Fall Concerns By Neal E. Flomenbaum, MD, Editor-in-Chief

If you were asked to identify the busiest level I trauma center in New York State, it is unlikely that you would pick a not-for-profit hospital located on Manhattan’s well-to-do Upper East Side. But according to the New York State Department of Health trauma registry data, that’s the case. This is partly a reflection of the rapidly increasing incidence of falls, which are included by New York State in its trauma data, and partly due to a decade-long decline in the incidence of penetrating trauma, which is also referred to by the chief of our trauma service as “trauma of an interpersonal nature.”

Advance data published by the CDC last month indicate that falls are the leading cause of nonfatal medically attended injuries in the United States, with annual incidences of 76 episodes per 1000 population among all persons aged 65 and over (2005 data) and 51 episodes per 1000 population in noninstitutionalized adults 65 and over (2001-2003 data). Slipping, tripping, and stumbling are the most common causes of fall-related injuries in older adults, followed by loss of balance, dizziness, fainting, and seizure. Nearly three-quarters of these injuries occurred in or around the home, and more than half took place on a floor or level ground. Fall rates were higher for women and adults who were divorced or separated.

Almost 60% of older adults who fell and injured themselves were evaluated and treated in emergency departments, which in 2003 accounted for 1.8 million visits and more than 421,000 hospital admissions. The total cost of these injuries was $27.3 billion in 1994 and is expected to increase to $43.8 billion by 2020.

A spate of falls and “pedestrians struck” arriving in our emergency department during the week before Labor Day dramatically underscored these statistics. Most of the victims were elderly, about two-thirds were taking warfarin or other anticoagulants, and all had some form of head or facial injuries. About half ended up with serious disability or succumbed to their injuries despite rapid assessment and stabilization, careful monitoring, and in some cases early attempts at reversing the anticoagulant effects.

It is not too great a stretch of the imagination to conclude that we are in the early stages of a silent epidemic of devastating or life-threatening head injuries from seemingly trivial trauma. If this is true, and taking into account our rapidly aging population, emergency departments and trauma centers will be facing an unprecedented demand for services and resources, accompanied by—at this point—few reliable indicators or decision rules to guide management.

For example, when adults fall and hit their heads, the first CT scan may show no evidence of intracranial bleeding. But when should the follow-up scan be obtained? After four hours? Six hours? Twelve hours? And based on what criteria? Mechanism of injury? Use of anticoagulants? Age? All of the above?

The nature of trauma centers is also changing. Should we bemoan the current dearth of penetrating trauma “teaching cases” in this country and perhaps even strip some trauma centers of their designations? Or should we instead accept the fact that the practice of medicine and surgery continues to evolve and that blunt trauma is no less valid a form of injury than penetrating trauma? The applicability of emergency trauma surgery to other forms of elective surgery is also changing, as the former still depends mostly on open procedures whereas other types of surgery increasingly utilize minimally invasive and laparoscopic techniques.

For those who do feel strongly that penetrating trauma, blast injuries, and high-speed vehicular trauma are essential to surgical and emergency medical training, there will always be places in the world that have far too many such cases and more than enough opportunities to train.

Emerg Med 39(10):8, 2007