Fragile Load

The Attack One crew begins its shift with vehicle cleaning, equipment checks and the monthly responsibility to check the controlled substances in its inventory. The medications in the drug boxes each month are changing due to the ongoing drug shortages plaguing the country. As crew members begin their tasks, the station tones sound, and they receive a dispatch to a senior living facility for a patient “screaming in pain.” As they enter the assisted-living portion of the senior community, they bring all the usual equipment needed for an illness.

The staff member who greets them says, “We don’t know what’s wrong with this lady. We found her lying on the floor in her room, but she says she didn’t fall. She just screams that she’s in pain!”

The elderly lady is sitting in a chair in her room as the crew arrives. She is in no obvious pain and is not screaming at this time. As they approach she offers a smile and says they’re more handsome then the crew that took care of her a few years ago. But as she sits up in the chair to listen to them speak, she suddenly screams loudly, “Ow! Ow! O-o-ow!!!”

The woman is now in obvious pain and reaches toward her back. “That is what happens!” she says, indicating her lower back. “I just move a little bit, and it hurts, it hurts!”

With their patient now in distress, crew members move quickly to help her. The sudden onset of pain has startled them all. They look at her back and find no evidence of injury. The EMT closest to her gently touches her and starts to massage the middle portion of her lower back, where she is pointing.

“That might feel better,” she reports. “Could you put my heating pad on it?”

“We could try that,” the EMT replies, and the nurses’ aide who has helped them offers to get one of the microwave heating pads the facility has for patients.

With the patient now quiet, they interview her about the pain and her medical history. She says the pain started around 0600, as she stepped across the room. She had a sudden and severe pain in her back and lay down on the floor as it became more severe. She gives a lucid history of taking her morning medicines, going to the bathroom and walking down the hall to get her coffee. At no point did she slip, fall or experience anything that would injure her back. She’s had no similar problems and no prior back trauma. The only injury in her life, she says, was a hip fracture about four years ago.

As they take her history, it’s obvious the patient’s sudden pain is resolving. The crew member massaging her back has added the heating pad and notices the patient appears to be comfortable when she does not move her back at all. Her vital signs are within normal limits, and upon carefully palpating her upper abdomen while she sits upright, the paramedic does not find any pulsatile mass. He also feels the pulses in her feet, which are warm and pink. He advises the EMTs that the patient does not obviously have an abdominal aortic aneurysm, which would be a life-threatening cause of severe back pain.

By the time they tell the patient she’ll need to go to the hospital to have this checked, she is again talking to them with a smile. But she asks if it wouldn’t be better just to leave her where she is. “When I’m sitting very still with that heating pad in place, the pain is gone,” she says. “It seems that when I try to move, it just hurts so much. Can’t you just leave me here?”

“Eventually you’ll have to move,” the paramedic replies. “Something must be wrong; you know that is true. We can’t leave you here to have that kind of pain again. A sudden pain that comes in spasms and goes away when you’re still is often from muscles that are irritated. That could be from an old injury, or it could be from a problem like a backbone that has collapsed. Unfortunately, as we get older our bones get soft, and sometimes the backbones just break down.”

The EMTs are trying to decide what method will allow the patient to be most comfortable for transport to the hospital. The lady has found a position of comfort sitting upright in the chair. They ask if she’d like to move to the ambulance sitting upright, and she says she would. They bring a stair chair to the room and offer to lift her carefully to that, leaving her heating pad in place.

The paramedic is thinking about pain medication. At rest the patient doesn’t appear to need any medication, but he’s concerned movement will make her pain recur. At this point he believes the sudden pain is muscle spasms and could be from a compression fracture of her lower back vertebrae. He thinks through muscle-relaxing medications also but knows the medicines in their drug box all may make the patient feel groggy.

“Ma’am, we would like to make sure you are comfortable for your trip to the hospital,” he tells her. “We have pain medicines and medicines that help relieve muscle spasms. Would you like us to give you some pain medicine to make you more comfortable?” He’s being as gentle as possible, afraid that any movement may once again set off her pain.

As he feared, the patient does not want any medicine. “I want a clear head to talk to the doctor and won’t have that if you give me medicine,” she declares. “They gave me medicine when I broke my hip, and it made me so sick and confused, I will never do that again!”

The crew members gather her medication list, clothing and purse and move toward the ambulance. They transfer her comfortably to the ambulance stretcher, and almost accomplish a pain-free trip to the hospital. But crossing a bump as they approach makes the vehicle lurch, and the patient abruptly screams again and is still in pain as they enter the emergency department.

Hospital Course

They wheel the patient in and transfer her to the ED stretcher. The paramedic is apologetic about the patient being in so much pain, and he finds the emergency physician to explain how she had sudden episodes of it, then got relief with the heating pad and careful positioning and refused any medication. Then it took just one bump to set off her pain again.

The physician and nurse examine the patient, offer her pain medicine (which she again refuses) and then ask for the x-ray tech to do a quick set of films on her lower back. The patient requests the EMT who massaged her back the first time come back to the room to try to relieve her pain again.

The x-ray evaluation is done within minutes, and the physician shows the films to the crew. Just as the paramedic had warned the patient, she has a compression fracture of one of her lumbar vertebrae, and severe osteoporosis that has softened all of her bones. There is no sign that cancer is present in the bones, a fear the emergency physician explains to the Attack One crew.

“Sometimes cancer will invade the vertebrae, and one will suddenly collapse and cause severe pain,” he says. “Fortunately this lady has no signs of that. We will admit her to the hospital for pain control and ask our orthopedic surgeons to see if any of the new techniques of managing these fractures may help her.”

After admission the patient is evaluated but is not a candidate for any type of surgery. Anesthesia does a pain block to the area, and after a few days the patient is released back to her assisted-living facility.

Case Discussion

Compression fractures occur in bones that are weakened by osteoporosis. This condition is more common in women and those with long-term abnormalities of hormones and calcium metabolism. Compression fractures usually result in a collapse of the front of the vertebral body, so the remaining bone has a wedge shape. The collapse can press on nerves, causing spasms of pain. It results in long-term loss of height, crowding of internal organs and loss of flexibility in the back. The patient will often find a position of comfort, which is hardly ever on a long backboard. This position of comfort should guide prehospital and hospital staff in how to place the patient. Some patients will feel better with heat or massage, as was the case here. Minor trauma, or even a slip without a fall, can precipitate this kind of collapse and sudden onset of pain.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.