21 May 2008

Circumlocution

I hate taking care of old people. Don't get me wrong -- I have nothing against old people, and I always give my geriatric patients my full, undivided attention and the respect and compassion they deserve. But the problem is this: the ER is very busy, and I don't have a lot of time to spend with each patient. Wish I did, but I just don't. I have to be quick and efficient to keep ahead of the onslaught. So you remember way back in medical school, when you learned how to take a history? In my school, they really emphasized the need to need to ask a lot of open-ended questions and let the patient take the lead in providing the history.

Not in the ER. You get one open-ended question: What brought you to the ER today? And after that, it's a series of very directed questions: Where is the pain? How long? What type? Worse if you move? etc. These are the critical data points I need in figuring out where to go in evaluating your symptoms, and I acquire them quickly and accurately in the very limited time I have to spend with each patient.

But old people, Oh Jeebus save me, they are a trial. I don't know what happens to your brain when you hit seventy-five, but for some reason at that age you become incapable of giving a straight answer to a direct question. For example, an honest-to-god conversation I recently had:

Me: What time did your chest pain start?
Granny: On the ferry.
Me: So what time was that?
Granny: Well, we were taking the ferry to the island, on account of my grandson was getting married. Now this is the grandson that I'm closest to, if you understand, because he's always been there for me when I needed him, and so of course I couldn't be expected to miss his wedding. I've got seven grandsons, three of them live out of state, and the others can't be bothered to call, let alone come over and help out. So when it was his big day, well, I just had to be there. Anyways, we were on the ferry, and there were five people in the car, two coming and two going, if you understand, and me. On account of that, I had to sit in the center seat in the car, and my legs were jammed up against my chest, because these foreign cars -- Japanese or Korean or some such -- they don't give you enough leg room in back, because they're all so short over there. And with my legs all jammed up tight against my chest, I just started feeling a little tight, you know?
Me: (trying a different tact) Has the pain been constant since then, or does it come and go?
Granny: I have the pain all the time, but only when I breathe, but it's worse when I go shopping, because they turn the air conditioning up so high in those stores, the cold air burns my lungs. It's not so bad when I ride in the little electric carts, but Safeway doesn't have the electric carts, so I usually shop at Albertson's....
Me: (banging head on clipboard)

At the risk of overgeneralizing, I've seen younger patients who were evasive and tangential, but when I go and see an octogenarian, the likelihood is far higher that I'm going to be in there quite a while and come out without all the data that I really want. I can understand that when I do give the open-ended question that people will get circumstantial in their response, which is fine. But when I ask a simple, clear, direct question, is it too much to ask that I get a direct response? Apparently so.

Which is why I kind of cringe when I pick up the chart and see the age of the patient is over seventy. I've gotten used to it, though, since on some days my median patient age is over eighty; lotta nursing homes in our district.

I wasn't intending to get political with this post, but I was googling for my favorite Abe Simpson rant to illustrate the point, and I came across this, which made me laugh:




Update:

Just for the record, when time permits, I love to chat with the old folks. It's just that time doesn't usually permit.

13 comments:

  1. For some reason, this post struck a chord. BRAVO!

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  2. I wonder if, when those 75+ year old patients were younger, their doctors DID have the time to talk to them, and also DID care about little details of their personal lives?

    Maybe it's a kind of culture shock to go to an ER these days with something scarier than the usual aches and pains to find, instead of a sympathetic doc who is eager to take as long as necessary to reassure you, the comfort and personal touch of a drive-thru window.

    It's not your fault you guys are under-staffed and only have about two minutes per patient to ask them questions. In a better system, old folks talking a little excessively wouldn't bring the entire ER to a standstill.

    When I talk to docs these days, most of them exude an aura of "please hurry", so I gamely try to sum up my problems as quickly as possible. Then, when it's all over, I realize I've left out things that might be important because I was rushed. I worry that I might be getting worse care because of the things I forget in my blind panic to sum up my entire life story before the doctor runs away.

    Those gramps and grannies have got something I apparently haven't got -- a way to force the doc to slow down.

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  3. Every so often, it's slow enough (esp. at like 8am or something) where I can actually sit and talk to a few of my older patients.

    I had an 87yo female come in about a week ago for a fall, with head contusion, and needed to be checked out. She was one of only a handful of people in my ED that morning (the rest were boarders from the night before and an ankle sprain), and I sat and talked to her for a bit (she had an interesting name).

    Turns out she survived the allied destruction of Berlin during WWII, and her father was imprisoned by Hitler for being vocal against his regime.

    I wish I did have more time to talk to some of my older patients....but most time it's very hard...but when I can, it's very rewarding.

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  4. Yep, he's too darned old to run. I'm 76 and I know this for a fact. Cut-off should be 60 max.

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  5. As bigotry goes, Shadowfax, ageism is no prettier than racism. Moreover, as they relate to presidential politics, your comments are also historically illiterate.

    The most effective post-WWII president was in his 70s during most of his Presidency. And before you parrot the usual tired canards about Reagan, read this new book by (progressive) historian Sean Wilentz.

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  6. In addition to the rambling response, there is the repeater.

    "Can you tell me about the pain?"
    "It hurts here, this is the third time I've had it."
    "OK, could you describe it to me?"
    "It's right here, and it really hurts"
    "Umm...it is sharp, stabbing, burning..."
    "Yeah, and it hurts right here"

    Those are the patients whose histories are taken from the old admission notes.

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  7. I am pretty sure that there are some folks who just read your blog waiting to find something they can quasi-intelligently bitch about (catron)... and then use words like "canard."

    Thanks for telling it how it is.

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  8. I think it's an issue with their RAM - random access memory. They can can pull the answer/memory up, but in bigger chunks.

    So then they have to decode all the surrounding content to get to the answer/fact.

    The chatterboxes have to say it to find it. Younger folks who aren't chatterboxes run through all the content and just say the answer.

    I also think this retirement life does it. They're not in a hurry, why should you be?

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  9. This is really funny! I can understand why it's frustrating to ER docs. When I fell and broke my hip the EMTs gave me morphine before transporting. In the ER I could answer all the questions succintly but when asked how I happened to fall I had to tell a story. I'd made my morning tea, set it on the computer table. Earlier I'd opened all the windows in my house because it was to be a very hot day. But as I sat down to the computer I remembered one window behind the kitchen table I hadn't opened. As I went into the kitchen I remembered it was my day to weigh myself and so pulled out the bathroom scales from under the table. But then I wanted to open that window before I forgot so went to do that first. As I opened the window I saw my neighbor's cat walking to my back deck where he liked to sun himself and said 'hi'. Then, with my cane, started backing out from behind the table, forgetting the scales on the floor. I went "teacup over tea kettle" backwards, landing with a thud on my hip and quickly understood I'd done some serious damage. I remember, in my morphine wooze, telling all this to the ER person. Whether anyone stayed to listen I have no idea. Sorry 'bout that!

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  10. Patricia,

    Just because life has you washed up and worn out at 76 doesn't mean everyone else is the same.

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  11. There is an art to learning how to get the ramblers to get to the point. And it can be done so the patient doesn't feel hurried. Maybe you could learn something by observing someone who has these skills.

    As a nurse I have the luxury of getting to listen to these people as I'm doing the IVs and procedures and their lives are interesting.

    Its not really a question of understaffing but with the cost of medicine being 14% of the GNP we can't afford to enlarge our ERs anymore so people can tell their life stories to every doctor that comes in to do an exam. I work in a busy ER and on the days when its busy and there's a 4 hour wait to get in efficiency is important.

    Some people of any age, you ask them what time it is, they want to tell you how the watch was made.

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  12. This comment has been removed by a blog administrator.

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  13. How did I know from the top that Abe's onion speech was going to come up?

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