The fake out or not. Can you tell for sure?

[spenac]

Ok on a post that got locked Kaisu wrote

seriously tho.. there are disassociative disorders that give the appearance of faking when in fact the patient is not capable of responding - for example, eyelids will flicker, reflexive responsives will be atypical yet the patient cannot open eyes or respond to questions. Often, they will be unresponsive to pain - the patient feels it but has disassociated from it to the extent that they would NOT be able to protect their nose. It behooves us to remember that just because we don't understand it doesn't mean its not real.

This was in response to my hand drop over the face breaking patient nose comment. First let me say I have never had a patient break their nose, for that matter their hand has never even touched their nose. Why because it is only used on those that are truly faking and yes before going to it I was 100% sure it was not a disassociative disorder of any type.

But I think it would be wise to discuss what Kaisu brought up because it is truth. Have you ever had a patient as described by Kaisu you suspect faking but just not quite 100% sure? What finally tipped you off they were not faking? What subtle differences do you find between the fakers and those that are disassociative?

[Michael]

Some relevant discussion here.

[mobey]

Hmmm, this may not fit the mold but it may be worth mentioning,

I had a 52 y/o female that was following commands such as "squeeze my fingers" and "wiggle your toes", but she would not open her eyes or speak.

She had deep non-laboured resps, and was slightly hypertensive, and drooling like crazy.

I thought for sure she was being stubborn - looking for attention.

But as the call went on she never moved her face at all. I was finally convinced when her head flipped forward and she began snoring and waving her arms frantically. Yup her face and neck muscles were paralized.

I really became a believer when the Doc told me of the big CVA on the CT.

I really did not think this was possible. There was no droop or unilateral paralisis or weakness!!

[spenac]

Well darn you spenac will you ever learn to use the search button? Worthless excuse of a 3 poster taxi driver want a be.

[akflightmedic]

I will share this story as it is an important teaching tool.

In my career, I have always been quick to recognize the fakers due to the obvious signs that we all are aware of. However, this one time, I had a patient demonstrating all the faking signs, eyelids flickering, arm drop, the guy twisted his head with the NPA insertion, yet after another attempt, he then allowed it after I verbally accused him of faking. His eyelids were fluttering, he would move his fingers and arms with purposeful movement, yet "pretend" to be unresponsive.

Also, not that it should make a difference in my clinical judgement, I did allow it to influence me. He was from a very depressed socio economic area, in an apartment complex known for its very low subsidized rent along with all the other typical problems that are present in that type of area.

So, I placed him on the stretcher and moved him to the truck. I did typical ALS stuff, IV, O2, Monitor and transport. I did not waste a lot of "my time" giving this guy the assessment he deserved as I was 100% positive he was faking. I handed him off to the ER and relayed my thoughts on this patient.

Due to my reputation, the receiving nurse allowed me to tunnel vision her down the same line of thinking. She quickly assumed and supported my opinion. When I spoke to the doctor and gave my report to him as well, he also said good job and I will get to the guy in a few.

I left and when I returned to the ER about 2 hours later, as I wheeled my current pt by the bed of this previous patient, imagine my surprise to see the guy on a ventilator!! After I handed over care I went to inquire about the patient and learned that he had a massive intracranial bleed.

I felt like the biggest ass on the planet.

Moral of the story: Regardless of you presuming them to be faking or not, give a thorough assessment to the best of your abillity, cause you just never know...

[fireflymedic]

AK - I had a similar experience early on in my career where my partner handed me a note saying "she just wants attention" to a little old lady who just said she felt bad. We ran on her all the time. Well, I was the sparky eyed new basic so I still did the O2, gave a decent assessment. Got her to ER and doc later revealed she had massive MI. Lady died two days later. Was a hard lesson learned that the faker one day may be for real.

The faker may be a pain in the neck and time consuming, but sometimes there is a reason behind it. Had a lady that used to fake seizures so her husband would stop beating her and called 911. Was her way to escape the situation. Best coping method? No, but I could understand where she was coming from. Also, don't forget those fun things called atypical presentations. Not every patient reads the textbook, so sometimes you see weird stuff, but it's okay, we live, we learn, and we go out on another call the wiser for it hopefully. It's only when we think we know it all and stop learning that we get ourselves in trouble. Be safe

Fire_911medic

[Just Plain Ruff]

I'll also relate a Feel like an ass moment

Had a 31 year old female from an accident(MVA)

She was c/o hip pain only. She was also a very needy patient and was whimpering a lot so I sort of wrote her off as one who was not so hurt.

I did not give her the evaluation that I have always been proud of and we got her to the ER.

She laid on a board for over 2 hours while the others from her wreck(three fatalities in the 2nd car) She was very stoic and didn't really talk much.

About an hour after she got off the board her pressure bottomed out, she went unresponsive and coded.

It turns out that this patient had one of her arteries in the pelvis lacerated and she was slowly bleeding out. She finally decompensated enough to crash. We never got her back.

She was actually the 5th fatality from that wreck. One of the worst I've ever worked.

[Kaisu]

Great posts people and thank you spenac for reopening the issue. You all make me proud of my profession.

[spenac]

Great posts people and thank you spenac for reopening the issue. You all make me proud of my profession.

Thank you. It is an important subject. To many times those of us that joke forget that some do not realize or perhaps even know not all is as it appears. Thank you more experienced members for the real life examples of that.

[AnthonyM83]

Wow, great topic! One I've been wanting to discuss.

Could someone link me to the previous thread referenced in this thread's original post (I've been away for a bit).?

We get a LOT of these calls in the area I work in.

A lot of them are fakers, but I feel some of them are actually legit. Sure it might all be psychological...but they're not actually "faking".

Last week had a lady at the courthouse, who collapsed when her son received his sentence. She had eyes open, blank stair, no verbal, no response to any pain, but did have eyelid flutter when touched. 30 min later at hospital, her head twitched, blinked her eyes, and snapped out of it. Had no idea where she was, thought she was still at courthouse, very sad/depressed worried for her son.

I never quite know how to describe such stuff to the nurse. I used "catatonic-like" once and she went off on how that wasn't catatonic. . . I asked her for a better word and she had none. :-/