptop he was carrying. He ended up breaking his shoulder socket in an interesting way. Six months of first-class medical care later he still couldn't raise that arm above the shoulder, and won't ever fully recover.

#52 ::: Cynthia Wood ::: (view all by) ::: July 18, 2008, 12:48 PM:

Marilee@50: "I was taught to drop what I'm holding, no matter how important..."

Yes, and no.

The worst spill I've had in my life occurred while I was a young mother and carrying a tiny infant. I would not take back the instincts that kept my newborn safe even if a conveniently placed concrete block hadn't saved me from a crushed foot.

Though I will say the child-protective instincts would probably kick in regardless of training, and in my experience they seem remarkably astute. When the same kid was 22 months old and I was seven months pregnant, I turned my ankle on a curb and went down while carrying the sprog on my hip. I came up on the other side having somehow managed to set my toddler securely on his feet while turning a complete front shoulder roll to protect my belly. I was shaken up and thoroughly scraped (gravel parking lot) with a sprained ankle, but both toddler and fetus were entirely undamaged.

And I'll be damned if I can even figure out exactly what I did - let alone attempt to duplicate the manuever.

#53 ::: Lila ::: (view all by) ::: July 18, 2008, 04:20 PM:

What Ginger Said @ #45. There's a lot of good research showing that just about any kind of exercise reduces the risk of falling in the elderly. (Go to Google Scholar and search for "reducing fall risk".)

The really annoying thing is that the common behavior pattern goes like this:

1. elderly person falls, or nearly falls.
2. elderly person becomes fearful.
3. elderly person becomes less active, thus weaker, leading to an increased risk of falls.

This is why "fear of falling" is itself a major fall risk factor.

#54 ::: Marilee ::: (view all by) ::: July 19, 2008, 01:21 AM:

Cynthia, #52, before you had the baby, did you have a stroke that damaged your ability to walk and not-fall? I was in a class for stroke patients. That's why I don't carry important things.

#55 ::: Cynthia Wood ::: (view all by) ::: July 19, 2008, 01:12 PM:

Marilee @54

No, I hadn't. I can well understand why someone in those circumstances would choose not to carry anything that couldn't be dropped. Though I find myself pondering the difficulties of young mothers who do have neurological injuries or other conditions that increase the odds of falling.

#56 ::: Robert Sloan ::: (view all by) ::: July 19, 2008, 01:40 PM:

That's interesting about the falling training that didn't help. I skied when I was in high school and the first lesson was in falling. It stuck in my mind because I spent money and went on a long bus ride to spend a whole day falling into snow. Yet it was a good idea, because thereafter I never broke a bone skiing.

I suspect that I haven't broken any bones later in life because of that fall-training in the ski program, but it's less formal than the judo training. It's more going loose like a cat and rolling with the direction of it, and I've done it in several household falls or outdoor trip and fall incidents over the years. Expectations seem to have a lot to do with it -- and I think the lady's right about Emma Peel, mental rehearsal is still real practice on some level. You know what to do and sometimes that cuts in.

#57 ::: Collin Fisher ::: (view all by) ::: February 03, 2009, 09:24 PM:

Commend you on your series Jim.
This stuff is gold, and comes across very well.
Some good and interesting discussion here too.

I did my first ever first aid course in 2004 - before that I used to get paper cuts opening bandaid boxes and my first aid kit basically consisted of a safety pin and a broken pencil.

It was a 2 day 20Hr course and was very practical, even to the extent of a scenario before we even got started to find out who could do what. At the end of the second day and the final full-on, no holds barred scenario my head was fizzing! How the hell was I going to remember all this stuff??

20 minutes into the journey home afterwards, I was one of the first cars to come across a seconds-old high speed headon. I still remember cresting the brow of the hill, seeing the scene and thinking that the instructors had set me up with another scenario...!
4 fatals, 5 criticals. Everything went into automatic - Walk to the scene assessing and putting gloves on as I went...Safety, get help rolling, triage, direct others. I was there for around 4 hours with my patient until they cut the car from around us.

Anyone even remotely considering that maybe they should do a first aid course - Book it now.

#58 ::: James D. Macdonald ::: (view all by) ::: February 03, 2009, 10:46 PM:

Wow, Collin. First-on-scene in a multi-patient multi-vehicle collision is challenging, even if you've been doing this for a while.

Your fast, correct action could well have been what kept it from turning into five, six, or more fatals.

Good job.

#60 ::: Xopher ::: (view all by) ::: February 03, 2009, 11:12 PM:

Bravo, Collin! As I've said elsewhere, when I say "Praise be to Aesculapios!" I usually mean "I'm sure glad there are good doctors and EMTs."

Praise be to Aesculapios for people like you!

#61 ::: James D. Macdonald ::: (view all by) ::: February 04, 2009, 10:17 AM:

Here's the curriculum for a two-day First Aid course. It looks pretty good.

Oh -- I'm going to be teaching a one-hour first aid course at Boskone: Sunday 1pm First Aid for Fen

#62 ::: Adrian ::: (view all by) ::: February 04, 2009, 11:41 AM:

Jim (61), thank you so much for bringing a first aid course to Boskone! Do you know if it will be only for adults? I'm not thinking of certification, just potentially useful knowledge for a child who has no time for scouts between karate classes and Hebrew school.

#63 ::: James D. Macdonald ::: (view all by) ::: February 04, 2009, 12:06 PM:

This isn't a certification course, and I'm not going to say anything that a child can't/shouldn't hear.

#64 ::: Mez ::: (view all by) ::: February 04, 2009, 12:47 PM:

I can't find the original from 2003 online anymore, but here's an obituary written by an old friend that a First Aid for Fandom course put me in mind of.

#65 ::: fidelio spots spam-like posts ::: (view all by) ::: May 11, 2009, 10:03 AM:

Yessir, yessir, three posts full!

#66 ::: Carrie S. sees linkspam ::: (view all by) ::: May 11, 2009, 10:03 AM:

Oh, so many, many links...

#67 ::: Danika Zoe ::: (view all by) ::: July 20, 2011, 12:12 AM:

Anti-spam patrol! (Hopefully this won't double-post as my last attempt did.)

I don't have any experience with trauma patients, but I did have a run-in with a deluded mother last night who claimed that her 30-year-old child didn't have a job because "there just aren't any jobs for nurses". Since I know that nursing is one of the skills shortages of my country, this was bewildering at best...

#68 ::: Cassy B. spots SEO spam ::: (view all by) ::: February 01, 2014, 08:10 AM:

@68. Alas, the deluge continues...

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