Appears Older Than Stated Age

There is a unique phrase in medicine that is generally used as a descriptive sentiment but often understood as a pejorative one. It is usually inked into the chart to describe a patient who is relatively young but appears much older, however it is often understood to mean that the patient has lived a difficult life leading to increased stress that has aged the patient beyond what one might expect given their years. Stress may take a remarkable toll on the physical frame. This includes anxiety, depression, abuse, working two jobs to keep the lights on but also cigarettes, alcohol, street drugs, homelessness (exposure to the elements) and did I mention cigarettes? All of these tax the body (not to mention the soul) but when seen in the chart this phrase is often a medically polite way of referring to the nicotine, booze and drugs more than the anxiety and depression. It is a reflection of bad luck, sure, but also bad choices, and while certainly the one or the other had the greater effect on the ultimate outcome, there is often little time to determine which, especially while in the hectic pell-mell of the emergency department, played a greater role. It is however a reflection of hard living, whatever the source.

However, all coins have two sides and this thought is no exception. I also see remarkably aged patients who look fantastically, almost unbelievably, young. These are the nonagenarians driving to church every Sunday and to the grocery store on Tuesdays. They dance Texas two-step every other Friday with people half their age and, yes, still knock down the odd martini or two with their usual and habitual level of moderation and aplomb. Yet, to my knowledge I do not believe that I have seen the term "appears younger than stated age" in a chart. This is a curious fact.

I suspect the reason it is not embedded within the medical record so often is that it suggests a healthy patient and we are trained to seek, describe, evaluate and treat the unhealthy patient-or at least the unhealthy aspects of the patient. It seems unnecessary to make positive descriptions-especially of the patient as a whole. It is not why we were consulted in the first place. And yet maybe, if we are aiming to treat the complete patient and not just some unique aspect of pathology, we should recognize the whole patient as they are. Socrates seemed to think so as he describes advice given to him by a physician of the Thracian king, Zamolxis. "For this is the great error of our day in the treatment of the human body, that physicians separate the soul from the body." (I take this quote from Osler's address "As Depicted By Plato" given to the Johns Hopkins Historical Club in 1893 where he cites Plato's Dialogues).

That wonderful thought trickling down from the 5th century BC, via the canal of 19th century AD Oslerian wisdom, puts the aforementioned phrase into a finer and more distinct light. It is a judgement on the soul as much as on the body and, as physicians are more inclined to pay attention to the pathological than the normal, it is a statement, though often likely inadvertent, on the state of the spirit as much as on the premature decrepitude of the body. It resounds across a chart with greater truth than perhaps we even meant by it. It, like our patients, has a much deeper understanding if we just dig around a little.

With all that being said, I recognize the impossibility of treating the entire patient-mind, body and soul-in an 11 minute emergency department visit for a sprained toe. If there is any specialty in the house of medicine where this would be especially unusual, it must be emergency medicine. In the ER, a toe is injured. I am busy. I have 30 other patients in various levels of work-ups. I would like to see the injured toe quickly, order an x-ray, determine if it is sprained or fractured, buddy tape it, treat the pain and discharge home with crutches and follow-up. But what if I said something like...

How did you injure it?

And the patient said something like...

I was running with sandals on and I tripped in a hole in the ground.

And I replied....

Why did you trip?

And she replied...

Because I was running from my husband, and it was dark out, and I had 7 vodka tonics.

And I replied....

Why were you running from your husband at night intoxicated?

And maybe she wouldn't answer that question. But maybe I might look up from her toe for a moment and really look at her. An old bruise on the neck. A tremor in the fingers. The faint saccharine smell of old alcohol. The yellowed nails of cigarette tar. A cracked cell phone and a cracked tooth. A quiet, pregnant look of understanding. Maybe this story ends differently than the first one. Maybe we do a little more for her. And then later, maybe I write in the chart "appears older than stated age."

In book news, I'm having a signing for The Meteorite at E Shavers bookstore on 326 Bull St in Savannah, GA on the 28th of February from 5:00 pm to 7:00 pm. I hope anyone who is interested can come out and I'd be happy to sign the book, sell the book or discuss the book with you in person. Also, if you loved or hated the book (preferably loved or at least thought worthy of reading) please don't hesitate to leave a review on Amazon or Goodreads. As always, I'd love to hear from you as well at authorandrewross@gmail.com. Many thanks to everyone who has supported the novel thus far and given kind words of encouragement and gentle critical advice. It has been wonderful to hear from old and new friends from near and far. I am very grateful. Thank you!