I think one of the worst mistakes you can make as a medical professional is to not give your patients the benefit of the doubt. Fortunately most of our patients are honest, polite and cooperative. Of course there are some exceptions to this, and those of us working in Emergency Medicine probably see a disproportionate share. Did you know that there are many legitimate medical conditions where patients can unintentionally “fake” symptoms with no purposeful deception?
In Somatic Symptom Disorders (DSM-V), formerly known as Somatization Disorder (DSM-IV), patients have physical symptoms that suggest a physical disorder, but examinations, labs and imaging studies are all normal. And, unlike Malingering or Factitious Disorder, patients are not deliberately faking or lying about their symptoms. They truly believe they have real physical ailments and often will experience anxiety and be mentally preoccupied with their plight.
But how can you as a provider sort through what’s real, what’s worrisome, and what needs intervention? I’ve never been a fan of the “hold the arm over the face and drop it” test for the “unconscious” patient because every once in a while it does drop (and now I’m the one who has to suture that busted lip). So, I’ve compiled a few tips to help sort things out.
1. THE BLIND PATIENT: “I can’t see anything!”
It’s difficult to fake perfect vision – if you can’t actually see the bottom row on the “E” chart, you can’t magically know what it says – but it’s VERY easy to pretend that you can’t read the giant E on top. So if a patient says they have extremely blurred vision or blindness, how can you test if that’s true? Well, there’s an app for that.
The eye has a built-in feature called the optokinetic reflex. This is what allows you to see each of the telephone poles along the side of the road as you pass by in a car. Even though you are moving and they are still, they look crisp, not blurred. The OptoDrum app ($4.99 on iTunes, or use a free video on YouTube) tests the optokinetic reflex. The reason it’s useful in determining true blindness is that you can’t turn it off consciously.
To do the test, hold your phone very close to the eye so that it’s almost touching the patient’s nose. If the patient can see the lines on the app going by on the screen, you will be able to see the optokinetic reflex at work which looks like a horizontal nystagmus.
2. THE PARALYZED PATIENT: “I can’t move!”
If your patient is unconscious, uncooperative or suspicious, and you suspect a possible spinal injury, testing reflexes is an easy way to sort things out. Reflex testing requires no participation on the part of the patient, so you can use them on the unconscious patient when you don’t have much else to go on.
The Babinski Sign is tested by stroking the bottom of the patient’s foot with a pen or some other fine point stimulus. In a normal or negative Babinski, the toes should curl downward. The test is positive (pathological) and suggestive of spinal cord dysfunction, specifically upper motor neuron disease, if the toes fan upward. But don’t be fooled – a positive Babinski is NORMAL in kids 2 & under.
In addition to testing for Babinski, testing a patellar reflex is quick and easy in the back of the ambulance. Simply use the edge of your stethoscope or the handles of your trauma shears to tap just below the knee cap. Absent (areflexia) or exaggerated (hyperreflexia) reflexes are suggestive of nerve damage as well.
3. THE UNCONSCIOUS PATIENT: “ZZzzzzzzz…”
For whatever reason, some people like to feign unconsciousness. I already mentioned I’m not a fan of the arm drop test, and ammonia caps came out of most EMS protocols years ago. So what’s left?
The sternal rub used to be considered a good way to elicit a brief noxious pain stimulus that patients couldn’t avoid reacting to if they were physically capable. What many pre-hospital providers don’t see is the trouble this can cause downstream in patient care, particularly when the patient wakes up with “chest pain.” To elicit a pain response, a sternal rub can require up to 30 seconds of pressure. A sternal rub lasting just a few seconds can cause bruising and chest pain that can’t be ignored. Was the person unconscious because of a heart attack now presenting as chest pain? You’ve just bought that person a potentially avoidable and costly cardiac workup. Instead, try applying nail bed pressure with a hard object, trapezius squeezing, supraorbital (over the eye) pressure or earlobe pinching. I’m much less concerned when my unconscious patient wakes up complaining of ear lobe pain than pain in the center of his chest.
You can also borrow a trick from Anesthesiologists and do an “eyelash check” where you brush by the patient’s eyelashes to see if you can elicit a blink reflex. In Guedel’s Stage III Plane I, the patient loses both the eyelash reflex and the gag reflex, giving you some information about their airway status as well.
And if all else fails, verbalizing the next steps in medical treatment of the unconscious patient can always help. “Well team, looks like we need to put a tube down his airway, place a foley, and put in much larger IVs. Get the biggest needle you can.”
Although these tricks may help tease out what’s really going on, don’t take shortcuts and skip your fundamental assessment. Most people aren’t faking it, and poor outcomes usually don’t come from taking complaints seriously. Better to spend the extra time than potentially miss something serious.