What would you do?

[the_alchemist]

Please share your response on this scenario:

Demented geriatric patient fell on concrete floor from wheelchair, sustained a laceration near the corner of the eye and bleeding was controlled. c/o pain in injured area. He is able to mention his name when asked. He is disoriented to time and place, same as baseline. He moves his hands as he has been known to do. Vital signs stable.Neuroassessment done. Pupils round and equal, able to follow objects. No distortion in the face. No fluids coming out of facial openings. Able to move extremities when instructed to do so. Grasps hands when asked to do so, equal. No episode of unconsciousness, no seizure, no sign of distress.

[Asystole RN]

Who is questioning?

DON, police, MD, Admin, Obama?

I hope the Nurse wrote in the order the type of transport...

"Transport pt to ER for eval non emergent"

[the_alchemist]

The patient stayed in the hospital for about 16 hrs before he died.

The DON and MD understood that pt was in no acute distress and not in an emergency situation, given the pt's condition before he left as witnessed by the EMTs and as documented.

Unfortunately, the other nurses are the one questioning WHY not sent 911? A company consultant was also aware of the situation, the same consultant who questioned another nurse a couple of years ago why a patient who fall with no injuries but c/o headache was sent 911, thus wasting the governments money.

It is not normally written in our facility whether or not for emergent transport, however that sound like a very good way of saving our butts.

Our facility has fairly good protocol. we do xrays, ct scan, or what have your after EVERY fall and the doctors agree with the protocol. if a doctor doesnt agree after we explain the need to, we document and monitor the patient.

[dudette10, MSN, RN]

Unfortunately, the other nurses are the one questioning WHY not sent 911?

They are only commenting after the fact? Were any of them in the facility while this was happening and suggesting that 911 be called?

[the_alchemist]

they weren't. There was another RN who asked if 911 was called, and she asked before she saw the patient. After seeing the patient, she agreed that the patient was not in an emergent situation and advised about the importance of documentation, which the attending nurse did well.

[scoochy]

What was the cause of death??

[CoffeeRTC, BSN, RN]

I've seen my share of falls in LTC. Unless it was facility protocol, I wouldn't have called 911 in a stable patient. If transport would have taken 45min to hr, then maybe I would have called them. (our hospitals are less than 15 minutes away)

What was the cod?

[the_alchemist]

There's no official report yet on cause of death, but the MD who saw him at the hospital said 'they found a lot of blood in the head"

[Penelope_Pitstop, BSN, RN]

There's no official report yet on cause of death, but the MD who saw him at the hospital said 'they found a lot of blood in the head"

That's what I was afraid of in this situation.

The head lac in of itself isn't a cause for concern; in fact, ANY TIME an elderly person sustains a fall there should be studies performed. It sounds like your facility has excellent protocols. If the gentleman fell on his rear end, didn't have any LOC changes or evidence of fractures, I'd consider it "non-emergent."

However, he obviously hit his head.

The elderly are already at a higher risk of a subdural hematoma because of the enlarging of the subdural space. If the patient had hypertension or was on any kind of blood thinner or anti-platelet agent, that makes him even more susceptible. And remember that SDHs can take a while before they are symptomatic (even longer than epidermal hematomas like the one that killed Natasha Richardson), so time is of the essence in these situations.

His death is still not that nurse's fault. Hindsight is 20/20.

[Asystole RN]

I was thinking epidural hematoma.

[Penelope_Pitstop, BSN, RN]

I was thinking epidural hematoma.

The only reason I discounted epidural is the lack of a lucid interval. The patient's LOC didn't change for at least the first hour and a half after the injury occurred, so there wasn't a chance for a lucid interval. Although the nature of the injury would suggest epidural hematoma.

I don't disagree with you, though, I'm not convinced it was SDH. I just thought that was the more likely option.

[Asystole RN]

The only reason I discounted epidural is the lack of a lucid interval. The patient's LOC didn't change for at least the first hour and a half after the injury occurred, so there wasn't a chance for a lucid interval. Although the nature of the injury would suggest epidural hematoma.

I don't disagree with you, though, I'm not convinced it was SDH. I just thought that was the more likely option.

The lucid interval is rare in people with EDH, 20% or so plus the pt's baseline was LOC x1 anyways so it would difficult to assess if there even was a lucid period or not.

EDH is rare in the elderly compared to SDH but the thing that made me shift towards EDH is the speed of demise. 17hrs from bang to box...

Do we know if there were anticoags onboard? Skull fx?

This would make a fascinating case study...too bad there won't be an autopsy. Any other guesses of CoD?

[kids]

I'm curious if the fall itself was the result of loss of balance from a slow brain bleed.

What was his ambulation status pre-and post fall?