Simulated Patient Scenario

Fall (No Loss of Consciousness)

Scenario Details

Scenario: Elderly Fall - No Loss of Consciousness

Simulated Patient: 80-year-old Male

Actor/Actress: Student Actor (Patient)

MDT Information

Non-Urgent Response - Fall
80-year-old male fallen at home, unable to get up
Patient is conscious and alert
Complaining of hip pain
No loss of consciousness reported by patient
Location: Home address, patient lives alone

On Arrival

You arrive at an apartment and are let in by the patient using a personal alarm service remote unlock. You find the patient, an 80-year-old male, lying on the floor in the hallway between the living room and bathroom. He is alert and oriented, but grimacing in pain and states he cannot move his right leg due to severe hip pain.

Scene Safety Note: Assess for slip/trip hazards. Note patient is on the floor.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Alert elderly male on floor, in significant pain, guarding right hip/leg.
Response	Alert and oriented to person, place, time, event. (AVPU = A, GCS 15)
Airway	Clear and self-maintaining.
Breathing	Rate and depth appear normal. No respiratory distress.
Circulation	Skin pink, warm, dry. Radial pulse palpable, regular rate and rhythm.
Disability	Alert (GCS 15). Severe pain in right hip, unable to move leg. No other obvious deficits.
Exposure/Environment	Indoor hallway environment. Patient wearing pyjamas. Focus on injured limb and potential for hypothermia on floor.

Secondary Survey and Simulation Progression

History (obtained from patient)

Allergies	NKDA
Medications	Ramipril, Metformin, Simvastatin.
Past Medical History	Type 2 Diabetes Mellitus, Hypertension, Osteoarthritis (hips and knees), previous Left hip replacement 5 years ago. Uses a walking stick sometimes.
Last Oral Intake	Dinner last night (~12 hours ago). Cup of tea this morning.
Events Preceding / Fall Details:	Mechanism: Was walking from bathroom back to living room (~1 hour ago), felt his right knee "give way", lost balance and fell onto his right side. Loss of Consciousness (LOC): Explicitly denies any LOC before, during, or after the fall. Remembers the entire event. Amnesia: Denies amnesia. Preceding Symptoms: Denies dizziness, chest pain, palpitations, or feeling generally unwell before the fall. States knee just buckled unexpectedly. Injuries/Symptoms: Immediate severe pain in right hip upon landing. Unable to stand or move right leg since. Denies hitting head or any other significant injury. Alcohol/Drugs: Denies alcohol or drug use.

Vital Signs/Assessment (Initial)

Parameter	Value
Resp. Rate (/min.)	18
Lung Sounds (L/R)	Clear bilaterally.
SpO2 (%)	97% (Room Air)
EtCO2 (mmHg)	Not indicated
Pulse Rate (/min.)	90, regular
CRT (sec.)	< 2 sec
ECG rhythm	Sinus Rhythm
12-lead ECG	Sinus Rhythm. No acute changes. (Consider if any suspicion of cardiac cause despite denial of symptoms).
BP (mmHg)	140/85
Skin	Pink, warm, dry.
Pain (/10)	9/10 sharp pain in right hip/groin, worse with any movement.
GCS (/15: E,V,M)	15/15 (E4, V5, M6)
BGL (mmol/L)	7.5
Pupils (mmL/mmR)	Equal and Reactive (PERL).
Temp. (°C)	36.5 (Monitor for hypothermia)

Physical Examination

General Appearance: Alert, oriented, in significant pain. Lying on floor.
Right Lower Limb: Leg appears shortened and externally rotated compared to the left leg. Significant tenderness on palpation over the greater trochanter and inguinal region. Patient unable/unwilling to move leg due to pain.
Neurovascular Status (Right Foot): Distal pulses (dorsalis pedis/posterior tibial) palpable and strong. Capillary refill < 2 seconds. Sensation intact to light touch. Able to wiggle toes slightly when prompted.
Head/Neck/Spine: Denies head strike or neck pain. No tenderness on palpation of cervical or thoracic/lumbar spine.
Other Limbs/Pelvis: No other injuries apparent. Pelvis appears stable on gentle compression (assess cautiously).

Assessment and Treatment

Appropriate Management Focus

Primary Survey (ABCDE): Confirm no immediate life threats. Identify likely #NOF based on mechanism, pain, and limb position.
Pain Assessment: Use 0-10 scale. Assess frequently.
Pain Management: Prioritise early and effective analgesia.
- Consider Methoxyflurane (Penthrox) if no contraindications.
- Establish IV access.
- Administer IV Paracetamol.
- Administer IV opioids (e.g., Fentanyl or Morphine titrated doses) for severe pain.
- Consider Fascia Iliaca Compartment Block (FICB) if trained, equipped, and protocol allows - highly effective for #NOF pain.
Immobilisation & Positioning: Keep patient comfortable. Support the injured leg with pillows/blankets in the position found. Avoid unnecessary movement. Do NOT apply traction splint. Prepare for extrication.
Extrication: Use appropriate device (e.g., scoop stretcher, vacuum mattress) to minimise movement of the hip during transfer to ambulance stretcher.
Neurovascular Monitoring: Perform and document CMS checks distal to the injury before and after any movement/splinting, and regularly during transport.
Hypothermia Prevention: Keep patient warm, especially as they have been on the floor. Use blankets.
Transport: Transport to an Emergency Department with orthopaedic capabilities. Pre-notify receiving hospital (Elderly fall, suspected Right #NOF, pain score, analgesia given, CMS status).
Teamwork & Communication: Clear roles. Reassure patient. Clear handover.

Debrief Focus Points

Assessment of falls in the elderly, focusing on mechanism and ruling out syncope/medical causes.
Recognizing the clinical signs of a Neck of Femur (#NOF) fracture (pain, shortening, external rotation).
Importance of thorough neurovascular assessment (CMS checks) in limb injuries.
Analgesic options for suspected #NOF, including consideration of regional blocks (FICB).
Principles of immobilisation for #NOF (support in position of comfort, avoiding traction).
Safe extrication techniques for patients with hip injuries.
Hypothermia prevention in elderly patients after falls.
Communication and reassurance for patients in significant pain.