Who's Really Gorked Out? Part 1

"Psychiatry consult service."
"We have a patient who sticks her tuckus in the air and her head in the pillow until her O2 sats drop into the 70's, and when she's not doing that she's abusing the nurses verbally, and when she's not doing that she's pretending to be asleep so you can't talk to her. What do we do? Does she have a personality disorder? How do we manage her?"
"OK, (sigh), we'll come take a look."

Anything else to know? (BTW, O2 sats are a common vital sign measured; normal is above 90%, and it is a measurement of the percent of binding sites for O2 in a person's blood that are filled. Below 60% is really bad news, but any drop below 90% is at least worth noting).

The patient is 38 and has been on dialysis for 20 years. TWENTY! Five or ten is pushing it. One failed transplant. Homeless often, polysubstance abuse. When she was admitted, there is a measured blood pressure of 277/119. We thought it might be a dictation anomaly, and that the real value was 217/119; either way, some serious hypertension. At that level, bad things happen.

Does she have a personality disorder? We investigate. We go in to talk to her, the two med students. As soon as I get to her room and see her chart, I have flashbacks to Medicine. The forty-plus medication list. The isolation gowns because she's had MRSA (resistant Staph, a bacteria that is harder to treat than normal), the monitors in her room that surround a tiny black woman curled up and snoring in her bed. For the next ten minutes we enter a cycle of waking her up, at which point she barks out a 'what?', we ask a question, and before we're done, she's snoring again. At one point she even gets out a 'well, go on and ask your question, doctor', with emphasis. She's been in and out of the hospital for twenty years and I wonder if she's purposefully emphasizing what we are not.

Back to the staff. Apparently she 'plays possum' and doesn't want to answer questions, but then sometimes wakes up and is abusive. Hence the personality disorder consult.

Except...what if she isn't playing possum? A personality disorder that would make you argumentative and abusive would fit in a cluster that includes antisocial, narcissistic, borderline, and histrionic. But you have to know the person for a long time, have seen this disturbance repeat and be durable. Personalities are the bedrock on which we constuct our glass houses, unchanging.

Is there anything else that could be leading to this behavior? Any other answer amidst the forest of IV poles, the disposable gowns, the surgeries, the failed organs, the unbelievable pressure in her vessels that traverse every tissue in her body, no matter how fragile?

We all agree she's gorked out, rather than playing possum. Even if you threaten (not that we would carry it out) to use some injection or antidote to her pain medication, she doesn't rouse. Still, is she just too seasoned to fall for our gambit?

Patients like this are the true test. They are difficult, they are unlikely to be 'fixed' or 'cured' and they may well be much more wily than, well, med students for sure. They often raise questions in me about the limitations of medicine and the patterns we can fall into, especially with these so-called 'professional' patients. Our attending was under the impression that she likely had some form of hypertensive encephalopathy--that is, the main problem was brain damage from her hypertensive episode, not a game of possum. But there's no way to know. So we tinkered with her meds, suggested a few changes--discontinue the Cymbalta, which can contribute to hypertension, consider reducing her narcotics (a fentanyl patch as well as Dilaudid, if I remember right); then, wait, and see.