Wednesday, 9 January 2019

Falling down

Of all the trauma alerts I get, the most frustrating has to be "FALL". These are usually elderly patients who fight gravity and lose, and their cases are seldom (if ever) satisfying. They typically are uninjured beyond bumps, bruises, and lacerations, though due to their age their recovery from such minor injuries can take several days or even longer. But if they do sustain serious injuries, they tend to be isolated to hip fractures, which I don't treat. The other types of falls (off a ladder, off a roof, off a bar stool etc) usually are from heights of 3-4 metres and are thus mostly uninjured (zzzzzzzz) or have broken ankles, which I still don't treat. All of this adds up to a very sullen me as I trot down to the trauma bay for yet another fall.

So when my pager alerted me to a fall recently (my third one of the day by 10 AM already), I got not a bit excited and tried my best to avoid the trauma bay entirely. I had only had one coffee by then, so I figured maybe the caffeine would elevate my heart rate even if the complexity of the trauma didn't. My Inner Pessimist, however, forced me to walk down to the trauma bay despite my efforts to ignore him.

The bustle when I got to the trauma bay confused me. Normally for low-level traumas the nurses and other staff sort of mill around chatting prior to the patient arriving, but in this case everyone was rushing around getting equipment. For a fall? What the hell is going on?

And about 30 seconds later, Xavier (not his real name™) arrived, and that question was quickly answered.

"Hey there Doc, this is Xavier. He fell off a cliff and . . ."

Wait, wait, wait. He fell off a what? Where the fuck is there a cliff around here??

"Yeah, you know the {Redacted} Cliffs."

Uh . . . no I really don't. I had no idea there were any cliffs in this area.

"Anyway, Xavier fell off a cliff about 30-40 metres. He woke up at the bottom and doesn't remember anything. 

No but seriously, where the hell is there a cliff?

"Ahem. Vitals have been stable though he's breathing a bit fast. He's complaining of pain all over his body."

Yeah, after falling 40 metres down a goddamned cliff I would be stunned if he weren't.

Normally the first thing I do is a full assessment, but my Inner Pessimist was insisting that I google where the fuck this cliff was. I resisted that urge and instead decided to, you know, examine my patient, an idea which seemed only slightly more important at the time. Xavier looked completely miserable. His blood pressure was fine but his heart rate was in the 140's. The most common reason for a high heart rate in trauma is bleeding, the second most common cause is bleeding, and third most common cause is fucking bleeding.  It could also be due to pain or heart injury or drugs, but bleeding is always my first concern. My concern was somewhat higher because his oxygen saturation was in the 80's (normal is 95-100%). 

On my initial head-to-toe assessment he was tender in his head cervical spine, thoracic spine, lumbar spine, chest, left hip, and left arm, though other than some rather crunchy ribs he had no obviously broken bones. His breath sounds were diminished on the left side, indicating that he likely had a pneumothorax (collapsed lung) under those fractured ribs. That concern was confirmed about 60 seconds later when I saw his chest X-ray.

His workup, which included X-rays and/or CT scans of pretty much every single body part (I think I skipped his thymus and right foot), showed that he was fucking broken. Think of a body part - go ahead, just think of one (other than the thymus and right foot, obviously). Yup, you got it, that was broken. He had fractures in his skull neck, upper back, lower back, ribs, hip, arm, and leg, along with his pneumothorax. He would need a chest tube for his lung, surgery for his hip, arm, and leg, and a neck brace and full back brace for his spine, which would not need surgery.

But the main question I had (other than "What cliff?") was, How the fuck do you fall off a cliff? And seriously, what goddamned cliff??

After several rounds of IV narcotics finally successfully controlled Xavier's pain (because of course he had a longstanding history of oral narcotic abuse), I got a chance to ask Xavier what happened. He very groggily told me that he was trying to show his in-laws the {Redacted} Cliffs while they were visiting that morning, and he simply got too close to the edge, lost his footing, and toppled.

This, I thought, is why I will never be out of a job.

As I contemplated the amount of human stupidity that it takes to get that close to the edge of a cliff (which, I learned later, has no guard rail on it), I looked at Xavier's blood work. While there was no major abnormality in either his blood counts or chemistry, his blood alcohol was about 3 times the legal limit to drive, which a quick calculation told me is approximately infinity times the amount of alcohol one should have in one's system while walking near a fucking cliff at 9 in the morning.

Xavier spent about two weeks with me before going home in a wheelchair, but it took me far less time than that to find out where these cliffs were. The moment I got in my car to go home the next morning I whipped out google and discovered that these cliffs are less than an hour's drive from the hospital. I briefly considered checking them out, but instead I decided to drive straight home and give my kids a big hug.

That seemed much more important. The cliffs can wait.

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