Pt faking seizure

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PNES is REAL and you should document it as such!

Psychogenic nonepileptic seizures (PNES), or pseudoseizures are paroxysmal episodes that resemble and often misdiagnosed as epileptic seizures; however, PNES are psychological (ie, emotional, stress-related) in origin.
PLEASE stop re-traumatizing trauma patients by feeding into the stigma and often incorrect assumption that PNES patients are "faking it"!

"Paroxysmal nonepileptic episodes can be either organic or psychogenic. Syncope, migraine, and transient ischemic attacks (TIAs) are examples of organic nonepileptic paroxysmal symptoms. This article covers only PNES.

The terminology on the topic has been variable and, at times, confusing. Various terms are used, including pseudoseizures, nonepileptic seizures, nonepileptic events, and psychogenic seizures. PNES is the preferred term and the one used throughout this article.

PNES are common at epilepsy centers, where they are seen in 20-30% of patients referred for refractory seizures. PNES are probably also common in the general population, with an estimated prevalence of 2-33 cases per 100,000 population, which makes PNES nearly as prevalent as multiple sclerosis or trigeminal neuralgia."

This chat board won't let me attach a link, but google "Psychogenic Nonepileptic Seizures" and "Selim R Benbadis, MD" and spend some time educating yourselves before you judge others or write "faking it" in your documentation.

Thanks for your attention and time!
 
Dada Simba Detuned said:
Psychogenic nonepileptic seizures (PNES), or pseudoseizures are paroxysmal episodes that resemble and often misdiagnosed as epileptic seizures; however, PNES are psychological (ie, emotional, stress-related) in origin.
PLEASE stop re-traumatizing trauma patients by feeding into the stigma and often incorrect assumption that PNES patients are "faking it"!

"Paroxysmal nonepileptic episodes can be either organic or psychogenic. Syncope, migraine, and transient ischemic attacks (TIAs) are examples of organic nonepileptic paroxysmal symptoms. This article covers only PNES.

The terminology on the topic has been variable and, at times, confusing. Various terms are used, including pseudoseizures, nonepileptic seizures, nonepileptic events, and psychogenic seizures. PNES is the preferred term and the one used throughout this article.

PNES are common at epilepsy centers, where they are seen in 20-30% of patients referred for refractory seizures. PNES are probably also common in the general population, with an estimated prevalence of 2-33 cases per 100,000 population, which makes PNES nearly as prevalent as multiple sclerosis or trigeminal neuralgia."

This chat board won't let me attach a link, but google "Psychogenic Nonepileptic Seizures" and "Selim R Benbadis, MD" and spend some time educating yourselves before you judge others or write "faking it" in your documentation.

Thanks for your attention and time!
Click to expand...

I am aware of the term. However if the cause is deemed to be psychogenic, then perhaps the patient is "faking it" if by choice or somewhat involuntary (mental illness?) if they are 'faking' the symptoms of a tonic clonic convulsion and passin g it off to be from a non psychogenic cause.
 
mycrofft said:
If I didn't have the diagnostic equipment or there were conflicting findings/history, I'd weasel out by assessing as "R/O Somethingorother"
Click to expand...
I've done R/O ankle injury, r/o seizure, and any time when i am going with a diagnosis that is pretty obvious but because I am not supposed to diagnose, it's a rule/out. is it a copout? sure. does it show what I was thinking? pretty clearly, to anyone who asks, but with enough wiggle room that if i'm wrong, i can say i was just ruling out something, and not making a diagnosis.
 
Dada Simba Detuned said:
Psychogenic nonepileptic seizures (PNES), or pseudoseizures are paroxysmal episodes that resemble and often misdiagnosed as epileptic seizures; however, PNES are psychological (ie, emotional, stress-related) in origin.
PLEASE stop re-traumatizing trauma patients by feeding into the stigma and often incorrect assumption that PNES patients are "faking it"!

"Paroxysmal nonepileptic episodes can be either organic or psychogenic. Syncope, migraine, and transient ischemic attacks (TIAs) are examples of organic nonepileptic paroxysmal symptoms. This article covers only PNES.

The terminology on the topic has been variable and, at times, confusing. Various terms are used, including pseudoseizures, nonepileptic seizures, nonepileptic events, and psychogenic seizures. PNES is the preferred term and the one used throughout this article.

PNES are common at epilepsy centers, where they are seen in 20-30% of patients referred for refractory seizures. PNES are probably also common in the general population, with an estimated prevalence of 2-33 cases per 100,000 population, which makes PNES nearly as prevalent as multiple sclerosis or trigeminal neuralgia."

This chat board won't let me attach a link, but google "Psychogenic Nonepileptic Seizures" and "Selim R Benbadis, MD" and spend some time educating yourselves before you judge others or write "faking it" in your documentation.

Thanks for your attention and time!
Click to expand...

I commented about this in the other thread. Yes people can have real seizureform activity lacking hallmark clinical signs of a true seizure but be outside the pt's control. It is fairly rare and we see many more cases of factitious seizures, so we miss it.

A thread with lots of good citations from recognized sources will go far to getting folks more exposed to this issue.
 
I'm a strong believer in benzos (Ativan, Valium) for thing that looks like a seizure. My thinkings is either:

1: They are really having a seizures, and the benzo will help with that. or

2: They are faking, and if they are doing this to the point where I have to deal with them they have a behavior problem and are disrupting my ER. So they need to be sedated. Benzos help with that too.

Win win
 
Your approach may not work for all patients and in my opinion...

... it is incredibly disrespectful and insensitive to patients with PNES. Some patients with PNES (although admittedly not the majority) may have a paradoxical reaction to benzo's and/or sedation, particularly those with a history of trauma.

Please see: Paradoxical Reactions to Benzodiazepines: Literature Review and Treatment Options Carissa E. Mancuso, Pharm.D., Maria G. Tanzi, Pharm.D., Michael Gabay, Pharm.D. Pharmacotherapy. 2004;24(9)

For those of us with (Dx'd or unDx'd) PNES, we are not "faking it" any more than someone with epilepsy or another involuntary motor movement disorder than can potentially be dangerous, and treating us like "fakers" or malingerers is basically an accusation and judgement rather than compassionate and thoughtful medical treatment.

"PNES are probably also common in the general population, with an estimated prevalence of 2-33 cases per 100,000 population, which makes PNES nearly as prevalent as multiple sclerosis or trigeminal neuralgia." http://emedicine.medscape.com/article/1184694-overview

PNES are commonly misdiagnosed as epilepsy. It is by far the most frequent nonepileptic condition seen in epilepsy centers, where they represent 20-30% of referrals. About 50-70% of patients become seizure-free after diagnosis, and about 15% also have epilepsy. Like most manifestations of conversion and other somatoform disorders, PNES occur more frequently in women (approximately 70% of cases) than in men. http://emedicine.medscape.com/article/1184694-overview#a0199

"Antecedent sexual trauma or abuse is thought to be important in the psychopathology of psychogenic seizures and psychogenic symptoms in general. A history of abuse may be more frequent in convulsive rather than limp type of PNES." http://emedicine.medscape.com/article/1184694-clinical

"By definition, PNES is a psychiatric disorder. According to the Diagnostic and Statistical Manual for Mental Disorders (DSM) classification, physical symptoms caused by psychological causes can fall under 3 categories: somatoform disorder, factitious disorder, and malingering.

A somatoform disorder is the unconscious production of physical symptoms due to psychological factors. The symptoms are not under voluntary control, ie, the patient is not faking and not intentionally trying to deceive. Somatoform disorders are subdivided into several disorders depending on the characteristics of the physical symptoms and their time course. The 2 somatoform disorders relevant to PNES are conversion disorder and somatization disorder. The vast majority of patients with PNES have conversion disorder. The Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) added a new subcategory of conversion disorder (from the Diagnostic and Statistical Manual for Mental Disorders, Revised Third Edition [DSM-III-R]) specifically termed conversion disorder with seizures.

Factitious disorder and malingering imply that the patient is purposely deceiving the physician, ie, faking the symptoms. The difference between factitious disorder and malingering is that, in malingering, the reason for the deception is tangible and rationally understandable (albeit possibly reprehensible). In factitious disorder, the motivation is a pathologic need for the sick role. An important corollary is that malingering is not considered a mental illness, whereas factitious disorder is.

A generally accepted view is that most patients with PNES have somatoform disorder rather than malingering or factitious disorder. Although the DSM classification is simple in theory, knowing whether a given patient is faking it is nearly impossible. In some circumstances, intentional faking can be diagnosed only by catching a person in the act of faking (eg, self-inflicting injuries, ingesting medications or eye drops to cause signs, putting blood in the urine to simulate hematuria). Malingering may be underdiagnosed, partly because the diagnosis of is essentially an accusation."

from "Psychogenic Nonepileptic Seizures Clinical Presentation" Author: Selim R Benbadis, MD; Chief Editor: Helmi L Lutsep, MD, found at: http://emedicine.medscape.com/article/1184694-clinical#a0218

So I disagree that your approach is a "win win." In the interest of "dealing with a behavior problem" and minimizing disruption in your ED, you are disrespecting the patients with PNES and potentially causing them harming through re-traumatization and stigma.

Please consider your ethical obligations and oath, do a bit more reading about PNES, and then think about what it might be like to experience from the patient's or patient's loved ones' perspective when you tell them that they are "faking it" and disrupting your ER.

Thank you for your attention and time,
Simba
(a PTSD and sexual trauma survivor and peer advocate who also happens to be Dx'd with PNES and interracts with health care providers like you on a regular basis)

zmedic said:
I'm a strong believer in benzos (Ativan, Valium) for thing that looks like a seizure. My thinkings is either:

1: They are really having a seizures, and the benzo will help with that. or

2: They are faking, and if they are doing this to the point where I have to deal with them they have a behavior problem and are disrupting my ER. So they need to be sedated. Benzos help with that too.

Win win
Click to expand...
 
Your approach may not work for all patients and in my opinion...

... it is incredibly disrespectful and insensitive to patients with PNES (previously Dx'd or not). Some patients with PNES (although admittedly not the majority) may have a paradoxical reaction to benzo's and/or sedation, particularly those with a history of trauma. Please see: Paradoxical Reactions to Benzodiazepines: Literature Review and Treatment Options Carissa E. Mancuso, Pharm.D., Maria G. Tanzi, Pharm.D., Michael Gabay, Pharm.D. Pharmacotherapy. 2004;24(9).

For those of us with (Dx'd or unDx'd) PNES, we are not "faking it" any more than someone with epilepsy or another involuntary motor disorder tht can potentially be dangerous, and treating us like "fakers" or malingerers is basically an accusation and judgement rather than compassionate and thoughtful medical care.

"PNES are probably also common in the general population, with an estimated prevalence of 2-33 cases per 100,000 population, which makes PNES nearly as prevalent as multiple sclerosis or trigeminal neuralgia." http://emedicine.medscape.com/article/1184694-overview "PNES are commonly misdiagnosed as epilepsy. It is by far the most frequent nonepileptic condition seen in epilepsy centers, where they represent 20-30% of referrals. About 50-70% of patients become seizure-free after diagnosis, and about 15% also have epilepsy. Like most manifestations of conversion and other somatoform disorders, PNES occur more frequently in women (approximately 70% of cases) than in men." http://emedicine.medscape.com/article/1184694-overview#a0199 "Antecedent sexual trauma or abuse is thought to be important in the psychopathology of psychogenic seizures and psychogenic symptoms in general. A history of abuse may be more frequent in convulsive rather than limp type of PNES." http://emedicine.medscape.com/article/1184694-clinical

"By definition, PNES is a psychiatric disorder. According to the Diagnostic and Statistical Manual for Mental Disorders (DSM) classification, physical symptoms caused by psychological causes can fall under 3 categories: somatoform disorder, factitious disorder, and malingering.

A somatoform disorder is the unconscious production of physical symptoms due to psychological factors. The symptoms are not under voluntary control, ie, the patient is not faking and not intentionally trying to deceive. Somatoform disorders are subdivided into several disorders depending on the characteristics of the physical symptoms and their time course. The 2 somatoform disorders relevant to PNES are conversion disorder and somatization disorder. The vast majority of patients with PNES have conversion disorder. The Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) added a new subcategory of conversion disorder (from the Diagnostic and Statistical Manual for Mental Disorders, Revised Third Edition [DSM-III-R]) specifically termed conversion disorder with seizures.

Factitious disorder and malingering imply that the patient is purposely deceiving the physician, ie, faking the symptoms. The difference between factitious disorder and malingering is that, in malingering, the reason for the deception is tangible and rationally understandable (albeit possibly reprehensible). In factitious disorder, the motivation is a pathologic need for the sick role. An important corollary is that malingering is not considered a mental illness, whereas factitious disorder is.

A generally accepted view is that most patients with PNES have somatoform disorder rather than malingering or factitious disorder. Although the DSM classification is simple in theory, knowing whether a given patient is faking it is nearly impossible. In some circumstances, intentional faking can be diagnosed only by catching a person in the act of faking (eg, self-inflicting injuries, ingesting medications or eye drops to cause signs, putting blood in the urine to simulate hematuria). Malingering may be underdiagnosed, partly because the diagnosis of is essentially an accusation."

All quoted passages above are from "Psychogenic Nonepileptic Seizures" Author: Selim R Benbadis, MD; Chief Editor: Helmi L Lutsep, MD, found at: http://emedicine.medscape.com/article/1184694-overview

So your approach is a "win win" for you, but not for the patient, the patient's loved ones, and the numerous providers who may have to try to "undo" the additional trauma to which you expose patient(s) with your approach. In the interest of "dealing with a behavior problem" and minimizing disruption in your ED, you are disrespecting the patients with PNES and potentially causing them harming through re-traumatization and stigma.

PLEASE consider your ethical obligations and oath as a physician (and first responder), do a bit more reading about PNES, and then think about what it might be like to experience your approach from the patient's or patient's loved ones' perspective when you tell them that they are "faking it" and disrupting your ER.

(With all due respect) Thank you for your attention and time,
Simba
(a PTSD and sexual trauma survivor and peer advocate, who also happens to be Dx'd with PNES and interracts with health care providers like you on a regular basis)
 
In NYC area, this is a good resources...

"Psychogenic non-epileptic seizures: stigma and strength in numbers"
Posted by Lorna Myers on Sep 24th, 2012 and found at: http://blog.nonepilepticseizures.com...th-in-numbers/

zmedic said:
I'm a strong believer in benzos (Ativan, Valium) for thing that looks like a seizure. My thinkings is either:

1: They are really having a seizures, and the benzo will help with that. or

2: They are faking, and if they are doing this to the point where I have to deal with them they have a behavior problem and are disrupting my ER. So they need to be sedated. Benzos help with that too.

Win win
Click to expand...
 
This is the kind of PNES I usually have when EMTs respond

But please note that this does not mean that we will "stay with you" if additional (internal and/or environmental) "triggers" occur. If someone with PNES is lucid and responsive, it is best to ask them if they know what their triggers are... so you can try to avoid them during the triage and transport. For some, merely being treated like a "faker" can be so emotionally upsetting (based on past neglect and/or inappropriate care from health providers) that it can induce a much more severe PNES (that CAN potentially be dangerous to the patient and the first responders, just like epileptic seizures). Most people cannot die from a "panic attack" but that is not always the case for everyone with PNES... falls, head trauma, uncontrollable high blood pressure... all of these are very real risks for some of us that should be treated accordingly.

MSDeltaFlt said:
I've seen fake seizures. And I believe I have seen an undiagnosed psychogenic seizure. Totally lucid the whole time and was upset that nobody could/would tell her what was going on. Would have the "seizure-like" activity including post ictal-like state that looked real. I would ask her, "You sti with me?" And she would immediately nod her head yes. Weird.
Click to expand...
 
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zmedic said:
I'm a strong believer in benzos (Ativan, Valium) for thing that looks like a seizure. My thinkings is either:

1: They are really having a seizures, and the benzo will help with that. or

2: They are faking, and if they are doing this to the point where I have to deal with them they have a behavior problem and are disrupting my ER. So they need to be sedated. Benzos help with that too.

Win win
Click to expand...

Actually, this is clinically appropriate as a differential. It doesn't have a specific psychogenic label, but that ought to be unearthed during history-taking.

What if a person thinks they have psychogenic seizures but they are having real ones? Also, I've seen quasi-sizure-like activity in persons who have passed out from vaso-vagal syndrome (after immunizations for instance) and from hyperventilation plus either psychological or alcohol/drug related issues. Benzo's don't help them, but in these cases it might be part of a differential between origins.

I CANNOT imagine why someone could not carry a card or some such identifying themselves as having some sort of psychologically-based somatic disorder which might imperil themselves or others around them. I'd make my own. And I would not be driving or operating machinery.
 
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Can someone explain to me how PNES can be fatal? I get the obvious episode starts while driving or at the top of a tall flight of stairs. But I can't see how the same issues exist as present with status epilepticus. Am I missing something?

Simba -- you mention in some of your youtube material that no one takes a PNES episode as seriously as a grand mal seizure. Why do you think that they should? What am I missing about this condition that makes it life-threatening? Why should the PNES patient be seen before an 80 year old with possible cardiac symptoms?

I don't claim to understand PNES, and I've read the articles that you've posted, including the medscape pages. I try not to judge people in the back of my ambulance, and try and show everyone respect, but I'm confused as to what you want from EMS and the healthcare system as a whole?
 
I'll try to respond to your questions...

(though on at least one of these threads it was suggested that I should stop posting...)

It depends on how acute/severe the PNES is. Most of the time I can control the symptoms well enough to lower myself into a safe position. However, if I am VERY triggered it is dangerous in many of the ways that any other seizure or involuntary motor condition may be.

For example, Thursday night I had a PNES after lowering myself to safely lie on a concrete patio. If no-one puts a pillow under my head... well you get the point.

Friday, after being discharged from the ED but while waiting for my paperwork before I was allowed to leave... I asked someone to help me because I could feel another one possible coming on. I was ignored, until I fell off the chair and was PNESing underneath some chairs in the hallway between the nursing station and patient beds... my attending and nurse were not present so everyone assumed I was having an epileptic seizure (because that is how I present when when having a severe trauma reaction).

I will likely not die from electrical activity related issues, unless I am having an epileptic seizure (which may be possible because of the small chance of co-morbidity). But... I can whack my head very hard, and my systolic pressure sometimes goes extremely high which can have dangerous consequences to my organs and otherwise.

I hope this answers at least some of your question(s).
 
Thanks for your thoughtful reply(ies)

(Like an epileptic) in Massachusetts the DMV suspends my license each time that I have a documented "seizure like episode" until my neurologist certifies that my condition is stable and I am safe to operate a motor vehicle.

Re: Benzo's and sedation, it may help with your DDx... I am merely suggesting that using such Rxs as a diagnostic tool can sometimes be harmful to patients if (like me) benzo's or sedation actually exacerbate the condition. And... if you make my PNES worse (after I try to refuse sedation and you ignore me), then I become MORE disruptive in your ED (or truck), not less. My case is particularly severe, because my first sexual trauma was related to a physician... so anytime a health professional tries to sedate me against consent it is a HUGE trigger. But many other PTSD and sexual trauma survivors have shared with me similar stories (sedation agitates trauma survivors in some circumstances).

Hope this is helpful/responsive to your comments and questions.

mycrofft said:
Actually, this is clinically appropriate as a differential. It doesn't have a specific psychogenic label, but that ought to be unearthed during history-taking.

What if a person thinks they have psychogenic seizures but they are having real ones? Also, I've seen quasi-sizure-like activity in persons who have passed out from vaso-vagal syndrome (after immunizations for instance) and from hyperventilation plus either psychological or alcohol/drug related issues. Benzo's don't help them, but in these cases it might be part of a differential between origins.

I CANNOT imagine why someone could not carry a card or some such identifying themselves as having some sort of psychologically-based somatic disorder which might imperil themselves or others around them. I'd make my own. And I would not be driving or operating machinery.
Click to expand...
 
"edited"

Sorry for the typos, I'm still recovering from the multiple PNESs of the long weekend and at times have difficulty with certain cognitive tasks (especially when experiencing the usual drowsiness phase after the PNES).

I forgot to include that I could also potentially aspirate on my own vomit.
Particularly if I am restrained or sedated against consent, I can become extremely agitated and combative... which is when it can be dangerous to first responders. It is ALWAYS better (in my opinion) when someone is seizing but still coherent (no matter what type of seizure) to ask if it is ok to help them and touch them. I (as the patient) don't want to hurt you, and I assume that you don't want to (unecessarily) hurt me... so it is better to just ask and listen to the patient and try to respect their request unless there is a clearly indicated reason to not do so. THAT is what I ask of the Western health care system. Don't accuse me of faking and then ignore me. Don't assume that I am an attention or drug seeking psych patient because you don't know my history as well as I and my team of neuro-psych providers do... so maybe show a little respect because I may just know a little bit more about my own body and mind and medical condition than you do! That is what I want health care providers to consider before judging me and treating me like a "faker" or a "drug addict" or a "psychotic crazy (insert appropriate term" here... After you have lived in my body and experienced my trauma, then you get to judge me... until then try to have a little compassion and respect. Most of you do that already as part of your job... and for that I am incredibly thankful. The rest of you... I just hope this helps you to stop and think for five minutes before you judge another "faker" in your ED or on your call. Thanks for your attention and time. Simba

Dada Simba Detuned said:
(though on at least one of these threads it was suggested that I should stop posting...)

It depends on how acute/severe the PNES is. Most of the time I can control the symptoms well enough to lower myself into a safe position. However, if I am VERY triggered it is dangerous in many of the ways that any other seizure or involuntary motor condition may be.

For example, Thursday night I had a PNES after lowering myself to safely lie on a concrete patio. If no-one puts a pillow under my head... well you get the point.

Friday, after being discharged from the ED but while waiting for my paperwork before I was allowed to leave... I asked someone to help me because I could feel another one possible coming on. I was ignored, until I fell off the chair and was PNESing underneath some chairs in the hallway between the nursing station and patient beds... my attending and nurse were not present so everyone assumed I was having an epileptic seizure (because that is how I present when when having a severe trauma reaction).

I will likely not die from electrical activity related issues, unless I am having an epileptic seizure (which may be possible because of the small chance of co-morbidity). But... I can whack my head very hard, and my systolic pressure sometimes goes extremely high which can have dangerous consequences to my organs and otherwise.

I hope this answers at least some of your question(s).
Click to expand...
 
Btw...

... not that this should matter in the least... but sadly it does to some people... I have an undergraduate degree, a law degree (and practiced health care law for 10 years) and a Masters of Public Health from Harvard. My father is a physician, my mother is a double masters and PhD cognitive neuro-psychologist, and my sister is a nurse anesthesiologist. I (obviously) cannot perform certain paid work right now and I have been on SSDI since I began having PNES over two years ago after I was prescribed Tramadol (Ultram) and multiple benzo's to treat an orthopedic trauma.

BUT in the last two years I have met numerous patients who have survived unspeakable sexual and other trauma... who also have PNES (and in some cases also have epileptic seizures). Western medicine and science has not yet caught up with the connections between emotions, trauma, brain and hormonal functions and other somatic issues. Until we have a better understanding of the body-mind connections and trauma reactions, I merely ask that some of you suspend your judgement a little bit longer and give at least some of us the benefit of the doubt before assuming we are "fakers" or don't need "real" medical attention.

Thanks again. With this post I will now take a break from this forum/thread (since it has been suggested at least once that I do). If you are sincerely interested in learning more about PNES and/or trauma reactions, please PM me and I will be happy to refer you to numerous sources for additional education, resources, treatment centers in the U.S., etc.

Be well,
Simba
 
Dada Simba Detuned said:
Re: Benzo's and sedation, it may help with your DDx... I am merely suggesting that using such Rxs as a diagnostic tool can sometimes be harmful to patients if (like me) benzo's or sedation actually exacerbate the condition. And... if you make my PNES worse (after I try to refuse sedation and you ignore me), then I become MORE disruptive in your ED (or truck), not less.
Click to expand...
So are you having grand-mal activity or not? Because you're making no sense. If you are having generalized seizure activity how are you snapping out of it to refuse benzos? Assuming your activity and "disruptiveness" get worse with sedation you would stand a fair chance of ending up RSI'd on a propofol infusion on my truck. What's your suggested treatment regimen?

Dada Simba Detuned said:
My case is particularly severe, because my first sexual trauma was related to a physician... so anytime a health professional tries to sedate me against consent it is a HUGE trigger. But many other PTSD and sexual trauma survivors have shared with me similar stories (sedation agitates trauma survivors in some circumstances).

Hope this is helpful/responsive to your comments and questions.
Click to expand...
I'm calling BS. I was diagnosed with trauma related issues that have since been treated. I know a lot of others who have as well. It was never a blanket excuse for unacceptable behavior, which is almost what this seems like. Call me an ignorant, hateful healthcare provider if you must but your post just don't sit well with me.
 
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