Movers and Fakers


One of the first things I look at when a new consult comes into the queue is the date and time that the request was faxed into the electronic medical record system. The next thing I look for is the date and time that the patient hit the door to the admissions area of the emergency department. Sometimes the difference between the two is as little as five minutes.  How can that be?

Well, you see, the ED is a very busy place. Patients are coming in with chest pain and vomiting and surgical abdomens and broken ankles and all manner of ailments. One of the first jobs of the ED staff is to triage these patients, that is, to decide who has a routine need like a badly scraped and bleeding knee, an urgent need like fever and nausea, or an emergent need like crushing substernal chest pain, an ashen face and radiating pain down the left arm.

Psych patients come into this swiftly flowing stream of humanity and get buffeted from one side of creekbed to the other. It’s almost a given, almost, that if the chief complaint is “I’m seeing little green men”, “Brad Pitt is in love with me and wants me to have his babies” or “The NSA is tracking all my phone calls”, then that patient gets shuffled off to the mental health area of the ED. (Oh, shoot, I meant to edit out that last example. Can’t use that one anymore. Note to self…)

Now, this is all well and good if the patient does indeed have a bonafide mental health problem and nothing else. She gets put through the usual screening process, has her clothes exchanged for luxurious blue paper scrubs, and is asked to take a seat in a hard cold plastic chair until someone can see her.

But what if this patient, who presents with let’s say, acute anxiety and a feeling of impending doom, starts to become ashen-faced, gets more and more short of breath, starts to have chest pain, and then collapses onto the floor in a heap? One then starts to think (really quickly and with feeling) about “real” medical problems like hypoglycemia, pulmonary embolism, and heart attack. Little green men and Brad Pitt be damned, people who have mental health problems also get sick with medical problems, and some of them will die if these are not recognized in time.

This is another special group of patients who come into the ED and have what appear to be anxiety, depression, tremors or even hallucinations, but in fact have an undiagnosed medical condition.

Could you give me an example, please?

Of course I can. Several.

Thyroid disease is one of those pesky problems. Have the thyroid gland rev up too much and a person can present looking as manic and paranoid as RIchard Pryor on crack. Stop it from working, and you have a depressed automaton, Al Gore on the campaign trail.

Anxiety, and a patient that looks jittery, jumpy and psychiatric in triage could come from hypoxia, pulmonary embolism or drug withdrawal.

Of particular interest are the connective tissue diseases and autoimmune diseases, which can take up to a decade to correctly diagnose. Patients come to the ED with funny physical sensations, migratory numbness or even hallucinations with no prodromal history of schizophrenia or any other psychiatric disease. I have heard many of these folks tell me after the fact that they started to believe they were “really crazy” after trying to explain their very real physical symptoms that seemed to have no rational or diagnosable cause to physicians who were skeptical at best.

As I’ve said before, all that glitters is not gold.

All that hallucinates is not schizophrenia.

Sometimes the patient who presents with weird numbness and one sided weakness is not having a conversion reaction but is suffering from a neurological or medical disorder that is diagnosable and treatable, if one will only look for it before the patient goes to ED mental health purgatory.

3 thoughts on “Movers and Fakers

  1. Yes. And sometimes people with bona fide psychiatric illness *also* have bona fide physical illness.

    One of my instructors used to intone with tiresome frequency, “Psychiatric patients always die from physical causes,” always reminding us not to take the easy option because sometimes the hoof beats are, in fact, zebras.

    I had a patient with a long psychiatric history who started having symptoms that included shortness of breath, palpitations, and a feeling of impending doom. Repeat visits to the emergency department and her PCP always ended with a diagnosis of anxiety. Finally–and I’m sorry to say I was not the one who was behind this–appropriate studies were done and it was discovered that she was suffering from Non-Hodgkin’s Lymphoma in addition to her anxiety disorder, the symptoms of one both exacerbating and masking the symptoms of the other.

    This wasn’t an easy call, but it probably would have been diagnosed sooner if someone had looked for a physical cause of the symptoms, too. Thank you for this post. It’s an important issue, especially in the ED.


  2. Greg,

    This is just good old-fashion medicine…acute observation, quick diagnosis, treating the presenting symptoms, & NOT preconceived ones! Our microwave dinner, quick fix society does not fit well in the medical field! Yes, quality time with the patient is imperative for accurate diagnosing…especially in your area.



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