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Brandt's Rants

Which Tests to Run for a 94-Year-Old Feeling Oogie? All of Them

Brandt, Robert MD

doi: 10.1097/01.EEM.0000574768.99968.e5
Brandt's Rants

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I recently took care of a 94-year-old woman with abdominal pain.

Me: So what brings you into the ED today?

Myrtle: I've had some grumbles and smidgerines going off in my belly.

Me: Uh-huh. Sure. When did this pain in your abdomen start?

Myrtle: Oh, there's no pain. It's just, well, a little bit grommetty.

Me: Grommetty?

Myrtle: Yeah, not quite sour but almost oogie.

Me: Oogie?

Myrtle: Exactly.

If you have been seeing patients in the ED for a while, you probably have realized that as soon as humans turn 80, the word “pain” is magically erased from their memories. They feel bungled, poppy, fizzy, oogie, or vompy in the belly. But no pain.

The ability to describe the uncomfortable sensation seems eradicated from their brains. What replaces the word “pain” is usually a conglomeration of sounds and utterances that the well-meaning elderly use to convey discomfort. For our newer residents, elderly patients may provide false confidence and early dismissal of potentially catastrophic conditions.

Needless to say, trying to decode the new vernacular can be difficult. The elderly patient with abdominal discomfort (or abdominal pokiness) is a landmine-riddled path through the ED, and we are all wearing clown shoes.

Does Myrtle have gas? Does she have constipation? Does she have a ruptured appendix? Tough to say because all of them present exactly the same, with identical vital signs.

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Downplaying Pain

Sometimes the Myrtles of the world will even try to give us the answer. I had an elderly patient complaining of right lower abdominal discomfort (of course, it was discomfort with some pressure but not pain). She winced when I pressed her right lower abdomen. She had zero discomfort with palpation anywhere else. Her vitals were perfect. She took few medications and looked quite well. I did the typical workup, waiting for her CT to show an uncomplicated appendicitis. And then, just as expected, I got a call from my radiologist. Uh-oh.

Good news: She did not have appendicitis.

Bad news: She had an aortic dissection of the entire aorta! More of her was dissected than not. I quickly rushed into her room where she was casually watching TV with her friend. Laughing. I asked her a few more questions. No chest pain, back pain, abdominal pain, or pain anywhere other than the mild right lower abdominal pressure. Aaaaah! I double-checked that it was the correct patient. Yup. I called the thoracic surgeon and got her admitted, and she went to surgery. The patient wondered if all this fuss was really necessary. Did she want pain meds? Of course not. She just wanted a baby aspirin, possibly cut in half.

I looked her up in the computer three days later. She had already been discharged post-surgery and was doing great. I have no idea how. Myrtle did not get to 94 by being a wimp. I assume this complete and utter badass walked home after a morning's breakfast of lightning bolts, and punched the surgeon in the mouth just for keeping her from watching Matlock. All this without a single complaint of pain.

We know the statistics. If elderly patients have abdominal pain, we should be sprinting into the room because they have a scarier mortality than anyone else in the department. We have code blues, code STEMI, code stroke, but what we really need is a code oogie. Whenever you get someone over 80 who is feeling oogie, you should wheel over the crash cart just to ward off evil spirits.

The elderly often downplay their symptoms as well. I had a nice gentleman who kept complaining that his belly button felt funny. Actually, he did not say funny. He said, “It's like it's doinking out.” Do you know what tests to run for an 88-year-old with a doinking-out belly button? I do—all of them.

No pain (of course), it just felt funny. It struck me as odd that he would come to the ED with this as his complaint, but he did look quite uncomfortable. It turned out that a myocardial infarction had something to do with his funny-feeling belly button. Any chest pain, sir? No, obviously not. No chest pain, chest pressure, shortness of breath, or heaviness. Only a funny belly button.

The next time you get a geriatric friend who says her curbumple is getting all venerated, sprint into the room and bring the crash cart. It might just be a code oogie.

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Dr. Brandtis an emergency physician with the Grand River Emergency Medical Group in Grand Rapids, MI. He was the winner of the 2008 Writer's Digest Short Short Story Writing Competition (http://bit.ly/1kIBaOf). Read his blog and other articles athttp://brandtwriting.com, follow him on Twitter @brandtwriting, and read his past columns athttp://bit.ly/EMN-BrandtsRants.

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