No, I’m not talking about bloggers who think their party has the corner on brains and answers, I’m talking about those few patients who arrive to the ED with a Chief Complaint that’s not real. Oh, it’s real to them, just not in reality.
Every EM doc has had these patients, and they can be imminently frustrating to deal with, which is why I now don’t. Allow me to explain with a few heavily-sanitized for-their-protection encounters I’ve had:
- Patient comes in wanting me to remove the device planted in their head by the CIA. Normal exam, not a danger to self or others, but has fixed belief there’s an implanted device (fixed delusion). After a thorough exam, I offered an X-ray of the skull to demonstrate that there wasn’t anything foreign in there. “Oh, they don’t show up on X-ray” was the response, and this is the crux of the problem trying to deal with these patients: they don’t want to be told the truth, they want their belief to be validated, real or not, sensible or not.
- Patient presents with CC ‘all my organs have been removed’. When queried as to how they’d be alive with no organs, answers ‘they put someone else’s’ in’. After exam showing no signs of drug or alcohol abuse, and notable for none but trivial scars of living, I pointed out that I’ve seen lots of patients with organ transplants, and they have rather remarkable scars, but you don’t. ‘They replaced my skin after’ was the response. There’s always an answer that refutes rationality.
- Patient presents with complaint of a foreign body in their nose, for 5 weeks, and there’s nothing there. ‘No, it’s right there’, pushes on completely normal area of nose. Examined 3 times for patient’s benefit, and no amount of reassurance can convince them it’s not there.
- Delusional parasitosis is probably the most common of them, but it’s harder to determine there’s not an actual cause initially, especially as they’ve usually scratched themselves into cellulitis by the time they’re seen.
These patients aren’t dangerous, not suicidal, and no amount of ED intervention will fix their problem. I have finally learned not to spend a ton of time with attempts at reason, as the human brain has a remarkable ability to explain away rationality to believe whatever they want. Though tempting, I won’t try a “got it out” ploy as a) it’s unethical and b) they’re delusional, not stupid, and lying will just make the problem worse. They lack the insight to question their self-diagnosis, so psych referral is not just dismissed but is a really good way to get them to go from disappointed to angry in about two seconds.
After two thorough attempts to explain the absence of actual physical confirmation of their complaint, I then refer them to their PCP for further evaluation, and that’s it. It’s disappointing for the patient, and for me, but there’s a limit to what I can fix in the ED.