Falls are a common and debilitating presentation to secondary care, it sadly still doesn’t receive the respect that it should!
I could start quoting facts and figures, but I think I’ll share a story.
Mrs X was a lady in her 80’s and I was asked to review her in the evening.
The admitting Doctor had said,
‘I am really sorry, it’s a rubbish referral, she’s had a mechanical fall, we tried to send her home, but…’
The attitude of all the staff, was as if she was an inconvenience and that she shouldn’t be in the hospital, a bed blocker, which was far from the case.
She had fallen in the hall when she had caught her foot on the rug. Simple, or is it?
I had retaken a full history and examined her, reviewed all her investigations, when I looked at her, there was something not quite right, I couldn’t put my finger on it at first, it was her face that gave it away and it was fear, absolute dread.
Lesson 1: Treat the patient, not results or ‘problems’
I went over the story again and this is what she told me.
When she hit the ground, she knew it was bad, the whole of her left hand side pulsed in pain. She couldn’t get up, no matter how hard she tried, she even tried to find something to pull herself up, but she knew she was stuck.
What could she do, she had no phone near her, no buzzer. She had no family or anyone who would come to visit, help was not coming.
Her house was semi detached and in her panic she decided to scream, as loud as her lungs could, in the slim hope that her neighbours would hear her muffled cries through the wall… Nothing. She can’t remember how long she carried on, until her voice went hoarse. In her desperation and thirst, she pulled a nearby plant pot and sucked on the soil!
In total she was on the floor for 12 hours, no sleep, no rest, just motionless agony on the floor, screaming with a hoarse voice and sucking on dirt to survive.
‘I really thought I was going to die‘
She was finally saved when she heard the mail being delivered, and she gave out one last shout. Thankfully she was heard and the police gained entry.
And here she now was.
She was clinically assessed, had no significant injury, by sheer miracle she had no AKI or rhabdomyolysis. AED wanted to discharge her, but due to ‘mobility problems’ she was referred for medical assessment and admission for ‘discharge planning.’
This woman had been through the most traumatic ordeal of her life and all we had done was dust her off and tell her how lucky she was not to have injured herself. But she did injure herself, psychologically.
I just want you to put yourself in her shoes, being on the floor, motionless, knowing that there is no one there, no one coming to save you, no matter how hard you scream and shout. Preparing yourself mentally that you may die on that floor, helpless and alone (and be under no illusion falls kill) and in a final act of desperation the only nourishment you can find is the dirt from a potted plant.
Tell me, how do you feel? How does it make you feel when a doctor tells you how lucky you are, you didn’t injure yourself? And finally how do you feel when a Dr tells you, that they have good news, you can go home now?
The reason Mrs X was filled with so much dread, was she was afraid we were going to send her back to her home, alone, again. Effectively back to the scene of a crime, for it all to happen again.
I said just one thing to her
‘You are safe now, we will help you’
Lesson 2: Reassurance and your comfort can be more powerful than any drug.
I can understand why this can happen, we are trained to find a problem and then solve it, but her problem wasn’t neatly laid out in front of us. No broken bone for us to follow a NOF pathway, or a pneumonia we can score a CURB on. This would require a lot more work.
Now I put it to you, how does the term mechanic fall help us in any way clinically. All falls are mechanical! If the aim of the statement is to imply it is not syncopal or neurological in cause, then why not say so. Even something as simple as a trip, could be a peripheral neuropathy, visual discturbance, rushing due to urinary incontinence, the list is endless.
Lesson 3: Mechanical fall adds nothing to the diagnostic process and is just lazy.
The problem with mechanical fall, is that junior clinicians think that it is the end of the diagnostic process, it’s the beginning. Yes Mrs X had tripped on a rug, but on detailed assessment, she did have a postural drop due to poly pharmacy and gait disturbance due to osteoarthritis and sarcopenia.
How much nicer would that of been on her admission diagnosis but that’s a separate discussion.
Mrs X progressed well after a brief admission on a geriatrics ward and subsequent intermediate care stay and discharged back home with ‘safety net’ in place. Sadly she is still fearful that she can fall again.
If you only take one thing away from this story, is to remember the patients ordeal in any fall and the impact it can have on them. Remember you are in a privileged position where you can be the one that makes them feel safe and give them a glimmer of hope.
If you have any doubt, admit the patient to a place of safety and liaise with your local geriatrician, no one will ever criticise any clinician who wants to ensure a patient is safe.
geriatricdr 