4.1 Protocol 17: Falls & Protocol 30: Traumatic Injuries

4.1 Protocol 17: Falls & Protocol 30: Traumatic Injuries

Quick Answer: Protocol 17 differentiates ground-level falls from a LONG FALL (a drop greater than 10 feet / 3 metres, coded 17-D-6) and an EXTREME FALL (greater than 30 feet / 10 metres, coded 17-D-1) — both DELTA determinants reflecting severe kinetic deceleration forces. Dispatchers must always identify whether the event was a mechanical trip or a medical collapse (e.g., syncope, stroke, seizure, or cardiac event); the precipitating medical cause takes precedence in protocol selection. Callers must be instructed in strict spinal precautions: keep the patient flat and still, and never help them up. Protocol 30 (Traumatic Injuries) governs blunt force, ocular trauma, and crush mechanisms, where dispatchers must anticipate lethal crush reperfusion syndrome and occult internal hemorrhage.

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1. Protocol 17: Biomechanical Forces and Fall Triage

Falls represent one of the highest-volume call types handled by emergency medical dispatch centers, spanning a vast clinical spectrum from minor ground-level slips in young adults to catastrophic decelerations from roofs, scaffolding, or balconies. Within the Medical Priority Dispatch System (MPDS), Protocol 17: Falls provides an objective, kinetic energy-based triage structure.

Ground-Level Fall (GLF) vs. Long Fall

The kinetic energy ($KE$) dissipated through human skeletal and vascular structures during a fall is directly proportional to mass and velocity squared ($KE = \frac{1}{2}mv^2$), with velocity determined by the height of the fall ($v = \sqrt{2gh}$):

• LONG FALL (DELTA 17-D-6): In the MPDS, a fall is a LONG FALL when the vertical drop exceeds 10 feet (3 metres). A fall onto the same level where the patient landed — including a fall on, rather than down, stairs — is a ground-level fall; a fall down stairs has its own code, 17-B-3 (Fall down, not on, stairs).
• EXTREME FALL (DELTA 17-D-1): A drop greater than 30 feet (10 metres) — roughly three storeys — representing extreme high-velocity deceleration trauma associated with severe multisystem failure.
• Ground-Level Fall (GLF): A fall occurring at the surface plane without vertical descent from an elevated surface. While low-energy in physics, ground-level falls in geriatric or vulnerable populations can produce life-threatening orthopedic and intracranial injuries.

+-------------------------------------------------------------------------+
|                     FALL KINETIC ENERGY COMPARISON                      |
|                                                                         |
|   Ground-Level Fall (GLF):   Low velocity, focal surface impact         |
|   LONG FALL (> 10 ft / 3 m): 17-D-6 - multisystem deceleration          |
|   EXTREME FALL (> 30 ft):    17-D-1 - massive shock, aortic shear       |
+-------------------------------------------------------------------------+

Deceleration Mechanics and Injury Patterns in Long Falls

When a falling body impacts the earth, energy dissipates along anatomical transmission vectors:

1. Axial Loading and Lover's Fracture (Don Juan Syndrome): When a patient lands feet-first, kinetic energy shoots upward through the calcaneus, tibia, femur, and spinal column. This classic triad comprises bilateral calcaneal fractures, burst fractures of the lumbar vertebrae (L1–L3), and secondary basilar skull injury.
2. Blunt Aortic Shear: At vertical falls over 15 to 20 feet, sudden thoracic deceleration causes mobile anatomical structures (such as the aortic arch) to shear against fixed points of attachment (the ligamentum arteriosum), causing acute aortic transection and immediate exsanguination.
3. Solid Organ Contusion and Rupture: Inertial deceleration propels the liver, spleen, and kidneys against the rigid abdominal and pelvic skeleton, causing lacerations and catastrophic intra-abdominal hemorrhage.

Vulnerability of the Geriatric Ground-Level Fall

While young adults often walk away from ground-level falls with contusions, the elderly population experiences high mortality from GLFs due to underlying pathophysiology:

• Fragility Fractures: Osteopenia and osteoporosis predispose seniors to femoral neck fractures and open pelvic ring disruptions from minimal rotational force.
• Intracranial Hemorrhage: Age-related cerebral atrophy stretches delicate bridging veins across the subdural space. A minor bump to the head during a GLF can tear these vessels, resulting in an insidious, fatal subdural hematoma. This risk multiplies exponentially in patients prescribed anticoagulant or antiplatelet pharmacotherapy.

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2. Mechanical vs. Medical Falls: The Cardinal Interrogation Branch

A paramount responsibility of the EMD is determining the inciting etiology of the fall. Untrained calltakers routinely code any patient found on the floor under Protocol 17, missing critical underlying medical emergencies.

                             [Patient Found on the Floor]
                                          |
                     Did the fall result from a TRIP or SLIP?
                                          |
                 +------------------------+------------------------+
                 |                                                 |
                YES                                                NO
                 |                                                 |
       [MECHANICAL FALL]                                   [MEDICAL FALL]
                 |                                                 |
       Protocol 17: Falls                               What precipitated collapse?
       - Evaluate height                                           |
       - Assess spinal pain                             +----------+----------+
       - Check bleeding                                 |          |          |
                                                     Syncope    Seizure     CVA /
                                                     (Prot 31)  (Prot 12)  Cardiac

The Priority Rule of Etiology

MPDS Protocol Rule: If a medical emergency caused the fall, the medical complaint takes precedence in protocol selection, unless severe life-threatening trauma overrides it.

During Key Questions, the EMD must ask: "Did s/he trip or slip, or did s/he faint, pass out, or become dizzy before falling?"

1. Mechanical Falls: The patient tripped over a rug, slipped on ice, or missed a stair tread. The initiating event was purely physical. Triage proceeds strictly on Protocol 17.
2. Medical Falls: The patient felt lightheaded, experienced chest tightness, suffered a transient ischemic attack (TIA) or stroke, experienced sudden cardiac arrest, or had a generalized tonic-clonic seizure, causing them to collapse.
   • If the patient lost consciousness before hitting the ground, the dispatcher must select the appropriate medical protocol (e.g., Protocol 31: Unconscious / Fainting, Protocol 10: Chest Pain, or Protocol 12: Convulsions / Seizures).
   • If the patient collapsed into cardiac arrest, immediate transition to Protocol 9 for Telephone CPR is mandatory.

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3. Spinal Precautions and Post-Dispatch Instructions (PDIs)

Secondary neurological devastation occurs when an unstable vertebral column fracture is displaced by well-meaning bystanders attempting to manipulate, comfort, or move a fallen patient.

The Bystander "Help Them Up" Reflex

When family members or coworkers discover an injured individual on the ground, their overwhelming psychological reflex is to lift the patient to a chair, sofa, or bed. Callers frequently state: "I'm trying to get him off the cold floor." In patients with cervical or high thoracic fractures, this reflexive movement can shear the spinal cord, converting a neurologically intact bony fracture into permanent, irreversible quadriplegia or respiratory arrest.

Non-Discretionary Spinal Instructions

The EMD must deliver explicit, non-discretionary Post-Dispatch Instructions:

"Do not move him/her. Keep him/her completely still and flat on the floor until the paramedics arrive." "Do not put anything under his/her head, and do not try to help him/her up."

If the caller expresses concern about a cold floor or hard surface, the EMD instructs them to place a light blanket or coat over the patient to prevent hypothermia, without lifting or rolling the torso or neck.

Airway Exception to Spinal Precautions

The only permissible reason for a bystander to move a suspected spinal trauma patient is active airway obstruction (e.g., unmanageable vomitus or secretions threatening drowning, or respiratory arrest requiring CPR). If an unresponsive trauma victim vomits, the dispatcher guides the caller to carefully log-roll the head, neck, and torso as a single unit onto their side to clear the airway while maintaining axial alignment.

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4. Public vs. Private Locations

Protocol 17 incorporates determinant modifiers based on scene environment:

• Public Locations (suffix P): Falls occurring in roadways, parking garages, markets, escalators, moving transit platforms, public stairwells, or shopping malls introduce external environmental hazards. The MPDS carries this as the Protocol 17 suffix P (PUBLIC PLACE) appended to the base code — for example 17-D-6P — so responding crews know to plan for crowd control, traffic safety, and potential secondary collisions. Protocol 17 uses four other scene suffixes: A (accessibility concerns/difficulty), E (environmental problems — rain, heat, cold), G (on the ground/floor), and J (jumper — suicide attempt).
• Private Residences: Calls originating inside private homes typically present access obstacles (locked deadbolts, guard dogs, narrow stairwells) requiring specific PDIs to secure access points for responding paramedics.

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5. Protocol 30: Traumatic Injuries (Specific Mechanical Trauma)

Protocol 30: Traumatic Injuries serves as the specialized gateway for physical trauma resulting from mechanisms other than falls, assaults, or motor vehicle crashes. This includes blunt impacts, industrial equipment trauma not involving heavy powered machinery, sports collisions, severe animal attacks, and localized tissue damage.

Crush Injuries and Crush Syndrome Pathophysiology

A crush injury occurs when prolonged, continuous compressive force is applied to skeletal muscle tissue (e.g., a collapsed wall, heavy machinery, or fallen vehicle pinning an extremity for extended durations):

⚠️ Clinical Dispatch Alert: Crush Extrication Danger

If a caller reports that a patient has been pinned beneath a heavy structural weight or vehicle for more than 15 to 30 minutes, the dispatcher must coordinate with field units. Lifting the object without advanced pre-hospital medical preparation (intravenous sodium bicarbonate, fluid loading, and cardiac monitoring) can trigger instantaneous cardiac arrest upon release. The EMD must advise callers not to attempt hazardous, rushed lifting if it places bystanders or the patient in greater danger.

Eye Injuries and Globe Rupture

Protocol 30 incorporates strict decision pathways for ocular trauma:

• Chemical Splashes to the Eye: The single exception where immediate, continuous irrigation takes precedence over all other trauma care. The EMD instructs continuous flushing with clean, lukewarm water for at least 15 to 20 minutes.
• Penetrating or Blunt Globe Trauma: The dispatcher must strictly instruct: "Do not touch or rub the eye. Do not apply any pressure to the eyeball, and do not attempt to pull out any object sticking into the eye." The caller is advised to cover the injured eye with a rigid shield (such as a paper cup taped over the orbit) to prevent external compression from extruding the vitreous humor.

Chest Trauma and Flail Chest

Blunt thoracic impacts (such as an industrial drop or heavy sports collision) can produce a flail chest, defined as two or more contiguous ribs fractured in two or more places. This uncouples a segment of the chest wall from the thoracic cage, producing paradoxical motion (the flail segment moves inward during inhalation and outward during exhalation). Dispatchers must recognize caller descriptions of "uneven breathing" or "chest caving in" as severe respiratory compromise requiring an ALS upgrade.

The Seatbelt Sign

A transverse contusion or abrasion across the clavicle, sternum, and lower abdomen resulting from rapid deceleration in a three-point harness is known as the seatbelt sign. While the restraint prevents fatal ejection, the severe compressive load often produces occult, life-threatening internal pathology: mesenteric vessel avulsion, small bowel perforation, lumbar spine Chance fractures, and blunt aortic contusion. Even if the patient is ambulatory, the presence of a pronounced seatbelt contusion mandates high-priority trauma evaluation.

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6. Comparative Triage Matrix: Protocol 17 vs. Protocol 30

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7. Realistic Dispatch Dialogue: Long Fall with Spinal Compromise

EMD:        "9-1-1, what is the address of the emergency?"
CALLER:     "405 Industrial Parkway, at the construction site!"
EMD:        "What is the phone number you're calling from?"
CALLER:     "555-0144!"
EMD:        "Okay, tell me exactly what happened."
CALLER:     "My coworker just fell off the second-story scaffolding! He's flat on the concrete!"
EMD:        "How far did he fall?"
CALLER:     "It's at least 15 feet! He fell straight down onto his feet and back!"
EMD:        [IDENTIFIES LONG FALL (> 10 FT) -> LAUNCHES DELTA 17-D-6 RESPONSE]
            "Is he awake?"
CALLER:     "Yes, he's screaming, he says his back and heels are killing him!"
EMD:        "Is he breathing normally?"
CALLER:     "Yes, he's breathing fast, but he's crying out."
EMD:        "Paramedics are being dispatched right now. Listen to me very carefully: do not move him.
            Tell everyone on the site to keep him completely still. Do not let him try to sit up,
            and do not put anything under his head."
CALLER:     "The guys want to pick him up and move him to the work truck out of the sun."
EMD:        "No, do not move him at all. Moving his body or neck could cause permanent spinal damage
            or paralysis. Keep him completely flat right where he is. If he is in the sun, have someone
            hold a jacket or cardboard over him to block the light, but do not touch or move his body."