I was in a hurry to get to the gate. The traffic from Marin to SFO was obnoxious and the TSA line very slow. I was wearing a heavy backpack. Optimistic about getting some work done on the plane, I had filled it with medical journals and my laptop. I was also pulling my wheelie. I was walking my usual fast pace when the ball of my left foot struck the floor first—it had been happening a lot lately—and I stumbled. As I tried to get my balance, the backpack slid up towards my head and propelled me forward and down—hard.
I took the brunt of the fall on my right shoulder, but the worst pain was in the middle of my upper arm. I couldn’t use it to help me get up off the floor. A kind passerby got down on the floor next to me and said, with confidence, “I am certified in first aid. Can I help?” Grateful, I directed her to take my left arm and gently pull me into a sitting position. By now, I am the center of attention, surrounded by airport police, passengers, and a United Airlines representative who told me, in no uncertain terms, that I would not be getting on my flight to Tucson (I actually asked him to please take me to the gate in a wheelchair). Although he kindly booked me on a later flight, just in case the injury turned out to be something minor, he had already called for an ambulance.
So that was how I ended up as a patient in the ER I used to work in. The emergency physician on duty was one of the few people I still knew at Kaiser South San Francisco. He sewed up a small laceration in my right eyebrow and arranged for the x-ray. The radiologist, an old friend from my running days, gave me the bad news. I had a displaced fracture of the greater tuberosity of the humerus plus a non-displaced surgical neck fracture. I was definitely not going to Tucson.
Why a fall is not just a fall
There are so many interesting and important questions raised by my fall that I want to share with you because I learned that a fall is not just a fall and a broken shoulder is not just a broken shoulder. Bear with me as I take you through some of my thinking.
First of all, there’s the question: Why did I fall? The folks at the airport and the clinicians in the ER asked all the right questions to make sure it wasn’t something that needed an urgent evaluation. Did I have chest pain, dizziness, palpitations? No. Did I trip on something—an uneven tile or an object on the floor? No. I am very clear on why I fell. I tripped over my own left foot. Once I explained that, people lost interest in why I fell and concentrated on the result of my fall—the proximal humeral fractures. But, we will come back to the why later on because it is one of the most important questions that can be asked about a fall.
The next question was what did I need for pain? I opted for 1 gram of IV acetaminophen; it worked like a charm and left my head clear so I could sort out the other issues, like notifying my client that I wouldn’t be at their meeting in Tucson the next morning and figuring out the best way to get home without having my husband schlepp an hour to retrieve me.
An obviously important issue to address: What’s the treatment? You can’t put a shoulder in a cast. I was given a sling and a follow-up appointment in Orthopedics for a week hence. I opted for NSAIDs for pain because I don’t like the nausea and foggy head that accompany opioids. It turns out that was all I needed.
The discharge from the ER was amazing. My friend, the ER doc, gave me a white and blue pocket folder filled with all the information I would need until I would see the bone doc. It included several sheets of paper that described upper extremity fractures, outlined the home care and follow-up instructions, and explained when to seek urgent medical advice. It also provided instructions on how to take the pain medication together with a note telling me that I could pick up my prescription at any pharmacy; it was already entered into the system-wide EHR (eat your hearts out, all you people getting care outside of an integrated delivery system). I tucked the paper copies of my X-rays in the folder, paid my $5 (no kidding) copay, and said my thank yous to the staff who had treated me so kindly and professionally.
I took a Lyft home, whining to the driver about how I was missing a great meeting in Tucson and, even more important, how I was going to miss the upcoming family trip rafting the Middle Fork of the Salmon that I had been looking forward to for months.
I got plugged into Kaiser’s orthopedic department and had regular x-rays to ensure healing was going ok. Of course, I spent hours on PubMed and other sites on the internet trying to determine what was the best treatment for my particular fractures. My fellow internists won’t be surprised to hear that the Orthopedic literature is a mess. Most of the papers I read insisted surgery was the treatment of choice, but I was being treated conservatively with a sling and physical therapy (PT).
So, I made an appointment with the shoulder specialist at my Kaiser medical center to review the literature—yes, you can do that. He described several studies—one from the UK that I had already read—that found that outcomes were the same for people treated with surgery and those treated with a sling, even if there was displacement of the greater tuberosity like I had. Further, he pointed out, the top of my humeral head had a good shape and there was plenty of room between it and the acromion so impingement syndrome was unlikely.
I was lucky. Even before I started PT, my shoulder range of motion started to improve. With PT, I am about 80% of the way to normal shoulder function (Hooray!).
A deep dive into falls and fractures
Because there is so much more to the falls and fracture story, I have decided to divide it up into different posts. Here are some of the issues related that I will be exploring over the next several months:
- The humerus is a big bone. Why did mine break after a simple fall from a standing position? Had my long-standing osteopenia progressed to osteoporosis? If I have osteoporosis, what is the best treatment? And, what are its side effects?
- Why did I trip? Did I have foot drop or some other gait abnormality? Or was it just a problem with my shoes, my clumsiness, or my inattention? Equally important, what can I do to prevent falling in the future—a huge source of morbidity for women (and men) “of a certain age.”
- How can I get back full and normal function of my right arm? Believe it or not, I was so good at holding it still by my side that I had to consciously remember to use it once it was freed from the sling.
- How do I overcome my newly acquired fear of falling and mental images of falling when I go up and down stairs or walk with my big old black lab? Is this a form of PTSD? What’s the best way to renormalize my disturbed sleep?
I want to explore all of these aspects of falling with you because I think all too often clinicians, friends, and family members,—and even patients—think that a fall is just a fall. But in many cases, as I have learned, a fall may be so much more.
If you would like to add to this list of issues to explore, please pass them along either as a comment on this post or as an email to firstname.lastname@example.org.