GGB

Doctors love acronyms. We use them for diseases (MI, CVA, TIA, ITP), medical studies (STEMI, NINDS, APACHE), and to show we belong (AMA, ACEP, ACS, BONER). The acronym GOMER stands for Get Out of My Emergency Room. I first read the acronym GOMER years before I became an ER doc. An author, with the pen name Samuel Shem, MD, wrote a book called "House of God". This was not a great work of fiction. The book chronicled the internship of a young doctor, at a fictionalized version of the Beth Israel Hospital in Boston. As with the old testament, there were commandments of the house of God. One of the commandments was "GOMER's go to ground".

I mean no disrespect to the elderly, I have a very alert 90 year old mother. As an aging ER doc, I find myself relating ever more closely with my elderly patients. The word GOMER in "House of God" refered to the elderly patient. Some may view this word as perjorative. I apologize if anyone is offended. The reality of the crowded ER is that less than flattering terminology is sometimes used by the ER staff.

A frequent complaint from the patient, the family or the care facility staff is that the patient fell. GGB= Gomer Go Boom. The most common cause of trauma in the elderly is a fall. Because of the increased incident of diabetes, hypertension, confusional states, thyroid disease, etc, the elderly are the victims of polypharmacy. They take many medications. Often different specialists and the primary care doctor are all prescribing medications. Sometimes a medication is prescribed to counteract the side effect of another medication. Many medications can cause drowiness, weakness, low blood pressure, low blood sugar and confusion. The elderly are often on aspirin, warfarin or other medications that cause or exacerbate bleeding.

The anatomical and physiological changes of aging also predispose the elderly to falls, and make the risk and extent of injury worse. Thinning of the bones, degenerative arthritis, diminished vision and hearing, decreased sensation and balance all are part the aging process. A minor head bump in a 30 year old can cause a life threatening bleed within the skull of an 80 year old.

Heart rythym problems, blood flow to the brain, and low blood pressure from many causes can lead to syncope. This is a sudden loss of consciousness. This may lead to a fall if the patient is standing or seated. Straining to urinate or defecate, even coughing can also trigger syncope. The ER staff must evaluate the injuries that occur during a fall, as well as try to determine why the patient fell.

I recently treated a lovely woman who had fallen at her assisted living facility. The EMT's did an excellent job. The patient was immobilized by means of a rigid cervical collar with bracing on the side, and was on a long back board. The patient didn't complain of any neck pain. She was alert but confused. The family confirmed her history of confusion, and a prior stroke. She moved the side not effected by the stroke. Having a high suspicion of head and neck injuries, the patient was sent for a head and neck CT. Multiple cervical vetebrae fractures were found, including what is called a hangman's fracture. A similar scenario occured several months ago. This patient was in her mid sixties and had tripped and fallen down a flight of stairs at home. She sustained a severe fracture of her shoulder. She did not complain of any neck pain, only shoulder pain. The EMT's again followed protocol and immobilized her neck, head and back. Plain x-rays revealed the shoulder fracture. CT of the head and neck showed a subdural hematoma (bleeding in the skull from a venous injury) with a skull fracture and unstable fractures of the cervical spine.

Hip fractures are extremely common in the elderly from even minor falls. Osteoporosis, loss of bone density, predisposes the patient to have fractures from seemingly trivial impacts. The diagnosis is usually evident from the complaint of pain and the position of the injured leg. The ER doc must be vigilant for other injuries and bleeding issues. A company has devised a type of padded undergarment that decreases the likelihood of a hip fracture from a fall. My mother said it would make her look too "hippy".

The signs of trauma are often blunted by the medications the elderly take and by the physiologic changes of aging. The increase in heart rate from blood loss may be obscured by beta blockers. These medication are used to treat hypertension, coronary artery disease, heart failure and other conditions. Pre-existing hypertension may give a false sense of stability in the traumatized older patient, when a normal blood pressure is measured.

The current older population lived through the depression and a world war. They are stoic and self-reliant. I admire this "Greatest Generation". During a trip to Chicago, I met a man wearing a cap that said USS Missouri. He was in a wheelchair being pushed by his daughter. I asked him if he had served on the Missouri during WWII. He had been present when the armistice was signed that ended WWII. This occurred in Tokyo Bay on the USS Missouri. The elderly present unique challenges to the ER staff. They have earned our love and respect. They are most appreciative of our efforts.

To seniors and their loving families, I would give some heart felt advise. Ask your family doctor to go over your medications and try to shorten the list if possible. Don't be stubborn. If your gait is unsteady, use a cane or walker consistently as directed by your doctor. My mother broke her hip because she was anxious to get a good seat at the nightly movie at her assisted living facility, and didn't use her walker. Lastly I would ask that the elderly driver to give up this priviledge when the effects of medications or simply aging makes them a danger. Family, friends, and doctors should intervene if necessary to keep an impaired older driver from injuring themselves or others.