Monday, October 25, 2010


We've run on him fifty times. I've written a dozen charts personally in the last year, and I'm one of twelve ambulance medics in our district. Everyone knows him. Everyone knows the address. We groan when the dispatchers name the apartment complex, and snarkily ask our partner if they need help getting mapped in.

Chest pain, always chest pain. He has the history -- a zipper scar, a boxful of pills, a 12 lead with Q waves. He looks scary -- pale, clutching his chest, always telling you it's real bad this time, it's never been this bad. The first time, and the second, and the third, you get worried, you work him up hardcore, pushing the nitro and fentanyl and repeating 12 leads and bypassing the community hospital to go to a cath lab facility, just in case. Just in case.

But the fourth, and the fifth time, your concern start to wane. Despite everything, he's stable. He doesn't decompensate or throw PVCs. He doesn't get cathed. And then the doc at the recieving facility starts to tell you about all his visits. How he requests narcotics by name. The mysterious morphine allergy. And the picture starts to come together in your head.

* * *

We were out of district when the call came down for a domestic at his address. We sent the cover unit an MDC message. Just so you know, if the guy claims chest pain, he's usually not as bad as he looks. Work him up, but he's got a history of seeking. Just so you know.

A while later they write us back. Wasn't him. He beat up his brother. He went to jail.

Huh. Isn't that something.

* * *

But an hour after that, we're toned to the police station. Law enforcement request for medical. I bet my partner a dollar it's him, that he's developed chest pain in the cell.

We walk in. I turn to my partner. "You owe me." He laughs. The firemen are standing around, getting vitals. No one seems rushed. I ask the cops about what happened. Is he still in custody. Yes? Okay. Which hospital? The one by the county lockup? Sure, we can do that. No problem.

I walk back to the cell. Vitals okay? Right. And when did he say the chest pain started? How does the 12 lead look?

"Well," says the fire medic, "actually tonight it's this weakness. And he's acting like he can't talk."

I blink rapidly, and look at the patient. He's not moving anything on his right side. The corner of his mouth droops. A fireman asks him about allergies, and his answer sounds like Animal from the Muppets.

Are you kidding me?

I do the neuro exams. He's definitely a "good" stroke, by the numbers. He's got the risk factors. The fire paramedic rolls her eyes. "He's pulled this before, too. Haven't you seen it?"

No. No, I have not. We can't treat it like he's faking. We have to work it up like it's real. It looks real to me.

"Absolutely," she agrees, and she is in fact a decent paramedic, one of the better ones to ride an engine. "All I'm saying is, don't get too excited."

We load and go. Code 3 to the closest hospital, call the stroke alert, large bore lines in both ACs for CT scans, 12 lead just in case, the whole Happy Meal deal, with toy included.

At the hospital, the ED doc thinks it's genuine. He passes the Hand Drop Test, smacking himself in the face. His reflexes are absent on the affected side. He doesn't have a bleed, on the scans. We tell the doc about the history of seeking and faking, and he nods, but says it's no reason this couldn't be the big, bad, ischemic stroke it appears to be. I agree readily. Absolutely, doc. Just want to make sure you have all the facts in hand.

"Appreciate it," he says. "We'll see. Neurology is coming in -- and pharmacy is sending the tPA up."

Six hours later, dropping off another patient, they tell us he got the 'lytics, and went to the ICU with some improvement showing.

Huh, we say. He finally had the real thing happen. Poor guy.

* * *

A month later, I run into the doc again.

Hey, you remember that stroke? The one who had the history of faking, but turned out to be having the real one? How'd he do?

The doc just shakes his head. "They did CTs and MRIs and all the tests you could imagine. Never found any evidence that he'd actually stroked."

What? Seriously?

The doc sighs and rubs his head. "Oh yeah. Yeah."

"Wow," I say. "What happened? I mean -- he got the tPA. How'd that work out?"

A shrug. "Who knows."

Another doc pipes up. "Bled out, probably. Poor bastard."