Wednesday, December 6, 2000:

Feeling:  Tired.
Must ... make it ... to:  Saturday!

I bought a T-shirt from him and I didn't die! :  Mikeleung.com ... sick and extremely funny.
(The Death Star one is my favorite.)

---

HAIL CAESAR

Intern's Note:

"Pt (patient) states he wants to go home today.  10 min later starting having generalized seizures times ten minutes.  Given Ativan I.V. twice.  Patient realizes importance of staying now."

CLOCKWORK DRUNK

(title guiltily ripped off of clockworkstorybook.com)

Rounds in my office:

"Mr. Caesar seized again last night, around six.  Then again this morning at eight and ten," the Innocent Intern tells me.

"He's on a ton of anti-seizure meds, and he's getting unbelievable amounts of Ativan and he's STILL seizing," the Big Senior explains.

"What's neurology say?" I ask.

"They haven't been around yet."

"Hmm."

"Could he be faking it?" the Stony Sub-intern suggests.  

It's my first week with the new resident team, and none too soon.  The change of pace always saves me from drowning in despair with some of the more depressing cases.  There's only so many jokes of your own that you can laugh at.  Misery loves company.  

I enjoy working with the residents, as their teacher and attending, and friend if I can help it.  It's one of, if not the best parts of this job.  They are always a joy.  I totally can't stress that enough.  

The Stony Sub-Intern is a fourth year medical student who's spent the better part of the past two years in the DMZ (Detroit Militarized Zone) hospital system (very different from the Imperial Hospital here).  

You can tell right off by her hard cynicism and that 1000-drunkard stare that she's spent many a midnight hour dealing with drunken drugged-out gun and knife victims, if no one else.  And she's not even an official doctor yet.

"What?  But he is soooo nice.  Why would he be faking a seizure?  He keeps saying he just wants to go home,"  the Innocent Intern defends.  She's originally from an ivory tower academic center, like myself.  

"I was thinking about that last night.  Saying he wants to go could be part of the act.  He always seizes after saying it, and then he gets his Ativan.  Like clockwork.  It's better than booze.  I hope I'm wrong though.  We'll do more tests," I say.  

4-LETTER NAME

My first encounter with Mr. Caesar was a pleasant one.  He was a large man, but was also kind, gentle, and appreciative.  I responded reciprocally.  He had an interesting tattoo across his knuckles though:

A four letter word that happened to be his real name.  

It reminded me of the psycho in Cape Fear with "LOVE" and "HATE" tattooed across his knuckles.  I found it amusing.  

That should have been a clue.  People who tattoo their knuckles are usually people who use their knuckles.

SAINT SEDATION

Mr. Caesar was a homeless alcoholic.  He had every reason to have real seizures, and for the past several days we treated him like any other withdrawing alcoholic: with kindness and benzodiazepines (sedatives).  They actually prefer the benzos.

He also had every reason to fake his seizures too.  A warm bed.  Warm food.  Television.  And something better than alcohol -- intravenous sedatives.  And all "free," and he knew it.  

I wanted to believe him.  It's our job to give everyone the benefit of the doubt.  But you have no idea of how many people take advantage of that fact.

No idea.

DON'T USE THIS INFORMATION FOR EVIL

The inconsistencies started adding up.  

"Prolactin?" I ask the team.

"Normal."

"Electrolytes, muscle enzymes, lactate?"

"Always normal."

"Head C.T.?  EEG?"

"All normal."

"Anti-seizure med levels?"

"All therapeutic."

"Incontinence?"

"None, until this morning.  He was wet after his 8 a.m. seizure."

"Hmm ... he knows we're getting suspicious.  He's upping the ante," I think aloud.

"He's never had seizures at night.  Never outside his bed.  Spaced every two or three hours.  And he's never drowsy or postictal afterwards."

After ten minutes of hyper-electrical activity frying your brain, you really should be a drooling boneless chicken, for a while at least.

"No tongue biting or bruises either.  After two dozen grand mal seizures you'd think he might hurt himself ONCE," I add.

"I think he's lying," the subintern adds firmly.

"How can you be so sure, my dear intimidator?" the Big Senior playfully teases the diminutive sub-intern (4th year student).

"How much time have YOU done in the DMZ?" she confronts him unblinkingly, as if her declaration is as obvious as fresh urine on a bare crack house floor.

Time, as in hard time, as in a prison sentence.  That's how it sounds when she says it.

She still doesn't blink.

WE.HATE.FAKERS.COM

"The neurologist saw one of his seizures and thinks its fake too," the resident tells us later.

We half-jokingly discuss ways to stop his fake seizures the next time we see one.

"We could roll him over and do a prostate exam.  That'll make him stop if he's faking.  Haha!" someone other than myself suggests.   

"The thumb screw test we do on comatose patients.  That should tell us," I say in total seriousness.  

It's the same test I do on corpses when I want to make sure they are truly dead.  It's incredibly painful, incredibly easy to do, and it doesn't leave a mark.  Sometimes I can even get a response from so-called comatose patients.  So far it hasn't woken anyone up from the dead though.  Yet.

"Maybe we can give him saline (water) injections instead of the Ativan and see if he stops," another suggests.  

"Good idea, but I don't think that's ethical.  We still have to treat his seizures as if they are real until proven beyond a doubt," I gently remind them, and myself.  

"I say we punch him in the groin!  BAM!!  That's always the circuit breaker," another adds in jest.  

I laugh more than someone of my gender or profession should.  But I say laugh when you can; you'll wish you did later.  This is also why my office door is usually closed.

The third year student is still shiny and eager to impress (this changes dramatically by fourth year).  He suggests an actual treatment for persistent seizures,

"We'll tell him he needs a lobectomy!"

(That's removing part of the brain.)

"Let's just get the 24-hour EEG first," I smile.

We detest liars and fakes, but no one wants to convict an innocent man.  

SHOWDOWN in LITTLE MANILA

The progressive floor is in between a regular medical floor and the Intensive Care Unit.  Mr. Caesar happens to be in the one populated mostly by a wonderful Filipino population, most of whom are related.  

By nepotism if not by coincidence.

It's affectionately referred to as "The Filipino Mafia," "The Filipino Cabal," and Dr. Slick's personal favorite "Little Manila."  

Today started out with Mr. Caesar asking for another shot of Ativan, minus the seizure this time.  Apparently, even he was getting tired of the act. The nurse refused.  

He then spastically shook the right side of his body for ten seconds, and stopped and said,

"Well, aren't you going to give me the f***ing Ativan for this seizure?!!"

The shocked veteran nurse refused again ... and backed away.

Then he destroyed $600 of EEG equipment and tore out his I.V.'s splashing his hepatitis C blood over the walls, and started trashing the room.  

The nurse ran and called security.  The big bald Korean Oddjob security guard wasn't enough.  They called in three others to restrain him.  

That's when the nurse called our Innocent Intern to yell at / inform her of the situation.

"He wants to leave now," the intern says, distressed.

"Did we get the results for the 24 hour EEG?" I ask.

"Yeah, negative, despite two episodes last night."

"Let me talk to the nurse .... Hi, this is Dr. Scott.  He's been faking all along (she already knew this at this point).  Give him the A.M.A. (Against Medical Advice) papers and let him go.  This guy is doing us a favor."

A few minutes later we arrive on the floor.  I rush to his room, more out of curiosity as to what kind of devil our gentle lamb had become.  The bed is already stripped clean of every blood-spattered linen.  The papers lie on the floor unsigned, like newsprint over doggy puddles.  

The nurse says,

"He's gone already.  Security escorted him out.  We could have used your muscle a few minutes ago Dr. Liles," she smiles.  

The nurse is old enough to know that complimenting a guys physique (whether he has one or not) is a majorly effective flirtation.  

The Innocent Intern knows this too,

"She wasn't that nice to ME two minutes ago!" she grumbled to us.

"It's a same sex thing," the sub-intern states.

"She'll be nicer to you when you're a senior," the Big Senior and I agree.

Yeah, she was mean the first time this happened to us when we were interns too.

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