From Denial to Hypochondria

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I have begun to notice that many of the patients I treat, can be broadly split into two categories; The ‘Hypochondriac’ and the ‘Patient in Denial’. Both of these conditions are not only unhealthy, but cause unnecessary confusion to medical practitioners. This is particularly true for first responders in the pre-hospital setting, because our access to diagnostic tools is limited. In EMS we rely heavily on signs + symptoms and the patients’ vitals, to make an approximate diagnosis and initiate treatment. If the patient is lying about his symptoms, it can throw us off the mark.

Behold – two fascinating examples of these extremes, on the same day.

The first call was in an apartment in a high rise building, in the center of town, with no parking in the immediate vicinity. None of this bothered me, because I easily maneuvered my motorcycle between traffic, and found a perfect ‘parking spot’ on the sidewalk, immediately outside. The call was for a 60 year old – male – ‘Weakness’. Calls that come in as ‘weakness’ are, more often than not, absolutely nothing, or at least not life threatening. For heaven’s sake, I feel weak after an afternoon out with the kids!

As I rode the elevator to the 7th floor, it occurred to me that I might be alone with the patient for a while; the ambulance didn’t stand a chance in the mid-afternoon traffic. I began to think of conversation topics, because once I confirmed that there was nothing wrong with him, I would have to sit and make small talk till my colleagues arrived.

‘Weakness’ is normally a straightforward BLS call, and so I approached the apartment ever so casually. An elderly lady with few teeth and a big smile opened the door, and ushered me into the room where her husband was lying on his bed.

I asked him how he was feeling.

“Leave me alone” he said in heavily accented Hebrew.

“And a good day to you too, dear Sir,” I replied – “What’s bothering you?”

Silence

I persisted in my questioning, and he eventually admitted that he felt slightly weak. His wife confessed that she had been the one to call the ambulance, ignoring her husband’s protestations. I gave him a quick once-over. He looked OK – good color, not sweating; this still appeared to be the run of the mill ‘weakness’. Then I felt for his radial pulse, found it, and started counting heartbeats.

Uh Oh.

His pulse was 28. I thought I had made a mistake so I tried again. His pulse was still 28.

A Normal pulse rate ranges from 60-100; 50 being borderline Bradycardia. 28 is significant bradycardia and life-threatening. It was a miracle he was conscious at all.

As I reached for my phone to request a NATAN, an ALS crew headed by a doctor walked through the door.

“How did you know?” I asked incredulously.

“Know what?” they responded in unison.

Turns out that although this call came in as a CAT B, the NATAN was the closest available ambulance, and protocol dictated that they had to respond. This patient was very lucky to have a full paramedic team and a doctor land unsuspectingly on his doorstep. He needed them to survive.

“Do you feel alright?” the Doc asked.

“I feel fine,” he insisted again.

He was, however, much closer to death than he could’ve imagined as the ECG subsequently showed. He was suffering from a third degree AV block, also known as complete heart block.

A heart block is a disease in the electrical system of the heart, and can cause lightheadedness, syncope, and if left untreated, death.

Before we rushed him out of the house, a line was started and defibrillator pads attached to his chest – just in case. A cardiac emergency response team was waiting at the hospital, and this man eventually had an artificial pacemaker implanted.

Just your regular ‘patient in denial’ claiming perfect health, while his life hung in the balance. At least heaven ordained that he get the proper care he so desperately needed in time.

As I was leaving the first scene, another call came in as “Severe chest pains, suspected MI” at an address 1km away. Expecting the worst, I did an immediate U-turn and headed to the call.

I arrived at the bungalow style house, walked inside, and found a man strewn across the couch in the lounge.

“Hi, I’m from EMS; what’s wrong?” I asked.

“I have pain in my chest,” he grimaced.

“Can you show me exactly where the pain is?”

“Right here,” he moaned, pointing to his belly button.

Things now took a drastic turn to the bizarre.

Further questioning revealed that (a) he was in no pain right now and (b) the last belly button attack had occurred the previous week! The reason he decided to call now, was, in his own words, “because it was convenient.” I held back laughter / disgust and took his vitals; all within normal ranges. Ultimately, he decided against going to the hospital and remained at home.

Just to recap for those of you out there doing a mental differential diagnosis. We have;

  1. Pain near the belly button
  2. From last week
  3. Normal vitals

If you guessed hypochondriac in the first degree, you’re spot on.