Wednesday, March 17, 2010

A Hat Trick of Tales

Three brief notes from the ED this past Saturday:

Mrs. Hulstead was a delightful 80 year old woman who came to see us after having an episode of unresponsiveness at a local restaurant. It turned out that a local physician I know well was also there for lunch, and helped ease the patient to the floor and attended to her until the paramedics arrived.

This reminded me of my own tale of restaurant assistance. About two years ago, The Bride and I were eating at a Cracker Barrel in Topeka. It was just after noon on a Sunday, and the after-church crowd was rolling in. I was fully engaged in the cholesterol bath (if quiet, you can actually hear your arteries snapping shut with cream gravy) when she saw an elderly man at another table starting to slump over his meal. She elbowed me and said I should pay attention and go help him out. I looked up, decided everything was okay, and went back to the unmitigated glory that is a plate of cheesey eggs.

This, however, was not the preferred response, and again the elbow collided with my rib cage. (Note that this was still relatively early in the marriage. Now I’ve been trained to respond at the first elbow.) This time the man was half out of his chair on the way to the floor. It turned out that, as usual, she was right. I should go do something.

I went over to the table, introduced myself, and helped the patient to lie down on the floor. I supported his head, monitored his pulse, and provided reassurance until the paramedics arrived.
I thought nothing of this, as I hadn’t really done anything. But the manager seemed grateful for my acute non-intervention, and comped our meal for the day. We also got a gold certificate good for another meal at a future date.

So two weeks later, it’s another Sunday, we’re back at Cracker Barrel, and the same thing happens. Old person starts to sag. I go over and say the magic words, “Hi! I’m a doctor.” We lay the patient down on the floor, I wait until the paramedics arrive, and I get another gold certificate.

I wish I could say that my luck continued to hold, but the next visit to Cracker Barrel provided unlucky…nobody got sick, nobody collapsed, not even a chance to continue the streak. But ever since then, when I go to a Sunday brunch, I’m always looking for those walkers, canes, and portable oxygen tanks. I just know there’s another golden ticket out there just waiting for me.

One of the elements of any good patient interview is the social history. In its brief ED version, it consists of asking the patient about the use of alcohol, cigarettes, and drugs of abuse. In older patients, one adds questions about their current living arrangements and the use of home medical or social services. Usually this is pretty straightforward, but every now and then the patient will surprise you.

Take Mrs. Jackson, a lovely African-American centenarian who was brought in by her family for generalized weakness. When I asked the usual questions about smoking and drinking, she proclaimed proudly said in the rich tones of Georgia, “Young man, I never have smoked tobacco or touched a drop of alcohol in my whole life.”

(While I’m not a particularly literal believer in the Bible, I have this theory that if the Lord gives you “threescore and ten (Psalms 90:10),” after that you’re on your own. As long as you’ve done well with your divine allotment, you’re free to enjoy whatever vices you choose after that. Of course, you probably won’t have the strength, or the will to do so, but it’s nice to know that after seventy the shackles of decorum are officially off. And for what it’s worth, I have a similar theory about very old…and very wealthy…men and women dating people decades younger than themselves. If you’ve outlived your spouse, and already done right by your children, you’ve got every right to blow what’s left of your nest egg any way you want to. We smile and nod if older folks fritter away wads of cash in Las Vegas, but we get upset if it’s spent on a grade-A bimbo? Please.)

There are some days I have problems with my internal filter. This was one of those times.

“Well, it’s about time you got started, don’t you think?” I said. “Times a’wastin’ here.”

Her family looked at me aghast, as if I’d just suggested that she sabotage over 100 years of work and scuttle her expected tenure at the right hand of God. But the patient looked thoughtful for moment, then turned to me with a warm but insightful gaze.

“You know, young man, I think you might be right.”

Mr. Spaulding was a hale and hearty older gentleman who had some abdominal pain. After a fairly complete workup, we could find nothing in particular wrong of the emergent variety; and as he was already feeling better, we decided not to fix what wasn’t broken and let him go. As he was getting dressed, he mentioned that the following day was going to be his anniversary.

“Congratulations,” I said. “How long have you been married?”

His eyes rolled up slightly, as if he was at the mental blackboard doing subtraction in front of the class. “It’ll be 63 years this time around.”

“That’s wonderful!” I exclaimed. As skeptical as I am about most things, I truly am impressed with people who have kept loving relationships going for decades on end. (It should also be noted that my father, who has been married to my mother for upwards of 50 years, introduces her on occasion as his “first wife” to see what kind of reaction he can get. They are each other’s best friends…and best foils.)

“Yep. We got married ten days after I got off a destroyer in the Pacific.” His brow furrowed in thought for a moment. “You know, I thought I was in love. But it turned out that after 16 months on a ship, I was just in heat.”

We shared a laugh, and I asked if he was still in heat. He smiled broadly. “Yep, I still am,” he noted proudly. “But,” he sadly confided, “since I hit 80, it’s down to once a week.”

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