Falling over & knots

I hate it when one of my patients falls over on the ward. Each time this happens, I feel as if I, somehow have personally failed to keep them safe, safe, when they are unwell and at their most vulnerable.

It is true, that people falling in hospital is complex, it is equally true that we can do lots to reduce the likelihood of falling – close observation, avoiding dehydration, proper footwear (special grippy red stocking slippers if no shoes in Doncaster), eating and sleeping well, treating infections, monitoring for postural hypotension – when an individual’s blood pressure drops when they stand-up (the opposite is meant to happen), reviewing medicines, and on and on.

Many of the people who fall on my ward shouldn’t be in hospital – they aren’t actually ill. Although I still refer to them as patients, for they are under my ‘care’ and are experiencing the ‘suffering’ process I have described previously (see People not patients #1) – by and large, many of these frail, vulnerable individuals should be at home. Such is the chaos of the social care system that it is easier to undertake cardiac surgery, treat Ebola, transplant genes and meddle with immunoglobulins than discharge an older person from hospital.

Hospitals are terribly dangerous places for older people.

So much of the infrastructure, the design, is aimed at minimizing infections (MRSA, ESBL & C.difficile being the most nefarious in the current microbiological hit-list) that we forget that older people when at home often navigate by their furniture, by the walls of their kitchen, their hall and bedrooms. They know where the handles are, the light-switches, the doors. Familiarity developed over decades (aka ‘home’).

The unfamiliarity of hospital is hazardous.

Therefore my patients sometimes fall.

We could prevent patients falling altogether – by preventing them from getting up and mobilizing independently, by restricting their movements and activities. This is practiced in some countries, still today – people immobilized in bucket seats, or trapped behind tables and chairs, to keep them safe. An alternative form of restraint is chemical – inducing a state of sedated stupor that keeps people from moving.

This is missing the point completely and a horrible notion. Balancing the risk of falls and independence is a Gordian knot that is beyond my ability to solve, for it is not the patients, or the environment, or even the medical care which the people receive (which we can manipulate in a multitude of person centred, holistic and multidisciplinary ways) –

It is the system that is flawed. Older people are flooding into hospitals in ever greater numbers, despite the attempts by doctors, nurses, social workers, care home staff and others; we know that hospital is often the last place a vulnerable person should be, yet the alternatives are few.

Once an older person sets foot into an A&E department, medicine or medicalisation takes hold, tests are ordered and diagnoses assigned, people transform into patients and the slippery slope towards institutionalization begins.

I’m not saying that all older people should stay away from A&E, more, we should have better systems to support those who do not need to attend A&E to remain at home, away from the ECGs, CT scanners and unnecessary antibiotics.

That is how we ensure independence and reduce falls.