While one could say I was born in the South, I had to move a lot closer to the Mississippi to find that my Southern California momma and daddy had left certain nuances of expressive gentility untouched in the process of raising me right. Northwest Arkansas, where we’ve come to settle, may not be considered the Deep South, but you certainly can hear it from here.

One good place to do that is what is now known as the emergency department, a place I’ve worked in and around for 35 years. Eventually, almost everyone has an ER encounter, either as the patient, a family member, or maybe as the friend who carried their neighbor Bobbie Sue into town when she broke her arm falling out of the hayloft that summer.

Remember that? You two were sitting near the top of that ladder making out when … The rest of the family doesn’t know that part, but I do. And I’ve kept your secret nigh up to … well, right now, and this story is just between the two of us, of course.

Anyhoo, this is an arena of medicine where you get to see a bit of everything. If all the South’s a stage, the ER certainly is a front-row seat. All too often, the reason for the visitation is unclear at first glance.

Momma might feel poorly, a bit puny, or just laid up. Uncle Enos presents as being plum tuckered out, maybe even right up to wore slap out, or worse yet, carries the grim prognostication of going downhill fast. The odds are, whatever it is, it hurts a heap and has most likely totally drained your gumption.

I cannot even count the number of middle-aged men who show up in the ER because they were drugged. As in, “my wife drugged me in here.” Getting a Southern man to the hospital when he has four dogs, 20 cattle, and a horse to feed is no small feat. At times, getting him to stay is even harder. As one woman explained when her hard-working husband resisted admission for a heart attack in progress, “He ain’t good looking, but he sure is dumb.” That sentiment ‘taint necessarily a Southern thing. I’m sure there are women in all 50 states who have had the same thought cross their minds a time or two.

One helpful presenting complaint was, “I just ain’t right, doc. Sick. You know what I mean, just plain sick! I finally came in ’cause I’m about fit to be tied.” My initial diagnosis was clear: his get up and go had done gone and went. Later this was amended to add an inflamed appendix that needed to be done gone and went, as well. A day or two later, when he got his first post-op meal, he reported that he was as happy as a tick on a fat dog.

Usually, we in the ER can fix the hitch in your giddyup and concoct a treatment when y’all are being eaten up with a rash or fever. That feeling of being pecked by a hundred chickens, sweating like a sinner in church or having the bowels done locked up (or maybe they were on the rebound and were runnin’ off again) all require some further investigation. The panic-producing “can’t get no err” (air) is a bit more complicated, and you can bet that when “that boy is acting crazier than a sprayed roach” a urine drug screen followed by a psych admit is likely on the menu.

Other times, the reason for our meet-up may be neatly clarified by the patient’s opening statement. My favorite leading line is usually offered by the patient’s best buddy, “So, Eugene here said, ‘Hold my beer, I betcha never seen this done before.'” I’ve got around twenty’ leven chapters for that line alone. The most recent of these involved a badly abraded scrotum from a “bob war” encounter (i.e., the part of the fence he didn’t quite get over). FYI: next time, don’t go commando, kiddo.

In meeting with Eugene and his friends, I’ve also learned that an extremity wrapped in duct tape might be the best place to start an exam. Although Lord only knows that there’s always more to the story before all is said and done.

Getting the details

Some basics of taking the patient history down South:

Recent medical care, such as the cardiology consult, the patient with recurring chest pain had scheduled and missed last month. It turns out he was fixin’ to, or maybe he would get to that directly but not actually. And now that his crushing chest pain is back, and his ST segments and cardiac enzymes are both elevated, the odds are that I am now fixin’ to arrange a visit with the cath lab directly, as in right now, before you can twitch an eyelash.

Exercise habits. As one wife of 45 years observed about her husband: “Well, he’ll never drown in his own sweat.”

Stroke history. It’s helpful to have family around so they can identify if that thick accent is a stroke or their normal voice. Maybe they know if the patient is now movin’ slower than a herd of turtles, looking pie-eyed or walkin’ cattywampus. If you trained in Jackson, Atlanta, ‘Narlins, Raleigh or Birmingham, you know that any of these findings can be suspicious for neurological impairment.

Family history: How your kinfolk passed. In Meemaw’s case, it sounds like a common case of the dwindles. As in, “She had the dwindles for a good long piece before she went on.” Whereas in Father’s case, it might be an obscure version of uppin. “We don’t quite know what happened to daddy, but one day he just uppin died.”

Mental health history. While it’s true that 45-year-old grown men brought to the ER by their momma could have organic disease, there’s also fair odds that somethin’ hain’t right in the haid. And when your nephew is nuttier than a port-a-potty at a peanut festival, it might be ’cause Sister drove her ducks to a bad pond o’water. Unlike folk north of the Mason-Dixon, people in the South openly recognize that everyone has crazy people in their family. The main point of contention is in deciding what side it comes from. Some general and unofficial psychiatric diagnoses we’ve heard include:

“We’re talkin’ three gallons of crazy in a two-gallon bucket.”

“That boy’s a half bubble off plumb.”

“Let’s just say that if stupid could fly, he’d be a jet plane.”

“That side of the family don’t have their cornbread done in the middle.”

Bottom line, when the EMTs find you out in the front yard ~2 a.m. nekked as a jaybird, well … here’s your sign.

Then again, if might be nothing more than an anxiety attack if it puts you in a tizzy. You might even have thrown a hissy fit. If it’s an especially bad day, you might could go on to have a conniption or even pitch a fit.

A bystander observing this hot mess might opine that “Isn’t she just full of grace?” These situations aren’t necessarily medical disorders and may just be the result of having to tolerate an excess of dimwits on a daily basis. God bless your heart, darlin’.

In the “does it hurt here” department:

Neck: “Only when I try to swaller.” Although it’s not always painful to have somethin’ stuck in the gizzard, if you felt like you swallered a frog that can’t either feel or taste good.

Abdomen: “Only when you mash on it.” During an abdominal exam, a patient once told me she had the collywobbles (butterflies in the stomach, nausea). I now know that if they sit upright directly after they say that, you should immediately hand them the nearest round receptacle to heave into, and step aside, post haste.

Wound care: Make sure that you don’t stint on the injectable anesthesia as some of the printable responses could include, “What in tarnation! Lord have mercy! Heavens to Betsy! What in the Sam Hill! I do declare! And my personal favorite: For cryin’ out loud, doc!” While I do numb people up well, it’s the first 30 seconds of the process that tends to raise the indignation.

Examining anatomy where the sun don’t shine

At least once or twice a shift, the search for a diagnosis requires a rectal exam. Unfortunately, this is a procedure where neither the patient nor I qualify for much-needed anesthesia. While I’ve received witty and profane commentary from the respondent during this personal procedure, my favorite ice breaker was from the guy who offered, “Why don’t you use two fingers and give me a second opinion?” We had to make do with one, but I concluded by advising him, “If either one of us is enjoying this, you need a new doctor.”

Using common sense with your patients

Just because my people may talk with an accent does not discount a sharp understanding of the obvious. As a 78-year-old gentleman with a terminal lung cancer diagnosis explained about not quitting smoking: “Now that there’s a lost ball in the high weeds.” At other times, a little situational awareness during the exam is helpful. When I asked a patient who was about two sugar cubes short of a diabetic coma about the brown liquid he was drinking, I was informed, “Of course, it’s sweet tea, doc. Is there any other kind?”

Is everybody happy here?

Every once in a while, the conversation with a patient’s family member could start with something like: “I’ve got a bone to pick with you.” That would be a good time to pay close attention, especially if it’s the spouse or mother. The added phrase “pray tell” could indicate a degree of skepticism. When that is followed by “that there’s total flumadiddle,” “I don’t give two hoots and a holler,” or the dreaded “with all due respect” (a.k.a. you can kiss my grits), it might just be time to back it up a bit and make sure we are all communicating in a clear and friendly manner. Just remember that when all’s said and done, if momma’s not happy…

Regarding the discussion of surgical options

As a patient with Crohn’s disease and an inflamed but not quite yet obstructed colon and I discussed his options, including seeing a surgeon at some point, I was advised, “My mama didn’t raise no fool, you never ask a barber if you need a haircut.” As we concluded a discussion of hospital admission and the ensuing diagnostic process, he added, “So if we don’t get it in the wash, we’ll get it in the rinse?” Yup, that about sums it up. As it turns out, he did just fine without seeing the barber, but he couldn’t avoid an encounter with that “durn butt scope guy.”

When people feel recovery coming on

Before leaving the ER on her way to a surgical admission, one dear lady whose gallstone pain was obliviated by an opiate-induced bliss professed that “there’s nothing like lah-tee-dah!” I had never heard the potent pain reliever Dilaudid pronounced that way, but she had the right idea. Earlier in the evening, she reported, “My husband thinks it’s my gallbladder, but I think he’s barking up the wrong tree.” Actually, nope. Maybe I’ll join that guy on his next raccoon hunt.

Living in or near the South is more than a lesson in euphemisms and pronunciation. It is a recognition of a way of life that emphasizes faith, family, and an uncommon grasp of the nuances of relationship. I’ve found that in the South, the language and the culture, just like old married couples, go together like moonshine in a mason jar. Keep in mind, friend, that you can say what you want about the South, but last I heard, no one moves North when they retire.

Jeff Baker is an emergency physician.