Fell in the shower


• Scene – Lift assist
• En Route – refused all treatment – IV, O2
• Hospital – Not known


• Response to prehospital treatment – N/A
• Disposition – unknown


• Mark Shelton Paramedic Woodburn Ambulance
• David Jones, MD Associate Professor Oregon Health and Science University


• Ritu Sahni, MD, MPH Oregon Health & Science University

• Leg Edema
• Psoriasis
• Mechanical fall due to prosthetic difficulty

Differential Diagnosis

Leading To Fall:
• Mechanical fall
• Arrhythmia induced syncope
• Infection/sepsis
• Stroke
• Hip fracture
• Orthostasis
• Dehydration
• Myocardial infarction
• Medications
• Vertigo

Resulting From Fall:

• Cervical spinal fracture
• Intracranial bleeding
• Rhabdomyolysis (if prolonged down time)
• Dehydration (if prolonged down time)
• Hypothermia
• Musculoskeletal injuries like an ankle injury

Patient Workup

• Patient states she was in shower, moved and hurt ankle while trying to put prosthetic on.
• Was found on ground in shower, denies loss of consciousness.
• Denies head, neck or back pain. Denies any other pain.
• Was initially a lift assist by fire, patient requested transport for eval.

Physical Exam

• No deformities to L ankle, R leg BTK amputee, severe psoriasis on L leg.

Editor’s Notes

What is the best way to manage patients who refuse treatment in the field? How do you manage adult patients who are failing to thrive? Please add a comment at the bottom of this case.

Suggested Approach

• Always consider cervical spinal injury and immobilization when someone falls and hits their head.
• It is important to think about both what may have caused the fall, as well as injuries that may have resulted from a fall.
• Even seemingly mechanical falls should have a glucose, a stroke scale and an EKG checked.
• Find out if they are on aspirin (salycilate), Plavix (clopidogrel), Coumadin (warfarin), Pradaxa (dabigatran), or other blood thinners, as these medications increase the risk of intracranial bleeds. Intracranial bleeds are one of the big concerns that could kill a patient
• Keep in mind that the elderly are already at increased risk of intracranial injury with even minor mechanism, even if they’re not on blood thinners.
• It is important to consider how long the patient was down for, what their functional status prior to the fall was, and what their body temperature is. Many older people fall and can’t get up for prolonged periods, resulting in hypothermia and muscle and skin breakdown from being down for so long.
• Whenever someone injures an extremity, check if they have strong distal pulses, motor strength, and sensation. If any of those details are missing, they need immediate evaluation at the hospital. If there is an obvious deformity, a cardboard splint can sometimes help with circulation/nervous/motor problems and pain control.
• Consider treating pain as appropriate per local protocol.

Suggested references

• Falls in the elderly
• Failure to Thrive in Elderly Adults


• Gender: Female
• Age: 75 years
• Height: Not Available


• Temperature: Not Available
• Blood Pressure: 113/55
• Heart Rate: 69
• Respiratory Rate: 18
• Pulse Oximetry: 90% RA

Signs and Symptoms

Ankle pain following shower accident; lower-leg edema


• PMH: Diabetes type 2; hypertension; R leg amputation; severe psoriasis – lifelong.
• Allergies: Morphine
• Dispatch info – Lifeline activation, no response.


• Patient lives alone.
• Uses a cane and walker for mobility.
• House was poorly kept, smelled of pet urine. Patient is borderline failure to thrive.


• Not known

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