200 Broadway — fall

Location: SEMS HQ

Time: 14:58 Wednesday

Conditions: Cool, light rain

Equipmentfully stocked



Captain Florentino, the long-suffering C9, has managed to convince you to mop out the base after you’ve spent the past few hours marinating on the couch. You’ve got chairs on the tables and the mop bucket filled when the base alarm kicks in and the loudspeaker radio crackles… (click for audio)

[Ambulance 61, respond priority 1 to 200 Broadway, apartment 589, for a fall. That’s a 68-year-old male who fell, conscious and breathing at this time. 200 Broadway is between Rawson Rd and Tufts St. With Ladder 1. Time out 14:59. A61?]

Click to expand



Oh well. Florentino can mop up himself if he’s so passionate about it.

You trot behind Steve downstairs toward the garage, roll up the doors, and are soon outside puttering down Broadway. This is the Lower Heights Apartments, one of your frequent haunts; there’s a substantial elderly population there, but it’s a normal apartment complex.

You arrive within four minutes, just behind Ladder 1; a police cruiser pulls in behind you. Parking at the curb, you toss a board and the C-spine equipment onto your stretcher along with the usual airway and first-in bags. You head in alongside the firefighters; the police officer moseys in after.

The stretcher fits into the elevator, just, and fire tells you — “We’ll take the stairs.” Up on the fifth floor, you follow signs to find apartment 589. As you knock, you hear “Come in!” It’s unlocked, so you do, bringing the first-in bag.



It’s a good-looking smallish apartment, and you find an elderly man sitting in an easy chair, alert. A middle-aged man is walking around, who tells you: “My dad… he fell.”


Initial Assessment

You approach and kneel by his side. He presents as a well-appearing elderly gentleman, in no apparent distress, breathing easily. He does look slightly vexed. As you take his wrist, you feel warm, dry skin and a strong, regular radial pulse.

“Hi! What’s your name?”


“I’m Sam.” You shake. “What happened?”

“Uh… I fell down.”

“Yeah? Why’d you fall?”

“I got dizzy and I fell.”





“What do you mean when you say ‘dizzy’? Lightheaded, like everything was going dark? Or like the room was spinning? Or something else?”

“Lightheaded, I suppose.”

His son chimes in: “He was standing up from the kitchen chair, and he just went down. I caught him and lowered him to the ground.”

“Okay… did you hit your head?”

Neal demurs.

“Do you think you lost consciousness?”

In reply, he frowns in consternation. Honestly, you’re not sure why you bother asking; nobody ever has any clue. His son replies for him: “Maybe for just a moment? He was a little confused for a few seconds.”

“But not really unresponsive, or just for a quick second?”

“Yeah, he came to pretty quickly.”

“Did you see his eyes?”

“They were closed.”

“And then once he came out of it he seemed normal?”

“Yes, I helped him to the chair, he seems like he’s been okay since.”

You’d hardly noticed, but Steve has been in there taking vitals, and he hands you a card with:




You ask him for a finger-stick as well. Then to Neal: “How are you feeling now?”

“I feel okay. I’m embarrassed about all this fuss.”

“Hey, it’s our pleasure. Are you feeling any pain?”

“Just my knees, but they’re always hurting from the arthritis.”

“Feeling dizzy at all?


“Is this something that happens to you sometimes — you get dizzy when you stand up? Or is this totally new?”

“Maybe a little, but not like this.”

You ask him to show his teeth — no droop — and hold out his arms — no drift. His speech sounds okay. For good measure, you do a quick peripheral neuro exam, revealing no focal weakness or deficits.

You find no notable signs of trauma on his head or neck, and he seems otherwise intact. His lungs are clear and his abdomen is soft and non-tender.

Steve reports, “153,” and trots off to get a medlist.

“What kind of medical problems do you have?” you ask.

“Oh… high blood pressure… hypothyroid… arthritis…”

“Any problems with your heart?”

“Oh, yes, I had open heart surgery a few years ago. And an irregular heartbeat sometimes, I take a pill for it. There’s a valve problem too.”

“Valve problem?”

“Yes… I don’t remember.”

“Ever had a stroke or anything similar?”

“No, nothing like that.”

“Any history of seizures?”



“My doctor has been warning me about it, but no.”

Steve comes back with this list:





“I guess he was on a couple others, but they discontinued ’em a month or two ago because of some interactions,” Steve tells you.

“Any idea what was changed in your meds?” you ask Neal.

“I was taking something for my blood pressure, but it was making me feel crummy, so we’re stopping for a while.”

“Any changes in how you’ve been eating?”

“Not that I can think of.”

“All right,” you tell him. “What do you think? Do you want to go to the hospital?”

“Well… not really. I think I’m fine, I feel okay. My son was just worried. What do you think?”





“It’s up to you. I know you want us to tell you that you’re either okay or you’re not, but we don’t really have the resources here to do all the tests you’d need to know for sure. To the extent that we’re able to evaluate you,  I can say that we’re not finding anything really alarming, and from what you’re describing it sounds consistent with what we’d call ‘vasovagal syncope,’ which is usually pretty benign. But with your cardiac history it’s possible there’s a problem with your heart, and it could be anything, even something pretty dangerous. The safest thing is always to get checked out at the hospital.”

His son asks, “Do you think it’ll happen again?”

“Well, I can’t say. Is there any reason that you’d be dehydrated right now?”

Neal shrugs. “I haven’t been drinking very much, but I never do.”

“That certainly wouldn’t help. It’s also possible that some of your recent medication changes could be playing a role, so if you keep having trouble I’d visit your doctor to talk about it. You don’t want to keep falling or you’re going to hurt yourself eventually. How about this? Let’s try standing and see how you feel.”

You cautiously assist him to his feet, standing in a “catcher’s position” in case he goes down. He seems okay, and a surreptitious finger on his radial pulse notes a modest increase in rate, but nothing dramatic. You watch him ambulate around the apartment, slowly but steadily.

“Looks pretty good to me. How are you feeling?”

“Fine… maybe a bit weak, but that happens sometimes.”

“Sure. Okay, well, as I said, it’s up to you; I can’t tell you to go to the hospital or not.”

“I think I’m okay,” he replies as he returns to his seat.

“If we leave you here, are you going to be alone?” You look over to the son. “Will you be here?”

“Yep, I’ll be here, I’ll keep an eye on him.”

“That’d be great — just be aware of how he’s doing, and make sure he doesn’t fall. If either of you notice anything else going on, or this keeps happening, feel free to head over to the hospital or give us a call back. You know the number, we’re always around.”

Everyone agrees with that, so you send Steve to fetch the computer. After recording some basic demographics, you have Neal sign a refusal of transport.

“All right, we’re out of here then. Best of luck to you. Have a nice day.”

With that, you’re off, hauling your bags and stretcher back to the elevator.

“Nice folks,” you yawn as you hop back into the truck.

“Yep,” agrees Steve. He clears over the radio and dispatch sends you to Bravo. He weaves through traffic while you tap at the screen.



Diagnosis: vasovagal syncope

The most common cause of syncope, or sudden loss of consciousness that resolves after collapse, is usually “vasovagal,” or sometimes labeled “neurocardiogenic.” The idea is that when you suddenly transition from a seated or lying position to standing upright, gravity pulls blood away from your brain and into your legs. In order to maintain cerebral perfusion, your body needs to compensate by vasoconstriction and cardiac stimulation.

In some cases, due to miscalibrations in the nervous system (particularly the vagus nerve and associated neural structures), this compensation is inadequate or backwards. As a result, the brain is temporarily hypoperfused, and you pass out. It’s common and usually benign — unless you hurt yourself when you fall — and can be exacerbated by existing hypovolemia (from dehydration, for instance) or drug interactions. Classic vasovagal syncope occurs shortly after standing (or sometimes when bearing down, such as on the toilet or while weightlifting), is associated with a “prodrome” of lightheadedness and sometimes other symptoms, and resolves almost immediately after you collapse to a more horizontal position.

Although vasovagal is among the most common causes of syncope and is usually benign, other causes can be less benign, so be sure you’re thinking about possibilities like arrhythmias, seizures, and stroke. Read more in our piece on Differentiating Syncope.

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