On our way to Birmingham, a stopover in Chattanooga, Tennessee seemed only natural,
since we lived in Chattanooga for 15 years before we moved north in 1988. The
evening and following morning we were there, we managed to look up many of our
friends there that we don't get to see very often any more, including the writer of
Readers of the last seven installments might understand how doctors can be so casual or uncaring in the face of illness. The disbelief is another matter. The average patient is totally unaware that as many as two of every five visitors to an emergency room are trying to get drugs or are otherwise faking it. When you're puking your guts out from a migraine, it might not occur to you that the last such patient was caught sticking her finger down her throat.
Outright fakery is one thing -- people who want narcotics, or a work excuse, or to sue bigtime for a minor injury. (A friend asserts that the world's worst prognostic sign is the phrase 'Fell at Walmart'.)
The truly difficult patients are the hysterics -- only one percent of the population but, since their lives revolve around imaginary symptoms which they consider real, are a much higher percentage of the patient population. These are not normal people. They have weird ideas of cause and effect, and weirder coping mechanisms. I won't discuss what underlies their bizarre and troublesome personalities any further because I went to a medical school with a purely biological outlook on psychiatric disease. We just figured it was something genetic and incurable, and left it at that.
Fifty years ago, when my mother attended medical school, her psychiatry class consisted mostly of Freud. (She told a funny story of the day the professor stated, "Men who go to bars together are latent homosexuals." Now, about the only extra-curricular activity any medical students back then had was to go out for a couple of beers. Every member of the class immediately looked panic-stricken, and for the next week or so there was an epidemic of sobriety.)
All we were taught about Freud was that, being Jewish, he was not allowed to attend at the Viennese mental hospitals and see the really crazy patients, so he wound up basing his theories of mental illness and the normal subconscious on Victorian hysterics. Nowadays, sophisticated hysterics have stomach-aches and headaches. Naive or unintelligent hysterics still have the symptoms of Freud's grand hysterics -- paralysis, blindness, fits. I once read an article in the British Medical Journal by an English doctor who did some time in St. Louis, and was astonished to find himself seeing patients identical to what Freud might have seen at the Salpetriere a century earlier.
(Freud is still occasionally applicable. A patient at the mental hospital once ran up to us crying, "Doctor, doctor, I've got a snake in my womb!" I'm afraid that we were caught off-guard and laughed.)
On the subject of the biological viewpoint of psychiatric illness, perhaps I might quote a song from our second year class show, a My Fair Lady take-off. (It was a hilarious skit, and I'm not biased as one of the authors. Honest.) Sing it to the tune of "Get Me to the Church On Time.
I'm treating crazies in the morning,
Dingdongs with problems on their minds.
First diagnose them, then with drugs dose them,
And get me to the couch on time.
None of this free association.
Adler and Jung are not my line.
Don't Sigmund Freud me, you'll just annoy me,
And get me to the couch on time.
If they're depressed then
If they are schizo
Even though our psychiatrists were more scientific than the average, we medical students still had the doctor's vague contempt for the least scientific specialty, as witness our last verse:
She's going to start psych in the morning,
Easy rotations are sublime.
Won't have to think now, she'll be a shrink now,
So get me to the couch, get me to the couch,
Make sure you get me to the couch on time!
(I'm no poet, but I am excessively proud of the Sigmund Freud rhyme. My friends thought my better lines from the sketch were, "When I'm chancellor of Wash. U., I'll just reach right out and squash you," and that exultatory homage to syphilis, "The signs of sin are often on the skin.")
# # # #
As a neurologist, I occasionally see people faking numbness or paralysis. The fakery is generally pretty easy to detect, though impossible to treat, stemming as it does from primary gain (the patient's got problems) or secondary gain (if I'm paralyzed, I won't have to go to work or I'll get a lot of money from the insurance company.)
Patients faking coma -- yeah, it's a weird thing to do -- are also easy to detect, though it can be hard to convince them to wake up. A neurosurgeon once told me of working in a hospital in Philadelphia that got lots of coma, and thus lots of pseudo-coma. He claimed that the refractory cases -- you knew they weren't comatose but couldn't convince them to give it up -- were treated in this cruel but effective manner: All the patient's clothes were removed, and the gurney on which the patient lay was kicked out into a busy hallway. My friend claimed that not a single patient failed to jump up and run for cover.
(I recently had a patient paralyzed all over. Her family haunted her bedside, waiting on her, even putting cigarettes in her mouth. The psychiatrist wrote an order that no one could help her smoke and, sure enough, the next day we found that one hand had been healed. "It's like a miracle!" she said.)
The hardest patients to diagnose or treat are those with pseudoseizures -- patients who fake epilepsy. For one thing, you have to be there sometimes to know if they're real or not, and for another, a major proportion of patients with pseudoseizures also have real seizures, and it can be tough knowing whether they need more anticonvulsants. (And occasionally pseudoseizures are actually real, but that's extremely rare.)
The first time I saw a pseudoseizure was when I was the medical student at City. We were leaving the ICU to go on ward rounds. There was a long bench outside the ICU. As we passed, it was hard to ignore a young woman lying down jerking all four limbs. She was not unconscious, however, but was following us with plaintive eyes.
"Sorry, dear, we don't have time for this now," said the chief resident as we walked by.
# # # #
Pseudoseizures can be very dangerous. There is, after all, a natural tendency for non-neurologists to consider them genuine and treat accordingly. This can especially be dangerous if the patient presents to the emergency room faking status epilepticus -- a series of grand mal seizures, a life-threatening emergency treated with dangerous medications and invasive procedures.
A friend told me once of a patient who kept faking seizures until the interns in the ER decided they needed to intubate her (stick a breathing tube down her throat -- necessary in an actual case of status.) Once they started shoving it down her trachea, the patient stopped faking and began fighting. At this point, a neurologist would have known what was going on and stopped (we tend to feel that if the patient doesn't want the tube, he probably doesn't need it), but by now the interns were in epinephrine storm and restrained her in order to intubate. It was messy and she wound up with a nasty peritracheal abscess.
The reason I remember this so well is that, when I was the neurology resident rotating on the psych ward, I told this case to the psych interns as an example of how far hysterics will go. I had no sooner finished the story when I was paged to see a new patient -- and it was that lady! Just one of those weird coincidences better suited to Dickens novels than real life.
As a first year neuro resident, I was briefly fooled by a pseudo-seizer. We had been paged to the ER at City Hospital to see a woman in status epilepticus, who had been found down on the floor of a fast-food restaurant. She had no identification. Her backpack contained personal articles that were all hospital-issue -- hospital-brand kleenex, plastic cup, toothbrush -- and a notebook in which was scrawled in childish handwriting over and over for many pages, the phrase: 'What to do if you get a seizure'.
On exam between convulsions, I saw that she had evidently had chest and abdominal surgery as well as numerous thrombosed veins and scars from venous cutdowns. I put it all together in my mind, and came up with some poor girl who had had a malignancy requiring lung and abdominal surgery -- lymphoma perhaps? -- and then had her veins ruined by chemotherapy. I was wrong.
She was actually a mildly retarded girl who travelled about the nation faking seizures whenever she needed a meal or a place to stay. All her scars were from treatment of her fictitious disease -- the thoracotomy scar was from when an attempt to place a central intravenous line had given her a pneumothorax (collapsed lung) and then an abscess requiring surgery. The veins had been ruined by the caustic, dangerous anticonvulsants. This girl was in constant danger of being killed by well-meaning doctors.
I stopped her seizures as the intern was doing the spinal tap. (Hysterics will allow the most painful and dangerous things to be done to them. A couple of years back, I read of one who faked a movement disorder which was intractable to therapy. It wasn't until they were wheeling her to the surgical suite to have a large portion of her brain removed that the patient suddenly sat up, completely well, and said, "Okay, I'm out of here.")
"You know," I said, "if this doesn't work, we'll have to intubate her." Evidently, she'd been on a breathing machine before, knew how uncomfortable it was, and decided that a prolonged stay in our hospital just wasn't worth it.
(One pseudoseizure at City, a down-and-out drunk, faked anesthesia. He would actually grab the pin from our hands and ram it into his leg until blood welled up, saying cheerily, "Look, doc, I can't feel it." This sort of behavior is a pretty good clue that something off the norm is occurring.
(The intern, wanting to prove that the man had intact sensation, snuck up one day while the patient was asleep and jabbed him gently with a pin. Sure enough, he woke up screaming.
(After that he was a bit miffed. He put on his civilian clothes and pea coat, and walked up and down the ward cursing out the intern. I ran into the doctor, who looked quite pale -- and he was from India.
("What's wrong?" I asked. "You're not scared of that dirtball?"
("No," he said, obviously shaken. "But now that he's dressed, I recognize him." It seemed that, about a month earlier, he'd seen a drunk lying asleep with his head on the freeway. The intern had stopped and pulled the man to safety -- and now realized that it was this patient! Another one of those Dickensian coincidences.)
# # # #
Confronting the patient with his faking doesn't work. My usual method of stopping intractable pseudoseizures was to administer a harmless medication -- normal saline. It only worked if you explained how unfailingly effective it was in an authoritative voice, and if no one cracked up. One laugh from a medical student, and the game is over.
I had this down to a fine art as chief resident. Once, I was called to the ICU to see a new patient who would not stop faking convulsions, upsetting the family and disrupting the unit. "All right," I said, looking sternly at one of the nurses. "Ordinary medication hasn't worked. We need XJ-47!"
"But doctor, isn't that dangerous?" asked the nurse loudly.
"Yes, but we have no choice!"
The nurse called to the other nurses. "Dr. Farber is going to give XJ-47!"
"Oh, I want to see!" Pretty soon, every nurse not otherwise occupied was crowding around, as the first nurse -- shoulders shaking as she tried to hold back chuckles -- stood at the medicine shelf drawing up normal saline into a syringe.
Meanwhile I, with stern gaze to keep any med students from laughing, explained that XJ-47 was a new anticonvulsant available on research protocol from the National Institutes of Health. Not only did it never fail to promptly stop seizures, but if the seizures didn't stop, they clearly had not been seizures to begin with. (That was the important point to get across to the patient, to convince them to quit.)
The resident, getting into the spirit of the thing, actually had the gall to pimp the medical students on the side-effects of the non-existent medication.
When I gave it to the shaking patient, I made sure to ignore her completely, meanwhile lecturing my subordinates. "Now, she may feel some burning as it's administered. Within fifteen seconds -- here, you time it -- it should start to take effect. First the little finger will stop twitching... Ah, there, you see? Now the left arm will stop shaking..."
If you were mean enough and convincing enough, you could draw it out indefinitely into a bizarre comic opera.
One day, when I was a first-year resident, we had a patient who had intractable pseudoseizures. She was a grand-hysteric. She also had mutism, being entirely unable to speak for the last six months, ever since her first day in a job-training program. (Secondary gain.) The attending wanted a good videotape of pseudoseizures, so we took her down to EEG, wired her up (to prove there were no abnormal brainwaves during the attack) and then started her convulsing with an injection "...to bring out your seizures." It was that versatile medication, normal saline.
She began to seize, sure enough -- and wouldn't stop. I gave her the normal saline again and she kept going. It was now almost five. The EEG tech and the cameraman wanted to go home. I had been working continuously since 7 a.m. the previous day, and I wanted to finish up on the ward and get the hell out of there, too. But she wouldn't stop, and we certainly couldn't return her to the floor like that.
Disgusted, I looked about the room for something I could use as fake medication. There was nothing except EEG supplies such as electrode paste (too messy). Then the little light bulb went on over my head. I got an eyepatch and soaked it in peroxide, all the while explaining to the intern that this was the most powerful anticonvulsant known to medical science, so strong you couldn't risk giving it by vein; you just put it in behind the ear (like transdermal scopolamine) and it absorbed right through the skin into the brain!
It was pretty hair-brained, but we were all desperate. To my shock, it worked, and she quit. I then assured her that these convulsions had cleaned out her brain, the way driving fast cleans your engine, and she should be able to talk again.
No such luck. The next day she was still mute -- until my chief, who was fed up, said, "You know, you're faking all this stuff."
"No, I'm not," she said. A cure! Except the next words out of her mouth were, "I see everything double." Her mother said she certainly couldn't go back to the job training program with double-vision. With hysterics, you just can't win.
The next year I missed the grand rounds where they showed the videotape. I got a lot of compliments for my ingenuity with the transderm peroxide, except for one cranky professor emeritus who evidently watched my performance, stood up, scowled and shook his head and said, "It just isn't fair."
# # # #
All medicines, including normal saline, have risks -- though not necessarily to the patient. Later that year, I admitted a young man faking seizures intentionally. (His new baby had seizures, and he was jealous of the attention.) He kept starting seizures in the ER, in radiology, even in the elevator. Since no one except my team seemed to understand that these weren't real seizures, every time he started shaking again they would call a code, and doctors and nurses from every part of the hospital had to drop everything and come running. I quickly got his spells under control with normal saline, restoring calm to the hospital.
The next day, after getting another injection of the medication, he 'woke up' and said to the student nurse, "That stuff's powerful. What is it?"
"Salt water," she replied cheerily.
I meanwhile was turning the patient over to another neuro resident. "He acts like a turkey," I said, "but the spells are controllable with saline." I didn't know that the student nurse had just totally blown it.
The patient began another fake seizure, and my colleague hurried off to stop it. There he was, jerking arms and legs, seemingly unconscious. The resident drew up the saline, injected it, and said to her students, "See? Now the seizures will stop."
She leaned in closer to watch, and the patient's jerking arm suddenly flew up and punched her in the nose.
"Well," I told her later, "you knew the job was dangerous when you took it.
"No, I didn't," she replied."
All illustrations by Teddy Harvia