When you come to the ER stating that you can't move your legs. That they feel paralyzed. That this happened a week ago after twisting wrong. That this got better after slipping and falling on your buttocks. That it got worse again after slipping, again. That the ED to ED ambulance transfer of 100 miles at 3 am for a stat MRI showed only old scarring from previous disc surgery. That your spine surgeon who was consulted by phone says they fired you for persistent narcotic shopping. That you say you are awaiting a second opinion that your spine surgeon ordered in a town 60 miles away. That you say you can't pee but have normal rectal tone. That you show signs of malingering on physical exam. There are certain things you can't fake.
When you have all this, the clues point to malingering. And the history and physical is backed up by that $2000 middle of the night MRI that has normal written all over it. The fear of "Am I missing something? " are overwhelmed by the feelings of "How could this not be malingering?" With all this available data pointing towards nonphysiological weakness I am forced to conclude that your complaints are either supratentorial or they are an intentional misrepresentation of the truth.
But the nail in the coffin? The sign that cinched my diagnosis? Your husband. His performance deserved an Oscar. He lay there for 30 minutes. Sleeping. Not once raising his head off the countertop. Not once opening his eyes. Not once acknowledging my presence. Not once showing even a hint of concern about your paralysis. Your husband could care less that you are paralyzed. That, my loyal Happy readers, is the strongest sign I could have ever asked for. It means more than all the questions I could ask. All the poking and proding I could do. All the objective data I can spend money for. What is this magical sign?
The Sleeping Husband Sign.
A test so wonderful that it can predict the lack of acute major illness 100% of the time. The perfect tool for ER medicine. Not much in medicine is 100% sensitive and specific. The sleeping husband sign is your best friend. And it doesn't cost you a dime.
Diagnosis: Malingering
Plan: Discharge from ER
If you're a student or a resident, it's time to tuck away these other great medical signs. But first, please enjoy this original Happy someecard.
Hence the reason my stint in ER was short-lived and miserable. I was used to oncology patients. You're having pain? Well, here's your morphine, and let me know if you need more. It was too much cognitive dissonance to go from that to malingerers. The first time an ER doc asked me if I thought a patient was faking a seizure I felt like I had fallen down the rabbit hole. Why would anyone want to fake a seizure???
ReplyDeleteCell phone sign. Without exception, if you can carry on a conversation on a cell phone, you are NOT in labor. Sure, the quick call to in-laws with instructions for the older siblings at home, maybe, but if you can giggle to friends that "today's the day!"... it's not.
ReplyDeleteWhat is even worse is when they come alone and they have split into about 10 different personalities – from happy thankful patient to mean crazy patient after you will not give them narcotics.
ReplyDeleteThis post got me to thinking. I understand you get many calls for referrals for admission from the Emergency Department. What percentage of the patients do you admit and what percentage do you sent home?. Do you use that opportunity to educate the Emergency Department physician?
ReplyDeleteDo you get calls from outside the hospital to do direct admissions or do all your referrals come through your Emergency Department?
ndenunz...We have very good ER docs (thank GOD). I do occasionally send folks home from the ER (a couple handful a year), but I don't think I need to be educating them about anything. And I do accept direct admissions from all over as well. We are a regional referral center.
ReplyDeleteDon't forget the classic calling the doctor an MF'er sign. When done by a family member when you refuse to write their mother/brother/sister narcotics because they are malignering then you know that they are in on the game as well and need their drugs. Yes it happened to me. I did not write the narcotics and the patient's daughter got up to push me so I walked out of the exam room. The kicker is that the next day the patient called the office wanting a medical note to turn her power back on after she didn't pay the bill. If you or your family calls me an MF'er I don't turn on your power or write you narcotics.
ReplyDeleteWe had a lady very similar to the above awhile back. Flakes.
ReplyDeleteIn pediatrics we call this the "sleeping parent sign". When you walk into a room and the parent is asleep on the stretcher or in the bed (or, in the case of last night, in the CLIMBER CRIB) and the kid is in the pack-and-play or on the floor, you can say with 100% specificity that the kid is not sick.
ReplyDeleteGood sign - had a patient the had an atypical seizure in PACU after routine day surgery. CT, stat neuroangio and neuroconsult all either normal or inconclusive (despite continued seizures with iv dilantin and valium). How did we figure out he had Munchausens'? When we called his mother from the neuroangio suite she told us to call back in the morning!
ReplyDeleteOh so true!!!
ReplyDeleteI had a chest pain patient on Thanksgiving Day, guy in his late 30's who had what looked like a STEMI on his EKG. We activated the cath team, cardiologist evaluated him and took him to the cath lab. We call his family and tell them we think he is having a major heart attack, they said they'd try to make it up later that evening after their meal and the football game.
ReplyDeleteCath results: no coronary stenosis
Labs: cocaine positive
That's pretty funny. I had a crazy abdominal pain lady whose husband would literally roll his eyes at me every time I'd see them in the ER.
ReplyDeletefunny thing. I am a biochemist. I build your clincal tests. I know the things you guys dont know. I know the gaps in knowledge you have and the areas where you are behind the science. your arrogance is so odd.
ReplyDeletesometimes maybe these folks-especially the narc seakers-maybe are as bad as you guys say. But the rest? In reality you are missing pieces of the puzzle. You cant identify the problem because you lack the correct biomarker, the correct type of test, the proper understanding or realization that you lack the understanding. But of course your tests and cognitive skills couldnt be flawed. the patient is the flaw, eh? You guys live in total denial.
Tell your stomach pain lady to stop eating wheat and milk for a week-see if it helps. search pubmed for "dueodenum" and "eosinophil" to find an interesting paper by mayo. See? Oh but those whiny stomach folks..
What about the jerks? The neglectful husbands or parents who just don't care much abut their family member's pain, even if it real? In my opinion, this sign gives to much credit to human beings for kindness and empathy.
ReplyDeleteThe sleeping husband sign may be sensitive but I don't think it's specific. I've had several husbands/baby-daddies who have slept through the delivery of their children! You certainly can't argue that women in labor are malingering.
ReplyDeleteThis is hilarious. I will try to remember this one in a few years when I start rotations.
ReplyDeleteWhen I was in labor with baby #1 my now-ex told me in disgust that I was "hysterical" because "labor doesn't hurt" and left after the nurse showed up. I delivered the next day.
ReplyDeleteSometimes family members are jerks.
I have a comment in regards to the "cell phone" sign...I was in labor with my first with no pain meds and lots of yummy pitocin for about 4 hours. When the doc came in to check on me I was having a conversation and not screaming and writhing uncontrollably- she proclaimed "ahhh, you're not in labor- a woman in labor doesn't laugh and smile." She then strolled out of the room, my water broke and I delivered about 15 minutes later! Only a tech and a brand new nurse were around-she didn't rush to answer her page because in her mind I wasn't in labor. By the way, the two who delivered the baby were AWESOME! I didn't need her anyway :-) Just please don't be so quick to generalize...I was in excruciating pain, I even passed out a few times, but didn't feel the need to make a scene. When I pop this new baby out next month, I'm gonna be as loud as possible just to get some attention :-) Just kidding!
ReplyDeleteOh Please! 100% certainty that a kid isn't sick if their parents fall asleep? Maybe they've been up for two days debating whether or not they should brave the jungle that it is the ER...Or maybe they've spent every moment of the last 20 something hours at the child's bedside and now that they're in "professional" hands, their guard is lifted a little. I can't even count how many times I've fallen asleep after sitting in a damn ER for 16 hours while the docs (usually residents) try to figure out if they're going to admit my CAH daughter. Never mind the fact that I haven't eaten or slept in the two days it took for her "sniffles" to turn into an emergency. I can't fake or over react to an adrenal crisis, but the human body can only take so much. You're all medical professionals, you should know that. Sheesh. Look at the whole picture, please. That line of thinking is where complacency comes from.
ReplyDelete