Münchhausen Syndrome

Münchhausen Syndrome is a form of malingering. “This extreme form of factitious disorder was named after Baron Karl Friederich Heironymous Freiherr Von Münchhausen, a retired cavalryman who told fanciful tales only to entertain others.” The stories were made up. Seems that military posers have been around since there has been military.

From a medical point of view, an old coot (Dr. Gavin) back in 1843 figured out that there are some patients that fake their illnesses. These patients come to the Doctor with a variety of complaints of either a physical or psychological nature or both. The symptoms are intentionally feigned and they behave in a way that eventually appears that they want to be sick. There is an absence of desire for economic gain, avoiding legal responsibility (that is a whole ‘nother topic) or getting better. The cause and pathophysiology are unknown. They are just looney-tunes. I have had patients that I recognized were in this category several times in my career, but my patient last night takes the cake.

She had several diagnoses that couldn’t be confirmed. When confirmation testing was scheduled, she missed the appointment or refused the test. She reported allergies or intolerance to medications used to treat the illnesses and what medications she did take were not taken as prescribed. I was having one of my typical busy nights and was not in an extremely sympatico mood. I wasn’t allowing myself to be manipulated by giving this or that drug to satisfy her whim. I was interested enough and spent some time reading her history and noticed that she has been playing this game on Heartland Docs for 17 years. I finally made up my mind and called it quits. No more pandering to this patient.

The patient, didn’t like the fact that this new-to-her doctor wasn’t playing along with her kabuki play. So she did what any discerning adult would do, she called 911. From her exam room. She called the police to report that I was being mean and not treating her.

How did we find this out? The 911 dispatcher called my secretary to let her know that my patient was calling them, barely stifling laughter.

I mean, what do my colleges do? Call the boss and say they are understaffed ’cause Dr. Ward got carted off to jail? I’ll bet that after pizza, the whole staff couldn’t of scrapped up $20 cash for bail even if they had to.

I have reached the pinnacle of my career. I can retire now.

Humbly submitted from your grumpy Uncle/Brother Dave.

There is a digital version of Münchhausen Syndrome.

Teenage abortion

It doesn’t matter which side of the abortion debate you are on, you ought to be able to follow this.

In the 1950’s, even the public discussion of abortion was taboo, much less the actual performance of the procedure. If complications occurred, patients couldn’t seek real medical attention because what they’d done was illegal and anyone helping them would be complacent in the act and subject to prosecution.

In 1973, along came Rowe vs Wade that essentially made abortions legal, under certain restrictions that allowed the state to regulate them. Initially things like the mother’s health and life and the fetuses viability (determined to be about 23-24 weeks) were considered. Essentially this covered abortions up to the second trimester.

Things calmed down in the battle for about a decade. Eventually, the liberals pushed to get Intact Dilation and Extraction, called partial birth abortion by most of us.

Now we consider the right to abortion up to and including live term infants?

But let’s not stop there. Have the baby. Let it live and see how you like it. If you don’t, then there is always the option of the “late birthed abortion”, say up to a year, when one could elect to terminate the infant if it doesn’t then suit your needs, desires or expectation.

Think, maybe we’ll eventually be able to knock off teenagers when they don’t act like we want them to?

Your grumpy Uncle/Brother Dave just wondering where this is going?

Weary

Live by the word, die by the word

A colleague and I were talking at work the other day. The secretary came up to us and addressed my colleague in a hushed voice, “Did you happen to drop the “F” word in room x?”

Blushing, he replied, “I don’t think I did, but I guess it could have happened.”

The secretary then stated that she was on Facebook and the patient was ranting that a Doctor had just dropped the “F-bomb” in front of him and his family. Her sister was a friend of this patient which is why she happened to notice the Facebook post.

It’s going to happen. If you use obscene or offensive language of any kind, sooner or later you will say the wrong word at the wrong time. Sure, use of language will, by definition, contain some words that are offensive to somebody, somewhere eventually.

But we are talking the commonly known 4 letter, English-words that are generally considered “offensive” in general public, the ones that would get you thrown in jail, if said to a police officer.

Yet, these words are also heard, occasionally, on children’s networks and in lesser rated (pg-13) movies. Huh, society?

Continuing with my story, my colleague and I talked some more. He is relatively new to private practice and I thought I would lend my advice. Yes, it is tried and true advice, deep from the well of experience.

I suggested he humbly return to the room and express his apologies in as sincere a fashion he could muster. If the patient rants and lambasts him mercilessly, take it like a dog with his tail between his legs. At the next opportunity during working hours, inform the department head of what happened and how it was handled.

He did.

When he came out of the patient’s room, he told me that it went well.

I asked, “Oh, how was that?”

Colleague, “After I apologized, they said there was no need to and that they thought it was cool. They said they were sick of Docs that pussy-footed around and wouldn’t come to the point!”

Still, I recommend following the above advice if you want to keep your job.

Your Grumpy Uncle Dave.

Weary

Dominoes or chaos

In the beginning of my career, I called shifts as being either busy or slow. I soon realized that there were some problems with this simple classification. Some of the busy shifts were fun and rewarding and some left me drained and contemplating a career as a hermit poet.

Then I realized, it wasn’t the number of patients that I saw per shift or even the complexity of their problem that determined the warm and fuzzy vs psychotic depressive feelings that I would have at the end of a shift. No, there was more to it than that.

I looked at the facility, the shift, the hours worked, the stage of sleep deprivation. I looked at the ED staff and co-workers, at the patient population and the hospital staff. I looked at the hospital administrative staff. I could not come up with a dead-on-target source for the difference in the 2 types of shifts.

And, there are exactly 2 distinct types of shifts.

On one, nothing is easy. No matter how simple or straight forward the patient’s problem is, no matter how obvious the solution seems, nothing is easy. Maybe the patient needs admission and is agreeable up to the point that I have done all the phone calls, paper work (yes, we still have to use pen and paper in 2018), computer entries and discussions with staff, family and physicians and after spending about 30-40 minutes focusing on this one patient, they decide to go home instead. Or, decide to be transferred to another hospital requiring me to repeat the entire 30-40 minutes or more, to accomplish this. Or, reveal a previously undisclosed critical symptom that must be evaluated causing the process to start all over.

And that is just one of thousands of examples I could give for the problem shift.

On the other hand, some shifts have no hiccups, are fun and challenging. They may be balls to the wall busy, extremely complicated medically but everything works like I am King Midas touching things turning them into gold left and right.

So I came up with the classification of dominoes or chaos. Surely, you can figure out which shift is which. And for the next 25 years, I used this classification. Being able to put a name to it and understand where I stand in the cosmos of Emergency Medicine on a particular moment is kind of stress relieving. It helps me deal with walking through the swamp full of alligators.

But recently, I have changed the classification.

Now I say I’ve had a domino day or a common core math day.

Weary

http://www.funnycaptions.com/img/138602/common-core-math-if-you-have-4-pencils-and-7-apples-how-many-pancakes-will-fit-on-the-roof-pu/

43 Hour Chess Match on the Farm

G sent me a text a few weeks ago.

“Grandpa, do you have any work on the farm I could do to earn money?” or something close to that. We had talked about getting her on the mower several times. Last summer she was on the garden tractor mower and did fine on a few small spots. She mows the yard at home with a self-propelled “push” type mower. A push type mower today is nothing like what I pushed, in my day.

So, I replied, “Sure.”

The reason this happened was that G wanted to participate in cheer leading the coming school year, and the uniforms cost about the equivalent of a Rolls Royce. Her Mom said that if she wanted to cheer, she had to buy her own uniform, so find a job and earn some money. Or, something to that effect. Amazingly by today’s standards, the children in this family already do chores. They don’t get paid for them because it is considered contributing to the family. So, G had to look outside the family for the additional income.

I was off this weekend and the wife was out of town. It would be just me and G. I figured she would need a training day on the mower, at least. Boy, was I right, and wrong.

I brought G out after her brother’s baseball game Friday night. She elected to just snack on the road instead of eating. By the time we got to the farm, she was beat and went straight to bed without supper. We slept in a bit Saturday morning and didn’t get started until about 9:30. I didn’t start off with the mower because it was wet with dew and the mower slips and slides on the wet grass and our little hills. So, off to the shop to start my list of projects.

Project one was to clean the refrigerator. I keep drinks in it for those hot days to save having to walk to the house to get a drink. But, in bad winters, when the temperature drops much below 0’F, the cans sometimes freeze and explode inside the fridge and make a mess. G diligently stripped the inside of the fridge, washed off the dried coke splatter, reassembled the shelves and restocked it.

Project two was general shop sweeping. It’s a wood shop and there is always lots of dust and wood chips around. I don’t sweep up unless it gets so thick that I trip over it. But, I took advantage of having G and put her to work sweeping. Sweep she did. She swept up dirt, saw dust, cob webs, spiders, shed snake skins and all manner of trash. Not a whimper and she did a good job. We discussed why there were snake skins laying around. It’s a farm shop and there are mice that think it is a really cool (warm) place to spend the winter when it’s cold outside. So, for as long as the shop has been there a local black snake (at least my best guess is that it’s a black snake) has been a resident. I don’t worry about him as long as he eats mice. I’ve only seen him once, when I grabbed him one cold winter day reaching for something when I was looking somewhere else. It’s a little disconcerting to reach for a drill battery and instead get a handful of muscular tube that is slithering away. But, I know he’s around because he sheds his skin periodically and I find those. I’ve kept them for comparison and the last one was just under 5 feet long. I figure he’s eating well.

Those two projects allowed me to work in the shop with her on another task that has been on my list for about 2 years. It was a great morning, albeit hot. G said that she had never sweated so much. Welcome to the world of work.

So we broke off work to go back to the house for lunch. I had the mower at the shop and explained how it worked. It is a Zero-Radius-Turn mower. I had her start it and set the engine just above idle and had her drive it to the house, about 1/16 mile, as a practice run. A bystander would not have ever guessed that this was the first time she had driven it. She got to the house and parked it exactly where I had told her to, jumped off and was 11 years of excitement and thrill.

“That was fun Grandpa.” She has driven bumper cars at amusement parks that have similar steering controls. In my day, they were just steering wheels, but the times they do change.

We had lunch. Normally, it’s hard to get kids to try food they’ve not had before. I fixed her a burrito of chopped left over BBQ brisket, cheese and salsa.

“How many do you want,” I asked?

“Oh, just one,” she said in a timid voice. Timid voice? That’s the first I’d heard that.

But, I guess she liked it because she got up and fixed a second after finishing the first. We took a break to cool off by going to the hardware store to buy a tool I needed for the project. It turned out to be the wrong size and she said that her Daddy did that all the time, so I didn’t feel too bad.

The afternoon session was for Project three, mowing. She was excited. We had a training session about the mower controls, safety, finding a pattern to mow in a particular space and cutting down (no pun intended) the space little by little. Little did I know what subliminal impression I provided with that phrase.

I turned her loose in an area of about 3 acres of semi flat, obstruction-less grass. I was about 50 feet away watching closely, but without her knowing it. She mowed about 10 minutes and pulled up to the shop and shut the mower down. I came out and asked what was wrong.

“I’m scared,” she said.

“Of what,” I asked?

The game was on. And game it was. Least the casual reader think that I, as some brutish old codger ogre, imparted tension in voice, language or manner, you are wrong.

She brought up a few facial expressions, body gestures and voice tones that any adult with experience with children would immediately recognize as techniques of manipulation children use on adults to get out of doing what they don’t want to do.

But, I gave her the benefit of doubt and did not want to force a child to do something of which she was truly afraid. (This, I freely admit, is the result of what our culture has forced on parents to the detriment of society.) It only took 20 minutes of this semi not-conversation to determine that the noise the mower made when the blades were turning (i.e. the wind roar of propellers) scared her, so she said. Then she said she couldn’t get a pattern in her head to mow by (meet my subliminal implant). Then, she said she was afraid of the noise it made causing her to think she had broken something (sticks or rocks being hit by the blades as she mowed). Gee, three different excuses in one shot, that ought to really convince me.

“OK,” I said. “There are a bunch of empty concrete bags in front of the barn that need to be thrown away. Roll up 4 bags and put them in the 5th until they are all done (there were about 50) and then throw them into the trash.”

“I don’t know what a concrete bag is, Grandpa,” she said.

“It’s a paper bag that is empty and says concrete on it,” I said and went back into the shop. I figured that I’d let her work by herself for awhile and I’d readdress the issue of the mower later. This girl did not have a scared demeanor, at all.

I continued with my project for about 45 minutes and then wandered down to the barn to check on her. OK, now I see a scared little girl. Distraught, pacing and pulling at her hair. She was crying. Absolutely not what I saw on the mower.

“What’s up girl,” I asked? Only one bag was lying out of the pile and was empty. No bags were in the trash. These bags were put here yesterday, they had not been laying around for ages.

After about 15 minutes of facial expressions, body gestures and voice tones that any adult with experience with children would immediately recognize as techniques of manipulation used on adults to convince them that there were monsters under the bed at bed time. I found out she was scared of spiders. I examined the pile of bags and saw spiders. Daddy long-leg spiders or cellar spiders (Pholcidae). If you don’t know, daddy long-leg spiders are harmless and have entertained children since the beginning of time as amusing fun things of nature to play with. I explained that they were harmless and to just brush them away and ignore them.

But she wasn’t buying that. She went into G-child-shut-down mode. She refused to pick up a bag. She refused to communicate by anything other than gestures, expansive comments that included “I don’t care” and “they scare me”. If you’ve ever tried to convince a 5 year old child to eat collard greens for the first time, you know what I’m talking about. She wouldn’t get within 15 feet of the pile of bags.

Improvise, adapt and overcome.

I asked, “Is it bad enough that you want to call your Mom?”

“Yes,” she said, petulantly. I dialed her Mom’s number and gave her the phone. While she was talking, I began cleaning up the bags to give her privacy. When she was finished, she returned the phone and stood there. I later found out that she only shared the spider incident with Mom.  Not a word about the mower.

“So, what did your Mom say,” I asked?

She shrugged her shoulders, twisted her right palm up and made a facial smirk while she glanced at the ground, in silence. All three times I asked. I later found out that her mother had told her to suck it up and finish the job. She wasn’t about to tell me that.

OK. On the outside, I said, “Let’s take a break and come back to this later. We’ll get a drink and cool off.” On the inside, I’m a Marine Corps Drill Instructor dressing down a recruit for a minor infraction. But realistically, I’m thinking of ways to strategize this into a victory for me. Seriously, I can’t let an 11 year 2 day old girl beat me this bad!

We have been working in conditions of 99’F 80% humidity. So, we went up to the house and got some drinks. I had a project installing new lights in a hall and started working on that. The air conditioning sure felt nice. But, every time I moved, G was right there wanting to help. I shunned her. I explained that I was perfectly capable of doing this by myself, I’d already done one by myself and I didn’t need her to help me with this one. She was over compensating and trying real hard to get involved with what I was doing in an effort to make up for the spiders and mowing-scare, but I wouldn’t let her. And that was my intent. After about 20 minutes, I stopped.

“G-girl, here is the deal. When you work for somebody, they pay you to do what they want or need you to do, not for what you want to do,” I said. There followed about 15 minutes of discussion about working for someone. At the end, I said, “Get your shoes on and lets go clean up the bags.” Why do kids always take their shoes off?

She wasn’t all too happy about going back down to the barn where the spiders were, but she did. When we got there I walked right past the pile of bags and went into the barn and started to look for something. She watched me with the curiosity of not knowing exactly what I was doing. I found a stick about the size of a broom handle, picked it up and went out to the pile of bags. Using the stick, I pulled a bag out away from the pile and proceeded to whack it violently with accompanying ninja screams, “Get out of there you nasty spiders.”

G about jumped out of her skin, and started laughing, but tried very hard to hide the laughing part.

“You scared me, Grandpa,” she said in a stern reprimanding tone.

“Like the spiders did,” I asked? With a silly grin.

Then we, and I mean we, finished picking up the bags. She used the stick and eventually got into the ninja screaming part of it. During the process, a spider crawled out of one of my bags and onto my hand. I flipped my hand to knock it off.

G pounced, “See, Grandpa, your scared of them, too.” She almost hid a grin under her accusatory face.

It happened again with the next bag I picked up. This time I left the spider on my hand and called G’s attention to it. It was just standing there, so I herded it around with my finger. G cringed, but it was obvious that I was not scared of them. We loaded the bags into the ATV and drove it up to the dumpster. I got out and immediately headed for the shop saying, “Put those in the trash and I’ll be right back.”

She did. I win. Knight takes queen, check. Another brilliant move on my part.

So, now G knows that sticks are bigger than spiders, and if you make noise you scare them off (actually, it has little if any effect on them but it feels good). Spiders are everywhere and only 2 of them are poisonous in the United States. And, that daddy long legs are not to be feared.

But, she still has to mow.

By now, it is late in the afternoon. It is cooling off a bit and there is a little breeze, making tolerable conditions in which to work. I parked the ATV in a shady area that had good view of what I wanted. It was a little patch of grass that needed mowing. About 10 minutes of mowing would knock it out. I told G to sit in the ATV and watch as I mowed just the perimeter of what I wanted her to mow. When I was finished, I told her to get on the mower and mow the inside of what I had just outlined. With sloth-like dispatch, she walked over to the mower and sat on it. And, sat on it. For about an hour I just sat there and waited patiently. We did talk, a little. When I glanced at her, she would say, “Whaaaat?” In the kids way of saying, “Why are you looking at me?”

I patiently explained that the only difference between mowing with the blades engaged and without was that the grass got cut. I explained that she couldn’t break the mower bad enough that I couldn’t fix it and that I would not be mad at her if it did break. I explained that I had looked and there were no sticks big enough to worry about mowing over. I inquired, repeatedly, as to what exactly was scaring her. I would have had more luck in talking hurricane Harvey out of hitting Houston.

Finally, after another quiet interlude of about 15 minutes, she started the mower and drove around the perimeter, stopping at the point at which she started. An extremely brief glance at me with a look of triumph on her face faltered when she looked back with a feigned look of surprise on her face. She had not engaged the blades. No grass had been cut.

I said, “Yes, that is exactly what I want you to do. You did a very good job of following the cut path. Now engage the blades and do it again.”

A textbook look of disgust appeared on her face and after another 10 minutes of silent waiting, she started the mower, engaged the blades and started forward.

Yes, I thought! Prematurely.

She mowed about 10 feet, stopped and turned off the mower. She silently refused to move. I’d had it. On the inside. I told her to go take a shower, change her clothes, no TV and pack her bags. I didn’t say we were going home, but that was what I was thinking. I figured that she was just too young and maybe we would try again in a year or so. At this point I was going to let her learn a lesson of the consequences for one’s actions, or lack of action in this case. I had a number of other projects that could have been substituted but realized that doing those instead would dilute the lesson at hand.  I finished mowing around the house before dark, which was enough for the moment.

After supper, I called G over to talk. I had thought about this a bit while mowing. Was it better to learn consequences or to succeed? G is a very smart girl. She wasn’t to young or immature to learn these things. I knew I had to find a way to get past these “fears”. But there is a limit. I counted that there had been two failed attempts at mowing so far. She deserved a third chance, at least.

“So here it is, G-girl. I’ll give you your choice. You can stay and try to mow again tomorrow, but it has to be an honest try. Or I can take you home tonight.” It was about 8:30 pm, so arriving home so late would be a real embarrassment.

“I don’t want to go home,” she said.

“So you will mow tomorrow,” I asked?

She nodded yes. I had already banned her from driving the ATV (“I don’t care”), which she had been driving for a couple of years and loved to do. No mower, no ATV. But I’d gotten the promise to mow tomorrow, so I allowed the TV. It’s all in the give and take.

Tomorrow came. We got up late and after breakfast did a few non-mowing chores in the shop and house. It gave me a little time to talk and let her know that I wasn’t mad and discuss the fears one encounters in life and how to handle them. Finally the time came. We’re going to mow.

Again, I mowed the perimeter and send G off to the mower. This is the area where she originally started yesterday but stopped. She sat on the mower for about 20 minutes. Then she got off the mower and said something I didn’t hear and began to pick up sticks. Twigs, really. Some as small as a pencil lead. Then she got on the mower and started actually mowing. She made a grand loop around what I’d outlined and when she got back to the starting point, I stopped her.

“Good job, girl. You stayed on track. You didn’t leave any skips. And, you’re still alive,” I said. Little victories mean a lot.

I sent her around again, hoping but fairly confident that the drama was over. To end a long story, she mowed for another 1 1/2 hours without any problems. By the end, she was talking technique with me. How to turn at this corner, how to back up on a hill, etc. She informed me that I didn’t need to mow the perimeter to outline what to mow, anymore. I should just tell her where to mow next.

We both cleaned up and headed for her home. She was talkative and back to her old self. No more petulant sulking. My opinion is that she was probably scared in the beginning. But once the gauntlet fell she had to keep up her position, besides it is a lot more fun driving the mower around randomly without engaged blades mowing in a boring pattern, than not.

I did ask her if next time she wanted to use her dads “push” mower instead?

“No,” she said!

Rook takes Queen, checkmate.

From your grumpy uncle Dave,

Weary