I'm often sent to a patient who has 'collapsed', sometimes this is due to a genuine medical condition – something like a heart attack, a stroke or diabetic problems. Often this is due to alcohol – the location and calltaker details often gives it away – the patient is in the street and the person who phoned for the ambulance cannot give us any details because they 'don't want to go near the patient', that or they are phoning for us from a bus or car.
'Drive-by calls' are normally for drunks in the street. Often homeless drunks who speak very little English.
The final sort of 'collapse' that we are often sent on is the pseudo-collapse.
This is a person who has not actually collapsed per se, but instead is pretending to be unconscious. Sometimes they will also pretend to have a seizure. As AD calls them 'status dramaticus'.
Now, were I an educated man rather than a mere stretcher monkey, I'd look things up in my big book of mental illness and see if there is actually some proper illness that causes people to pretend to be unconscious. While I suspect that there are situations where a mental illness might show up like this, in most circumstances it's a case of 'bad, not mad'.
So, how can I tell if someone is pretending to be unconscious? The simplest is the eyes – if you are unconscious and someone goes to open your eyelids, they open. In the faker the eyelids stay shut. It requires a conscious effort to keep your eyes shut.
The other way is the 'hand drop'. Raise the patient's hand over their face and let it drop. With an unconscious person the hand will hit the face, for the faker they won't want to punch themselves in the face and so the hand drops to one side.
These two tests, and some vital signs are pretty conclusive as to telling the faker from the really unconscious.
The trick then is what to do about it.
In my old age, my patience for such games has decreased, mostly because I don't want to be carrying someone downstairs who I don't need to – I'd reckon that my back has only a finite number of carry-downs, and wasting them on someone who does not require such service is just accelerating my early retirement through ill-health.
The relatives, for there are always relatives, will also need some serious explaining done to them in order to let them know that their beloved is playing a game. A not very convincing game at that.
And I can spend an hour explaining that their relative isn't actually sick, but as soon as they hit the hospital they will still demand that they be seen immediately as the poor little soul is obviously on death's door.
So, what I mainly do is talk to the patient, tell them that I'm much too wise to be fooled by them and that if they would kindly open their eyes and talk to me I can then fulfil their wishes by either taking them to hospital, or by leaving them at home.
Sometimes the patient will 'wake up', and either go to, or refuse, hospital. Often though the patient will steadfastly screw their eyes shut and continue their deception.
When the person wants to continue playing this game they seem to forget that I have dealt with this situation before.
One of the ways in which we assess unconsciousness is via the 'Glasgow Coma Scale'. To properly complete this assessment the apparently unconscious patient has to have painful stimuli applied to them.
Painful stimuli by someone with knowledge of anatomy.
Just allow that thought to roll around in your head for a bit.
There are several approved manners to cause pain without causing damage – the pen on the nail bed, the pressure to the orbital bone, the jaw thrust. All of which are rather painful.
The one that is frowned upon these days is the 'sternal rub', probably because it is so effective at waking the dead. Just rubbing your knuckles on someone's sternal bone is enough to snap their eyes open and have them talking to you.
Of course, this is devalued, and I would never do such a thing. That is until, like much in medicine, it returns in vogue.
Note, this is never done to punish the patient, this is done so that we can truly assess the level of patient's consciousness.
It annoys me that, when getting the patient out to the ambulance the 'persistently collapsed' will be picked up or dragged by their relatives – there is no need for it, and I keep telling the relatives that they shouldn't do it because (a) there is nothing wrong with the person, and (b) they are only putting themselves at risk of being hurt.
The reason I'm not carrying them is for much the same two reasons.
But still the relatives, while nodding and smiling and agreeing with me, will manhandle the patient down the stairs, out the door and into the ambulance when all the patient has to do is open their eyes and walk.
So, what causes these people to fake a collapse?
Overwhelmingly it is due to either some bad news, or due to an argument within the family.
I'm somewhat more sympathetic to those people who have had bad news, it's the classic 'shock' – not in the medical sense, but in the sense that someone gets a bit shaken up by some news and wants to demonstrate how shocking the news is.
These folks will often 'wake up' with a bit of gentle prompting.
Those who pretend to collapse into unconsciousness due to an argument find themselves perhaps not receiving my full sympathy (for my sympathy is like water in a bucket, it is finite and when that bucket runs dry then I really could care less about your 'troubles').
Husband and wife, mother and daughter, father and son, cousins and boyfriends and girlfriends (and scarily sometimes a combination of these), it doesn't matter, one feels so aggrieved that they want to 'scare' the other person – and so collapses.
And then we are called.
Only recently I was called twice to the same house, and the same person, for this very reason. The patient ended up telling us to 'fuck off'. Which was unpleasant. Thankfully the family agreed that if the patient did it again they'd drag them off to hospital themselves.
I don't know if there is a cultural element to this – I suspect that there is, but then most of my patient's are from the Indian subcontinent, so it is only reasonable that I would see more of these fake collapses in people originating from there.
So ambulance people in areas with different ethnic backgrounds have the same experiences, in the same numbers, that I do? Something for the researchers I think – although what to do if the actual answers are less than politically correct?
All I know is that these sorts of jobs are a colossal waste of time – I'm sent on blue lights to these jobs (a driving risk to myself and other road users). Meanwhile people who genuinely need an ambulance go waiting.
There is sadly no answer – these calls can't be triaged out effectively over the telephone, so we have to continue going to them, and I doubt that 'patient education' will be much help either.
I've not been dead, I've just been without muse. To paraphrase Warren Ellis I went from being a writer to someone who watches television. (The linked video contains some naughty words, so probably NSFW). Although in my case replace 'television' with 'World of Warcraft'.
Hopefully, I'll be writing a fair bit more – as well as getting my teeth into my Secret Project™. Well, one of two secret projects really – but one of them at least won't be secret for much longer.
I shall also be removing the hitchhiking tool from the post-digested food outlet and will be trying to make some changes in my life for the better.
15 thoughts on “Collapse”
Out here in the Colonies, Australia, we've got FAS, Floppy Asian Syndrome but your right, the complaint transcends to the other cultures as you move around the suburbs.
Oh yes! There is definitely a cultural element to it. We call it “Mrs Khan Syndrome” in my neck of the woods because we see it mainly in Pakistani women. I know, I know, not very PC of me.
I lived with a woman who did this sort of thing. Fainting, fake stomach pains, I saw the lot. Usually went to hospital and was seen by a doctor whose face would then turn the black of the darkest thunder cloud – or volcanic ash.In a word – Munchausens.
Personally, I love it when the 'patient' manages to resist painful stimuli and therefore is GCS3 (on paper at least). Always worth protecting the airway in cases like this, time for the NPA! Always a great reaction when I shove one of those bad boys up their nose!
…and as for the topic of cultural differences in responses to illness; here's a interesting post on the subject by Kal (Trauma Queen).
(sorry for the long link, no good at html).
Is it wrong I have no qualms what so ever about doing collar bone rubs? that tends to wake people up pretty damn fast.I know its so wrong but the slight sadist in me finds it fun 🙁
I knew I forgot to mention something, that something being the diagnosic value of airway adjuncts.I've read Kal's piece (I think I linked to it myself) and it is a superb read.
I've used the threat of a nasal airway on a number of drunk “unconscious” casualties when on various first aid duties. Never once had to actually use it. The exchange of “They're unconscious? Get me the KY Jelly!” (to allow the airway in easier though the patient generally doesn't know that) generally gets then up and awake in less than a second!
here in the western US ambulance world that is termed “hispanic panic” due to the high number of young, hispanic women who “faint” on a constant basis. also not very PC, but nothing in this job ever seems to remain PC for long, if ever. nothing beats a sternal rub to bring someone back to “consciousness”! gotta love it!
out of curiosity where do teenagers with mental health issues come?Looking back years ago i can recall “collapsing” after a rather large overdose. My legs did go from underneath me but i'm pretty sure i could have sat up but doubt my legs would have held me up honestly – however swiping at the wasp (a big fear) gave my game away slightly to the amusement of the MH staff.
collapsed yes. physically ill yes. mentally unwell also. But not totally unconscious. I know these days that my childish reactions were no excuse. But i would be curious to know your feelings.
(by that time i had also been sectioned for about 3/4 months, having just returned to the open ward for the PICU – to add a little context)
Mental illness is mental illness. Like diabetes is a medical illness. Sometimes I understand it, sometimes I don't.What I'm talking about here isn't mental illness, it's something else – but I'm not sure what.
Some years ago, I had a female neighbour who used to do this sort of thing. I remember her husband saying she had diagnosed mental health conditions. The main one manifested itself as physical symptoms that mimicked those of actual diseases or injuries but without the underlying cause. It was something like Brickets? Or Brickits? (I can't find it on Google so the spelling is probably not correct.) It was exacerbated by some sort of histrionic disorder.She was a right pain in the proverbial. Her husband and son seemed resigned to it.
Social illness – that they have no way of making themselves heard or getting people to pay attention to their needs than doing something like this?
Recognising the differences in society is PC.We see social groups that emphasize pain and others that play it down. Some whale while others become quiet.
My personal favorite is spitting. Cultures that had the black death find spitting on the ground repulsive while those that did not find the idea of spitting into a tissue and putting it in your pocked unhygienic.
As I come from the former, I hate spitting. I understand it but I still find it repugnant.
Recognising the differences in the diverse cultures we face is natural and to be applauded.
Well – in that case you risk 'medicalising' everything.For example – it's not 'sulking' it's Social Illness.
It's not 'envy' it's SI
I would hardly claim to be an expert in this, but when I did some work in India a long time ago, I noticed a few things about the way women would kick back at things they didn't like. Refusing to eat was a common tactic. Usually not in a very overt “Look at me” way, but a steady refusal that went on for ages and made sure the woman was upmost in people's minds because they were worried about them. Suicide by fire (not in my direct experience, but in the newspapers often) was another theme. The “collapse” is related.I think a lot of it stems from the fact that these women will often have no real power to change things they don't like. If they say overtly, don't do that, don't set things up this way, or whatever, they may well just be ignored. This leaves them with control over really, just their bodies, so they use them to try to assert themselves – “fainting” dramatically, making themselves ill by not eating, etc. The family have to take notice, and because the woman's action is framed as illness, it can't be criticised as bad or unseemly behaviour the way that simply answering back might be.