Making Things Up

P4_MakingThingsUp_title

Starting clerkships is like starting the Appalachian trail. You are truly optimistic about the survival gear you can fit in the gaping pockets of your white coat: almonds, clipboards, pens, reflex hammer, penlight, and stethoscope. When your shoulders hurt from the weight as you hike from patient room to patient room, you get rid of things until you are left with only sustenance (almonds), phone (other sustenance), and a small pad and pen.

Still, somehow, my coat balloons, bumping into people around me. It still feels heavy. Maybe I am nervous.

In my white coat, I go to see Ms. M., a 57-year-old woman who had her gallbladder removed a few weeks ago. She came to our hospital green in the face, her mouth settled into a thin hard line from pain.

“Bile leak?” my resident wrote as we rounded on her at 6 AM. Usually patients are sleeping, but she was wide awake, sitting with her sister, looking grim at the thought of another surgery.

She wasn’t friendly to our team of residents and medical students. We moved like a pack from room to room, two of us examining patients while others watched and wrote silently, like a hospital inspection team.

I always threw a smile at the patient on the way out, but I felt generally useless. When a patient wasn’t friendly, it made sense to me—who wants to face a crowd early in the morning while in pain? But when a patient wasn’t friendly, I could tell the team didn’t like it. When Ms. M wasn’t friendly, asking repeatedly how long she would stay in the hospital after surgery, my resident wondered aloud, as we left, striding down the hallway in our phalanx of white coats, “another Munchausen patient?”

Munchausen syndrome is a psychiatric “factitious” disorder where patients feign disease for attention, sympathy, or reassurance. Its incidence in clinical settings is about 1%. A physician first described it in 1951 in The Lancet,naming it for Baron Munchausen, a character in German literature known for telling tall tales. Patients with Munchausen syndrome make up untraceable symptoms like pain.

When I scrubbed in for Ms. M’s surgery, I assumed it was clear that she wasn’t making it up. We made four tiny incisions, three for instruments and one for a camera, using the scars of a previous operation’s incisions as our guide. We saw deep green fluid on camera in recesses between the liver and abdominal wall, buried in loops of bowel. We irrigated and suctioned fluid for what felt like 15 minutes. We searched for the source of the leak and cauterized it shut.  The attending said, to no one in particular, “If I had done this operation, it never would have leaked like this.” 

Abdominal Cavity_Hannah Singer“Abdominal Cavity” by Hannah Singer, MD

When I saw Ms. M later that day after she had woken up from anesthesia, I remembered the green fluid swirling around her distended abdomen getting suctioned into our clear plastic tube like strange juice of a million cartoon limes. Her skin looked sort of green, or maybe that was still the bile, dancing in my imagination. Her sister was there and they looked at me with skepticism pulling down the corners of their mouths and eyes.

I coughed by way of introduction, an awkward habit I have developed. I made a mental note to stop doing that and crouched by her bed. I left to put hand sanitizer on my palms—I forgot!—and came back again to crouch. Something about my awkwardness softened her. She smiled.

“How’s your pain?” I asked.

“Pretty, pretty bad,” she mumbled.  It was hard for her to sit up— pain and nausea overwhelmed her.

“Do you have a headache? Chest pain? Shortness of breath? How would you rate the pain from one to ten? Are you walking? Have you urinated yet?” I asked, as I checked her abdomen with my gloved hands as she winced a bit.

She looked stressed. I asked what she did for work. She told me she worked part-time with no benefits. She’d been out enough days to lose her job if she didn’t go home tomorrow. She wanted to go home tomorrow.

“I will report back to the team,” I said.

I returned to my team meeting to give the update. When I got to her, as soon as I said her name, someone rolled his eyes.

“Oh yes, our Munchausen patient,” someone said.

I pretended I didn’t hear and presented the update. Somehow, I felt the room was itching for me to finish. Finally, I got to my last piece of information—“She would love to go home tomorrow if possible. She is worried about losing her job and tomorrow is the last day before they fire her.”

I felt sad but strangely triumphant delivering the last line. If anything were to prove she wasn’t making up her pain, wouldn’t it be this?

“I’m sure she ‘wants to go home,’” someone says, drawing air quotation marks. “Munchausen,” he chuckled, shaking his head.

I looked down at my pages of notes painstakingly elaborating the exact trajectory and nature of Ms. M’s pain, what made it better or worse, where it radiated. I told myself that I am not the expert—they are the ones who know who to believe. They have had countless patient encounters. Maybe it is just one more thing I have to learn.

Ms. M was discharged two days later while I was home over the weekend. On my last day of the rotation, two weeks later, I got a message, “Ms. M, s/p bile leak here for excruciating pain and possible abdominal infection.”

I could not believe it and yet I could. I read the text over and over.

I saw the ellipsis on my iPhone as someone on our team formed a response. I imagined they would express regret for doubting her. I was speechless as I read, “Oh no, not her again. Munchausen!”

We saw Ms. M, our whole team. She was tired and afraid, but when she saw me, she smiled. I wanted to ask her if she lost her job, but there was a ball in my throat. She said, “See you tomorrow” as we all traipsed out of her room. I knew I wouldn’t see her again since I’d be on another rotation, but I hoped she got home soon.

I wonder if it’s sometimes easier to call it Munchausen than to deal with a problem that’s difficult to solve.

Vidya Viswanathan is a third year medical student at the Perelman School of Medicine of the University of Pennsylvania and the founder and president of Doctors Who Create, an organization promoting a culture of creativity in medicine.

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