Thursday, June 8, 2017

How to fall to your death and live to tell the tale.











     This is my third article for Mosaic, the web site of science and medicine run by the Wellcome Trust, the largest medical charity in the world. Mosaic publishes its pieces under a creative commons license, meaning they can be reprinted by anybody, provided they give me credit as the author, and link back to the original story here. The enigmatic images are copyright of the photographer, ©Dave Imms.

How to fall to your death and live to tell the tale

Slipping in the shower, tripping down the stairs, taking a tumble in the supermarket – falls kill over 420,000 people per year and hospitalise millions more. We can’t eliminate all falls, says Neil Steinberg. So we must to learn to fall better.
Alcides Moreno and his brother Edgar were window washers in New York City. The two Ecuadorian immigrants worked for City Wide Window Cleaning, suspended high above the congested streets, dragging wet squeegees across the acres of glass that make up the skyline of Manhattan.
On 7 December 2007, the brothers took an elevator to the roof of Solow Tower, a 47-storey apartment building on the Upper East Side. They stepped onto the 16-foot-long, three-foot-wide aluminium scaffolding designed to slowly lower them down the black glass of the building.
But the anchors holding the 1,250-pound platform instead gave way, plunging it and them 472 feet to the alley below. The fall lasted six seconds.
Edgar, at 30 the younger brother, tumbled off the scaffolding, hit the top of a wooden fence and was killed instantly. Part of his body was later discovered under the tangle of crushed aluminium in the alley next to the building.

‘Fall 1 – Journal of Falls’ © Dave Imms
But rescuers found Alcides alive, sitting up amid the wreckage, breathing and conscious when paramedics performed a “scoop and run” – a tactic used when a hospital is near and injuries so severe that any field treatment isn’t worth the time required to do it. Alcides was rushed to NewYork-Presbyterian Hospital/Weill Cornell Medical Center, four blocks away.
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Falls are one of life’s great overlooked perils. We fear terror attacks, shark bites, Ebola outbreaks and other minutely remote dangers, yet over 420,000 people die worldwide each year after falling. Falls are the second leading cause of death by injury, after car accidents. In the United States, falls cause 32,000 fatalities a year (more than four times the number caused by drowning or fires combined). Nearly three times as many people die in the US after falling as are murdered by firearms.
Falls are even more significant as a cause of injury. More patients go to emergency rooms in the US after falling than from any other form of mishap, according to the Centers for Disease Control and Prevention (CDC), nearly triple the number injured by car accidents. The cost is enormous. As well as taking up more than a third of ER budgets, fall-related injuries often lead to expensive personal injury claims. In one case in an Irish supermarket, a woman was awarded 1.4 million euros compensation when she slipped on grapes inside the store.
It makes sense that falls dwarf most other hazards. To be shot or get in a car accident, you first need to be in the vicinity of a gun or a car. But falls can happen anywhere at any time to anyone.
Spectacular falls from great heights outdoors like the plunge of the Moreno brothers are extremely rare. The most dangerous spots for falls are not rooftops or cliffs, but the low-level, interior settings of everyday life: shower stalls, supermarket aisles and stairways. Despite illusions otherwise, we have become an overwhelmingly indoor species: Americans spend less than 7 per cent of the day outside but 87 per cent inside buildings (the other 6 per cent is spent sitting in cars and other vehicles). Any fall, even a tumble out of bed, can change life profoundly, taking someone from robust health to grave disability in less than one second.
Falling can cause bone fractures and, occasionally, injuries to internal organs, the brain and spinal cord. “Anybody can fall,” says Elliot J Roth, medical director of the patient recovery unit at the Shirley Ryan AbilityLab in Chicago. “And most of the traumatic brain injury patients and spinal cord injury patients we see had no previous disability."

‘Fall 2 – Journal of Falls’ © Dave Imms
There is no Journal of Falls, though research into falling, gait and balance has increased tremendously over the past two decades. Advances in technology improve our understanding of how and why people fall, offer possibilities to mitigate the severity of falls, and improve medicine’s ability to treat those who have hurt themselves falling.
Scientists are now encouraging people to learn how to fall to minimise injury – to view falling not so much as an unexpected hazard to be avoided as an inevitability to be prepared for. Training may even have been a factor determining the outcome of the Moreno brothers’ fall to earth nearly ten years ago.
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Doctors at NewYork-Presbyterian did not want to risk moving Alcides Moreno from the emergency room into a surgical theatre for fear that the slightest additional bump might kill him. They started surgery in the ER. He had two broken legs, a broken arm, a broken foot, several broken ribs, and a crushed vertebra that could have paralysed him, as well as two collapsed lungs, a swollen brain, plus several other ruptured organs. Alcides was given 24 pints of blood and 19 pints of plasma before the bleeding could be stopped.
Doctors marvelled that he was alive at all, reaching for an explanation not often used in medical literature: “miracle”.
By 100 feet or more, falls are almost always fatal, apart from freak accidents. People have fallen miles from planes and lived, due to tumbling down snowy hillsides, the way extreme skier Devin Stratton did when he accidentally skied off a 150-foot Utah mountain cliff in January 2017 and escaped unharmed, his fall arrested by branches and cushioned by deep snow. He was wearing a helmet, which cracked even as its camera recorded his plunge.
“It’s not the fall that gets you,” the skydiving joke goes. “It’s the sudden stop at the bottom.” Deceleration is the key to surviving falls and reducing injuries − it isn’t the length of fall that’s relevant, but what happens as you reach the ground. This was dramatically demonstrated in the summer of 2016 by professional skydiver and safety expert Luke Aikens. He jumped from a plane without a parachute at an altitude of 25,000 feet, or 4.7 miles, hitting a 100-by-100-foot net positioned in the southern California desert and emerging without a scratch.
One theory was that Alcides lived because, when the scaffolding gave way, he lay flat and clung to the platform, as professional window washers are trained to do. The scaffold fell not in the open street but in a narrow alley – air resistance may have built up against the platform, slowing it. The platform also may have scraped against the building and its neighbour, reducing its rate of fall. The aluminium crushed on impact, and landed on a pile of cables, both of which absorbed some of the impact, forming a cushioned barrier.
Survival from heights prompted the first medical writing about falls. Hippocrates, in his treatise on head injuries, observes, sensibly, that “he who falls from a very high place upon a very hard and blunt object is in most danger of sustaining a fracture… whereas he that falls upon more level ground, and upon a softer object, is likely to suffer less injury”. The first modern medical paper on a fall was Philip Turner’s ‘A fall from a cliff 320 feet high without fatal injuries’, published in the Guy’s Hospital Gazettein 1919. It examined the case of a Canadian Army private who stumbled over a chalk cliff on the coast of France in 1916 and lived.
In 1917, an American air cadet named Hugh DeHaven was flying in a Curtiss JN-4 “Jenny” when it collided with another biplane 700 feet above an airfield in Texas. Among the four men aboard the two planes, DeHaven alone survived the plunge. He spent the rest of his career trying to figure out why, culminating in his pioneering 1942 paper, ‘Mechanical analysis of survival in falls from heights of fifty to one hundred and fifty feet’.
In it, he examined eight cases of people surviving long falls – ignoring his own, but including the lucky Canadian private from 1916 – and found that those who landed on newly tilled gardens could walk away surprisingly intact, noting: “It is, of course, obvious that speed or height of fall, is not in itself injurious.” That might sound like the first half of the skydiving joke, but his research led him to design and patent the combined seatbelt and shoulder harness worn in every car today.
Up to the 1960s and 1970s, scientific papers on falls focused on forensics – their subjects tended to be dead, the medical questions centring on what had happened to them. This was important, for instance, when assessing trauma to children – could this child have fallen and suffered these injuries, as the caregiver claimed, or is it abuse? Falls as a separate, chronic, survivable medical problem began to get attention only in the past quarter-century. The journal Movement Disorders was begun in 1986, but the bulk of papers examining the interplay of balance, gait and falls at ground level appear after 2000.
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You can trip or slip when walking, but someone standing stock still can fall too – because of a loss of consciousness, vertigo or, as the Moreno brothers remind us, something supposedly solid giving way. However it happens, gravity takes hold and a brief, violent drama begins. And like any drama, every fall has a beginning, middle and end.
“We can think of falls as having three stages: initiation, descent and impact,” says Stephen Robinovitch, a professor in the School of Engineering Science and the Department of Biomedical Physiology and Kinesiology at Simon Fraser University in British Columbia, Canada. “Most research in the area of falls relates to ‘balance maintenance’ – how we perform activities such as standing, walking and transferring without losing balance.”
By “transferring”, he means changing from one state to another: from walking to stopping, from lying in a bed to standing, or from standing to sitting in a chair. “We have found that falls among older adults in long-term care are just as likely to occur during standing and transferring as during walking,” says Robinovitch, who installed cameras in a pair of Canadian nursing homes and closely analysed 227 falls over three years.

‘Fall 3 – Journal of Falls’ © Dave Imms
Only 3 per cent were due to slips and 21 per cent due to trips, compared to 41 per cent caused by incorrect weight shifting – excessive sway during standing, or missteps during walking. For instance, an elderly woman with a walker turns her upper body and it moves forward while her feet remain planted. She topples over, due to “freezing”, a common symptom of Parkinson’s, experienced regularly by about half of those with the disease.
In general, elderly people are particularly prone to falls because they are more likely to have illnesses that affect their cognition, coordination, agility and strength. “Almost anything that goes wrong with your brain or your muscles or joints is going to affect your balance,” says Fay Horak, professor of neurology at Oregon Health & Science University.
Fall injuries are the leading cause of death in people over 60, says Horak. Every year, about 30 per cent of those 65 and older living in senior residences have a fall, and when they get older than 80, that number rises to 50 per cent. A third of those falls lead to injury, according to the CDC, with 5 per cent resulting in serious injury. It gets expensive. In 2012, the average hospitalisation cost after a fall was $34,000.
How you prepare for the possibility of falling, what you do when falling, what you hit after falling – all determine whether and how severely you are hurt. And what condition you are in is key. A Yale School of Medicine study of 754 over-70s, published in theJournal of the American Medical Association in 2013, found that the more serious a disability you have beforehand, the more likely you will be severely hurt by a fall. Even what you eat is a factor: a study of 6,000 elderly French people in 2015 found a connection between poor nutrition, falling and being hurt in falls.
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‘Fall 4 – Journal of Falls’ © Dave Imms
Alcides Moreno underwent 15 more surgeries and was in a coma for weeks. He was visited by his three children: Michael, 14, Moriah, 8, and Andrew, 6. His wife, Rosario, stayed at his bedside, talking to him. She repeatedly took his hand and guided it to stroke her face and hair, hoping that the touch of her skin would help bring him around. Then, on Christmas Day, Alcides reached out and stroked not his wife’s face but the face of one of his nurses.
“You’re not supposed to do that,” Rosario chided him. “I’m your wife. You touch your wife.”
“What did I do?” he asked. It was the first time he had spoken since the accident, 18 days earlier. His doctors predicted he might walk again, after lengthy rehabilitation, though the challenges proved to be not only physical but also mental. People who fall suffer the expected physical injuries, but accidental falling also carries a heavy psychological burden that can make recovery more difficult and can, counter-intuitively, set the stage for future falls.
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Children begin to walk, with help, at about a year old. By 14 months they are typically walking unaided. Those first baby steps are guided by three key bodily systems. First, proprioception – input from the nerves in the muscles, a sense of where limbs are relative to each other and what they’re doing. People whose limbs are numb have difficulty walking even if their musculature is completely functional.
The second sense is vision, not just to see where you are going, but to help process information from your other senses. “Most people who walk into a dark room will sway more than if they can see – about 20 per cent more,” says Horak, an expert in how neurological disorders affect balance and gait.
And third is your vestibular system, canals of fluid in the inner ear that work in a way not very different from a carpenter’s spirit level. The system takes measurements in three dimensions, and your body uses the data to orient itself.
With these various systems doing their jobs, you can step forward and begin to walk, a feat that performance artist Laurie Anderson once described in a song with succinct scientific accuracy: “You’re walking, and you don’t always realise it/But you’re always falling/With each step, you fall forward slightly/And then catch yourself from falling/Over and over.”
Or don’t catch yourself. We fall when the smooth, almost automatic process of walking goes awry. Perhaps it is something as crude as your step being blocked by an obstacle: you trip, over a prankster’s outstretched foot perhaps. Or the traction of your foot against the floor is lost because of a slippery substance – the classic banana peel of silent movie fame, what researchers call “perturbation”.
Christine Bowers is 18. She hails from upstate New York, and is a student at the Moody Bible Institute in Chicago. One day she hopes to teach English abroad. In January 2016 she had a cavernous malformation – a tangle of blood vessels deep within her brain – removed.
“It paralysed my left side,” she says, as her physical therapist straps her into a complex harness in a large room filled with equipment at the Shirley Ryan AbilityLab. “I’m working on preventing a fall.”
Under the supervision of Ashley Bobich, the therapist, Bowers is walking on the KineAssist MX, a computerised treadmill with a robotic arm and harness device at the back. The metal arm allows patients freedom of motion but catches them if they fall. This version of the device is quite new – the AbilityLab only got it at the end of 2016 and Bowers is the second patient of Bobich’s to try it. Previously, those in danger of falling would be tethered to overhead gate tracks, a far cruder system, which still can be seen in the ceilings above.
Being a student, Bowers often finds herself in crowded academic hallways, and says she values her cane as much to alert those around her that she has mobility problems as for support. Seeing the cane, she says, her classmates tend to give her a bit of room as they hurry through the corridors.
Still, she has fallen several times, and those falls made her very skittish about walking, a serious problem in the rehabilitation of those who have fallen. “It’s huge,” says Bobich. “Fear of falling puts you at risk for falling.”
Elliot Roth agrees. “Falls often cause fear of falling, and fear of falling often causes fear of walking, and fear of walking often causes abnormal or inadequate walking,” he says. A challenge of rehabilitation is to not only increase physical capacity, but also build patient confidence.
"We've been doing what’s called ‘perturbation training’, where I pick a change in the treadmill speed,” says Bobich. “She’s walking along, I hit the button, and the treadmill speeds up on her and she has to react… Her biggest fear was slipping on ice, so I said, ‘You know what? I have a really great way for us to train that.’”
The treadmill hums while Bobich speeds it up and slows it down, and Bowers, her right hand clasping her paralysed left, struggles to maintain her balance.
“You’re getting better at this,” says Bobich. “You’re getting way better.”
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The KineAssist is an example of how technology that was once used to study ailments is now used to help patients. Advanced brain scanning, having identified the regions responsible for balance, now diagnoses damage that affects them. Accelerometers attached to people’s ankles and wrists have been used in experiments, plotting induced falls directly into a computer for study, and are now being used to diagnose balance problems – or to detect when someone living alone has fallen and summon help.
“Over one-half of older adults who fall are unable to rise independently, and are at risk for a ‘long lie’ after a fall, especially if they live alone, which can greatly increase the clinical consequences of the falls,” says Stephen Robinovitch. He and his colleagues are working to develop wearable sensor systems that detect falls with high accuracy, as well as providing information on their causes, and on near-falls.
Researchers at the Massachusetts Institute of Technology took the “wearable” out of the equation by developing a radio wave system that detects when someone has fallen and automatically summons help. The Emerald system was shown off at the White House in 2015 but is still finding its way to a market chock-full of devices that detect falls, invariably pendants.
Not that a device needs to be high-tech to mitigate falls. Wrestlers use mats because they expect to fall; American football running backs wear pads. Given that a person over 70 is three times as likely to fall as someone younger, why don’t elderly people generally use either?
The potential benefit of cushioning is certainly there. The CDC estimates that $31 billion a year is spent on medical care for over-65s injured in falls – $10 billion for hip fractures alone (90 per cent of which are due to falls). Studies show that such pads reduce the harmful effects of falling.

‘Fall 5 – Journal of Falls’ © Dave Imms
But older people have all the vanity, inhibition, forgetfulness, wishful thinking and lack of caution that younger people have, and won’t wear pads. More are carrying canes and using walkers than before, but many more who could benefit shun them because, to them, canes and walkers imply infirmity, a fate worse than death (80 per cent of elderly women told researchers in one study that they would rather die than have to live with a debilitating hip fracture). This sets up another vicious cycle related to falling: fearing the appearance of disability, some elderly people refuse to use canes, thereby increasing their chances of falling and becoming disabled.
Padded floors would seem ideal, since they require none of the diligence of body pads or canes. But padding environments is both expensive and a technical challenge. If a flooring material has too much give, wheelchairs can’t roll and footing is compromised. That’s why nursing homes tend not to be thickly carpeted. People pick up their feet less high as they age, and so have a tendency to trip on carpets.
There are materials designed to reduce injuries from falls. Kradal is a thin honeycombed flooring from New Zealand that transmits the energy of a fall away from whatever strikes it, reducing the force. A study of the flooring in Swedish nursing homes found that while it did reduce the number of injuries when residents fell on it, they fell more frequently when walking on it, leading to a dilemma: the flooring might be causing some falls even as it reduced the severity of resulting injuries.
One unexpected piece of anti-fall technology is the hearing aid. While the inner ear’s vestibular system is maintaining balance, sound itself also seems to have a role.
“We definitely found that individuals with hearing loss had more difficulty with balance and gait, and showed significant improvement when they had a hearing aid,” says Linda Thibodeau, a professor at the University of Texas at Dallas’s Advanced Hearing Research Center, summarising a recent pilot study. “Most people don’t know about this.”
Horak agrees, saying that people who have cochlear implants to give them hearing also find their balance improves. Hearing is not as critical for balance as proprioception, vision and the vestibular system, she says, “But hearing may also contribute and we don’t understand how. We think you can use your hearing to orient yourself.”
Thibodeau says one reason it’s important to establish this link is that insurance companies don’t typically cover hearing aids, because they are seen as improving lifestyle more than sustaining basic health. Hearing aids can be expensive – up to $6,000 – but a broken hip, which insurance companies do cover, can cost five or ten times that figure, or more, and lead to profound disability or death.
More than half of people in their 70s have hearing loss, but typically wait ten to 20 years beyond the time when they could first benefit before they seek treatment. If the connection to balance and falls were better known, that delay might be reduced.
The role of hearing reminds us that, while walking is considered almost automatic, balance is at some level a cognitive act, achieved by processing a cloud of information. Pile demands on our attention and that itself can cause falls, particularly among people who are already compromised physically or cognitively.
Thibodeau once led a group of people with hearing impairments to the Dallas World Aquarium to test out wireless microphone technology in the real world. “There’s a stairway going by an enormous fish tank,” she says. “I had a participant fall on the stairs, and someone at the aquarium told me, ‘A lot of people fall going down those stairs, looking at the aquarium.’” (Asked to comment whether this indeed is a common problem there, the Dallas World Aquarium director did not reply, a reminder perhaps that the legal aspects of falls can inhibit dissemination of information about them).
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Given the tremendous cost of falls to individuals and society, and the increasing knowledge of how and why falls occur, what can you do to prevent them? And can you do anything to lessen harm in the split second after you start to fall?
1. Prepare your environment
Secure loose rugs or get rid of them. Make sure the tops and bottoms of stairs are lit. Clean up spills immediately. Install safety bars in showers and put down traction strips, and treat slick surfaces such as smooth marble floors with anti-slip coatings. If there’s ice outside your home, clear it and put down salt.
2. Fall-proof your routine
Watch where you are going. Don’t walk while reading or using your phone. Always hold handrails − most people using stairways do not. Don’t have your hands in your pockets, as this reduces your ability to regain your balance when you stumble. Remember that your balance can be thrown off by a heavy suitcase, backpack or bag.
Roth asks most of his patients who have fallen to describe in detail what happened. “Sometimes people are not paying attention. Multi-tasking is a myth, and people should try very hard to avoid multi-tasking. No texting while walking.”
The more problems you have controlling your balance, the more attention is required, says Horak. “If you’re carrying a big backpack on a slippery log, you don’t want somebody to ask you what’s for dinner.”
3. Improve your gear
Wear good shoes with treads. On ice, wear cleats – you can buy inexpensive soles with metal studs that slip over your shoes. Do not wear high heels, or at least have a second pair of flat shoes for walking between locations. Get a hearing aid if you need one. Wear a helmet when bicycling, skiing and skateboarding. Use a cane or walker if required. Hike with a walking stick.
4. Prepare your body
Lower body strength is important for recovering from slips, upper body strength for surviving falls. Martial arts training can help you learn how to fall. Drugs and alcohol are obviously a factor in falls – more than half of adult falls are associated with alcohol use – as is sleep apnoea. Get a balanced diet to support bone density and muscle strength. If you feel lightheaded or faint, sit down immediately. Don’t worry about the social graces, you can get back up once you’ve established you are not going to lose consciousness.
Understandably, some elderly people fear falling so much that they don’t even want to contemplate it. “People should know they could improve their balance with practice, even if they have a neurological problem,” says Horak.
5. Fall the right way
What happens once you are falling? Scientists studying falling are developing “safe landing responses” to help limit the damage from falls. If you are falling, first protect your head – 37 per cent of falls by elderly people in a study by Robinovitch and colleagues involved hitting their heads, particularly during falls forward. Fight trainers and parachute jump coaches encourage people to try not to fall straight forward or backward. The key is to roll, and try to let the fleshy side parts of your body absorb the impact.
“You want to reach back for the floor with your hands,” says Chuck Coyle, fight director at the Lyric Opera of Chicago, describing how he tells actors to fall on stage. “Distribute the weight on the calf, thigh, into the glutes, rolling on the outside of your leg as opposed to falling straight back.”
Young people break their wrists because they shoot their hands out quickly when falling. Older people break their hips because they don’t get their hands out quickly enough. You’d much rather break a wrist than a hip.
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Alcides Moreno underwent a long regimen of physical and occupational therapy at the Kessler Institute for Rehabilitation in New Jersey, working to strengthen his legs, restore his balance, and walk. Occupational therapy was necessary, as well as counselling, as he had grown depressed over the loss of his brother, Edgar.
He is unable to return to work but received a multimillion-dollar settlement in his lawsuit against the scaffolding company, Tractel, after a Manhattan court found that it had installed the platform negligently. The sum wasn’t revealed, but a source said it was more than the $2.5 million that Edgar’s family received.
Alcides and his family moved to Arizona, and live outside Phoenix. “This weather is good for my bones,” he told the New York Post. He keeps busy, driving his kids to school and to sporting events, and likes to work out in the gym.
Last year he and his wife had a fourth child, a son.
“I keep asking myself why I lived,” he told the BBC this year. “I have a new baby – he must be the reason, to raise this kid and tell him my history.”

4 comments:

  1. Very informative and good to know.

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  2. The reason I never go on a descending escalator- too fearful of the possible consequences of missing that first step.

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  3. Neil, very interesting post today. The Army Airborne jump school training I received 45 years ago helped me manage several bad "landings" later in life but I doubt that I have the reflexes to handle a fall now. I think that most seniors are concerned about getting injured in a fall.

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  4. Excellent article. I just read about Phil Collins having to cancel concerts because he fell in the middle of the night and hit his head. It's interesting to me that as you age, the tendency to stop falls with your hands diminishes. As a musician, the few times I've fallen, I've always pulled my arms in to protect my hands resulting in very bruised knees and hips. Reading this, as I get older, I'm going to have a lot of broken bones. Going to have to learn these falling techniques.

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