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Hello, everyone and we're come today. Week reminded Leap Webinars. Today we're going to Teo be joined by Dr Animal Brain is going to deliver a session on what to do when you have to assess someone has fallen junior your own. Cautious, Um, as always, please feel free. Toc Any questions you might happen to common section well replied to them during the session or at the end. And so if there's anything pressing, please food free to ask. Also, if you'd like to send us any questions after the webinar, these feel free to do so and and then we're going to have a Q and A section afterwards. Um, all of the sessions are recorded and you'll send. We'll send you, then link for the session today. If you register at mindedly dot com, I'm going to post a link in the common section on so you can sign up later on. And before we started, just a quick shot that I was sponsors the MD. Please don't forget to start. I'd your MD foundation membership before you start your son doing on unless you feel they Fundacion application for him. The membership you had when you were a student to a season December, so it's essential they do have, um, appropriate and damage coverage. The police at this check if you have signed up and I'm going to include the link in the common section as well. So for night I'm just going to hand over to doctor an adult who's going to talk to you about Falls. Thank you so so thank you, everyone to who's joining us today. This is our webinar on assessing falls. So it's a common anxiety among new doctors on it's a source of much uncertainty. This webinar is aimed at tuned to be F one doctor's first responders, nurses and other healthcare professionals. If there any occupational therapist for physiotherapists tuning in, please say high in the tract, there will be an opportunity to share your last knowledge only questions at the end. Um, so let's get started. So to introduce myself, my name is an herbal. I'm a foundation year. One doctor working in a hospital in northwest London in the UK on day as one of the junior members of the team assessing falls on call on on the take, which is where people are coming into a knee for the first time is something I do very frequently. So hopefully we can get a little bit of a handle on that knowledge today. So today will be covering Introduction to falls on Common Cause is you've been bleeped on what to do one on call and some helpful hints and tips assessing someone who's out of full investigations on a summary at the end. So why is this topic important? Well, firstly, it's common. As a junior doctor. You often assess patients who have fallen both on the call on on take force, the most frequent cause off unintentional injuries in elderly people. Onda that it's life threatening as well. So causes of falls very from the innocuous to the life threatening always need assessment. So when your uncle, even if it's busy, you always need to assess someone that's had a fall on the ward. But it could be helpful for your nursing colleagues if you say when you're gonna be there. If you're particularly busy, Um, thirdly, there's a variety of causes. It requires bit of practice to assess why someone has fallen. So hopefully with this introduction today, you can get get to know what kind of things you're looking for. So essentially any pathology in every system in the body can cause a full. So a detailed history is essential in determining the cause of falls. You want to be relying on collateral history from your niacin colleagues, health care assistance on anyone else who was there on the ward when someone has fallen. But also you want to be speaking to the patient themselves, on their family members or next of kids, if they were there for the full, so you need to be systematic. One approaching a full starting with the cardiovascular causes heart rhythm. Problems can often cause falls, and it's quite difficult to get an idea of why this has happened on often. This will require 24 hour trace after the fact, so arrhythmias, bradycardia and also violating the heart disease, Ultram and causes of falls but also static hypertension is a very common one in that when someone stands up, their BP drop causes them to have a vasovagal event and fall over. Um, so that's the cardiovascular causes infected causes conversion, but the two most common are a community acquired pneumonia or cap on a urinary tract infection, or UTI. These can often be seen on either X ray for a cap, chest X ray or a UTI by your independent urine and CNS. So neurological causes stroke is a common and serious cause of four and needs prompt assessment if you suspect a stroke. Peripheral neuropathy is slightly less serious, but it can also be a cause before, if people have. If patients have less off less feedback coming back at them, for instance, from their feet not quite sure where the ground is not quite sure where they're slippers are or anything like that, it could make it more likely that they were. Full metabolic reasons include hypoglycemia and also alcohol excess, often for gotten in the elderly community because off assumptions that people make about lifestyles of patients but always important to ask. And we ask everyone who comes into hospital, how much alcohol do you drink on a daily weekly monthly basis. Musculoskelatal causes include arthritis, both in the small joints and into the large joint, such as the shoulders, hips and knees. Disuse atrophy as well, is where the muscles become wasted away after not being used. A common problem in elderly patients, especially those who are no active on in a similar vein deconditioning as well. If someone has just come out of a long state in hospital and they haven't been working with a physical therapist, not a patient therapist before they leave, it could mean that they're deconditioned to being at home. On it can offer be a cause off for finally in the nose and throat conditions, but even a wax. So the last section in the causes of falls is practical issues. Now your patient therapist colleagues are the experts on this, but things like inadequate mobility AIDS like, If they need afraid, do they use their frame? Do they need a stick? Do they need a rail and all they actually using them that can all be all contribute to someone falling over when at home, especially if they're particularly if the rail or the mobility aid is out of reach on They're not familiar with using them, or they're nervous about using them. So a lot of patients find that when they go home, where the due to cognitive impairment or due to deconditioning they are not using the same ability is that they got used to all in hospital. Other practical issues that can cause falls are Poly Pharmacy, so this definition very slightly. But it's for patients who have got more than more than three drugs that they're taking on that can interact in unusual ways and cause. Falls on visual impairment is a common one, and also dehydration both, of course and consequence of falls azelas things like slippers and inappropriate that work. So on calls, tips Let's say that someone has bleak to you about a four on the ward. What do you need to do? Well, you need to put these ideas about causes for falls into practice. It's really helpful to gather information over the phone first. Often it's one of your nursing colleagues. Calling about Fall on the ward on essential information Includes that the patient's observations Are they on the floor but quite comfortable? They have a new zip zero. They have no shortness of breath, no race, heart rate or anything like that. Or are they quite sick? And they've fallen while they were quite sick, a swell so recent observations are really important. Another key question is, are they on anti calculation This makes a big difference because if someone is on and regulation of falls and hit their head, they should get a CT head is part of the nice criteria for a CT head, but we will get onto that a bit more later. There's also especially on a busy on call shift. It could be really helpful to make any initial requests when you first get the school, such as any CG on also getting any initial initial visitations and initial investigations. The 80 approach that you may be familiar with is much better done in person, but you can get in bit of an idea of it off, asking your niacin colleague or whoever's making a call a couple of basic questions, but overall needs to be done in person. As always, it's nicer to give a timeframe as well. So if you say okay, please try to get that you see GI for me. I'll be there in 20 minutes. So you're noticing Colleague gives your hand over in s bar for at Let's begin. So 75 year old gentleman has had a fall on the ward and you've been picked about it. I want if you're nursing colleagues. The story is the gentleman in bed three having on witness fall and fell forward. No seizure background is he's had a previous hip replacement surgery in 2005. He also has hypertension or high BP, diabetes and hypercholesterolemia, or high cholesterol. The assessment over the phone from your nurse and colleague is he's got a news of one. Pulse is 95 but he's now back in bed and he's got a painful knee. The recommendation from your lesson colleague is Please come and see him. So a few things may be going through your mind. On a good thing. To bear in mind is just a quick set of questions. Look, thankfully, this with this hand over, you've got a lot of information just from yes bar. But, for instance, why? My add to this is say is ask is going on and calculation on, please. Could you get any CD, then on your way there on and also when you're gonna be that too. Let's say you're gonna be there in 10 minutes. On your way there, you want to be thinking about what kind of questions you're going to be asking on a really helpful way to structure. This is before, during and after on, especially on a night shift on a busy on call shift. Simple things like before during after is much easier to remember than a complicated list. So before the fall, when you get there, you want to ask the patient or if it was a witness. Four. And the patient has cognitive difficulties and therefore can't answer the collateral history you want to ask. Did you get any feeling of your heart pounding in your chest? Any palpitations? We short of breath. Did you have any chest pain or pain anywhere in your body, Such a shoulders or back before you fell? Did you have an aura so often? People won't know one or is, but you can ask other and visual changes. Did you have any funny smells or anything like that before you fell down? Any dizziness, any weakness or any loss of consciousness? A telltale sign is if a patient falls over on. They don't remember hitting the floor that can often be assigned that they lost consciousness before they fell. So for someone who was conscious and it's not constantly impaired, they will be able to describe that they saw the floor coming towards them or they felt themselves falling or something like that. But if you don't get that from the history, then consider that they've had a loss of consciousness during again. Maybe they fell and then they don't remember what happened. Was there any loss of consciousness? Did you hit your head? Did you have any instance of shaking of your arms and legs and a feeling of a seizure? Any tongue biting that can also be a sign of a seizure and couldn't point you towards more neurological course and find the afterwards how long we want the floor for? How did help come? Did you call out for a nurse? Did they spot you did any? Did another patient in the Bay Lotus or something like that on then how are they now? They drowsy. Do they feel weak? Are they postictal so often after a seizure? Patients can be quite confused and not really not really feeling themselves. They're a bit slowed. Answer questions. They're a bit out of sorts, and especially for patients with known epilepsy. They feel that it's a familiar feeling. After a seizure and we call it Post picked up. So you've asked these questions to either your nurse and colleague or HCL weapons there to get a collateral history on. You've talked to the patient themselves. Now you want to gather the background. You need to approach the notes on approach the drug chart to get some background on the Y. The patient is in hospital. You want the reason for admission and how long they've been in hospital, their past medical history. And do they have any postural hypertension, a sudden drop and BP when they stand up? Any previous stroke, Any known arrhythmias? Any diabetes for that peripheral neuropathy we were talking about earlier or even high hypoglycemic episode. You need to look at their drug chart or drug card. Any anti hypertensives, any opioids, any hypoglycemic agents, which could cause the hypo full and any sedatives. What you got that information? You have a lot before you example. Patient. So this is when the examination comes, you need a full A T E and talk to toe examination again. As we said earlier on a busy uncle, shift is difficult to remember. Complicated things. So stuff like 80 and talk to toe is just a simple way of approaching patient, but making sure you get a low key areas. So you want to go absolutely talk to toe and 80. You want to inspect and palpate any cuts, bruises or injuries? Absolutely essential is make sure you palpate and ask about any injuries on the head, hips and femurs. But a lot of bony prominences as you go down the body are said chill to check over. The reason why this is is because something like a fractured neck of the femur or a fracture in the knee or the elbow, or anything like that is often a a consequence of falling. But if miss, it could be really painful. I'm really unfortunate for the patient, because the outcomes much worse if you miss these things. So you also want to clearly document their GCS or Glasgow coma scale. Um, as rated by eyes voice on best motor response on their neuro examination findings is always useful to do a quick neuro examination such as power tone, coordination, reflexes and sensation in the upper and lower limb, um, for completeness, but also for your own piece of mind, that you haven't missed anything then things like the other things that are by the bedside, such as that catheter, any bruises, any check, any pain anywhere on anything that may have contributed to the fall. Is there a wet floor next to them? Is that other easy jillions tangled around their feet or anything like that? Finally, you want to review the observations and get a lying and standing BP. So that's on the ward. What if you're on the take, which is when people come in the front door through a li and you need to Clark someone in or take their history? So this case is slightly different. So this gentleman is 81 he's been admitted from home with a four. The presenting complaint is that he's had low eating and drinking the last few days on, he felt after tripping on a pile of clothes in his house. Background is, he's got high BP, hypercholesterolemia depression, vascular dementia and lives alone know carers. Um, his wife sadly passed away last year, who used to cancel him on a The ambulance crew has kindly provided a lot of scale, so the class scale come very from 1 to 9. Based on how much fat is in someone's house. Um and so in this gentleman, it's a five. His medications are unloaded peons citalopram atorvastatin on center for constipation. So your plan will then depend on your assessment. So you've done your full history like we've talked through. You've done the observations on you've done some basic first test like an E C G. What's next in your plan? So either on the ward or on the take, it will really depend on that first assessment where the injuries. What sounds suspicious in history? What kind of thing you thinking about once you got the C G. Bloods are really helpful on for a deep dive into that topic in what bloods to order when we've got seminar from last week about ordering bloods on analyzing them but for our purposes today, you'll want a basic set off over routine bloods with a bone profile will be helpful and then anything else you might need based on that presentation. Neurological observations If there's any head injury on X ray of any injuries, so injured bones and joints are really crucial here, and that's where you begin your X rays. Finally, there's a lot off discussion about whether you need a CT head if they're significant injury, such as they had a strike of their head against the floor or table. Anything like that if the patient is on anti coagulation and more risk of intracranial bleed on, if there's abnormal neurology. All of these the criteria that are part of the nice guidance of when did your CT head and I really recommend looking through that guideline when you have a chance? Because it's a really helpful piece off, Um, advice. So we mentioned this a bit already. Common order Set Post fall. We're looking for your routine bloods, which is full blood count using these CRP lft. Also, bone profile is very helpful, especially in elderly people, thyroid bitten D and hematinic. So which is B 12 and folate? So the plan continued. Do you have an idea of the underlying course? Can you optimize the drug chart, for instance, did they have their hypoglycemic this morning? It caused him to have a hypo on because of the interactions from the new and what's that you started them on? It's been mawr potent than it would be otherwise. And it caused a tab a high protein for Could you change around those drugs to make sure? Does this patient need 1 to 1? Nursing. Have they have more than one full? Do you think that risk of another one do you need to hold the anti coagulation while you wait for a CT head? And do you need to speak to one of your seniors either an S H O or a registrar on depending on the time of day? Even your consultant, These will depend on your assessment, and it always comes back to your history, examination and your investigations. So in summary, we've talked through a few things today. We've talked about how falls a common, but they have many varied causes. We always want to use an 80 approach and talk to toe and also make sure that you're collateral. History is good. You're collateral history. Maybe coming from your ambulance ambulance sheet, which has prided by a paramedic colleagues. It may be from a nurse or HCA or PT or ot, or even another patient on the ward, but it could also be from the patient's home environment is it from their neighbor. Is it from the next of kin? Is it from one of that carers? Is it from their nursing home? All of these require bit of detective work and a bit of digging. And ideally, with enough time, you can get to the bottom of any collateral history. Of course, when people have unwitnessed falls, it's much more difficult to get this. But a collateral history can still be helpful when, for instance, if you have someone at home, you have unwitnessed fall. But their care is often noticing that they are almost falling or having a lot of near misses that could be really helpful as well. You always need to be thorough, uh, in these patients, because a full somewhere along best day, or as the reason that they come in to hospital could be a really game changer in how you treat them and how you get them better. If you're thinking about a cardiac course, things like a 24 hour tape on an echocardiogram, which is the ultrasound of the heart, can be really helpful to see whether that the cardiac cause could be helped in some way and to see what's the exact reason why they may have for them? There's always a risk with the 24 hour tape that you won't actually see an arrhythmia because he read me happened during four. But it's really helpful just to see whether that arrhythmia can come back or anything like that. So in summary Falls a common but can have many very causes always use an 80 approach in the collateral. History can be invaluable. We're here to answer any questions on DWI, joined by our other colleague, Doctor and, uh is here is well on. We can answer any questions that you put in the chat on. Then there's just a couple more things from us before we finish. Hi, Annabelle. Can you look it? Yeah. And great talk learned a lot of I haven't actually got any questions at the moment it so if anybody does have any questions on the talk, please do and write them in the chart and we can answer them as best we can and or falls was something that I used The Phantom find very tricky when I was first called Is an F only used to really scared me If I'm honest. It's just so many different things that can cause a person toe have a fall and stuff that you wouldn't consider. Um, I know I had a lady once. Um, she had very affordable glasses. Oh, yeah, just when she moved you quickly and then like all of that I sites and that caused her to fall over in end up in hospital. And if something is similar, it's just I have changing our glasses and having Thio and just with 11 prescription for glasses stopped her from falling. Yeah, so just a little things. I think the number as well of people that I've seen where it's because of their ear wax in their underlying vertigo. And, you know, heart is fine. Big? Yeah, no big pathologies. But it's the little things as well as the practical things, exactly as you're saying. That can really make a difference in actually making and better by the time they go home. Definitely. Would you have any more tips to add for what? When you're on call and you get a call about a call about fall on the ward and at the trust I'm currently working at who we have and falls protocol, which is a movement which I only found out about it recently and pry like prior to using a spoon like I would do like you said, Try and go through everything. But there is quite a lot to remember. Sometimes I would get to the end of thinking what I forgot to ask this question. Where was with the end booklet? You can fill the booklet out of the teacher through step by step to make sure you've answered all questions and the quite m easy to fill out or with regards like Aura. It says, like, did your patient happen over yes or no? You definitely know if you've asked it and got response for it, so I would highly recommend everybody uses. That's yeah, it's a great audience. Project is Well, I bet for today. And one who, if their hospital doesn't have that kind of performer we have, does your one have a set off like next steps like investigations and a plan? Or is it more like the assessment portion? It's more of the assessments, but it does have it there on the bottom, which I was find helpful. This is if in any doubt, contact the med Reg is used to run by the patient's four. And I think a lot of my colleagues have used it just to give them a being, discuss what happens and then get some senior advice rather than sitting worrying about it and leave. And okay, Ancient. Yeah. Yeah, that makes a lot of sense. Yeah, we joined one question on the on the chance and CSF a question from Linda. She just said if patients are on VT a poor phylaxis, should they still be scanned for a head injury? Really? Good question. So if in so I'd be interested to hear what you think about this is, well, Anna, but in our hospital, if they haven't had, if they're not on a dose pack or warfarin, the low molecular weight heparin at the small dose that we give as prophylaxis doesn't necessarily qualify as anti coagulation. However, if they've got a head injury that is significant, it's likely that a CT head would be warranted or if it's got another. If they have another one of those criteria, like ongoing neurology, then that would definitely want a CT head. But just the fact of being on low molecular heparin in our hospital tends to not be a criteria. Um, which would you say the same as you always still. Or is it or is it different? No, I completely agree exactly the same. But I think we just got a very laws. And since they're like suspicion level, So if you're worried by any things at all, normally get CT scan. Oh, yeah, yeah, on those. And it's always always better to be safe than sorry. Yeah, there's even if we were talking Thea the day about case where we had someone who had a fall on the ward on unfortunately, it did lead to a bleed. Later, on a nest, day on day dropped their GCS, but it was only about four days afterwards on it was discussed at the mobility and mortality meeting, and we were looking through the notes on the documentation of when the lady had fallen. It was all a bit scattered, and it wasn't clear when she hit her head or no, because one of the nurses had written that the HCA thought she said that thought that she hit her head but wasn't a shore on, then in the next set of assessment, And when the performers filled out when the on call team it, it'll said about know, hitting her head on down. So I think it really that case when you talk about theme Porton so good documentation and really getting a good collateral. Because in that case that affected my colleagues, we realized that it was only the small things, like writing about what they actually saw on what they thought happened was a really game changer in like the next steps. Yeah, definitely one end Funny. It's itself funny by any means, but it did make me laugh at the time with the lady I've had a few ladies have tripped over the dogs. You know, people who have had a little small, subtle dollars to start. Did they look under the feet and that had looked really none of them being seriously injured by anyway. Oh, bless. I should have a practical dogs. Oh, hopefully the quality of life benefit of having a little sausage dog. Definitely let me, too. Actually, the, uh if we didn't have any more residents, yeah, we could move on to our the last bits from us. Amazing. And so we're going to pose a QR code on this night, and I'm going to pose the feedback for, um in the common section. Um, please, Everyone has attended. Feel in the feedback full and be asked, detailed and specific. Responsible because this does help Annabelle and it does help the mind oblique platform. Teo, about few deceptions. Um, and it's helpful for us to know what's improved. So you have few minutes very pleased getting the feedback for him on did. There are no questions at the moment, and you think of the questions in the future least just send a semester on Facebook or my mind oblique on on the website on Do Thank you very much. Um, a bell, thank you very much on a thank you. And, um, just a quick reminder for everyone. Teo, join us for the next session next week. It's on Wednesday. It's 8 to 9 again, and it's going to be a session on complaints on the liver. Time goes on from the MD, so I hope everyone will join us on. Please remember, So you sign up and register Ford and lined the Leep website and Lebanon on. I hope to see everyone here next week. Thank you. And as well you can get a stiff but for attending the webinar. If you fill in the feedback form after you get stiff, you've attended on. You could put that in your portfolio as well. On bit can count as non Cortijo of your portfolio. When you start off one on it's good for your CP and things like that on Exactly. So I said it really helps us on. We want to improve on need it for our portfolios too. So that would be really great if people could be back. Otherwise, Yeah, we'll see you next week or M do you on dealing with complaints. Thank everyone. Thank you so much.