So Dark the Con of Man

Yea, I saw The Da Vinci Code last weekend. I liked it very much. But no, this is not what my post is about. My supervisor was doing some teaching today and mentioned to the students how some patients, for whatever psychopathology, intentionally harm themselves. The topic was factitious hypoglycemia.

The students seemed skeptical. Like she was making that up, because, why would a person intentionally harm themselves? But no. I think all practising physicians have seen the darker side of the human psyche.

There was this 34 year old woman I saw as an intern, who was admitted for yet another episode of respiratory distress, from an apparent upper airway collapse. ENT couldn't find any problems with the airway, yet she'd appear like she would go into respiratory complications spontaneously. Couldn't eat; she'd gag and aspirate on anything that went into her mouth. The swallowing study was equivocal, and the radiologist reading the study suggested that the aspiration was intentional. She had a percutanous gastrostomy tube placed for feeding. And a tracheostomy, because while people were suspicious, she did appear to have unexplained upper airway collapse. And she insisted on having an epi-pen near her all the time, despite the allergist having proved that she wasn't allergic to anything.

The nurses who looked after her noted that her breathing problems would always occur when physicians were rounding or nearby. Never while asleep. And, there would be periods when she would stroll out of her room, to be gone an hour at a time.

And then one day, a physician who happened to go across the street for lunch at a nearby restaurant sees her there, shoving forkfuls of food into her mouth, plate after plate. Despite being unable to swallow. And then, he tailed her back to the hospital room, where she settled down for another day of the "can't swallow, can't breathe" charade.

Sometimes these are financially or pharmaceutically motivated. Like that patient who betrayed my trust and conned me into giving him a short course of narcotics for severe pain. When I refused to provide another prescription, he threatened to hurt himself. To which I calmly replied, "Just sit tight. Because you've threatened to kill yourself, I'll have to call the police now. Wait right there." He promptly recanted and said he was 'joking'. I fired him from my practice after that.

These might be easier to fathom. The ones with no apparent gain aside from medical attention, those are the ones that remain a mystery.

Munchausen syndrome.

Like that woman who had recurrent forearm abscesses growing polymicrobial bugs including gut flora. Strangely enough, these occur only in areas of her body that were within reach. Everyone who heard her story raised an eyebrow (she was cutting herself and wiping stool into the wounds).

I catch myself wondering, what on earth has to go wrong in one's childhood, for a person to be so messed up like that?

I suspect we'll never know the answers, why Man does what he does. One can only be thankful for a normal childhood and a loving family. But it's scary, how far a sick mind can take you.