# Patients "playing possum" vs. a true issue.



## Aidey (Jul 23, 2009)

This is an issue that comes up every so often at work, and I'm wondering how you guys approach it. 

Many people I work with seem content to assume that most patients who are conscious but won't respond to questions are just "playing possum" and there isn't anything legitimately wrong with them. I prefer to approach it as if they do have an issue and only consider the "possum diagnosis" as the last option. This has garnered me some ridicule at work, along with people calling me gullible and naive.*

Basically, my question is how do you convince people that you don't think a patient is playing possum? 



*Here is the pt info for that situation. 40ish F assaulted by her boy friend. He hit her 5 times in the head, and she has 3 palpable bumps on her head, and the beginnings of a black eye. He chased her out of the house and down the street where she fell, a passerby called 911. It is unknown if there was an initial LOC. Her GCS when I arrived was 15. Pt states she has drank 4 beers this evening, denies any other alcohol or drugs. 

Pt was backboarded by FD PTA for neck pain. We're transporting and shes crying and saying how much her head hurts and how scared she is when suddenly, mid word she stops talking and crying. I look over at her and she is flaccid, eyes open and staring straight up. I try and get her attention with both verbal and painful stimuli, to which she has no reaction. She also did not close or twitch her eye lids when her lashes were flicked and she failed the hand drop test. It lasted for about 45 seconds to a minute before she came out of it. When she did, she picked up mid word right where she stopped off, was crying again etc. 

I don't remember her exact vitals, but they were within normal limits, and her CBG was in the normal range also. The only abnormal finding was that her L pupil was sluggish to respond compared to her R pupil. Her L eye was the one that had the beginnings of a black eye around it. 

I am about 99% positive she was having an absence seizure (no seizure hx though). I had a friend growing up who had them, and so I've seen quite a few and it was to the letter the exact same thing. 

My partner that day is a paramedic student waiting to test, and she, along with the nurse taking report at the hospital were both convinced I was "taken" by the pt and she was playing possum. I tried convincing them otherwise, and that is when I was called gullible and naive. The ED was swamped so I was never able to talk to the doc myself.

Basically, I don't think of myself as gullible or naive, I see it as being cautious. I don't think there is anything else I could have done to test this pts LOC, and yet I'm being treated as if I fell for some big trick.


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## 46Young (Jul 23, 2009)

Regardless if a pt is faking or not, always perform the proper diagnostics and prophylactics. Whether they're full of it or not is for the Attending to figure out. Tell your co-workers that you're not going to be the one who goes to court and loses their cert. I treat every pt as if they're legit, even if I know they're not. Besides being good medicine, you won't have to worry about any negligence suits.

Nothing wrong with giving a pt O2, a stroke assessment, ortohstatic V/S, 12-lead, IV, spinal motion restriction and such if appropriate. Just don't empty your drug box if you're suspicious of their presentation. Treat all meds as if they have the potential to kill.

BTW, I like to twist the skin on the inside of the upper arm for a responsiveness check if other methods produced no response. It's quite painful, and unexpected by the pt as well.


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## el Murpharino (Jul 23, 2009)

Aidey said:


> Basically, I don't think of myself as gullible or naive, I see it as being cautious. I don't think there is anything else I could have done to test this pts LOC, and yet I'm being treated as if I fell for some big trick.



I see many providers of all levels treat these types of patients like they're faking it.  Maybe it's burnout...maybe it's disdain for the job...and some want to believe all people are faking it (especially of certain genders/races/socioeconomic class/etc.).  All it takes is that one time that they're NOT faking it for you to get in hot water.  Keep a cool head and treat them accordingly...there are some things they can't fake.


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## Shishkabob (Jul 23, 2009)

Or an ammonia inhalant ^_^


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## 46Young (Jul 23, 2009)

Also, punitive IV's are a no-no:lol:


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## 46Young (Jul 23, 2009)

el Murpharino said:


> I see many providers of all levels treat these types of patients like they're faking it.  Maybe it's burnout...maybe it's disdain for the job...and some want to believe all people are faking it (especially of certain genders/races/socioeconomic class/etc.).  All it takes is that one time that they're NOT faking it for you to get in hot water.  Keep a cool head and treat them accordingly...there are some things they can't fake.



That's what I'm saying. Let your guard down and you're out of a job. I've seen it happen several times.


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## VentMedic (Jul 23, 2009)

Linuss said:


> Or an ammonia inhalant ^_^


 
Tell me you are joking...

You do know the many complications they cause, some of which can be fatal. There are reasons why ammonia inhalants are no longer standard on EMS trucks. That and the fact that they were over used and used for abuse by people who thought it was "cool". It ranks right up there with slammin' narcan.


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## Tincanfireman (Jul 23, 2009)

Aidey said:


> This has garnered me some ridicule at work, along with people calling me gullible and naive


 
You were the one in the back of the unit and you were the one responsible for this patient's care. You saw what you saw and (IMHO) acted appropriately. I would counsel you to be careful on future calls with this particular partner; sounds like they are a lawsuit waiting to happen. With 5 blows to the head and evidence of trauma, not to mention a possible LOC, she was prime for a bleed. You done good...


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## Shishkabob (Jul 24, 2009)

VentMedic said:


> Tell me you are joking...
> 
> You do know the many complications they cause, some of which can be fatal. There are reasons why ammonia inhalants are no longer standard on EMS trucks. That and the fact that they were over used and used for abuse by people who thought it was "cool". It ranks right up there with slammin' narcan.


Hence the "^_^"


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## DrankTheKoolaid (Jul 24, 2009)

*re*

Aidey stick to your guns. First and formost we are supposed to be patient advocates.  The worst part about what you said besides your other coworkers burnout is the fact that the partner that is going to be a new medic is already coming into this with bad habits.

On a side note i laughed out oud reading you did the hand drop.  I hope you didn't document that )


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## Aidey (Jul 24, 2009)

Partner was only a temp partner, so I don't work with her any more. 

Corky, that is literally the third time I have ever done that in 6 years. I only have used it as a last ditch I really can't tell if they alert or not move. Not only did her hand land in the middle of her face, she didn't even close her eyes when it happened. 

My biggest concern with this is that I don't want to get a reputation as someone who blows things out of proportion. If that happens it could be detrimental to my patients if the nurses think I'm just overreacting on my patch when I really do have a serious patient.


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## DrankTheKoolaid (Jul 24, 2009)

*re*

You know what, who cares what the nurses think.  If your consistantly err on the side of the patient that will speak volumes for your character and our worth as a provider. If the nurses dont see that then to be honest they really dont matter as every patient you bring into the ED is going to be seen by a physician who WILL notice it. 

Im not sure about everyone else but i always consider the worst first and stay in that train of thought until S/S dictate otherwise.


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## Aidey (Jul 24, 2009)

While its true that everyone will see a doctor, eventually, but the nurses are the gatekeepers and I do not want to have them thinking I don't know what I'm doing.


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## exodus (Jul 24, 2009)

Aidey said:


> While its true that everyone will see a doctor, eventually, but the nurses are the gatekeepers and I do not want to have them thinking I don't know what I'm doing.



Signs indicated that what you were thinking is 100% possible. Several lumps on the head. PT fell while running away and had to have 911 called. Why they hell would they even fake a seizure! I can understand if it was a druggy, but this seems like a legitimate MOI. If i had this, I would divert to a trauma center.


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## JeffDHMC (Jul 24, 2009)

No corneal reflex? I say legit, never seen anyone legit lack it.


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## Cory (Jul 25, 2009)

No, what you did was good. You are a good paramedic, your partner wasn't. Just take pride in knowing you did the right thing, and you will continue to do the right thing. I'm sure no matter how much ridicule you get, it will all be worth even if you just get a simple compliment on it. As Corky said, stick to your guns. Good patient is a quality vital to this job.


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## fma08 (Jul 25, 2009)

Aidey said:


> This is an issue that comes up every so often at work, and I'm wondering how you guys approach it.
> 
> Many people I work with seem content to assume that most patients who are conscious but won't respond to questions are just "playing possum" and there isn't anything legitimately wrong with them. I prefer to approach it as if they do have an issue and only consider the "possum diagnosis" as the last option. This has garnered me some ridicule at work, along with people calling me gullible and naive.*
> 
> ...



I'd go along the absence seizure line too, especially with all the potential for having a bleed of some sort going on there.


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## abckidsmom (Jul 25, 2009)

46Young said:


> Also, punitive IV's are a no-no:lol:



But in this case, the IVs aren't even close to "punitive."  She's a trauma patient with an altered mental status.  Whether she's faking or not, she's getting an IV with this presentation, maybe two.

I think it's completely possible she wasn't faking, and I'm with you; people who always think patients are faking get on my nerves.


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## marineman (Jul 26, 2009)

could've skipped the hand drop, I know I've posted about using it before but that was in jest. If you can brush the eyelashes and there is no reflex I'd consider it unresponsive. 

Tell your partner once they pass the paramedic test and are responsible for the patient they can treat it as they wish but you did the right thing. Also try to politely and professionally tell the nurse that you treated the patient in a manner that you deemed acceptable based on what you saw while the patient was in your care, now the patient is in the nurses care they can treat it however they'd like. I usually try not to butt heads with them too much but if you feel you've done the right thing stand up for yourself and use that as your answer to any issue that comes up. Nobody can fault you for doing what you feel is in the patients best interest.


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## 46Young (Jul 26, 2009)

abckidsmom said:


> But in this case, the IVs aren't even close to "punitive."  She's a trauma patient with an altered mental status.  Whether she's faking or not, she's getting an IV with this presentation, maybe two.
> 
> I think it's completely possible she wasn't faking, and I'm with you; people who always think patients are faking get on my nerves.



I was speaking in a general sense, not in regards to the OP. I've seen some medics start IV's that weren't necessary, just to punish a pt that would feign syncope or AMS. 

When I was BLS I assisted a medic unit responding to a 16 y/o female who faked syncope and unresponsiveness after a fight with her boyfriend - "Since you're not responding to us and are unconscious I have to give you a needle(introduced forcefully, with a reaction from the pt) and give you medications". This pt failed the arm drift and sternal rub tests. The medic gave D50, thiamine, and narcan. To mess with her further, he started bagging her forcefully until she pushed him away. 

The family must have been to ignorant as to proper medical Tx to file a complaint/sue, as the medics got away scot free with this.


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## emtbill (Jul 27, 2009)

She could be faking buy really who cares. Whether she is or not is not going to affect your care. The change in consciousness could be from the head trauma, but since she is already immobilized there's nothing to do about increased ICP unless you're a flight service with mannitol, or _maybe_ you could RSI (premedicating with lidocaine) to put the patient in a drug induced coma to decrease further brain swelling, but that would be very aggressive and I would not do it, though some providers might. I would also be monitoring EtCO2 to ensure adequate ventilation and changes in respiratory rate and depth but other than that this is a supportive care patient. I would have also started an IV. With this type of altered patient where many things could be going on there is nothing wrong or excessive with starting a routing 18 or 20 gague saline lock in their AC as some are saying.

On patients playing possum in general: If your assessment of the patient returns normal, including 12 lead, SpO2, FSBGL, neuro exam, etc, don't get too caviler thinking this is a drug overdose and trying to fix it with a bolus of narcan. As vent said this is done far too often. If the patient is unresponsive and is perfusing (SpO2=100%) and ventilating (EtCO2=35mmHg rather than 70mmHg) adequately, but is breathing 6 times a minute, I put the patient in recovery position and write "patient rested comfortably throughout transport" on my run report. Breathing and ventilation are commonly confused and if you understand the difference between the two it's a major clinical upgrade. Narcan does not always have a wide safety margin in a "coma cocktail" as many are taught, and can produce (but not limited to) grand mal seizures in the chronic opiate users. This is why ambulances generally do not carry romazicon, because it will get used far too often and will leave the seizing patient untreatable.

On patient you suspect are seizing for a benzo bolus: again, the best way to differentiate this is with EtCO2. If the patient is having a legitimate, sustained grand mal seizure (which is the only type you should be treating in the field), then the patient's medulla oblongata will also be affected, and the capnogram will show apnea. I have several strips of an EKG showing noise from the patient's "seizing", but the capnogram shows a normal waveform. They'll get tired of shaking in a minute and stop.

If you don't have EtCO2 nasal cannulas, get some. Steal from the hospital if you have to. It's worth your time to learn to read the waveforms.


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