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.

26 comments:

  1. Age vs. Gravity is our most common fall, here, too. yuo will be glad to know that there are five questions we ask in assessing the patient, and if they get the answers right, you never get to meet them (at least until next time)
    the questions are:
    did you hit your head?
    do you remember the entire fall?
    do you know the day of the week?
    do you know who the president is? (we get some great answers to that)
    and most importantly:
    Do you want to go to the hospital?

    of course, if they get the answers to the first ones wrong, they don't get the last one - they just go, especially if they are on blood thinners.

    and yes, by total coincidence, first thing in the morning, this morning, I got the pager tones that usually mean someone on the wrong part of a cliff - with nothing but carrier wave after - and no chatter on either of the common working channels. maybe once I take my phone out to cellular range, there will be a text message explaining, and maybe not.

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  2. Oh i Love *redacted* cliffs! Its near my home at *Location withheld*

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  3. Doc, I got some real weird looks as i laughed out loud in public.

    Thank you for this post.

    Yep, they occasionally let me out in public although it is spoiled by having to tolerate my responsible adult.
    She who is usually seen heading away when some gadget or shiny thing or funny gets my attention.

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  4. Hmmm. Soooo...have you *not* almost ever fallen off a cliff?...not even once? (Okay, that is almost as fun an icebreaker as "Have you ever gotten anything irretrievably stuck inside one of your nostrils?")

    But seriously, I would rather appreciate knowing that I am not quite so unusually stupid or nearer than the average person to winning a Darwin Award in having very nearly slid right off a cliff, myself. (Wait. Can the deceased receive a DA posthumously? ...because there is no way I would have survived the fall).

    It was the cliffs along this hike in Kauai: http://www.dayhiker.com/directory/hawaii_nopali.htm. I was youngish (23), revelling in my first solo Hawaii vacation after saving for many months and I didn't hesitate to greedily snatch up as many adventures as possible during my time in that gorgeous island (including about six solo day hikes). On this one particular hike, about 7 miles in, when I hadn't seen anyone for a couple hours, I paused to take a break in a small stream under a smaller waterfall while staring out over the cliffs down to the awesome ocean; and when I climbed back out (sighing in pure bliss over the perfection of this spot [and actually even smug over my genius in being the only one there to savor such paradise]) I began to walk a short distance so I could recline on a flat boulder in the sunshine to dry off. The drop to the rocky shore below was at least 100 feet but I wasn't intending to sit near the cliff. I mean, the boulder I was meandering towards was a good 12 feet away, albeit down a slight incline right before the 100+ foot drop. But just as I tossed my shoes near the boulder, and turned to gaze out over the ocean again, my bare feet slid in the muddy, mossy ground and then I tripped on some vines and smacked face first onto the incline and began to roll and slide ...and slide and roll. It was ultimately like a movie--no, worse, like a cartoon, where the stupid Bugs Bunny monster character is forced to grab onto rocks and vines to slow his fall and then his lower body is dangling over the cliff and Bugs Bunny smiles while chomping his carrot and slowly peels the monster's fingers off the vine, one by one and...well, except Bugs wasn't there. Not a single witness was around except, perhaps, some Hawaiian gods determining whether or not I was too stupid to live.

    They were presumably merciful and I managed to clamber back up the incline; and (for various reasons, including the shame I felt over my total stupidity) I actually never told anyone about that until years later. But it did have an impact on me, reminding me of my mortality and how selfishly reckless I had been. I doubt my body would have been found for days (if at all) so there would probably have been a 'missing person' search and no closure for my family/friends for some time ... And my last words (< faceplant> "Ooof-ow! "Ooohh crap. Oh f*** f*** f***!!!") would only have been heard by ...the really quite magnificent natural wonders thereabouts so actually that part would've been okay but still; not even a trauma surgeon to indirectly entertain with the circumstances of my stupid plummet off the cliff.

    I mean *maybe* some Hawaiian coroner could have added another tick mark to some "idiot tourist deaths" tally but that's about it.

    So now ...anyone else? Or do I definitely win the DA by ~7 miles or so on this one?

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    1. have to say that is a close call I have managed to stay a safe distance away from.

      and yes, DAs are most commonly awarded posthumously. in fact, it is exceedingly rare for a person to survive qualifying for one.

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    2. Ah, yeah that actually makes far more sense as I consider the DA's qualification requirements. I suppose I just assumed they were only awarded to survivors like Xavier. (Cuz of the whole "don't speak ill of the dead" golden rule thing, don't you know. [Not that I am a great adherent of many such "rules," myself; I just figured the DAs were too popular to be as insensitive as ... well, as I am])! ;)

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    3. The DA's are for those who have, through acts of stupidity, removed themselves from the gene pool, advancing the survival of mankind by a slight amount. So, congratulations on NOT being in that pool, Cole!

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    4. Thank you, Scott (unless u r being facetious and actually sense it might have been better if I did fall off that cliff and earn a DA in which case ...how rude, Scott).

      But speaking of pools and Kauai (sorry, I can't help it)..later on that same hike (yes, I kept going after a second quick shower under the little waterfall to wash off the mud and blood), I actually think I *flew* out of a natural pool when I glanced down and saw what appeared to be an underwater black scorpion an inch away from my hip. It turned out to be crawdad but ...< shudder> looked very much like a scorpion.

      Oh, and I probably almost earned another DA that same hike when I drank some of the water from a stream, risking ingesting whatever bacteria or amoeba it is that resides in such natural water sources.

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    5. when I was young, I was fully resistant to all wild bacteria in my area. today, I wouldn't take the chance, because I haven't maintained it.

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    6. One can "win" a Darwin Award only by removing oneself from the gene pool, either by dying or by eliminating the ability to reproduce (as the rules state: dead or sterile).

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  5. I tend to stay away from high falls. I've got a rather wicked fear of falling, so I get nervous if I even get 'close' to an edge or something that feels unstable.

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  6. Did some freeclimbing up a cliff as a kid, had a bad time about 5 stories up or so when I couldn't find another handhold to keep going up, and couldn't go back. In retrospect makes me think unkind things about the trip chaperones, there were like five of us doing it. First real intimation of personal mortality, still get panicky thinking about it.

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    1. I did a little amateur climbing as a kid, then took a climbing class in college. now I'm on the technical rescue team, and we do have a small percentage of calls for an amateur climber who got stuck. protip: if you have to telephone for help, and can possibly do so, take some pictures of distinctive landmarks, and coordinate to send them to the rescuers by text message. one of our rescues involved sitting for two hours saying "well, we think he's right below this point, but we can't be sure because his battery died and we can't ask him. if we'd had a picture to refer to, we could have compared the landmarks.

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    2. addendum: that particular call ended with the helicopter crew finally getting back from fueling and saying "well, as long as we're here confirming his location, we'll just scoop your rescue"

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  7. Okay, so I am still quite new to posting comments on blogs but assume there are rules (of etiquette if naught else) that should serve to prevent me from responding too often or otherwise seemingly intending to pollute/subvert/capsize/etc. our favorite Doc's forum. IOW, I should probably refrain from ever adding 2x the amount of text in my comments as Doc offers in his original post, here (or whatever the proper ratio might be).

    Yet there is so much I am now inclined to chat about:

    What we would vote as the ten funniest lines in Doc's short but sweet first post of 2019; whether a wicked fear of falling (like Dakala's) can be classified as a phobia since it isn't irrational the way a fear of heights (i.e. empty air) is and cone to think of, why we generally consider "air" synonymously with oxygen rather than nitrogen; how Anonymous *did* manage to return safely to the ground and what the youngest age is for most humans to truly recognize their mortality and whatever were those trip chaperones doing and thinking; exactly what Scott Aylor's cool pic is depicting (a giant werewolf holding a 🐱?); why kitties are so perfect and whether the t.gondii bacteria is responsible for the ancient Egyptian worship of kitties; who Ken's employer is and how his career isn't constantly placing him in danger of falling off cliffs; who the DA winners you have personally encountered might be and what did they do to earn this award; whether opting to never reproduce exempts one from being eligible to win a DA; if typing into Google News some of the keywords contained in Doc's posts might reveal specifics he is obliged to redact and if he is trusting us not to seek any specifics; why SPAM is a favorite staple in Hawaii; what are some of the best responses Ken has received to the "Who is the President?" query; what are some of the "last words" Doc has heard [w/ apologies for my morbidity]; whether most humans would prefer dying out in nature or tucked up in a bed; why the U.S. is still not using the metric system; whether anyone else feels a special connection to the place one was conceived as I feel for Kauai (ewww...TMI, I know); how my fave young e-cousin, Connor, is doing in *Location withheld;* why professional athletes and entertainers make more money than health care workers, firefighters, and other first responders; why the Universe exists; and so on.

    < sigh> But I must resist.

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    1. "whether a wicked fear of falling (like Dakala's) can be classified as a phobia since it isn't irrational the way a fear of heights (i.e. empty air) is"

      I'd consider my response a bit irrational. If I miss one step on the way down the flight of stairs, I'm latched onto that hand-rail with enough grip to leave finger-nail marks in the wood. And this is from someone who normally doesn't have that kind of grip strength.

      Granted, if whatever I'm standing on feels stable, I'm fine. But I have had that 'fun' response in elevators if they're a bit quicker than standard.

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    2. the US is not using the metric system because our entire country is quite literally built on imperial measurements, which are perfectly suited for measuing commonly measured things, while forcing metric will either involve making a prohibitive number of adaptors, or having things built in REALLY strange measurements. case in point, do you really want to go to the lumberyard and ask for a 1219.2 X 2438.4mm sheet of plywood? because that's what you will have to buy to match the 4X8 sheets the rest of the country is paneled with.

      think about that over your next .568261 liters of beer.

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    3. my height response is very deeply connected to my trust of whatever it is I'm standing on. I've launched into 100 feet of free space on a rope, but wobbly wooden stepladders make me very nervous at any height.

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    4. Also converting every single road sign, spedometer, screw and screwdriver and everything else in the entirety of the USA would cost a metric fuckton. Remind you, the USA is Waaaaay bigger than the whole of Europe

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    5. and keep in mind there are many places in europe that are officially metric, but locals still use legacy units of measurement for a lot of things.
      really, metric measure is great for scientific pursuits, but it is a headache fr day to day use, because the basis of the entire system is a completely arbitrary distance - something about meridians passing through Paris. so it doesn't coincide with any natural thing you are ever likely to cross paths with.
      so trying to get the real world to align with metric measurement is like trying to convert to metric time: 10 seconds in a minute, 10 minutes in an hour, 10 hours in a day, 10 days in a week, 10 weeks in a month, and 10 months in a year.

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    6. Here in the good ole UK *Waves* we have both metric and imperial.
      Distances are unofficially in metric as the UK never got around to making it law so road signs are metric heights are by law metric but they must also show imperial, canal signs are metric, weights in stores are metric although pints and half pints in pubs remain imperial. It used to be illegal to sell produce in markets in imperial although we did manage to change it so it could be sold in metric or imperial (metric with imperial weight also shown)
      Fuel is sold in litres.
      i always ask for the imperial weights and cannot figure out distances in metric even though i was educated using both)IE a quarter of this or a quarter of that
      Europe is metric and now we are leaving the EU (hurray woop woop ) i wonder if there will be another campaign to revert back to imperial.

      I think we did it just to piss the hell out of europe. :)

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    7. you do know metrics are phrench, don't you?

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    8. I remember back in 4TH grade our teacher told us the USA was going to convert to the metric system in less than 5 years. I'm in my mid 60's now. We never did convert.

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    9. I guess I'm not the only one who doesn't feel like estimating distance by pacing it off and then multiplying by .9144.

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