Munchausen's Syndrome

There was a fascinatingly awful patient care experience last month that I've been waiting to say something about. Maybe it would have been interesting to see what I would have said in the heat of the actual experience, but I'm trusting that a little emotional distance will provide some better perspective.

Late one night during my shifts last month, a woman was admitted to the hospital with trouble breathing and chest pain. (Obviously, this woman's name and any identifying info will be omitted or changed.) As I looked into her medical record, I found something that I had only heard about before, namely Munchausen's Syndrome.

This syndrome was named after the good Baron von Munchausen, pictured in a bust above, who apparently was famous for telling wild adventure stories from his travels that all turned out to be lies. The medical diagnosis that bears his name involves patients that have no underlying medical problem, but desparately desire to be a patient. Often, they will do some ill to themselves in order to be treated for something, and many times the more severe the treatment the better. They often have a medical background of some kind, travel from hospital to hospital, show up with wild problems, and always desire some very invasive treatment plan. You hear stories about this diagnosis in medical school, but obviously it should never become a label unless it is very well substantiated, since it will dramatically affect how future care is provided. Note that this is different from "I have lots of pain, doctor, and I need narcotics." Narcs can make you high and you can sell them. There is no secondary gain for a Munchausen's patient except to get to be in the "patient role".

So my patient was admitted to our hospital 6 months ago with abdominal pain and found to have air inside her abdomen, usually a very ominous sign of a perforated bowel or something equally dangerous. She was taken to the OR, where surgery found no source for this, but did evacuate out acetone-smelling fluid that, after much investigation, was concluded to be some cleaning solution that the patient had injected into her own abdomen. She got better. Then the story broke, through her husband, that she had multiple underlying psychiatric diagnoses (all of which she denies to this day and refuses treatment for) and had been to many other hospitals with bizarres stories in the past.

So for the next several nights, I would be repeatedly paged with reported problems from this patient, for all of which she desired something to be done to her. She "vomited over 200 times" (none of which were witnessed or have made her at all dehydrated by our testing), so she "really needed an NG tube (tube through the nose to the stomach) and a PICC line (super IV that goes into the vena cava)". She held her urination until we were forced to catheterize her, lest her bladder burst, and then she asked for a larger bore catheter. On and on it went. We tried to discharge her, and she petitioned Medicare to let her stay until her case was reviewed to see if there was any reason for her to stay in the hospital. They said no, and she finally went home.

The bizarre nature of this is probably evident to everyone, but the hardest part for me was a suppression of every instinct that I've garnered since starting medical training. We are trained to seek out problems as clues to some disease or malfunction of the body, and to never ignore a patient's problem. Here, these very instincts will contribute to making the patient sicker and sicker and perpetuating her problem, when what she really needed was to go home and be out of range of some medical intervention.

I don't know if this rings of a lack of compassion. I hope not. Patients most often have a quite notable instinct as to what they need for their own health, but there are unfortunately many people (not just people with impossible-to-treat psychiatric disease) who think some thing is what they need, when I am convinced that it just adds to their problem. These are always difficult times, since I must act for their best interest, whether they believe it to be or not.

Rushing in where angels fear to tread? I pray never. God, give your grace, your light, your healing.