The Placebo Chronicles: Strange but True Tales From the Doctors' Lounge

by Douglas Farrago M. D.

  She took my advice literally and moved to I another county. When the request for a copy of her medical records arrived from her new doctor, I felt a wave of relief sweep over me. It was none too soon, for on our last visit she put me in the dilemma of having to choose between her short-term impulses and the opposing principle of what was best for her (and society) in the long run: she complained about her loss of sexual desire and what could be done about it?

  EDITOR‘S NOTE: Thanks for sharing about your “problem” patient. You should have told her about your lack of desire … lack of desire to see her. Or you could have put the clitoral ring back in!

  HAIRPIN CURVE

  My wife (we'll call her Amy), a wonderfully competent board certified and usually very empathic psychiatrist, escorted the tearful, middle-aged woman out of her office to have her rescheduled and get her some medication samples.

  When she brought her into her office for the psychiatric interview, she nestled back into her chair with pen at poise - her office emanating that low, “womb-like” comfort lighting. During the interview, Amy thought the patient had a rather unusual hairpin of sorts in place above her forehead, but was riveted by the tale of loss and sadness and focused on trying to help her through this major depression.

  Now, interview complete, in the full fluorescent light (Ä of the main office, as the Jpsk patient approached the ir scheduling desk, our receptionist remarked, “So, who's your friend?” The patient looked perplexed and then Amy turned around and saw the “hairpin” in all its glory.

  It seems that the patient had walked out of her home, in a hurry to get to her appointment, and passed through some type of spiderweb. Now, embedded in her hair spray-hardened hair, was the brittle, but large carcass of a thoroughly deceased Japanese beetle embraced by the tender silken threads of the web. Amy just absolutely lost it - she tried not to laugh but before she knew what was happening she was laughing so hard she was crying. Now, usually, the psychiatrist doesn't laugh out loud after having just spent an hour with a tearful, depressed patient but Amy could not help herself. To no one's surprise, the patient never returned.

  A BAD ITCH

  I was trained in Syria and did my residency in the United States. This story happened two months after the 9/11 tragedy.

  A young woman came to see me on a Monday afternoon. Apparently on Saturday, she ate seafood (some shrimp and what have you). A few hours later she developed a rash with severe itching. In the emergency room, our friend was given a shot for the reaction and told to follow up with me. Nothing remarkable was found on my exam, but she was still having the itch.

  After we finished our discussion, I made a decision and said, “Madam, I am going to give you some Atarax.”

  Atarax is a drug that works well to stop pruritis, or itching.

  Unfortunately, the patient didn't truly

  understand what I said. With a frightened

  look on her face she screamed,

  “No, sir, do not give me

  ANTHRAX, I don't want that!”

  The lesson here is to always be careful

  with your pronunciation

  especially if you have a foreign accent.

  A FAMILY DOC IN THE LAND OF THE AMISH

  An Amish man came in with a chief complaint of having his “right ear blocked for two years.” He had a big piece of cotton stuck in the ear after trying “sweet oil” and other natural remedies. I checked the ear and it was indeed packed with cotton and wax. After my nurse did extensive lavage, I rechecked the canal and found it clear. As I handed him the bill he said, “Doctor, can I have my cotton ball back?” I handed it to him and asked, “What do you want it for?” He responded, “Well, everything is so loud now.” Guess I'll be seeing him back in a couple of years.

  Another time I came in after hours on a weekend to sew up a seven-year-old Amish child. He had cut himself in the forehead playing with sharp and dangerous farm implements. The father brought him along with three other children. I soon figured out that the “yes, we are patients in your practice” over the phone actually meant “we go to the other doc up the road, but he won't come in on weekends.” With a sigh, I had the father fill out the patient information sheet while I set up the suture tray.

  I looked at the sheet and said, “Okay … Jacob, hop up on the table and let's take a look.” This kid was incredibly stoic. Not a flinch when I said, “Okay, Jacob, now you'll feel a bee sting as I numb you up.” Jacob never moved a muscle or said a word. I fixed him without a problem and told dad to call the office for a suture removal appointment in five days.

  Seventeen days later, Mom brings him back in. The front desk can't find his chart anywhere. After ten minutes of searching in vain, I tell my staff to just put him in a room. I figured I would take his sutures out and find the chart later. As I am struggling to extract my now completely buried handiwork from his forehead (he's as stoic and wordless as ever), I say, “Sorry, Jacob, I know that this may hurt a little ”

  Mom cuts me off and with a big smile says, “Oh! It wondered me why you didn't find the record of him! This is Amos, not Jacob. My husband always gets them mixed!”

  I remember having a case of a mini-Munchausen about eight years ago. I did a Bier Bloc (a type of local anesthesia) on a lady for hand surgery. I had to give her a social dose of Versed for her severe anxiety. We took her to the Recovery Room, where we noted she I was unconscious. Then she started posturing in a weird paralyzed sort of position. I thought maybe she got I walloped with a big slug of IV lidocaine when we let the tourniquet down - even though we did it slowly and watched her in the OR before we went to Recovery. I started treating for local anesthetic overdose.

  Man, it never occurred to me!

  I used to do that trick in the ER holding the hand over the face and dropping it. Truly unconscious people will hit themselves in the face - if you let the hand actually fall that far – whereas fakers will always have the hand drop off to the side.

  But I never saw the hand stay in the air.

  Anyway, I go out to face her husband. He asks if he can see her. I take him to the recovery room, he looks at her, shrugs his shoulders, and says,

  After thirty minutes she was still posturing and unconscious. I called for a stat neurological consult. The guy walks in, lifts her hand up in the air and lets go … and her hand stays up! He turns to me and says, “She's awake” and walks out.

  I go running down the hall after him. He tells me that holding her hand up like that is a voluntary movement and he's going back to the office.

  She does that all the time.”

  I couldn't believe it!

  Finally he tells me she sees a shrink. I call the psychiatrist and he goes ballistic. Apparently, this lady had a bad “incident” in the hospital as a child after a tonsillectomy and keeps having surgery. The unconsciousness is a conversion reaction. Over the next year I saw her in pre-op two more times and had to call her shrink and the surgeon each time to get the procedure canceled.

  Who says we never learn.

  I bet this young lady keeps torturing other anesthesiologists today.

  TRUE ANECDOTES

  An aerospace engineer came in with five days of rectal bleeding. He saved all of his used toilet paper and brought it in to the exam in a plastic bag in case the doc wanted to see it.

  There are some things even a $15 co-pay won't cover.

  A lady who kept trying to kill herself was found unconscious with her head in the oven. Paramedics called in to the ER stated that she had carbon monoxide poisoning because of her bright red face. Trouble was, only her face was red.

  Diagnosis: drug overdose followed by placing head in an electric oven, causing first-degree burns.

  A patient today who is a total train wreck with arachnoiditis (inflammation of the spine) and spinal stenosis (narrowing of the spinal cord) now with a failed back. He asked me for a script for Viagra. I was blown away. Who would he be having sex with? And how? He was going to Mexico for a funeral the n
ext day. He told me, “Doc, I haven't had sex in two years, I'm going to Mexico tomorrow and I'm going to get laid even if I have to get AIDS.”

  We don't stand a chance. The patients are winning.

  A TRUE DIAGNOSIS

  These Munchausens are a couple of kooky “diabetics” who don't know each other but have a heck of a lot in common.

  Sarah was a 27-year-old woman who complained of terrible left groin pain. No one was able to define what the problem was. She eventually was sent to an endocrinologist because of her history of diabetes. It seems she had had this disease since age thirteen. “Strange, but she only acquired diabetes during this past year?” he thought.

  Gertrude was 18 years of age and she too had diabetes. Her primary care doctor thought that she would need the help of a specialist (the same endocrinologist). The weird thing about Gerty was that she only consulted her family doctor once about the need for insulin and whoosh, she was whisked away to the specialist. She did have high blood sugar readings on her home monitor; however, and had problems with polyuria (urinating all the time) and polydipsia (drinking all the time).

  Sarah had an immense past medical history for such a young girl. She had a hysterectomy for heavy menstrual bleeding, a laparoscopy for chronic abdominal pain and surgery to remove a malignant tumor from her arm (no record could be found on that one).

  Gertrude had some interesting medical problems as well. Another hospital had found that she had psychogenic polydipsia. In other words, she would drink water to excess and this would make her physically ill. Upon further inspection, Sarah also had been diagnosed with psychogenic polydipsia in the past. What was going on here?

  The plot thickens. Sarah's husband had type I diabetes and needed insulin. Gerty's boyfriend also had type I diabetes and needed insulin. Here is the kicker. Both were found to have normal glucose testing while being hospitalized! There were no abnormally high levels found on regular finger sticks. No abnormalities on glycohe-moglobin testing. There were no abnormalities on oral glucose testing. Our endocrinologist got wise and brought in another specialist. Wouldn't you know it, both Sarah and Gertrude were labeled as Munchausens by the same psychiatrist.

  Our physician hero picked up both Sarah and Gerty because he was able to hospitalize them. This was an advantage the primary care doctors didn't have. In a contained environment and with a good eye (as well as suspicion), physicians everywhere have a chance to spot one of these rare Munchies.

  No, Sarah and Gerty were not the same person nor did they know each other. Was their modus operandi of shooting their significant others’ insulin a coincidence? Were their similar histories a “twilight zone” theme? We don't know the answer to these questions. What we do know is that there are probably more sweethearts like Sarah and Gertrude out there and they are coming your way.

  This story was liberally embellished from: Aust NZ J Med 1998; 28.

  BENZO BEGGER

  These types of patients all do the same thing because they have the same motive. My hat goes off to the physician who had to live through the hell.

  I am a psychiatrist. I was working in a hospital in NYC, in the outpatient mental health clinic. Upon arrival, I inherited a caseload of many patients from my overloaded peers, usually without getting any details or warnings about the patients. Everyone was just too busy for a “sign-out” of patients.

  One of the patients was “Bonnie,” a 38-year-old black female who was on Klonopin for her “Generalized Anxiety Disorder.” She would never keep her monthly scheduled appointments, but would come in now and then and demand to be seen on the spot. More specifically, she would come to my office and bang on my door, and insist on being seen right away. She often claimed she'd “lost her Klonopin” (a controlled substance, a benzodiazepine). This is a frequent occurrence, because Klonopin can be abused, taken excessively, or even sold in the street (for $3 a pill!). Naturally, psychiatrists are hesitant about replacing a prescription. The first time she “lost” her bottle (“I left it on the bus”) my supervisor and I spoke and we decided to give her a week's worth, with no refills. Bonnie came back in three days saying she “had dropped them down the sink accidentally.” Her attitude was belligerent and bullying. This time I refused to refill it. She got angry and left yelling at me as she walked away. Subsequently, Bonnie went to her therapist and said I had been “abusive to her.”

  Twenty minutes later she opened my office door (I should have kept it locked), strode up to my desk and brought her fist down on my forehead. She ran out of the clinic. A welt immediately appeared on my forehead. I was sent down to the ER, given Tylenol and some ice for my head.

  I asked my family if I should press charges. They said, “Nah, what can you do, she's mentally ill.” The next week at work, my boss called me in; “A detective came here looking for you.” He'd left a number, which I called. He told me that on the day the patient punched me, she'd gone to the local precinct and filed a complaint stating that I had hit her on the head with a staple gun.” I had to consult with a lawyer (big bucks!) who accompanied me down to the precinct to straighten this out.

  A month later, the patient's caseworker admitted to me that the patient had assaulted the doctor who had previously covered this patient. One day this patient barged into her office while she was with another patient. Bonnie (my assailant) demanded to be seen right away. When the doctor asked her to wait outside, she picked up an umbrella and hit the doctor over the head with it, then took the umbrella and swept all the charts off the doctor's desk onto the floor. All the warning signs and the pattern of behavior were there. Then I arrived on the job - and the patient was transferred to me, without any warnings from this doctor or the caseworker.

  I asked my boss what we could do about this patient. He said we “should all meet with her and agree to a verbal contract that would set limits on her behavior.” He sent her a letter inviting her to such a meeting, but she never came in. A secretary in the front office was the only one who comforted me. She said “There's no excuse for that patient hitting you. Even mental illness is no excuse.”

  Thank you, voice of sanity.

  Needless to say, I changed jobs soon thereafter. The clinic director wrote her a letter stating she was not to return to the clinic and her chart was being closed. She could, however, get help at other clinics in the area and listed the names and phone numbers of those three other centers. Wouldn't you know it but one of those clinics was where I worked at part-time! (The idiot hadn't asked me where else I worked!)

  Luckily, I never saw the patient, or her k fist, again.

  Have Stones, Will Travel

  Mr Jones was a 52-year-old white male who presented for an initial evaluation of flank pain. He seemed to be a pleasant, engaging, and intelligent man in appearance. He stated that he had a long history of nephrolithiasis (kidney stones) and he had seen several urologists in the past for these kidney problems. He reported that he recently had an ultrasound done by his last urologist that showed a stone in the uretero-pelvic junction. It was so thoughtful of him to carry this study with him to my office

  It turns out that Mr. Jones was a Vietnam veteran having served with the infantry and did two tours of duty earning a purple heart and a bronze star for heroism. Having served in the army myself, as well as the infantry, I felt a connection with this pleasant man and admired his sense of duty and patriotism. We discussed the rest of his past medical history and I wrote him a prescription for Percocet for his pain. He told me that this medication was the only one that worked for him in the past. I subsequently set him up for a spiral CT scan of his urinary tract, as well as a trip to a local urologist for possible lithotripsy, as his stone was quite large.

  Mr. Jones quickly spoke up and stated that he would not see any of the local urologists due to “interpersonal” conflicts with all three doctors. My ears went up as more red flags were flying right and left, but I did have in my hands a documented stone on an ultrasound. By this time his urinalysis came back with pinkish color
and many RBCs (red blood cells). I referred him to a specialist in a nearby town and set him up with me for follow-up to discuss his progress. Later that day, I placed a call to one of the urologists that had “interpersonal” problems with Mr. Jones. It turns out that Mr. Jones did in fact have a history of drug-seeking behavior and this urologist would no longer see him due to escalating usage and suspicious behavior.

  Several days later, Mr. Jones called me for a refill on his Percocet. I had given him forty tablets, which should have lasted one or two weeks. When he came in, I recommended alternative medication, which he quickly blocked due to sensitivities to Toradol, Ultram, Ibuprofen, etc. He complained of escalating pain that ran along his flank down to the testicle on the same side as his stone showed on ultrasound. Repeat urinalysis did again show blood in the urine. Reluctantly, I gave him a second prescription for forty Percocet with no refills.

  Several days later I got a call from my receptionist that Mr. Jones was in the waiting room with his Percocet bottle in his hand. It contained a milky white solution with pill fragments. Wouldn't you know it, his wife washed his pants containing the bottle of Percocet and now he needs a refill.