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As people age, they become more susceptible to trauma and injuries. Factors like osteoporosis, vitamin deficiencies, and tumors increase the risk of fractures and falls. Older patients may also have spinal issues like kyphosis and scoliosis, which make it challenging to provide proper care. Alcohol abuse, weakened blood vessels, and coagulopathy disorders can lead to serious head injuries. Environmental factors like hypothermia can also be dangerous for older individuals. When assessing elderly patients, it's important to consider their pre-existing conditions and potential medical events that may have caused their injuries. Prompt treatment, transport to a trauma center, and thorough assessments are crucial. Managing bleeding, suctioning, and monitoring vital signs are essential steps. Psychological support and documentation are important parts of care. I'm going to keep doing them. Nearly half of fatal falls are the result of a traumatic brain injury, a TBI. Remember, a moderate impact to the head can cause a severe brain bleed because they have that extra movement in the brain because the brain is atrophied, shrunk, so you have more room for the brain to shift, causing more damage. Anatomic changes, changes in pulmonary, cardiovascular, neurologic, and musculoskeletal systems make older patients more susceptible to trauma. They don't have as much psychomotor abilities, their, how would I say, their reflexes, they're not as good. They're not as quick, so they're more likely to sustain trauma. Osteoporosis predisposes patients to hip and pelvic fractures, and those can be life-threatening in an elderly patient. Contributing factors, stress of ordinary activity, standing, fall, literally I've seen people stand up, turn, pop their head. Vitamin D and calcium deficiencies, metabolic bone diseases like osteoporosis, and tumors. My ex-father-in-law went to pick up a box and fractured his humerus, for picking up a box. Didn't know anything beyond that, went to the hospital, they did an x-ray, and it was a tumor, cancerous tumor in his arm. They did another x-ray and found that he had lung cancer. He smoked his whole life, but the type of cancer he had was non-small cell lung carcinoma which is a non-smoking cancer, and metastasized to his lung. He died of cancer maybe a year later. With age, the spine stiffens as a result of shrinkage of disc space and the vertebrae become more brittle. These intervertebral discs dry up, they become more brittle, and the bones become more brittle. So they have more bone-on-bone grating, it hurts to bend over, it's like people hurt when they bend over, and they walk with that kind of blunt edge over. Compression fractures are common. Sometimes you get the elderly patients with a kyphosis, ovidosis, or scoliosis. A kyphosis is a pot's curvature, it's that bowing up here, and the patient's like this. A lordosis is down in the lumbar, and they're over like this. Scoliosis is the curvature. And a spondylosis is actually, spondylosis is a change front to back, so it kind of loses, see how it kind of curves out and then in, so it kind of goes like this? Well, spondylosis would do a different curvature, whereas scoliosis is a curvature this way. And so patients have all kinds. And imagine you have a patient with a pot's curvature like this. How do you backboard? How do you put a collar on him? Do you just take him and kind of smoosh him down onto the stretcher? Don't do that, you'll hit, as you break his spine. So, when you put him on the stretcher, you've got to kind of pat around him. You've got to kind of make, I've done that before, you can't put him on a backboard, you've got to put him on the back, on the stretcher, and you pat around him, and you kind of stabilize him. You do the best you can. Sometimes it's difficult. Acute subdural hematomas are among the deadliest of all injuries. Actually, the chronic subdural hematoma has a 60% mortality rate in the elderly because it's not usually seen. It's hidden, it's what they call... With the pelvic pressure, how do you... You use a scoop stretcher, you put him on his back, you put him on, pick him up with a scoop stretcher, put him on the stretcher with a sheet, take him to the hospital, and then you just remove the scoop stretcher, and you leave him on the stretcher itself. And you have a sheet there, and you pick him up and move him on the sheet. It's very painful. No, it's not. You can use a pelvic binder to splint it, if you have one. Most of the time, we just put him on the scoop stretcher. We don't put a pelvic binder. Other factors that predispose an older patient to serious head injuries include long-term alcohol abuse. Number one, alcohol abuse, because they tend to not have the wherewithal, they tend to, when you're under the influence, you tend to fall more. They also have weakened blood vessels and coagulopathy disorders. Reoccurring falls, repeated head injury, and anticoagulant medication. Maybe they take anticoagulants due to DVTs or TEs or history of strokes. Environmental injury, internal temperature regulation is slowed. Half of all deaths from hypothermia occur in all older people. Many times, it's indoors. I've gone into people's homes where it was colder indoors than outdoors. They lock their windows, lock their doors, close them up. They can't afford heat, so they just wrap up in blankets. You walk in their home, and you can see their breath. You can see their breath in the air in their home, because it's so cold. Death rates from hypothermia are more than doubled in older patients. Patients over 85 are at the highest risk. Again, especially in the city. I live on the first floor or the second floor, so I've locked my windows. I don't put an AC, because it can be kicked in. So, I close up my house to be safe. So, my inside of my house may be 100 degrees, so I turn fans on. And literally, it's like a convection oven. You just blow 100 degree air around. Trauma is never isolated to a single issue when you're assessing and caring for an elderly patient. If you have a trauma patient, let's say a femur fracture, but they have CHF, that's multi-system involvement. Because it's respiratory, and it's musculoskeletal, right? So, whatever they have, remember they have pre-existing conditions, which are going to exacerbate the problem. And you won't know until you get a good history. So, look for clues that indicate the patient's traumatic incident may have been preceded by a medical event. Why did they fall down the stairs? Why did they fall out of bed? Why did they have a car accident? Did they have a heart attack? Did they have a stroke? Did they have a cyclical episode? Bystander information may be helpful. Geez, you know, I saw the patient walking, and then he just fell over into traffic. I have no idea what happened. I said, yeah, my dad was walking down the stairs, and then he just dropped. He fell down the stairs. My grandma, during COVID, her blood sugar went down as it is. She went downstairs to grab something to eat, and she fell and broke her hip. But that was the trauma, but it was caused by a medical condition. Mechanism of injury is important to establish whether an injury is considered critical, and the effects of treatment and transport consideration. High priority. Whenever you have an elderly patient, high priority treatment. Address by dress and determine the transport priority. Don't be afraid to transport high priority and go to a trauma center. Form a general impression. So, as I come up to the patient, my CT and PBSI, which is my overview of the scene, then as I approach the patient, I'm going to do my overview of the patient, which is my general impression. Are they conscious and alert? Abundant and responsive? Are they following with their eyes? Is there bleeding? Are they holding their chest? That kind of thing. Then I make contact and do my primary assessment. Older patients may have a diminished ability to cough, so suctioning is important. And remember, patients who have bracers, dentures, and crowns, and bridges, so just be aware of that because those can cause airway obstruction if they become loose. Manage any external bleeding immediately. Obviously, it goes with everybody else. Drinking alcohol while taking anticoagulant medications can make internal bleeding worse because it increases the coagulopathy, decreases the body's ability to cough. Older patients can more easily go into shock because of less of the compensatory mechanism. Patients who, again, remember this, patients who were hypertensive prior to the injury may now show normal blood pressure. Dude, your blood pressure is better than mine. No. No? Dude, he's in decompensated shock because he's normally hypertensive. That's why history is so important. Considerations in your assessment must include past medical history, even if they are not currently acute or symptomatic. Again, part of that is that shock response. Perform your physical examination, perform in the same manner as for any adult, but with consideration of the likelihood of damage or trauma. Any head injury can be life-threatening. Check lung sounds or look for bruising and other evidence of trauma. Then do your head-to-toe assessment. Don't be afraid to do a head-to-toe assessment on most of your geriatric patients, even if you think you can do, like, a focused assessment on a geriatric patient. I probably wouldn't do it because they can have a multitude of different conditions, so I would probably want to do a head-to-toe assessment. It only takes a couple minutes. Assess all your vital signs. All the patients may take beta blockers, which can inhibit tachycardia. Repeat your primary assessment. Talk to your patient. Constantly talk to them. That's psychological medicine. Broken bones are common and should be splinted. This is a woman with a hip fracture. See how they're putting her on a scoop stretcher. That scoop stretcher comes apart. I put it under her and I clip it together. I don't have to wobble or move them at all. They put a pillow under her leg in order to stabilize it in place. Strap her onto that scoop stretcher and then move her right to the regular stretcher. So, with a patient like that, which I like elevated, how would you put the strap around her? Just put the strap around the pelvis and around the upper and then around the feet. Do not force a patient with joint inflection or kyphosis. Again, we've got the kyphosis, the lordosis, the scoliosis, and the spondylosis. Do not force a patient into an abnormal position. Whatever position they're in, just keep them in that position. We don't want to force them. Prevent hypothermia by keeping the patient warm. Document everything that happened. You want to really write up a good report. Give a good report to the nurse or doctor. Psychological support is as good as medical treatment. Remember, talk to your patient. Sometimes, you know what? Sometimes, you might be the only person that person has talked to in weeks. They might live alone at home and nobody comes to visit them. You come in. We've done that. When I was up in Soul Friendship with the fire department, I did some volunteer work for the fire department. We had a couple of patients that would call us every now and then. I just don't feel well. You'd go and spend a half an hour with them. One of the firefighters would make her a sandwich. We'd kind of sit with her and do an assessment on her. Then she's like, no, I think I'm okay. She just wanted to visit. That's okay. That's what safe access is for. Many calls will occur at nursing homes or other skilled nursing facilities. The calls can be challenging because maybe the patients are unable to communicate, especially if you go to one of these, I hate to say the word fly-by-night, but some of these less expensive or less prestigious nursing homes where the staff doesn't speak English overnight. You're trying to figure out something and you can't understand what they're saying. Sometimes, you just take the med chart and just go. If you go to a nursing home, you're going to get a report from a nurse. Ask the nurse. Get the information from the nurse, but I always recommend talking to the CNA. Talk to the home health care aide. They're the ones that are with the patient all the time. They bathe them. They feed them. They walk them. They do everything with them. They're going to know just as much about the patient's presentation. The nurse will give you the technical stuff. She'll give you the med chart, the discharge, all that stuff, but the CNA will tell you how the patient is feeling, what's different today. That's what we're going to ask. We're always going to say, what's different today? Why am I here? Sometimes, nursing homes, they're over-sensitive and understaffed. They will call with the most obscure signs and symptoms just because they don't want to have them overnight. They'll ship all patients to ER overnight because they don't want to have them. I've seen it. All of a sudden, a nursing home calls with five discharges or five emergencies within 15 minutes of each other. Then you realize, and you go to pick up the patient, and there's no nurses around. You're like, I know what's going on. He's complaining of abdominal pain, or he's just not right. I hear that all the time. He's just not right. Well, what's wrong with him? He's just not acting himself. You talk to the patient. He's in no time for school. I don't want to go to the hospital and find him. What's my bargain? Can I take him? No. What if the nurse says, hey, you're in my facility, and I'm telling you you have to take him? Do you have protocols? She's not your boss. She's not my boss, and the patient's in no time for school. I can't take him. I've done that many times. And the nurses get pissed off. Too bad. You've got to deal with him. What is it? Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. Take care of him. A couple more dialysis could be fatal. I don't want to go. All right? If you're conscious and alert, you can make that decision. Infection control needs to be the priority of the EMT. MRSA, methicillin-resistant staphylococcus aureus, is a common infection found in nursing homes. You take regular EMTs that do nursing home visits, and I guarantee you swab their nose. Most of them have MRSA in their navels. Your body fights it. You're healthy. You're young. You won't get MRSA. It's the older and your immunocompromised that you get. You're susceptible to it. And you can get GI MRSA. You can get MRSA in the GI tract. You can get it pulmonary, in the lungs. And you can get cutaneous MRSA, which means that's like the flesh-eating bacteria staph infection. That's what they talk about. What happened to the 17-year-old surgeon in OR? What happened to the what? How he stayed healthy. A 17-year-old surgeon in an OR. A 17-year-old surgeon? That's a hell of a surgeon. A 17-year-old surgeon. A 17-year-old surgeon. A 17-year-old surgeon. A 17-year-old surgeon. A 17-year-old surgeon. A 17-year-old surgeon. 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A 17-year-old surgeon. A 17-year-old surgeon. A 17-year-old surgeon. If there's any questions, when in doubt, resuscitate. When in doubt, resuscitate. It's more defensible to say, I treat it, than not. Elder abuse and neglect. Any person or any action on the part of a person's family member, caregiver, or other person can take advantage of a person's person, property, or emotional state. This includes active permission, where I wanted to do it, or I just omitted facts, or didn't do things that I should have done. Things I did, and things I shouldn't have done. Again, in Massachusetts, you have to do a mandatory reporter's 19A, which is elder abuse, abuse of a patient over the age of 65, or people over the age of 65 in need. Chapter 19A, what that form is, you fill out a form. What you're saying is, I see something that needs to be addressed. Maybe a person needs elder services. Maybe they live alone. Maybe their family isn't caring for them. Whatever. All you're doing is saying, I see something that I think needs to be investigated. You're not accusing anybody of anything. It has largely been hidden from society. Definitions of abuse and neglect among the geriatric population vary. Victims will often hesitate to report. Especially if it's family members. They don't want to report a family member and get them in trouble. Maybe they were abusers in their young life, and now they feel they're getting retribution for it. They feel they're afraid of retaliation. They're afraid they'll be kicked out of their home. The abused person may feel traumatized and afraid that they'll be punished. Like I said, elder abuse occurs more often in women older than 75. Who is our most vulnerable population? Single women over the age of 75. Like my mother. She lives alone. She's going to be 84. She'll be 83. And she lives alone. And she's the most vulnerable population. Abusers of older people are sometimes products of child abuse themselves. Take note of the environment and conditions where the patient lives. And again, look at the conditions of the patient. If you would say, hey, I feel uncomfortable walking in here, then it's probably unsafe. It's probably unsafe for the elderly patient. Look for injuries to the patient. Are there soft tissue injuries? Like bruises to the face or the buttocks or the back. Cigarette burns, cigar burns, brittle burns. You know, anything to the hand or forearm is usually defensive. But anything like, people don't injure themselves on the backside, on their buttocks. They don't hit themselves. They don't burn themselves with cigarettes. They don't bite themselves. So, these are all questionable things. Glove burns. Somebody put their hand in something. Suspected abuse is when answers are concealed or avoided. A lot of times, get the patient alone. This is an adult. So, you don't necessarily, a family member says, well, I want to go with mom because I have to help her out. No, no, ma'am, that's okay. You can drive in the car, follow us, because you're going to have to get her home. Or you can drive in the front seat, but I have to be in the back for insurance reasons. We can't let you in the back. Get the patient alone so you can say, are you safe? I see something that I don't feel comfortable with. I see something that shows me that you're unsafe. Do you feel unsafe? Allow them to have a chance to say it without crying eyes. Or suspected abuse when answers given are unbelievable. Information that may be important in assessing abuse includes apathy. Like, the caregiver just doesn't care. Eh, she's fine. She's fine. Always complaining. Always complaining. Overly defensive. The caregiver answers every question. Doesn't let the patient talk or talks over them or stifles them. Repeated visits to the ED. Patients been to the ED like six times in the last month. Four. Balls. A history of being accident-prone, unbelievable, or vague explanations. And what you want to do is you don't want to get into it with what you suspect to be the suspect or the person doing it. So what I would say is I tell a patient, yeah, you know, my mother, she's really accident-prone all the time too. Let's get it up. Let's get your mother to the hospital. You follow her in the car because you're going to have to get her home. Probably be there for an hour or two and then you bring her home and everything will be fine. I do this all the time. What I'm trying to do is I'm trying to make him feel at ease or at ease so that she's, oh, yeah, okay, well, I'll follow him in the car. And then you get the patient back in the ambulance and you call the hospital and say patient X or you say abused elderly patient. I need police at the loading dock. I need police at the ambulance bay. And then that is a way to protect the patient.