Ask, in this order: Did he hit his head? Is he on anticoagulation? Can he move everything? Is there obvious deformity or a shortened, rotated leg? Was he found on the floor, or was the fall witnessed? Observations and glucose?
Tell the nurse: do not move him if there is neck pain, deformity or an inability to move a limb — spinal precautions, not abandonment: assess him where he is, keep him warm, give analgesia, and move him with trained hands and the right equipment rather than leaving him on the floor waiting for a decision · full vitals · glucose · lying and standing BP once safe.
Job 1 — the injury. Head injury — and anticoagulation changes the threshold, so apply the local head-injury rule properly rather than from memory. Under NICE NG232 (recommendation 1.5.13), anticoagulation — or antiplatelet therapy other than aspirin alone — is reason to consider a CT head within eight hours of the injury, or within an hour if he presents more than eight hours after it. Consider, not require: it is a prompt to think, weighed against how hard he is to assess and whether anyone would notice him deteriorating overnight. And it sits alongside, never instead of, the immediate-CT red flags — falling GCS, suspected skull fracture, post-traumatic seizure, focal deficit, repeated vomiting — which demand imaging within the hour on their own. Then cervical spine, hip and pubic rami fracture, wrist, and in the frail, a fracture with almost no pain.
Job 2 — the cause, which is the one that gets skipped. The fall is a symptom. Arrhythmia, postural hypotension, sepsis, hypoglycaemia, stroke, delirium, seizure, drugs (antihypertensives, sedatives, alpha blockers, anything new), anaemia, or a simple mechanical trip. Treat an unwitnessed fall in an older patient as potentially syncopal until the collateral history, the examination, the ECG, the postural pressures and the drug chart make something else more likely.
FIRST MOVES Examine before you mobilise. Full neurological examination and document the baseline GCS so the next person has something to compare with. ECG, glucose, lying and standing blood pressure, and a look at the drug chart with the question “what did we start yesterday?” Delayed presentation matters: chronic subdural bleeding can present days later, so the documented neuro-observation plan is part of the treatment and not paperwork — frequency, deterioration triggers, and who gets called, per the local protocol. That is not the same as keeping everyone in for days after a normal scan; that depends on the injury, the cognition and who is at home. Then complete the incident documentation, and tell the family — most institutions require both, though in a patient with capacity that conversation is theirs to authorise and not yours to assume.
Ward call: [AGE]-year-old [SEX], day [X] for [REASON]. Fall at [TIME]. [WITNESSED — mechanism / UNWITNESSED, found on floor]. Head strike: [YES/NO/UNKNOWN]. Loss of consciousness: [Y/N/UNKNOWN]. Anticoagulant or antiplatelet: [WHICH, last dose]. GCS now [X], baseline [X]. Focal neurology: [X]. Neck pain: [Y/N]. Able to weight-bear: [Y/N]. Limb shortening or rotation: [Y/N]. Pain sites: [X]. Obs: HR [X], BP lying [X] standing [X], temp [T], glucose [X], sats [X]%. ECG: [X]. Drugs started or changed in the last 48h: [LIST]. Give me two separate lists: what I must exclude as INJURY tonight, and what I must exclude as CAUSE. State plainly whether this patient needs a CT head and on what rule. Tell me what my local head-injury protocol will likely specify for neuro-observation frequency and duration, and the delayed-bleed risk it is guarding against — I will verify it against the protocol itself. Then name which of these drugs is most likely to have contributed.