As Ruth Bader Ginsburg has aged, she has earned a certain notoriety, thanks to her formidable career and, let’s face it, her celebrated workout routines. Her boxing, in particular, is evidence that she is a fighter in both the intellectual and physical sense. But she is also human, and sometimes humans, due to advanced age or bone density, fall. Ginsburg is reported to have fallen in her office Wednesday night, and per her doctor’s visit Thursday morning, she cracked three of her ribs in her fall. Given this, her age, and the fact that she likely takes blood thinners (standard practice for patients with cardiac stents, like the one she had placed in 2014), it must be acknowledged that, statistically speaking, her risk of developing dangerous and even deadly complications in the short term is alarmingly high, perhaps exceeding 50 percent. (I am not her doctor and have not evaluated her personally.) Fortunately, Ginsburg has a good track record of beating the odds. I am confident she has nothing but the best medical care and that she and her physicians are doing everything possible to maximize her chances for a swift recovery. But falls are also serious medical events, even though they seem trivial. The challenge for patients, their families, and their doctors is recognizing how serious such injuries can be and figuring out how to properly treat them before complications develop.
Interviews with older patients in the emergency department who are being evaluated after a fall often begin pleasantly enough. The patient fell, and something hurts. They’d like to make sure nothing is broken and have their pain treated. Sounds simple. Not infrequently, though, at some point during the encounter, the patient’s brow may furrow as she begins to suspect something is amiss; that I am not merely gathering information but that I am gently cross-examining them, as if they are on the witness stand. That’s because with time and experience, emergency doctors like me have learned a hard truth when it comes to falls in the geriatric population. Trust nobody; interrogate vigorously. (I’m sure RBG approves of the latter admonition.) A student or physician in training may believe the elderly patient whose explanation for a fall is simply “I took a bad step.” But the seasoned professional offers a rebuttal; all falls are the result of a bad step. The relevant question is: Why, after perhaps hundreds of millions of steps in the person’s lifetime, did the bad step occur today? A very clear story can be exculpatory. “I got tangled up in the cord of my vacuum cleaner” tends to be fairly credible evidence of a purely “mechanical fall.” Uneven pavement, however, is not. On hearing of a fall due to uneven pavement, my mind races. What new circumstance, we wonder, rendered the person unable to negotiate the sidewalk like they always have? We often find that our fall patients have a heretofore unrecognized underlying medical problem brewing, sometimes days, or even weeks, in the making. Bladder infections and even seemingly mild cases of “walking” pneumonia are typical culprits. Other more serious problems, from a heart attack to cancer, can present as a “mechanical fall.” Discovering such causes behind what may have appeared to just be a simple fall takes an astute emergency provider asking the right questions.
Patients tend to downplay preceding medical symptoms when they have fallen. They can be evasive about the details. I’ve never been entirely sure why this is, but perhaps it is simply that no one likes to admit that they are getting older. Patients want to be treated and discharged so that they can go home, back to work or back to their boxing class. But if there is incontrovertible proof of aging, a fall resulting from even a mild underlying medical problem certainly ranks high on the list.
There is a downside to downplaying. While it is becoming more widely known just how dangerous falls are to elderly patients, what is perhaps still less appreciated is how meaningful the event can be for diagnosis. To borrow a phrase from poker, it’s a tell. When someone falls and the story doesn’t quite add up to a strictly mechanical fall, some degree of medical work-up often becomes necessary. We don’t do every test on every patient (that’s wasteful and even harmful), but we do try to home in on what clandestine risks may be at play. Has the patient been experiencing nausea? The fall may be a sign of dehydration. Has the patient been coughing? It could be early influenza or pneumonia. A careful interview with a forthcoming patient can help doctors understand what is really going on beneath the surface, which allows them to propose treatment options.
In Ginsburg’s case, it’s likely that she went to sleep after her fall Wednesday night feeling some chest-wall pain and simply woke up feeling much worse, so she went to the doctor and discovered the broken ribs. Chalking her discomfort up to a mild bruise or a muscle strain could have been disastrous for her. For the most part, rib fractures are managed conservatively—they don’t usually need to be repaired in the operating room, and they heal on their own with time. But when a patient has three or more rib fractures, the rates of complications skyrocket. Broken ribs often cause secondary damage to the lungs. That can lead to bleeding or other fluid accumulation, which in serious cases can lead to life-threatening infections and respiratory distress. Those are conditions that doctors can indeed treat, as long as they know about them.
We can also treat pain, and in this case, pain control is about more than just decreasing the patient’s immediate suffering. Pain control increases the chance that the patient will continue to take good normal healthy breaths. Failure to take those normal breaths in favor of shallow and less-painful ones can contribute to slowly simmering disaster scenarios: Shallow breaths mean that air does not reach all parts of the lung. Stagnant lung is akin to still or standing water. Before long, lung tissue can collapse or become infected as bacteria take up residence. Pneumonia or other causes of respiratory distress syndrome can quickly become fatal in severe cases. Even patients who initially have no respiratory symptoms at all can turn out to develop significant complications 48 to 72 hours after an injury to the thorax. That is why pain control is not just a nice thing to do for our ailing patients but an essential component of their medical treatment.
Researchers tell us that there are certain types of patients who are more likely to suffer and even die from chest-wall trauma, even after initially appearing stable from seemingly mild injuries. Those risks include older age, the number of rib fractures (three or more rib fractures usually necessitates transfer to a Level I trauma center), previously existing heart and lung disease, and whether or not the patient smokes or takes blood-thinning medications.
We know that Ginsburg is older, has a history of coronary artery disease, and likely takes some kind of blood thinner. This puts her in a higher risk pool. But we also know that she did not wait terribly long before being seen in the hospital, which bodes well for her. Many patients make the mistake of waiting days before being seen, by which time the feared complications of rib fractures have already occurred and progressed, making them harder to treat and reverse. Which means we would all be wise, especially the older patients among us, to follow the justice’s lead and seek early medical evaluation following any blunt trauma.
The opinions expressed in this article are solely those of the author and do not reflect the views and opinions of Brigham and Women’s Hospital.