Angels on the Night Shift (10 page)

She calmly repeated what she had told Jeff in triage, then asked me what I thought was happening to her.

“Where did you have dinner?” I questioned her.

“Captain’s Quarters,” she answered, naming a chain seafood restaurant on Cherry Road. “We go there every once in a while but have never had any problems. And I’m not allergic to anything, no shellfish or stuff like that.”

“Do you remember what you had?” I persisted, beginning to think this might be the answer.

“Sure,” she said without hesitation. “I had the special—grilled mahi-mahi. But I’ve had that before, and I’ve always been fine. Why? Could that have caused this?”

“Maybe,” I told her. “Do you remember how it tasted? Was there something different about it?”

“No, not different,” she answered, putting her index finger on the side of her face, thinking hard. “It was blackened this time, and pretty spicy. But not different.”

That was it. I had been down this path myself once. Some blackened tuna from one of the local restaurants had done me in. The peppery flavor should have tipped me off, but I had been hungry and in a hurry, and had eaten the whole serving. Within twenty minutes, I was lighting up like a Christmas tree.

It’s called scombroid poisoning, and it happens often enough that not only had I had it myself, but I had seen several cases of it in the ER. It’s caused by a bacterium that forms a toxin on improperly prepared and stored fish. The toxin resembles histamine, thus the allergic-type reaction we see. The extent of the reaction and flushing is dose-dependent, and by the looks of Dakota, she had gotten a pretty good dose. Just like me.

“We’re going to give you some Benadryl,” I told her. “And if it’s what I think it is, you should be a lot better in fifteen or twenty minutes.”

Jeff walked out of room 5, having given Dakota her injection of Benadryl fifteen minutes earlier.

“She’s doing great, Doc,” he said, walking over to where I stood. “Almost back to normal and ready to go home.”

I had explained the poisoning to Jeff and Susan and told them the young college student should do fine, with no further problems. I was about to tell them about my personal experience with this, when I suddenly remembered the rest of the story. At the time, I had looked up the condition in a medical textbook to make sure I wasn’t going to die. It sounded straightforward until I came upon a very troubling statement.

One to two hours after the onset of symptoms, the patient will develop abdominal cramps and profuse diarrhea.

It had been uncanny. As I had closed the book, my stomach had begun to rumble, and then—

“Hello, nurse?”

It was Dakota Flanders, peering out from behind the curtain of room 5, her voice sounding strained.

“Is there a bathroom nearby?”

3:05 a.m.—the witching hour.
We had made it to the time of night when anything might come through those ambulance doors or through triage. Clara Adams had been right the other day when she had said the patients who came to the ER in the middle of the night could be very “interesting.”

Jeff had discharged our only remaining patient and we were sitting at the nurses’ station with Susan. The buzzer from the business office fired off, indicating there was a new patient out front.

Having just sat down, Jeff grumbled something unintelligible, pushed back his chair, got up, and ambled out to triage.

A few minutes later, the door to triage opened and he walked back into the department leading Lucinda Banks. When I saw who it was, my heart sank.

Lucinda was a fifty-year-old accountant, and this morning she was dressed as usual, wearing a neatly tailored business suit and high heels. Jeff rolled his eyes at me as they passed the counter and headed toward room 4. Lucinda’s eyes remained intently focused on the back of her nurse’s head.

Lucinda Banks would have made Baron Munchhausen proud. Of course, he should be proud of
himself
. After all, how many people had a “syndrome” named after them? Munchausen’s Syndrome (somebody dropped one of the H’s over the past century or so) describes those individuals who make up fantastic, exotic, and totally untrue stories about themselves. In the baron’s case, he was apparently trying to impress his friends and acquaintances with tales of daring and adventure. With those suffering from the syndrome, the intent is totally different. Their goal is to convince their health-care giver that they have a significant and sometimes life-threatening illness, their ultimate objective being admission to the hospital.

Early in my career, I just didn’t believe this syndrome really existed. It seemed too far-fetched. These individuals were apparently willing to undergo all manner of testing, poking, and prodding—at times quite painful—just to be believed and admitted. It just didn’t make any sense to me, and I couldn’t comprehend it. I was convinced it was an illness concocted for a magazine article or a TV show—until I met Lucinda.

The first time I had met her had been in the ER about two years ago. She had come in during the middle of the night, just like tonight, and complained of shortness of breath. The triage nurse was concerned enough to put her in the cardiac room and then immediately came to find me.

Lucinda was complaining of right-sided chest pain, shortness of breath, right calf pain, and an episode of nearly blacking out. Her vital signs had all been stable, her oxygen saturation was normal, and clinically she looked fine. The problem was that all of her symptoms pointed to her having a pulmonary embolus—a blood clot in her lung. She was a classic presentation. Her reaction to this news was a little peculiar, though. She had almost smiled when I told her and seemed almost happy I had come to this conclusion. I explained that we would need to do some further testing, including a blood gas, which was a painful procedure. It involves a needle puncture of the radial artery at the wrist, and then aspiration of a small amount of arterial blood. It hurts, and it’s not anything I would want to have done unless absolutely necessary. But it was part of the workup for Lucinda and would provide additional support for this diagnosis.

She would also need a lung scan, as well as additional blood work and an ultrasound of her right leg.

“Sounds like I’ll need to be in the hospital,” she had remarked, strangely calm and seeming to be almost relieved at this turn of events. This was a life-threatening problem, and I had done my best to explain the seriousness of her condition to her. Maybe I wasn’t communicating very well.

A couple of hours later, I had the results of all of her studies in front of me. Everything was completely normal. Now what?

As I explained these findings to her, her face seemed to cloud over, and she became a little agitated. I had expected her to be happy that things were pointing away from an embolus.

“Oooh!” she began moaning, clutching her right chest. “I can’t breathe!”

She was gasping, and I was just standing there looking down at her, when one of our nurses hurried into the room. She had heard the moaning from out in the hallway.

“Dr. Lesslie, is there anything we need to do?” she had asked me anxiously.

At that point, I had given up. I talked the pulmonary specialist on call into putting her in the hospital with a diagnosis of “possible pulmonary embolus” and then seeing how things would shake out over the next few days. When I saw him in the ER later on that week, he told me he had sent Lucinda home the next morning.

“I still don’t know what’s going on with her,” he had told me. “All of her studies stayed normal, and she never ran any fever or had any abnormal vital signs. She didn’t want to leave the hospital, but I told her she had to be discharged. We weren’t doing anything for her here except providing a bed and three meals a day.”

He
had
learned a few things from her family doctor, though. She had reported a history of cancer (not true), a recent five-hour plane flight (also not true), and a distant family history of an unusual bleeding problem (how could you ever confirm that?).

“She seemed to know all the risk factors for an embolus, and she had all of the symptoms. And you know what, Robert? It’s almost as if she wanted to have one. That’s what beats me.”

I hadn’t felt so bad when I learned she had stumped one of our best pulmonary guys. But Lucinda Banks was puzzling—something I had never run into before.

The next time I saw her was a few days after Thanksgiving, about a year later. On this occasion she came to the ER in the middle of the afternoon, dressed the same way as before—very professional and very polished.

She had all the classic symptoms of a heart attack, but with none of the physical or laboratory findings. One of our cardiologists reluctantly put her in the hospital and, as expected, everything turned up normal. She even had a negative heart cath.

When I saw the cardiologist a few days later, we talked about Lucinda. He mentioned the idea of Munchausen’s and wondered if that might be what was going on with this woman.

When I got the chance, I looked up this strange malady. The more I read about it, the more it seemed to fit. In fact, it perfectly described Lucinda and explained all of her behavior, all of her lack of objective findings, and all of her expert knowledge of her disease du jour.

We hadn’t seen Lucinda again after that chest pain visit, not until tonight. I was curious about what her complaint was going to be this time. Based on Jeff’s reaction, it must be something interesting.

He walked out of her room and over to the nurses’ station.

“Good luck with this,” he whispered, handing me the chart and glancing back over his shoulder. “I can’t make heads nor tails of it.”

The buzzer had gone off again and he headed back out to triage.

He had written
multiple complaints—headache, visual changes, kidney failure
—on Lucinda’s ER record.

Kidney failure?
I thought.
Now that’s something different. How did she come up with that one?

Another quick glance at her chart informed me that her blood pressure was normal, as were her pulse and temperature. Again.

“Ms. Banks,” I said to her as I stepped into room 4. “I’m Dr. Lesslie. What can we do for you tonight?”

“I remember you, Dr. Lesslie,” she replied pleasantly, looking up at me and smoothing the stretcher sheet on either side of her. She was sitting up with her legs dangling from the edge of the bed, crossed at her ankles.

“I’m just not sure what’s wrong with me,” she sighed, slowly shaking her head and folding her hands in her lap. “I started having this strange numbness in my hands, and then in my feet. And I’ve noticed that my vision isn’t what it should be.”

She paused and rubbed her eyes, struggling to focus on some object off in the corner of the room.

“And then all my joints started to hurt, especially my wrists and fingers and hips. I feel like I’ve been run over by a truck!”

She looked up at me, waiting for a response. I just stood there, nodded my head, and waited for her to go on.

After a moment, she continued. “And these headaches—they’re awful! Right here at my temples.” She was rubbing the sides of her head now, wincing in terrible pain.

She didn’t say anything further, and this time I couldn’t wait her out. I finally asked her, “Tell me about this kidney failure. Who diagnosed that, and when did it start?”

She seemed relieved that we were finally moving down her list of complaints, and she stopped rubbing her head. She looked up at me and sighed.

“My family doctor was worried it would only be a matter of time,” she informed me. “My urine output has been diminishing over the past few months, and now, my kidneys seem to have shut down completely.”

She said this with a surety and calmness that rattled me a little. This was a bright woman, and I was having a hard time believing what I was hearing.

I glanced down at her vital signs again. Most people with kidney failure had an elevated blood pressure. Lucinda’s was 110/78. And her pulse was 70.

“I haven’t been able to produce any urine in more than 24 hours,” she told me, searching my eyes for the hoped-for alarm.

I was tempted to have one of the nurses put in a Foley catheter and call her out on this, but something told me that wasn’t the way to handle this. That’s probably what she wanted me to do, as well as get a bunch of lab work. Instead, I just stood there, holding her chart, and meeting her gaze with mine.

There was a split second where I thought I saw the corners of her mouth turn down. Then there was that smile again, almost condescending. But she was beginning to lose her patience. I wasn’t jumping down this rabbit hole quickly enough.

“Do you…do you think I could have lupus?” she asked with feigned trepidation.

“Hmm…” I responded, and started stroking my chin, seemingly struck by this surprising possibility.

Of course it sounded like lupus. She was describing all of the symptoms of this disease, even stretching things to the point of manufacturing the findings of one of the disease’s end-stage complications—kidney failure. But that one was going to be hard for her to validate. Yet…what was the best way to handle this? We had already put her in the hospital twice for imagined maladies, and that was just at Rock Hill General. Who knew how many other places she had been with these complaints? And who knew how many other diseases there were whose symptoms she had manufactured?

“Dr. Lesslie, do you think lupus could explain this?”

She leaned toward me, turning one side of her face for me to examine.

I hadn’t noticed it before in the less than optimal lighting of the exam room, but as she came closer, I could see that her cheeks and forehead were obviously a little more flushed than the rest of her face. It was the classic “butterfly” distribution of the facial rash of lupus—the “red wolf.” She had really done her reading.

But how had she managed to do this? The rash
was
in the typically described form and was the appropriate color. I looked closer. It was all I could do not to say something, but there was the answer. It was clear that Lucinda had applied a faint dusting of makeup to her cheeks and forehead. It was very subtle, but it was definitely makeup.