Where the fall happened: environmental hazards
The place of a fall finds fixable hazards and gives a clue to whether the fall was mechanical (caused by an outside factor) or medical.
Remember
Asking where a fall happened looks for hazards in the surroundings, for example a wet bathroom floor, and the answer gives a clue about whether the fall was mechanical or medical.
Memory aid
who, when, where, what, how, and where is about the surroundings
Use the five themes to organise a falls history, and remember that where is about the surroundings.
A falls history is organised around five themes: who, when, where, what and how. The where step asks where the fall happened and which hazards were present, such as trip hazards, slippery floors or poor lighting.
The answer finds environmental hazards that can be corrected, such as loose rugs or missing handrails, and an occupational therapist (who can help with fitting rails or other adaptations) can address them. It also gives a clue to the mechanism of the fall.
A mechanical fall has an outside cause, such as a slip or a trip. A wet bathroom floor is a classic setting for a slip. A sudden fall on a clear, level floor, with no trip or slip, suggests an intrinsic cause (one that arises from the patient). Examples are syncope (a faint, where a drop in blood flow to the brain brings a loss of consciousness) or a seizure.
Remembering the whole event argues against a loss of consciousness. A fall with no protective reaction (the person did not try to protect themselves) and no memory of it is a clue that the person may have lost consciousness.
The answer is combined with the rest of the story, because a hazard does not rule out a medical cause. A fall after standing up from the toilet needs care, because passing urine or stool can trigger a situational faint, and standing up can trigger orthostatic hypotension (a fall in blood pressure on standing). Even when a fall is a trip or slip, what caused the trip should still be explored, such as poor vision or footwear.
Key facts
- The where step
- asks where the fall happened and what hazards were present.
- Two purposes
- it finds fixable hazards and gives a clue to a mechanical or a medical cause.
- Mechanical fall
- one with an outside cause, for example a slip on a wet bathroom floor.
- Clear, level surface
- a sudden fall with no hazard to explain it suggests an intrinsic cause such as syncope or a seizure.
- Follow-up
- an occupational therapist can help with fitting rails or other adaptations.
- A hazard is present
- it does not rule out a medical cause, so the answer is combined with the rest of the story.
Exam traps
- Falling just after using the toilet does not show a slip, because passing urine or stool can trigger a situational faint.
- Falling at home does not separate a slip from a faint, because both commonly happen at home.
- A faint or a mechanical fall can occur indoors or outdoors, so being inside or outside does not separate them.
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