Geriatric slips, trips and falls: 3 assessment considerations

Tim Nowak Critical Clinical Concepts
by Tim Nowak

Former President Jimmy Carter was transported to the hospital for treatment and observation for a pelvis fracture after a fall at his home in Plains, Georgia. 

This is the third fall for President Carter, 95, in recent months. A spring fall required hip replacement surgery, and a recent fall required 14 stitches, despite which, the President traveled the next day to Nashville, Tennessee for his volunteer work with Habitat for Humanity.  

In these instances, transportation was clearly required. But what about when it’s not so clear? 

“Each year, millions of older people – those 65 and older – fall,” the CDC reports

Whether it’s caused by body weakness, vitamin deficiency, balance issues, vision problems, or simply poor footwear, falls are no small stumbling matter. 

In fact, death rates due to falls in the U.S. have increased by 30% from 2007 to 2016 for older adults, and at this current rate, could lead to seven fall deaths every hour by the year 2030, according to the CDC. 

At the forefront of many falls by elder – geriatric – patients, is our response: an EMS presence. 

Regardless of the circumstances or the etiology behind a fall, there are a number of considerations that should be on our checklist to help guide our course of action. Is this a “simple” lift-assist call, do we need to transport, or should we have the patient sign an against-medical-advice release? Here are three considerations for evaluating geriatric fall victims. 

1. Evaluating lift assist calls 

We’ve all been there. There’s likely a good chance that any call you’re dispatched for between 2 a.m. and 5 a.m. is for a lift assist. These calls, however, aren’t always as they seem. It’s not always as simple as “tripping on a rug” while walking to the bathroom in the middle of the night. 

Falls are not an uncommon geriatric problem. One in four older people fall each year, but less than half actually tell their doctor about it. That’s where we come into play. EMS may be the ones who recognize a pattern – something more than an isolated lift assist event. 

Here are some checklist considerations for your next lift assist call: 

  • Is this an isolated call – the first time – or is this a pattern, or cyclical event? 

  • Does the individual’s story match the actions? 

  • Does this really seem like a true “fell out of bed” call? 

  • Can the individual ambulate on his/her own – before you depart from the scene? 

2. Considering patient transport 

If the story doesn’t seem to be adding up – or if new injuries are present – you may have to advocate for the patient’s transport to a hospital. This, in itself, may not always be an easy task. 

Obtaining your party’s blood pressure – and I say “party” because they may not be a patient quite yet – may be a courtesy measure that you offer to any individual that you interact with. But once you notice that something doesn’t seem right – or that there’s more to the story than you’re being told – you may no longer be dealing with a “party” ... you may be dealing with a patient. 

If your gut tells you that this individual needs to get checked out, it’s time that you transition your discussion toward patient advocacy, rather than just a lift assist. This also means that your patient warrants a full (appropriate) work-up – including blood pressure assessment, blood glucose analysis, and maybe even a 12-lead ECG interpretation. It also means that simply gathering the party’s name and phone number won’t suffice; now you need to complete a patient care report. 

Here are some considerations that may sway your decision toward patient transport of an elderly fall victim: 

  • Are there any injuries noted or observed (old; indicating a pattern of multiple falls, or new; indicating recent trauma)? 

  • Are there any complicating factors that might have led to the fall (i.e., medications, additional symptoms, etc.)? 

  • Is the patient prescribed any blood thinners (anticoagulants or antiplatelets)? Do you have an available list to reference these medications? 

  • Is there something more to this fall? Could the patient be suffering from a stroke or TIA, or could this have been the result of a syncopal episode? 

3. Deciding on an AMA release 

Let’s face it, if your patient is alert, oriented and ambulatory, he/she may refuse transport to the hospital (and that may be OK). In situations where you do feel that transport is necessary – and not just a good thing to do – it’s important to document the patient’s recognition of the events, awareness of the potential complications and acknowledgement that they should still seek medical evaluation as a part of your release record. 

In any situation where you feel a bit uncomfortable having the patient sign a release, it’s certainly not a bad idea to call your medical control physician to have a one-on-one (recorded) discussion regarding the events. Many factors and considerations may sway your (or the physician’s) decision toward an against medical advice refusal. 

Here are some considerations that may put your mind more at ease if you’re at the junction point of releasing your patient: 

  • There is another capable adult on scene to monitor and care for the patient if further falls or complaints arise 

  • The patient has access to an alert button and is aware of how to properly activate it 

  • The patient’s residence lacks trip risks (e.g., floor rugs, transitions from hard floors to carpeting) 

Overall, it’s important that we be advocates for our patients – or even our civilian parties – even in instances where we’re dispatched for “just” a lift assist. If you gut is telling you one thing, but your patient is telling you another, don’t discount it. After all, we may be the only one who ever knows the details of this encounter – so it’s important that we keep everyone’s overall health and safety at the forefront. 

[Read: Silent but deadly: The trauma we miss in geriatric care]  

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