M. P. Ravindra Nathan

Sometimes, you are fooled by a patient. This was one such instance when I learned a lesson.

When the Emergency Room (ER) woke me up at 3 a.m. to evaluate a patient with severe chest pain, I knew I would have to make a trip to the hospital. Clark Mason (not his real name) was a 50-year-old male with a prior history of coronary bypass surgery (CABG). He was traveling from Georgia to Fort Myers and, when he reached Brooksville, experienced severe chest pain and pulled into the emergency room. The EKG faxed to my home showed a minor abnormality called left bundle branch block and was not much help.

In the ER, Clark was indeed in agony; the first dose of morphine clearly didn�t give him relief. He had poor venous access and hence I decided to insert a central line through a neck vein (CVP). When I was looking for sites, I suddenly found that he already had an infusaport (a semi permanent CVP) in the left subclavian region. That was surprising since such access ports are usually reserved for cancer chemotherapy or parenteral nutrition in chronic illnesses. And he certainly didn�t look like he seem to be suffering from any conditions that I know of, needing an infusaport.

"What is this for?" I asked in surprise.

"Oh, you know I have very difficult veins. After the bypass surgery, they put one in so that I can have medicines in an emergency." He sounded a bit apologetic, that he was giving us so much trouble at this hour.

"That is funny; insert a permanent line for venous access in an otherwise healthy man." I mumbled to myself. "Are you sure that you don't have any other problems?�

"No sir, I don't have any other problems. Just a lot of scars from old war injuries," his voice broke. I found that the infusaport wasn't working either and my attempt to cannulate right subclavian vein was unsuccessful. So, I wound up putting one in the thigh (femoral vein) and started the whole works with IV nitro, morphine, beta blockers, blood thinners, etc., the way you would treat somebody with a possible heart attack.

After the second morphine, he appeared to settle down and thanked me profusely. I thought he would oblige me with some answers now.

"So, where did you have the surgery?"

"In that big hospital down by the water in Seattle."

"You don't remember the name of the hospital, Clark?"

"How can I remember all these details? It was five years ago!"

"Do you remember the name of the surgeon?"

"Right now, I am very tired and in pain." He didn't think that my question was pertinent.

"That is funny; you had a major heart surgery and you don't know the name of the hospital nor the surgeon." To this, he responded by starting to roll again in pain and contorting his face into a big grimace. He asked for more morphine and received a second dose in fewer than 10 minutes.

I was beginning to feel that there was something strange about Clark. He was alternatively convincing and sort of �faking.� I didn�t even want to entertain the possibility of malingering since not treating a heart attack can have disastrous consequences.

"Tell me who do you live with. I want to let them know that you are here." He said that he lived with his elderly mother in Clearwater and didn't want to let her know. Why? Because the news of him being in the hospital would kill her! Other stories emerged soon. He was divorced and has two children with his ex-wife. He was visiting his girlfriend in Georgia with whom he has three children now � 2, 5 and 8 years old. He didn't want us to call them either. But to the nurse, he said that he had altogether seven children. He wouldn't give any telephone number of anybody and wouldn't show even the license in his wallet! I couldn't quite understand such secrecy! Things didn�t quite add up with this gentleman.

In the ICU, it was more of the same, constant pain and demands for more morphine. But the EKGs remained the same and cardiac enzymes (usually elevated in acute heart attacks) were normal. He even suggested to the nurse that we put him on a PCA pump for continuous intravenous infusion of morphine!

"I need to talk to your mother. Can you give me her phone number?" I asked again.

"I don't want you to bother her."

"Why this secrecy, may I ask?"

He appeared to be visibly upset. Later, the nurse called me aside and said that he wanted some injection all the time and asked for more morphine. His stories were inconsistent. The social worker came in later and tried to break his code of secrecy in vain. Gossips started floating around the ICU. One nurse even hinted that he could have a shady past.

"How do we know if he is not a criminal? He even has that looks," one nurse suggested.

"Oh, I didn't know that they came with special looks!" I said trying to lighten the situation.

I told him the ideal thing would be to take him to the heart catheterization lab and study him. After an initial protest, he gave the consent. but immediately wanted more morphine in exchange. After the morphine shot, I asked him again:

"We need to know the surgical details and hook up of the grafts before we can do another cath. Tell me the name of your previous hospital." He became upset.

"Give me my clothes." He demanded.

"Where are you going?" Actually, I wanted to ask him if he was going hospital shopping.

"You don't believe me, do you? You think that I am some kind of a phony, right?"

He had already worked himself into an angry mood, so I refrained from making any remark except advising why he shouldn�t discharge himself against medical advice. But ignoring that, he got up, dressed himself and walked out of the ICU. He clearly knew that we were on to his case. There was not even an inkling of pain on his face! I immediately asked the ER physician to call the other emergency rooms in the area to warn them about our patient.

What is my final diagnosis? Munchausen Syndrome? Mr. Malingerer? Or just plain Mr. Junkie? Although I couldn�t be certain, most likely he belonged to the first category.

The term Munchausen Syndrome is named after an 18th century German, popularly known as Baron von Munchausen. A soldier who served in the Russian army against the Turks, he was notorious for telling boastful but entertaining stories, entirely made up. The term is used in medicine to describe a group of patients who repeatedly seek medical attention and often hospitalization by simulating symptoms of serious illnesses. In other words, they have factitious symptoms that are dramatized and exaggerated. Some even undergo repeated abdominal surgeries, willingly!

There have been recorded cases of �International Munchausens� � patients who flee from one country to another to escape detection of their true illness. I came across one while working in West Middlesex Hospital in London, when the patient was admitted with chest pain and turned out that the same guy has not only exhausted several other London hospitals but also recently hospitalized in New York for the same condition. A description of that patient (which fitted our patient well) appeared in New England Journal of Medicine with a warning to look out for him in case he appeared in an ER. Another interesting variant of this condition is �Munchausen by proxy,� which are disorders in children produced by parents or other caregivers � to make the child appear sick and ensure treatment. One such case occurred in Miami and received a lot of media attention a few years ago.

Every physician will come across these enigmatic cases periodically.

Cardiologist Dr. M. P. Ravindra Nathan, director of Hernando Heart Clinic in Brooksville and editor-in-chief of the AAPI Journal, lives in Brooksville.