Several wags at the Grand Rounds suggested an individual with a compulsion this severe could not possibly go as long as eight months every year between such gratifying examinations. The presenting professors agreed this was odd, indeed. In the late spring of the next year, an addendum was reported: the man was a dual American-Canadian citizen, and under a different name he evidently was on 10 to 15 evaluation lists for Medical School Urology clinics all over Ontario and Quebec, where he would be examined by young medical students!
Problem?
One busy day before Thanksgiving, when I was an intern in Family Medicine at a large inner city hospital, a dressed-too-nice-to-be-in-my-clin-ic couple came in to talk with the physician on duty. She was a bank branch manager and he was the general manager of a local Toyota dealership. Our clinic nurse took the couple into the exam room, but she was unable to elicit any information from the couple about their complaint. She was not able to obtain any medical history, for that matter. My medical student and I entered the exam room and introduced ourselves; we encountered the patient, a well-kept middle-aged woman, sitting on the exam table. She appeared very anxious and nervous, wringing her hands; her patient husband was standing at her side.
I noticed that she had a brown paper department store bag at her feet.
Trying to impress my medical student with my ability to obtain information from paranoid patients, I asked some brief questions. I finally determined that the best reason for this patient's visit was that she was seeking medical help for a problem she had discovered. This being the afternoon before a major holiday, this was the only clinic that would see her on short notice.
Her vague complaint was that she had discovered that the FBI and the CIA, along with the local police department, and even hospital security, had a plan to take over the United States.
Biting my bottom lip to keep from smiling where the patient could see, and looking smugly at my medical student, I asked the patient to detail this plot she had discovered.
After some assurance from me that she could trust me, she confided that the FBI and CIA were inoculating all family dogs with rabies in order to deteriorate our nation's healthcare system. This action would devastate the United States population and enable them to take over the country.
As I was doing my best not to start laughing at this point, the patient reached down to pick up her shopping bag and said,
When I looked into the bag, it contained the head of her pet dog.
She requested that I check the dog's brains, and I would see the rabies.
I decided at this point that I would notify hospital security and arrange for an emergency commitment for the patient. Leaving the medical student alone in the exam room with the patient and her dog's head, I asked her husband to step into the hall with me to advise him of our plans for admission. After walking a few steps down the hall, away from the patient's ability to overhear, I looked at the patient's husband and asked bluntly, “How long has your wife had this problem?”
Without hesitation, he answered,
“What problem?”
SLEEP STUDY
I was on call during Internal Medicine residency when the code pager alarmed at its usual hour, 4 a.m. I arrived to find the code underway on an elderly nursing home patient with multiple medical problems. Efforts were unsuccessful. Unfortunately, previous attempts to persuade the daughter to allow the ill patient to pass away naturally, without resuscitative efforts, had been equally unsuccessful.
The resident in charge of the patient was busy, so I told him I would contact the daughter and private attending. I hadn't worked with this attending extensively so I wasn't sure if he would want the “quick version” or all of the details. When he returned his page I gave him a synopsis of the patient's clinical deterioration that night and a recap of the code, ending with, “ … which was unsuccessful.”
There was silence on the phone for long moments, then unexpectedly he sleepily asked, “She's still intubated?”
Stunned and admittedly confused, I stammered, “Y-yes? … “
“Get a pulm and cardio consult,” was the reply.
Cutting through the confusion, I exclaimed,
“Doctor, I'm trying to tell you the patient is DEAD!”
“Oh … Okay.” Click. Dial Tone.
I hung up the phone and walked over to some fellow residents who had been at the code. I must have had an uncharacteristically astonished look on my face, since they instantly stopped me to ask what the attending had said. In my usual deadpan I told them, “He wants a pulmonary and cardiology consult.”
Now they looked as disbelieving as I had been. I said, “Either he was half-asleep or ‘Covering Your Ass’ has really gotten out of control.”
TEACHABLE MOMENT
My story begins with the first case of the day in my residency procedure clinic. Ms. Chatterly, a 17-year-old female, has been referred to me for a colposcopy for cervical cancer. (The colposcope is a machine that allows us to look at a woman's cervix close up.) Her mom stayed long enough to sign the consent form and vanished. The young girl was not a patient I had seen before. I began by taking her history. Shortly after the history taking began she proceeded to start balling about, “Why is this happening to me?” We found out that her mother had had a hysterectomy at 25 years of age for cervical cancer. I was not surprised to discover that Ms. Chatterly had dropped out of school last year. As near as I could tell she had to quit school to pursue her other interests, which include smoking one to two packs of cigarettes per day and spending time with her suitors. She had managed to encounter 12 to 15 sexual partners since age 13. I then recognized a “teachable moment” and had a LONG dialogue with her regarding her lifestyle choices as they related to her current condition.
The actual colposcopy with biopsies went about as expected. Strike that. There was more crying than I expected. Following the procedure I left to allow her to dress and to prepare my speech. When I returned I found her standing dressed and ready with coat on, her Marlboro Lights in one hand and lighter in the other. Before I even had a chance to speak, she asked, “So Doc, how long do I have to wait before I have sex?” I then forgot my speech, and calmly replied, “Three to four months.” I didn't think she would believe a year.
Whilst working in a busy trauma and burns ICU as a tired and permanently stressed resident, keeping my head above water was a Herculean task. The day-to-day grind of the job could be worsened by the arrival of my boss, a particularly toxic little surgeon who more than compensated for his small stature and male pattern baldness by being generally unpleasant to any unfortunate member of staff he came across. As is often the way with such people, he was unbelievably vain and wore the most fantastic (and expensive) hairpiece that money could buy.
The fact that the whole world could tell it was a wig appeared not to have crossed his mind and he was often seen running his short, stubby fingers through his rug whilst gazing intermittently into any darkened window he passed. I will of course refer to him from now on as Dr. X.
On one particularly unpleasant day, a patient we had been ventilating and inotroping for a week following a nasty house fire started to decompensate. Oxygenation became difficult and the chest X-ray showed the severe ARDS (acute respiratory distress syndrome) we had been expecting for days. All ventilatory maneuvers failed to resolve the problem and I called Dr. X to avail him of the situation. He reviewed the case notes and radiology and announced to us that he wanted the patient turned to the prone position.
Turning a ventilated patient prone involves a significant coordination of manpower to ensure that all those carefully placed lines and tubes are not pulled out or dislodged. To his credit, Dr. X rolled up his sleeves and donning a gown offered to help with the head end during the turn. Myself and a group of nurses prepared the lines and on Dr. X word disconnected the ventilator and began to turn the patient.
Unfortunately for my esteemed boss, I had failed to put the ventilator into its standby mode after disconnecting
and the machine (only following it's programming, I suppose) sensed a drop in airway pressure and tried to compensate by delivering an almighty breath from the disconnected tubing.
To my horror, a huge spray of pulmonary secretions (which had been hiding in the tubing and filter) shot into my boss's face and lifted the front inch of his toupee from his forehead!
The silence that followed seemed to last forever as we desperately tried to complete both our proning maneuver and turn off the flailing ventilator. At least two more blasts of secretion covered Dr. X who, as he was holding the airway, was unable to move out of the way.
After we had finished (and I had tried to apologize at least twenty times), my boss, a bright shade of crimson, walked off the ward and toward the changing rooms. As he went through the door into the corridor every nurse and respiratory tech in the unit started to laugh. He slowed his pace as if to turn, but then hurried out.
I had another month of burns to suffer prior to moving to another position and in all my remaining weeks my relationship with Dr. X remained curt but polite.
The incident was never mentioned, although the wig changed.
Pheobe was in the nursing field. She had a bad case of hypertension. It seemed that whatever medication the doctors would try would eventually fail. Soon Pheobe began having hypertensive crises. The headaches, tachycardia and sweating were unbearable for her. This is where our story starts. A little background on Pheobe first, however. She had three miscarriages in the past due to increased blood pressure and high blood sugar. Her only delivery of a normal child had the complication of severe eclampsia (hypertension in pregnancy/delivery). She stated that her father died in his 50s due to a hypertensive crises as did five of her siblings from the same problem in their 50s as well. Hmm. Obviously, a genetic component was at work here.
Prior to our authors getting a hold of Pheobe, investigations were performed at many different hospitals. Catecholamine testing, 24-hour urine testing, clonidine inhibition tests, MIBG scintigra-phy, CT of the abdomen, and MRI of the abdomen were all done to find the cause of Pheobe's duress. No luck. Much of the same tests were performed not once more, but twice more, and again no answer. Finally, Pheobe made her way to our hero's den.
She didn't look well. She was about 130 pounds. Actually, that was about it. Everything else on exam was completely normal. Her blood pressure of 140/80 mmHg was pretty good as well. Then the blood testing began. Everything was normal except the adrenaline and noradrenaline were way out of whack. This lady had a pheochromocytoma! Forget horses, we have a zebra here.
Our authors now began their diagnostic studies. Ultrasound of the throat and abdomen were normal. CT of the neck, thorax, abdomen and pelvis were normal. MRI of the abdomen was normal. MIBG scintigraphy and arteriography was also normal.
Soon our friends began taking venous blood samples to find the location of this pheochromocytoma. This tumor which causes extreme hypertension needed to be found immediately. Luckily an “enhancement” showed up in the right adrenal gland and soon it was removed surgically. Wouldn't you know it but under the microscope the adrenal gland was normal? Even worse, Pheobe's hypertension crises were continuing.
By this point Phoebe was getting pissed. Up to six hypertensive crises were occurring a day. Her doctors were running tests and doing useless surgeries and they were finding nothing. She must have thought them incompetent. They tried every blood pressure medicine they could find, even ones not available in her country, and yet there was still failure.
The doctors tried testing all over again and were stumped once more. Then something showed up. A glimmer of hope. The concentration of adrenaline and noradrenaline were exceptionally high in left adrenal vein. Due to more life-threatening blood pressure crises, the surgeons were called and the decision was made to take out Pheobe's left (and last) adrenal gland. It was go time.
Like a miracle, something showed up out of nowhere and in the nick of time to stop the surgery. A clue had unearthed itself to spare Pheobe another useless procedure. Thank goodness. It seems the medical staff had found bottles of nor-adrenaline and adrenaline as well as syringes (some half-filled) around Pheobe's bedside. Hurray!
So here is how she did it. Pheobe would take the syringe and with perfect timing inject herself intravaginally. Ouch! She would even pull this trick off during some of the diagnostic studies! When she was confronted, Pheobe denied all. In fact, her hypertensive crises got worse and more frequent right after the confrontation. A forced admission to a psychiatric ward under constant surveillance cured everything. Who says “Big Brother” is always a bad thing? No more hypertensive crises were ever found.
Pheobe couldn't stay forever. Eventually she was discharged and off to visit another hospital of her choice. Our authors ended their discussion by stating that they had heard Phoebe “had developed a new Munchausen syndrome.” Good luck Pheobe and let's hope you can be a little more careful next time.
Liberally adapted and embellished from the European Journal of Medical Research (1998) 3:549-553.
During my residency I found myself with some time on my hands one long call night. (I know what you are thinking, this cannot be a true story because what resident has time on their hands?) But indeed it is true and I swear to you that it did occur. You can ask my victims.
I was eating peanut butter when it occurred to me that the texture, color, and viscosity resembled something I had encountered on a proctology rotation. With this inspired thought, I carefully applied about two tablespoons of chunky style to theside and sole of my right shoe. I added a small smear of strawberry jam and I was off to the Emergency Department in search of a victim who would provide me with the reaction I craved.
I spotted Nancy, a registered nurse of long experience and a finely tuned and accurate bullshit meter. She smiled at me pleasantly and then turned as I addressed her.
“Oh man, look at that will you? I can't believe I got that on me!”
I yelled while pointing and looking down at my shoe.
“What is that?” Nancy asked, her eyes wide with horror at my anticipated reply.
“What does it look like? It's shit!
I shouldn't have walked into that guy's room; diarrhea all over the floor, the bed, the walls … aarrhhhggghh!!!”
Nancy tried not to smile as she contemplated my situation. But her amusement turned to distress when she realized what I was now doing. She made a quiet gagging sound and with her hand over her mouth she ran like the wind to the ladies’ restroom.
Mission accomplished, I retreated to my call room after I finished licking the rest of the peanut butter and jam off my shoe via my right index finger.
I heard later that Nancy did not emerge from the restroom for the better part of thirty minutes, pale and diaphoretic, with a few choice observations about my character, my intelligence, and lack of class.
The remaining nurses on the shift made my life a living hell for the rest of the night and well into the next day as they called me for orders which were not necessary, which they normally handled, and strategically spaced in time so as to interrupt the maximum amount of REM sleep possible. I didn't mind though, what's another lost night of sleep compared to the sheer joy of completely disgusting an ER nurse?
It doesn't get much better than that.
NEVER TOO LATE
As a resident with three months to go in residency, patience with patients begins to run on the short side. Taking call becomes a little less educational and a bit more … well, let's say laborious. Although I'm not complaining about resident's pay … but a night of moonlighting is a stark difference.
At 8 p.m. on the evening of a Sunday night call, I received a call from the nurse requesting me to speak with a 35-year-old female with the complaint of diarrhea for eleven days. Covering for some twenty staff physicians, I had no idea who this person was, but by this time in residency I had come to know the type of patients that her staff doctor seemed to attract. A quick scan on the computer showed that this
patient suffered from irritable bowel syndrome (IBS) and depression to name a few problems.
Over the phone, the patient relayed that she was having a flare of her IBS resulting in four to five “blowout” stools a day. The patient had been ordered by the staff's nurse to try Lomotil to control the diarrhea but to call the office or go to the ER if the Lomotil did not work. So, here we are 11 days into this “flare” and she is calling me to get permission to go the ER … I mean she had taken a whole three Lomotil today and had “failed” her therapy!!!
In what amounted to be a twenty-five minute phone conversation to map out a plan of attack for this patient, I tried to point out that waiting another twelve hours for the clinic to open would be wiser than “utilizing” the ER. My main point was that it would be at least $500 cheaper to wait. “Oh no,” she exclaimed, “it won't cost me a penny because I have Medicaid.”
I blurted out,
“Medicaid is not free,
I pay for it!”
Oops, not the best thing to say to an unstable, depressed patient with “explosive” diarrhea.
Amazingly the comment slid by … or so I thought. Twenty minutes later the nurse calls again stating that the patient wishes to speak to me directly. She had reviewed her notes of our conversation and now had become offended. She requested an apology, which I was quick to give … but I also made sure she understood Medicaid is not a free ticket (at least for those who have to pay).
Now I wait … wait for the next phone call – that being the one from my program director.
The Placebo Chronicles: Strange but True Tales From the Doctors' Lounge Page 11