Molly Jones

Molly is 85 years old. She has been a widow since 2007. Molly and her husband, Ron, were married for 53 years and lived for the majority of their married life in a large four bedroom house where they raised two sons. One son still lives locally and pops in to see his mother twice a week, the other son lives abroad. Molly has lived within a mile of where she was born all her life and has strong ties to the local area. Since her husband’s death Molly has continued to meet with her friends at least once a week to play bridge. She still drives her car every day and recently purchased a new car after writing hers off in an accident. Both she and the other driver were unhurt.

One Spring morning Molly opened the back door to go shopping but as she started down the steps she slipped and fell on the concrete path. She left via the back door but misjudged the last step and fell onto the concrete path. She tried to get up but was unable to do so and attempted to drag herself to her car without success. She called for help and was eventually heard by a passer-by two hours after her fall. The emergency services were called and her rescuer stayed until the ambulance arrived. 
Her Story:

Paramedic Assessment

Generally: Assess ABCDE: Focus on Safety of patient and self and others
Assess: Airway and Breathing:     
  • Breathing spontaneously, R = 22/min, equal chest expansion, SpO2: 95% (oxygen saturation)
Assess: Circulation Disability:      
Assess for signs of:
  • haemorrhage, shock: Pulse 80/min, BP 132/87, T 34.60 C, 
  • head injury-level of counsciousness: AVPU- alert but unable to describe what happened, wants to be carried inside the house and have a cup of tea.
  • neck and back injuries/
  • threatened limb (loss of neuro-vascular function) 
Specifically: Assess for site and mechanism of injury, age and co-modibity
  • Age 85 yrs- High risk of osteoporosis and hip fracture, fell from a stem onto concrete onto her left side.
  • Hypertension/type 2 diabetes/risk of pressure sores to the left side- shoulder, elbow and hip. 
  • Time on the floor is approximately 2 hours, unable to get up, complaining of pain in her hip and knee, evidence of shortening and external rotation of the left leg. 
Interventions:
  • Left leg immobilised and splinted to right leg, entonox offered during the transfer to the ambulance and to hospital. 
  • Was this enough pain relief/if so/not so why?

Pain Management at the Scene and During Transfer

Assessment priorities re: pain and AB CD (see above)

Please complete the section of the story related to Molly's pain assessment by the paramedics. 
Please include the pharmacology use and side effects of entonox 

Priorities of Care in the Emergency Department Within the First Hour: 

  • ABCDE assessment
  • Access and administer adquate pain relief to allow for comfortable change of position to protect from pressure sores
  • Assessment and maintenance of fluid and electrolyte balance/Support and maintain body temperature
  • Assess nutrition and elimination
  • Assess co-morbidities
  • Assess mental state
  • Assess previous mobility/ functional ability 
  • Social circumstances 
  • Radiological assessment of the affected hip / chest x-ray/ Blood glucose/ blood group/FBC/INR/U and E's urea and creatinine/ urine sample.

Information on Assessment: 

Past medical history

  • Diagnosed with Type 2 diabetes in 1980 
    - Metformin 500mg twice a day with food.
    - Glipizide 5mg once daily (before breakfast)
  • Hypertension in 1990
    - Labetalol 50mg twice daily with food
    - Simvastatin 20mg once daily at night 
    - Aspirin 75mg once daily with food
  • Left hip replacement in 2001
  • Neurogenic bladder diagnosed 2010
    - Intermittent self-catheterisation 4 times a day

Recent History

  • Two falls within the last 12 months 
    - Tripped on her door step and sustained bruising to her head
    - Fell in her bedroom, can't remember what happened but sustained a laceration to the bridge of her nose. Went to her GP who referred her to the local accident and emergency department. Admitted overnight for observation and treatment, referred to the falls clinic.
    - A falls clinic assessment identified the following: 
           - Some short term memory loss but not sufficient to cause concern
           - Diabetic neuropathy to both feet
           - BMI 26.4 (Has lost 2 stone in the last 2 years)

Assessing Pain in the Emergency Unit: 

There is a high risks of under-treated pain in the elderly, particularly those with cognitive disorders. The use of a systematic pain assessment tool throughout the patient's journey can improve patient management.

Evidence: 

In an audit of 100 consecutive patients admitted with hip fracture in Belgium Petit et al (2013) found that pain assessment and management in elderly patients with hip fracture with still suboptimal with: 
  • Little or no pain assessment in the emergency department (ED)
  • Limited follow up on the surgical unit of patients with advanced dementia and /or acute confusion  delirium. Tramadol was frequently prescribed in the ED without prior assessment of the patient and recognition that it may worsen delirium in the elderly.

(Petit et al. 2013. Audit of perioperative pain management and outcome in elderly patients with hip fracture. European Journal of Anaesthesiology. 30: 223)

According to Thiekle et all (2012) following longitudinal study of 5,093 people over 65 years musculoskeletal pain is not automatically associated with advancing age, it is frequently intermittent with periods of remission. Based on this finding they propose that:
  • Pain should be effectively assessed
  • Risk assessed for co-morbidity factors such as depression, obesity and poor health
  • Managed and evaluated using multidisciplinary approach

Thielke et al. 2012 Persistence and remission of musculoskeletal pain in the community-dwelling older adults: results from the cardiovascular health study Journal of the American Geriatrics Society, 60: 1393-1400 at http://deepblue.lib.umich.edu/bitstream/handle/2027.42/93534/jgs4082.pdf?sequence=1

NICE, 2011[updated 2012]. The management of hip fractures in adults: NICE 124. London: NICE

SIGN 2009. Management of hip fracture in older people: SIGN publication 111.Edinburgh: SIGN

NICE 2013. Falls: assessment and prevention of falls in older people: NICE GG16.1 London: NICE
http://www.nice.org.uk/guidance/cg161/resources/cg161-falls-guidance

What tools are available and how valid and reliable are they? 

Clinical tools and guidelines:
The multidisciplinary guideline development group. 2007 Number 8: The Assessment of pain in older people. National Guidelines accessed at: 
https://www.britishpainsociety.org/static/uploads/resources/files/book_pain_older_people.pdf

Things to Think About

  • What is comfort? 
  • Humanising care (see The IPE Pain Model page) how can this improve pain management in emergency and acute care?
  • Interprofessional communication? How can this improve pain management?
About this Resource:
This resource has been developed by the Faculty of Health and Social Sciences at Bournemouth University (BU) and funded by the BU Centre for Excellence in Learning. The contents have been developed and co-created by staff and students from BU. The site was designed by Thomas Galloway & Abraham Weiskorn, a Graphic Design Student from Portsmouth University and a Digital Media Design Student from Bournemouth University. The editors are: Dr Carol Clark Senior Academic - Physiotherapy and Dr Desi Tait Senior Academic - Nursing from Bournemouth University.

The aim of this site is to promote and facilitate inter-professional learning and collaboration in the theory and practice of pain management using a humanising approach to care (Todres et al 2009).