Archive for November, 2016
Two people came in an ambulance together. He was twenty-eight, she was twenty-six. They were put in the same room and had been instructed to undress and put on gowns. They both told the intake nurse they had things crawling out of their bodies. He focused mostly on his skin but she also had “things” coming out of her eyes, ears, nose, mouth and vagina.
When I entered the room, he was sitting quietly on the gurney while she was agitated and walking around the room. Usually, I start by talking to patients to find out what their symptoms and history are. Then I do an examination. It was not possible to do that in this situation because, as soon as I walked in the door, the young woman started to talk and, boy, did I get an earful! She came to me and started showing “them” to me. She had an LED flashlight and a magnifying mirror. She held the mirror up to her face, shined the flashlight onto her eyelid and said something like, “See that!”
When I asked her what I was supposed to be seeing, she gave me an exasperated look, turned the light and mirror to her lip and asked me, again, to look with her at what was crawling out. When I told her I didn’t see anything, she loudly voiced her indignation, pointed to her skin and said, “See! There it is right there! Are you telling me you don’t see anything?”
Patients with mental problems causing them to believe their skin is infested often have sores where they have been digging at themselves. They point to these sores as evidence of their disease. In this woman’s case, there was not a scratch or sore anywhere she pointed, just normal skin.
As soon as she detected that I didn’t believe she was infested, she got really upset. She started referring to others who had seen “them” and asked me what I thought the others had seen, if there was really nothing there. The most specific I could get her to be when referring to other witnesses was “the doctor at the shelter,” but she was too agitated to tell me if she had been previously seen by another doctor and what, if anything, had been done for her.
When I continued to be unconvinced she had something coming out of her various body parts, she suddenly turned her attention to her partner. She pointed to his skin, which was marked by multiple sores which looked like he had been picking at himself. He was not nearly as animated as she was but he sat there, patiently trying to help her identify things crawling out of him. He was no more successful in showing me what they were looking for than she was.
When I tried to get specifics about how long this had been going on, what these things looked like, how big they were, what color they were and where they went after they crawled out, it only made them more indignant, unhappy and agitated.
At this point, I turned to an approach I developed years ago to deal with patients who are convinced they have a problem when I am sure they don’t.
I told them I recognized that they knew they were infested with something and I acknowledged how upsetting this must be. I told them I also knew they were not infested. I told them they had a mental disorder and named it: delusional parasitosis. I said I understood that they didn’t believe me. I also told them I was firm in my opinion and they were not going to convince me otherwise. In concluding, I said something like, “So, it is time for you to leave. I will give you the telephone number for our Mental Health Urgent Care clinic as well as a number to get a Primary Care Physician in a clinic.”
I have found that this sort of firmness is necessary because truly delusional people can’t be convinced. The more you try to get them to see logic, the more they get upset that they are not convincing you. I just have to tell them I am sorry, recommend they get psychiatric follow up and send them out, almost always upset and unhappy with me.
In this case, things just went from bad to worse when I followed this time-tested approach. The woman got even more agitated. She paced around the room, hollering about the lack of care they were being provided. She demanded to see my boss and the head of the hospital so something could be done. She was so agitated that the nurses called security and soon there were three uniformed officers outside the room. It got so bad that a Sherriff’s officer, there with a prisoner from the county jail, came to the room to see what was going on.
My two patients refused to get dressed. Refused to leave. Refused to take their discharge papers. They said they were not going anywhere until something was done for them. Finally, after the Sherriff threatened to arrest them, they got dressed and stomped out, the woman hollering and cursing.
Over the years, I have seen many cases of delusional parasitosis and its companion condition called Morgellon’s Disease, where people think they have fibers coming out of their skin. Each case has been a little different. Some patients are calm and, in every other way, reasonable. They talk logically of their complaints. They are pleasant in taking recommendations to follow up with their doctor but they remain convinced they are infested. On the other end of the spectrum, some patients act truly crazy, as with the woman described above.
Sometimes people connect their infestation to their environment. I once saw a man who was certain something was crawling out of a mat he had to stand on at work. No matter how many times the mat was changed and the area cleaned, as soon as he went back to work, he got them again.
I had a patient who was sure she was infested with bedbugs. No matter how I tried to help her understand that bedbugs just crawl out of your bedding at night, suck your blood and then crawl back to the bedding to wait for another night, she was sure she had bedbugs under her skin. She could not be convinced otherwise.
Another time, I saw a twenty-five-year-old woman who was convinced she had lice in her hair. The fact that no lice or nits could be produced had no effect on her beliefs. She had been treated multiple times for lice and, yet, she was sure they persisted. She constantly dug at her hair with a pencil until she had a huge ball of tangled hair on the back of her head. Even as she talked with me, she dug and dug in her hair, trying to get a bug out to show me.
Once, I had a couple come in wanting papers they could use to force their landlord to do something about the bug infestations they had from their apartment. Their place had been fumigated multiple times and the landlord and pest people told them there were no bugs. My patients were unable to provide a bug as evidence. Yet, they wanted a doctor’s note saying they were, indeed, infested so they could force the landlord to do something about it. When two people are equally involved in a delusion, it is called folie a deux.
I have seen many patients with delusions over the years. This case was amazing for two reasons. It was a fascinating case of folie a deux. Also the woman had absolutely the worst case of delusional parasitosis I have ever seen. She had things coming out of every part of her body. She was agitated and aggressive. She was threatening and refused to put her clothes on and leave when she was dismissed. It is an amazing example of how your brain can play really nasty tricks on you.
If you are interested, read more at my favorite medical reference: https://en.wikipedia.org/wiki/Delusional_parasitosis
Alex was the head cook when I was the baker at our church’s girls’ summer camp. This recipe came from him. Easy to make and a good way to dispose of left over M&Ms from Halloween!
2 1/2 cups flour
1 teaspoon baking soda
1/2 teaspoon salt
1 cup butter
1/2 cup sugar
3/4 cup brown sugar
2 teaspoons vanilla
2 cups M&Ms or chocolate chips
1. Heat oven to 375 degrees.
2. Mix flour, baking soda and salt. Set aside.
3. Cream butter and sugars together until light and fluffy.
4. Add vanilla and egg. Beat well.
5. Add dry ingredients to creamed mixture. Mix well. Stir in M&Ms.
6. Bake 10-12 minutes until edges and bottoms just browning. Don’t over-bake!
The other night, an overhead announcement in the emergency department caught my attention: “Dr. Tad to Room 11, STAT! Dr. Tad to Room 11, STAT!” Since I know my staff would not call me like this unless there was a real reason, I dropped everything and hustled to Room 11.
I got there just as the patient was being moved from a wheelchair onto the bed. I made my way through the crowd of staff filling the room, everyone hurrying to take her clothes off, get vital signs, put her on a heart monitor and start an IV.
When I got to the bedside, I saw a young woman who looked dead. She was pale as a sheet. She was unconscious and not breathing or moving. I could not feel a pulse.
I barked orders to make sure someone was doing each of the many things that needed to be done at once. In situations like this, we use the pneumonic “ABC” to prioritize our actions. “A” is for Airway. Before figuring out what her underlying medical problem was, we first took steps to protect and keep her airway open. I told the respiratory therapist to prepare to intubate her, pass a tube into her windpipe.
After Airway comes “B” for Breathing. Once the airway was open and protected, we would check to see if the patient was breathing well. If not, we would need to breathe for her by putting her on a ventilator.
“C” is for Circulation. Does she have a pulse? What is her blood pressure? Is she bleeding? What needs to be done so that blood is getting to her vital organs?
In Room 11 that night, I soon was able to stop worrying about “A” and “B” because, once she was out of the wheelchair and flat on the gurney, enough blood got to her head that she woke up. She started to complain of pain and asked for water. Airway and Breathing were good.
It was now obvious that Circulation was her problem. Along with the pallor I already described, her blood pressure was low and her pulse was fast. These are all signs of hemorrhagic shock. Since she was not bleeding on the outside, my assumption was that she was bleeding internally. I took a quick listen to her heart and lungs. I felt her abdomen, which was tender and distended. More orders were given in response to this new information.
As the rest of the team pressed to get IVs started and get blood work for the laboratory, I turned to find out who had brought her in. I went into the hall and found her concerned husband, a young Vietnamese man. His English was weak, but there was no time for a translator. I was able to learn that she had been complaining of abdominal pain and might be pregnant.
As soon as I heard that, I instructed a clerk to call the obstetricians and tell them to come to Room 11 immediately. I then ran an ultrasound probe over the patient’s belly and found just what I was expecting. Her abdomen was full of blood.
I called for Type O-negative blood to be rushed up from the blood bank so a transfusion could be started. This blood can be safely given to anyone if there is not time to check the patient’s blood type. The blood bank keeps some available for just this kind of situation.
About this time, the obstetricians came rushing into the room. I quickly told them what I had found and what we were doing. One stayed to help with the resuscitation and to try to get more information from the husband. The other called the operating room to say they were bringing the patient straight up.
The pregnancy test came back positive just as they pulled her gurney out of the room, headed for the operating room. There, they found her abdomen full of blood from a ruptured ectopic pregnancy.* She had a rough go of it but they were able to stabilize her by stopping the bleeding and giving her more fluids and blood. She left the hospital a few days later. She had a scar on her abdomen and was missing the fallopian tube in which the pregnancy had established itself. Otherwise, she was no worse for wear.
Reviewing this case fills me with gratitude. This lady was dying. It makes me glad I knew what was needed to keep that from happening. It also makes me glad we have the facilities to provide the care she needed. In times gone by and in many places in the world today, if this happened to a woman, she would be dead. I am really appreciative of my team. They did just what was needed when a life was on the line. I am also grateful for good luck. If the patient and her husband had delayed in coming to the hospital or gotten stuck in traffic or lost, we might not have had the chance to give her the services we trained hard to provide.
*If you are interested in reading more about ectopic pregnancy, here is a reference frpm my favorite medical resource: https://en.wikipedia.org/wiki/Ectopic_pregnancy
This recipe was forwarded to me by Eli, a nurse in our emergency department. Even though I chilled the dough all day, it was too soft to be able to seal it around the filling and roll into a ball. I had to scoop balls of dough onto a plate covered in plastic wrap. I then covered the balls with another sheet of plastic wrap, flattened them, then put them in the freezer until they were stiff enough to handle. It complicated the process a lot but people really liked them in the emergency department.
3¾ cups all-purpose flour
1½ teaspoon baking powder
½ teaspoon salt
½ teaspoon ground cinnamon
¼ teaspoon freshly-ground ground nutmeg
1 cup unsalted butter, at room temperature
1 cup granulated sugar
½ cup light brown sugar
¾ cup pumpkin puree
1 large egg
2 teaspoon vanilla extract
8 ounces cream cheese, softened
¼ cup sugar
2 teaspoons vanilla extract
½ cup granulated sugar
1 teaspoon ground cinnamon
½ teaspoon ground ginger
Dash of allspice
1. In a medium bowl, whisk together flour, baking powder, salt, cinnamon, and nutmeg. Set aside.
2. In a stand mixer with a paddle attachment, beat together butter and sugars on medium high speed until fluffy.
3. Blend in pumpkin puree, egg and vanilla.
4. Slowly add dry ingredients on low speed just until combined. Cover and chill dough for an hour.
5. To make the cream cheese filling, blend cream cheese, sugar and vanilla together. Chill for an hour.
6. Heat oven to 350 and line your baking sheets with parchment paper.
7. In a small bowl, combine the sugar and spices for the coating and set aside.
8. To make the cookies, take a tablespoon of the cookie dough. Flatten it like a pancake and place a teaspoon of the cream cheese in center.
9. Form another tablespoon of the cookie batter into a flat pancake shape and place on top of the cream cheese. Pinch the edges together sealing in the cream cheese and roll into a ball. Roll in the cinnamon sugar coating and place on the prepared baking sheet 2 inches apart.
10. Repeat until the dough is gone and flatten the cookie dough balls with a heavy bottomed glass or measuring cup.
8. Bake the cookies for 10-15 minutes or until the tops start to crack. Let cool on the baking sheet for 5 minutes and transfer to a wire rack.