Plus ca change

The more things change, the more they stay the same. It sounds classier in the original French. I was somewhat blocked as to a subject for today's blog. While waiting in line at Starbucks, I ran into an old friend. This gentleman is 11 years older than me. He went into medicine in his 40's after a career of writing. He and I worked together in the ER where I still practice. He was forced out and went to work in a small town in Vermont with an ER that sees 1/5 the volume of my hospital. He is approaching seventy and still going strong. I am only hoping to get to 67 before retiring.

There are quirks of ER practice that occur repeatedly. New generations of patients still have the same odd behaviors. The numbers keep going up and the mix of patients varies but somethings stay the same.

"I have this pain in my back for a month." After sliently groaning, I try not to roll my eyes and ready my questions. Bladder function, bowel habits, fever, chills, numbness, weakness... "I have an appointment with my primary care at 11:00 but I couldn't wait any longer." This is said to me at 2:00 AM. Why? The patient waited weeks to get an appointment but was unable to wait an additional 8 hours.

I approach a lovely woman in her eighties. The chief complaint is abdominal pain. "What is the problem tonight?" I ask with some trepidation. She begins her story in 1936. She regales me with issues from the Great Depression, WW2, her marriage and children. An older gentleman responds to the same question by taking out a notebook that details everything he has eaten in the past 6 month and how his body reacted to each and every meal.

A mother and infant on the stretcher resembling a renaissance painting of the Madonna and child. The chief complaint is fever and a runny nose. I ask what she gave for the baby's fever and she says "nothing, I brought him to the ER". In loco parentis. ER's have become substitute parents. This is especially true of first-time teen mothers. My dear friend Elizabeth, was an ER nurse who trained at Children's Hospital. She cared for the baby and gently educated the mother.

Vomiting and eating is a recurrent issue in the ER. The toddler who is in the ER for vomiting is being fed cheese puffs by his mother while seated on the stretcher. The first thing a patient who is retching in the barf bag asks is, "can I have something to drink?".

0600 on a Tuesday morning, after a three day weekend. The bus has arrived. Five patients in triage for mild complaints. The hidden agenda is the doctor issued work note. Mr Jones skipped work on Friday and now needs a note to justify his absence. Citizens who have scheduled court appearances also seem to develop vague symptoms early in the morning of their court date.

The patient generated diagnosis is usually from a visit to WebMD prior to arriving in the ER. When a young man tells me that he has Lupus, when I see a contact dermatitis on his face from his new cologne, I know that the internet is to blame. The appropriate cliche is "a little knowledge is dangerous". The herd of zebras that thunder through the ER is driven by various web pages devoted to empowering the patient. I am told what tests and scans that the patient feels he or she needs. I gaze over my reading glasses and try and explain a more rational approach to finding a cause of their listed symptoms.

My colleagues in primary care and other fields of medicine contribute to the cavalcade of self diagnosing and self ordering by my patients. "My pediatrician says Susie needs a CAT scan because her stomach ache could be appendicitis." "Jimmy has a headache and my doctor said it could be meningitis, so I want him to have a spinal tap." Susie is playing her video game while scarfing down an ice cream sandwich, and Jimmy was seen running around the waiting room and yelling at the other patients.

As my good friend Clyde pointed out to me over a cup of good coffee, plus ca change, plus c'est la meme chose.