Wednesday, April 8, 2015

Shaken, Not Stirred

A long time ago, in an ER far, far away. I wrote a post about pseudoseizures, or seizures that are faked. Of course, because nobody does anything intentionally anymore, and everything is the fault of someone or something else (see "fibromyalgia"), we now call then Psychogenic Non-Epileptogenic Seizures (PNES seizures...and that's exactly how it's pronounced, much to the glee of our prehospital crews who get to report this finding over the airwaves).  I often make fun of patients with pseudoseizures, and often rightfully so.  Some of them are so badly done that you can't help but laugh, especially when the sound of your merriment makes them open their eyes and then turn away when they see you staring and pointing from a disrespectful distance.  (Pro tip:  No flopping.)  But if I'm being honest, there's also a part of me that has a sneaking admiration for one done right.  I can't even figure out how to shake it, bake it and make it bounce, let alone coordinate a rhythmic tremor of all extremities coupled with some raspy breathing and suppressing any response to pain.  So for those brave souls willing to undergo getting stuck by multiple needles simply for a whiff of rectal valium...well, in my own way I salute you.  If you're a worthy opponent, I don't mind being beaten at the game.  

(I'm not beaten often, but I do commend a guy several years ago who came in with flank pain.  He gave me the perfect, Wikipedia-referenced story for a kidney stone.  But not only was he complaining of the right pain at the right time in the right place, but writhing in the most convincing fashion and even managing to get some blood in his urine (I know how they do that) and to break out in a cold, pale sweat (that one's still beyond me).  He got two doses of Dialudid, a strong narcotic that's about as good as we got.  He felt better, his pain went way...and his workup was totally negative. No kidney infection, no kidney stone, no tear in a major artery causing his blood to pool in his abdomen.  Only a request for a note before he went home saying we had given him narcotics in the ER to give to his probation officer the next day before his scheduled drug test.  Well played.)  

This particular time, however, I'm not so convinced about this woman in her early twenties.  Neither are the paramedics, who have correctly diagnosed a PNES seizure over the radio, prompting multiple guffaws from everyone except the nursing student who couldn't figure out how a female could have such a thing.

When she arrives, her eyes are closed and she's shaking all of her arms and legs.  A bit off in tempo, one arm slightly more rapid than the other, but a fair effort. (At least there's no flopping.)  The closed eyes means I can't do Seizure Detective Trick #1,which is something I call the Stooges Maneuver.  You spread you index and middle finger apart like a fork and jab them towards someone's eyes.  If they blink, the seizure is fake.  (This is also how you tell if someone who claims to be blind can actually see).  The maneuver is enhanced if you say "Nyuk Nyuk Nyuk" during the process.

Now we go to Seizure Detective Trick #2:  The Hand in the Face. In essence, if I hold your hand about your face and let it drop, the awake person will reflexively move their hand to avoid it falling onto the face.  The truly unconscious person will let it fall.  

I lift her right hand and place it a foot and a half above her nose.  Holding her lightly by the wrist, I let go.  

The hand stays above the face, for a moment, then gradually arcs downward to lay on her shoulder.  

It's not real, but she made a valiant try, so there's no reason to be rude about it.  I bend down and whisper to her, as if we're sharing a confidence.  "You know, you're not really having a seizure.  It's okay to stop."  

She opens her eyes, staring straight ahead.  

"I c-c-c-c-c-c-can't."

I give her shoulder a pat.  "No, I think you c-c-c-c-c-c-can." 

With one last intense shudder, it does.  Norman Vincent Peale, meet the PNES.

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