Something interesting happens to physicians and nurses after several years of service to the Emergency Medicine gods. They are vested with a strange power. It is a unique ability which comes upon them as a reward for their many Herculean efforts. One day, after many trials, travails and tribulations they develop a kind of sixth sense regarding the hidden motivations of people. It’s quite spooky, really and very often Dr. Cranky can discern the truth behind a patient’s stated medical complaint with a mere glance. Emergency Medicine professionals refer to this as their bullsh*t detector, and after 20-odd years of clinical practice Dr. Cranky believes his has been tuned to an exceptionally high degree of precision. It was only several days ago that alarm bells sounded as your host’s detector went off, and warned him he needed to get his hip boots out of storage with a patient he shall refer to as Ms. P.
It was during a day shift when Ms. P chose to grace Dr. Cranky’s presence. He had just finished discharging a patient and had placed their chart back in the rack when he looked up and beheld Ms. P as she entered his field of vision. She was young, in her mid-twenties, attractive, and was being pushed in a wheelchair by the triage nurse. One look at her body language and face said it all; tragedy. It was obvious this was not just any tragedy, mind you. This was tragedy on a grand scale. Tragedy which permeated the depths of her very soul. Tragedy mixed with . . . despaaaaair. And directly behind was a whole host of worried family members in hot pursuit.
The patient, triage nurse, and family disappeared into Room 2 and Dr. Cranky looked at his computer screen to discern the reason for Ms. P’s visit. The word “headache” appeared by her name, as if by magic. As is his habit, Dr. Cranky immediately began formulating his differential diagnosis. First of all, as any good emergency physician is trained to do, he considered the worst-case scenarios of subarachnoid hemorrhage (bleeding in the subarachnoid space surrounding the brain) and meningitis (an infection/inflammation of the membranes surrounding the brain). Next, he listed possible trauma with its concurrent complications of subdural or epidural hematomas (collections of blood from disrupted veins or arteries). Third on the list were chronic conditions such as migraine and cluster headaches as well as temporomandibular joint syndrome and tension headaches. And finally, as his bullsh*t detector was telling him, Dr. Cranky was afraid there was the very real possibility he would soon be dealing with that condition dreaded by emergency physicians far and wide known as APS – Acute Princess Syndrome.
First of all, dear reader, Dr. Cranky feels he would be remiss if he did not give you a brief explanation of what Acute Princess Syndrome entails. Whenever he sees a patient, the first thing any competent emergency department physician must determine is whether the problem in question has an organic (physical) cause or is of a functional (psychological) nature. Many times there is a component of both, and this is especially seen in APS . In the emergency medicine vernacular, a Princess is a someone, usually female, who uses illness as a means to exert influence or control over those around her (and for those readers who are overly concerned about gender issues, fret not because Dr. Cranky shall examine the male variant of APS in his very next post). This is in contrast with another interesting personality type seen in the ED known as the Drama Queen. The primary difference between these two personalities concerns the patient’s underlying motivation. A Drama Queen likes the emotional jollies she gets by inflicting chaos upon her surrounding environment and could care less about influencing others. A Princess, in contrast, is more goal-directed. She seeks to use illness and/or emotion as a tool to gain control of any hapless soul who finds himself trapped within her sphere of influence.
Within a few moments the patient’s nurse, and one of Dr. Cranky’s favorite people to work with (a nurse by the name of Sweet Sandra) came up to your intrepid chronicler with the patient’s chart. One look at Sandra’s face told the tale as she contorted her face into a mock-pout and informed Dr. Cranky that, “princess has a headache.” And so it was, with a heavy heart and two Maalox tablets, that your host made his way over Ms. P’s room, knocked on the door and entered.
Dr. Cranky’s initial gestalt upon entry was not good. Ms. P lay on the hospital stretcher, arms to the side with her palms up and eyes closed. All around was her entourage; various family members huddled about the bed with looks of anguish etched upon their faces. Indeed, the scene reminded Dr. Cranky of The Ascension of Mary by Guido Reni.
A Reasonable Facsimile of the Scene in Room 2
All that was missing was the dreaded “wet cloth sign,” whereupon some family member tries to invoke the healing properties of a wet washcloth by applying it to a patient’s forehead. And yet, your host could not shake the nagging feeling that something was not quite right. Something was missing. Some key element. A vital member of this mise-en-scène had yet to make an appearance.
Dr. Cranky introduced himself, sat down and began the interview with the open-ended question of “why have you come to the Emergency Department.” It did not go unnoticed that Ms. P did not answer this question herself. She just lay there, eyes closed while her mother answered the query. “Well,” the mother began, “P and her fiancé were discussing their upcoming wedding and plans for the honeymoon when she suddenly developed this terrible headache.” Your tireless correspondent pondered this for a moment and then asked several key questions. His inquiries revealed that Ms. P had a long history of similar headaches and had seen her family physician in the past for these episodes. She had been evaluated with a prior CAT scan and MRI and no structural lesions could be found. She had been referred to a neurologist, and an electroencephalogram showed no evidence of any electrical abnormality of brain function. This headache was similar to her prior episodes and was not the worst headache of her life. There had been no recent head trauma, viral/bacterial illnesses or fever. This was all good news as it meant the possibility of a life-threatening problem was miniscule and no extensive workup was required. The only thing left to do was to ask a final question and perform a quick physical examination. Things were looking good.
It was at this moment that the missing element made his appearance. Without warning, the door opened and in rushed Mr. M, who just happened to be the patient’s aforementioned fiancé. Without a word, he made he way to the bedside, took Ms. P’s hand and asked her if everything was all right. The manner of his entry confirmed Dr. Cranky’s suspicions. He had seen this sort of drama many times before and his heart sank. He knew what would soon follow. Things were about to become complicated; much more complicated than before and perhaps even ugly. Every damsel in distress needs her protector and Princess’ Knight in Shining Armor, the Macho Man, had just arrived.
It is time to take a moment to acquaint you, dear reader, with that variant of the masculine gender known as the Macho Man. Despite modern sensibilities, Macho Men still exist in our society. They are not bad people, really. In fact, they can be quite gallant and considerate. Such a person generally has old-fashioned ideas of what it means to be a man and looks upon himself as a protector of those he holds dear. He works hard, fights for what he considers right, and is just the sort of fellow one would like to have next to him should the proverbial excrement hit the fan. Unfortunately, he also tends to not be very bright, and is easily manipulated. This poor soul is putty in the hands of someone as devious as a Princess.
The next order of business was a general physical examination of Ms. P and she was found to be in good general health. This was followed by a detailed neurological examination, and it was obvious that Mr. M was watching your humble servant’s every move closely. In situations like this, to reassure the family, Dr. Cranky will comment on the results of his evaluation as he conducts it. Specifically, he will say such things as “lungs clear, heart without murmurs and with good rhythm, cranial nerves normal,” etc. Then it came time to assess Ms. P’s motor function. Your faithful examiner held out his index and middle fingers in front of his patient and asked her to squeeze them as hard as she could. With that request, Mr. M proceeded to reach over, take hold of Ms. P’s hands and lift them up to Dr. Cranky’s fingers with the comment “she’s too weak to lift her hands, Doc.”
There was no need for further evaluation. An extensive workup had already been done, a specialist consulted and the patient’s symptoms were no different from their usual pattern. Dr. Cranky asked his final question, “What were you talking about just before the headache started.” “Well, doc,” Mr. M began, “we were talking about where we should go on our honeymoon. P, here, wants to go to Hawaii but I think it would be better if we took an Alaskan cruise instead.” All of the pieces were now in place. The final question of motivation had been answered. Dr. Cranky proceeded to explain to Mr. M and the family why he thought Ms. P would be just fine and that all she needed was a little rest. He pointed out that a prior CT scan, MRI and EEG had all been normal. He reiterated that a neurologist had pronounced the patient’s neurological health hearty and hale. He assured all concerned that, with a normal physical exam and no deviation from her usual symptom pattern, Ms. P did not require any further testing. Of course, should things change, the family should bring their beloved back in for re-evaluation. We were always happy to have her return if necessary.
There was silence in the room and Dr. Cranky took his leave, waiting for what he knew would soon follow. He did not have long to wait. No more than five minutes passed before Mr. M came out of the room and asked to speak with him. “You don’t understand, Doc,” he said, “there’s something wrong with P.” Dr. Cranky began, all over again, to explain why he thought Ms. P would be fine. He had not finished his first sentence before Mr. M placed himself even closer, easily within the acceptable social distance our culture permits and said, “You don’t understand Doc, you need to do something.” Think what you will of a Macho Man, be it as a forgotten hero who should be admired or a throwback to be castigated. Whatever your bias, you should always remember this; one should never publicly challenge this member of the male sex, nor should one dismiss his concerns outright. “What do you suggest?”, Dr. Cranky inquired, knowing what the answer would be. “I don’t know, you’re the doctor,” Mr. M responded, “Personally, I think she needs another CAT scan.”
This was not the first time Dr. Cranky has found himself in this situation and it was with great effort that he stifled the urge to say, “and would you like fries with that?” It was hopeless. This was a situation where no amount of logic or reasoning would prevail. Your host is painfully aware of how quickly such encounters can turn violent and he did not wish to call Security. Nor did he wish to spoil the future Mr. and Mrs. M’s wedding by requiring the family to bail Mr. M out of jail and/or pay any future court costs. Instead, he responded to Mr. M by assuring him that he would be more than happy to subject his bride-to-be to another round of potentially hazardous ionizing radiation. And so it was done.
Needless to say, Ms. P’s unnecessary CT was normal and she, along with her entourage and the ever-protective Mr. M, were soon on their way. It was not much longer after this that Sweet Sandra came back over to Dr. Cranky and informed him of Mr. M’s displeasure. “He was unhappy with your care,” she informed him. “Mr. M thinks you should have done more tests. He said he’s going to refuse to pay the bill and intends to write a letter of complaint to the hospital administrator.”
“I wouldn’t worry about him writing any letters,” Dr. Cranky answered back, “I think Mr. M is going to have his hands full trying to decide which pair of swimming trunks he’s going to pack for his honeymoon trip to Hawaii.”
And with that Dr. Cranky picked up his next chart. All in all, it was just another day in Paradise.