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Journey of a DPT Student

Falls -- They Come in Threes

Published January 21, 2014 12:26 PM by Lauren Rosso

Just over a week ago, I had my first experience with an incident report. All in all, it wasn't a big deal. A patient of mine with T11 paraplegia was attempting to stand from his wheelchair to complete a 10-meter walk test. As it turns out, his brakes (even when engaged) barely work. He went to push up from the chair, it started to slide backward, and he basically dipped himself down onto the floor. Minor incident report. No harm, except to my ego.

Six days later. Much bigger deal. Another patient of mine s/p TKA with an extensively complicated orthopedic history has been in PT for 12 weeks now. She has been dealing with the chronic effects of brain injury since she was 17, the same incident that caused her to have bilaterally fused ankles. Surely not a good prognostic factor for TKA recovery. We've been addressing any and every aspect of balance, strength, flexibility and mobility in the attempt to avoid another knee surgery, but it's been a rocky road.

I put together an obstacle course of familiar activities to encourage functional knee flexion. I wasn't really on high guard at the start (big mistake) as she was ambulating over quad canes, which she has never had trouble with before. I didn't even have time to react when she caught her foot on the cane, was unable to catch her balance with her bad leg, and fell to the ground faster than I've ever seen. On the way down, she hit her head on a step. All in the middle of the gym.

I was completely mortified, as was she. Thankfully she's fine. I kind of wanted to walk out of the clinic, turn in my ID, and call it quits on this whole "PT career." Now, I'm waiting to see if falls really do happen in threes. I'll keep my fingers crossed and gait belts on until I know I'm in the clear.

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Unfortunately at some point we will experience a patient that has a fall or near fall. I had a patient during my clinical in inpatient rehab  who was ascending stairs that nearly fell on my watch. She was previously performing stair negotiation with just some support for balance, however on this day her knee buckled and I had to catch her. Luckily I was able to support her on my knee and the other therapists came over to help me and she never hit the floor. However, I felt like this was all my fault and I was a bad therapist. After my clinical was over, I went back to visit my CI one day and she told me another patient we were working with before I left had also suffered a fall during stair negotiation. This made me feel a lot better because I realized that this happens to experienced therapists, not just me. As unfortunate as a situation like this is, I have used this as a learning opportunity and I will be extra cautious to prevent another incident like this.

Kristian February 20, 2016 9:24 AM

I have had the experience of a patient falling on my watch.  It was a long story and it was not due to my lack of supervision, but there is something unpleasant about going to tell your CI that you need to fill out an incident report.  It did not initially occur to me that I would need to report a fall because the patient did not actually hit the ground but better to play it safe- especially in a hospital setting.  This did not occur in a crowded gym, so there was not a large group of onlookers, but I was somewhat paranoid that my coworkers were going to think I was a terrible therapist.  My CI was actually somewhat annoyed, but only because it was the end of the day and he was busy and attempting to leave to make it to his part-time job and the paperwork was a major inconvenience.  I am sure there are people who will read your blog and some of the comments and look down on those who have had a patient fall, but these folks have probably not done very extensive work in patients with TBIs.  The unpredictability makes it exciting.  Thank you for being willing to share your own triumphs and struggles as a student.

Jon McPeters January 12, 2016 7:23 PM

Having a patient fall was one of my biggest fears whenever I was working with a patient.  I had gone through my first two clinical rotations without anything happening until I started my third clinical in inpatient for stroke patients.  I was working with a patient who was about to be discharged the next day because she was doing so well. As we were walking around a mat table she lost her balance and we both fell to the mat table safely.  I had been using a gait belt which helped me assist her safely to the mat table, but it was a scary situation.  I guess situations like these teach us to always expect the unexpected.

Julie March 23, 2014 10:16 AM

Hi Lauren, I just finished my last rotation in inpatient rehab, and I feel that I can sympathize with your situation. As a student in this setting, I feel like it is ingrained into your memory that priority #1 with your patient is "don't let them fall!" So much so that it can clout your judgment and often times take away from the progress of your patient because you don't allow them to increase their independence. Thankfully, I did not experience any falls on my watch, but at my facility, we had other PT students working and one girl did experience a fall. She was ambulating with a patient who was post brain injury, and she had worked with this gentleman for weeks on gait training. The fall happened right next to me as I was stair training with another patient, and when I witnessed it, it was like my stomach fell out of my body. So scary to actually see..thankfully no one got hurt, and the student was pretty shaken up. But her CI gave her reassurance that even the best, most experienced therapists have mishaps every so often and to not let it get the best of her. A bad situation turned into a great teaching moment for all! Don't stress over your situation either. You will continue to be a great therapist and while minor obstacles like falls do happen, hopefully you can take the situation, learn from it, and be a better therapist because of it! No worries!

Jonathan, SPT March 22, 2014 2:25 PM

The first and only complete fall of an otherwise fall-free career occurred while I was working as a CNA in a nursing home back in the late '70's before applying to PT school.  I was walking a woman to the lunch room and she just required supervision. I had forgotten to bring a 'chuck' as she had occasional accidents. She had stood safely many times as we talked in the halls and I didn't question the safety of leaving her standing with her walker as I ran to get the pad. By the time I returned, she had fallen and broken her hip. I know that her hip may have fractured while standing (she was obese), but the very sad thing is that she passed during the surgery. I will always remember her as I used to have long conversations with her and were very friendly. I know that there are situations that come up that surprise - like the fact that she had not, until that time demonstrated any difficulty stepping over canes on the floor, and unfortunate things can happen. But to this day I am very careful when walking or transferring anyone and prepare the area and make sure the situation is safe. A gait belt is my best friend and is used at all times. I never use a typical gait pattern when walking someone: I stand to the side and very slightly behind the pt. and I always lead with the foot that matches the side I am on.  If on the left of the Pt., I lead with the L foot and never pass it with my right so that I have a wide base and am never caught off guard (a step-to type of pattern). I also  always keep a cursory eye on their feet in addition to everything else, as the feet give an indication of what will happen... not clearing toes, not clearing obstacles, too narrow a base, etc. If there is trouble, I can always use my outside arm to help keep their trunk up and even pull them (with the gait belt) back into me and steady them if need be. It is good to learn early to be ever vigilant and to never let your guard down.

Ruthie, Physical Therapy - Staff PT March 15, 2014 7:40 PM
Sacramento CA

Sorry for the same response twice, the first one was posted under the wrong blog.

We have been learning about falls in our program recently.  From what I have learned in the classroom, I do not think you will be alone in a fall happening during on of your sessions.  I know it is scary to experience- my grandmother had a recent fall and my mom said (just as you did), "It was like boom, a blink of an eye and she was on the ground."  She got a big gush to her head, two black eyes, and trip to the emergency room.  I don't think it is only your ego that got "shot," but she may have been embarrassed herself (I know my grandmother was).  Keep it up and make sure she, just as you, still feels confident and as independent as possible.  You are one of her great hopes in maintaining a functional status.

Sarah March 7, 2014 11:18 AM

I am about to head out on my first clinical of PT school. Having a patient fall is one of my biggest fears, especially working in acute care as my first experience. This post really brings home the fact that a fall can happen at any time, with any patient. It does not have to be while up walking around it can be from something that should be considered safe, a wheel chair. Thinking about the wheel chair incident you had makes me very aware of the details I need to pay attention to. Hearing stories like this reassures me that everyone is human, but we must also take every precaution to be safe. I know with more experience, I will know many more things to watch out for and just get the feel for how a patient is doing during therapy. I know this was a learning experience for you and I hope I can take this small example with me to do the best that I can on my clinical.

Jenny March 6, 2014 6:27 PM
Greenville NC

I remember when my first patient fell…over 20 years ago. I can still picture the incident clearly in my head. I was devastated. The head nurse, one of those old school, tough as nails, told the doctors off, and terrified everyone on the floor kinda gals; put her arm around my shoulder and told me, "You're a good therapist. We all make mistakes 'cause we're human. There are a bunch of other people on this ward who need you to pull it together so they can go home. Chin up and go make them well." She then gave me what I believe was the only smile of her adult life. I learned that I was human, that I was a good therapist, and that I still had lots to give. OK, you got humbled. You won't make those mistakes again. Now go make people well :-)

Dean Metz January 21, 2014 2:57 PM

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