I cover trauma call for the eastern suburbs of Cleveland at a level II trauma center. Given our patient population, we don't exactly see the Friday Night Gun Club sorts of cases like one would experience at level I urban centers. Ours is more like the Saturday Afternoon Fall Down and Bump Your Head Club. Other than blunt trauma from MVC's, our next most popular mechanism of injury is some little old lady or little old gentleman losing balance, and whacking his/her dome against the floor.
What I find annoying is the high percentage of these elderly patients (many in their 80's and 90's) who are on anti-coagulation therapy for atrial fibrillation. This buys the injured patient a ticket to the ICU and multiple CT scan to make sure there is no delayed intracerebral bleeding. Mucho dinero. Even more annoying is the fact a lot of these people are frequent flyers. You browse through the computer chart and you see three or four admissions over a 2 year period for similar falls.
The rationale behind anti-coagulating people with atrial fibrillation is that you want to reduce the risk of clot formation in the fibrillating heart chambers and subsequent embolic stroke. There's a fairly recent RCT from Scotland (the BAFTA study) that seemed to support the use of coumadin over aspirin even in elderly patients (>75) with afib. But the data showed that, despite the use coumadin, there was still a 1.8% risk of stroke over the course of one year. And the trial didn't use a control of patients without any anti-coagulation; it just compared coumadin versus aspirin.
I find it difficult to wrap my mind around the idea that anybody over the age of 85 needs to be on coumadin for afib. Not because of rationing, mind you, but simply for safety reasons. It's not clear to me that the benefit outweighs the risks, even in the most optimal candidates. Certainly anyone with a history of prior falls, dementia, or a GI bleeding history ought to be excluded; but in this era of fragmented care (hospitalists and subspecialists and lack of communication) it gets harder and harder to make sure that we aren't just mindlessly implementing "best practice recommendations" without looking at the individual patient...