Munchausen Syndrome

A Surgeon’s Blade

William Lynes, MD

November 29,2019


Night call was hectic, little sleep to be had.  A new day and as usual, Jackson Cooper, MD. anticipated another long busy one.  At task presently, consults from hospital services asking for urologic evaluation.  As junior resident on the University Medical Center urology service, he was responsible for timely completion of these hospital urology assessments.  He stood that morning in the urology resident’s office, a cramped crowded room filled with three old wooden desks, a well-used pot of burnt tasting coffee, and a wall of incoming department mail niches.  Consults were recorded by the department secretary in a small tattered ring binder which was jammed into the lower corner slot.  Three new consults filled the book, a full morning of labor for the overworked urology resident.  

Jackson stood just under six feet tall, with a messy head of brown hair in need of a cut.  He had, some would say, friendly, smoky blue eyes covered with heavy brown rimmed aviator shaped glasses.  He was dressed in an alternative uniform to the common surgical scrubs, a button-down white shirt, blue and white stripped hastily tied tie, and brown corduroy cuffed pants covered with the usual white coat.  He stood with style however, in his signature scuffed carrot colored iguana cowboy boots.   The resident sighed when he thought of the work before him.

 He read from the binder of consults.  There was a 75-year-old male with a history of prostate cancer, a pediatric cancer patient with nighttime wetting or enuresis, and lastly a 45-year-old female with a persistent urinary tract infection (UTI) and fever.  Clinic would begin in just one hour, so he would have to get moving, each of these three patients waiting to be seen.  He decided to work from the end of the list, tackling first the UTI in a woman named Gloria Sands on the internal medicine service.He was soon to be off to complete his task, a ritual however, needed to begin the day.  

Jackson looked over his shoulder, confirming that he was alone.  On the floor by the corner desk sat a brown leather attaché case with a candy red stripe.  He lifted the case, a Christmas gift from his sister, and opened the briefcase with a pop.  Retrieving a large prescription bottle, he opened the vial, shook out and downed two oval white tablets.  Here in lay the ritual, he turned the bottle in his hand and read silently the pharmacy label.  Dated one year before in the summer of 1982, the bottle was marked as containing the opioid Percocet.

Gloria Sands was a plump round woman with an asymmetrical short bob of dirty blonde hair.  She possessed close-set hazel colored eyes which seemed too small for her face.  She covered them with a pair of green and black leopard pattern cat shaped glasses secured with a pearl beaded eyeglass chain.   When Jackson entered the room, she was very involved, laughing and occasionally applauding, the wall-mounted television broadcast of Jeopardy.

“Ms. Sands.  I am Dr. Cooper from the urology department.  Your doctor, Dr. Fitzgerald, asked me to review your case.”  Jackson reached and shook the preoccupied woman’s hand, pulled up a chair and sat at the bedside.  “Now I understand that you have been having fevers for a couple of weeks, is that right?”  

The patient continued to be distracted, continually glancing at the broadcast and seeming to not listen.  Jackson reached for the off switch on the set.  “Can I shut this off?”Gloria eventually looked at the resident, first at his nametag and then his face.  Grudgingly she said: “yeah . . . yes . . . sure . . .I don’t care.  What was your name?”“Dr. Cooper.  From urology.  

Now, I understand that you have been having fevers for a couple of weeks

.”Gloria slipped her glasses off, letting them hang on her chest.  “Yes . . . my Mr. Whiskers . . .I found Mr. Whiskers on the kitchen floor.  Fevers, I’ve had a fever ever since then.”

“Mr. Whiskers?  Who’s Mr. Whiskers?”

“My cat, Mr. Whiskers is my cat.”

“Your cat?  Was your cat dead?”

“Absent . . . I prefer the term absent, Jackson.”  

Jackson let the use of his first name ride for the time being.  At least she didn’t call him Jack, his dreaded nickname.  “I’m confused, what did the cat have to do with the fever?  Do you know, Ms. Sands?”

“I don’t really know.  Isn’t that what you are supposed to tell me?”“So, you’ve been having fevers, every day since the . . . since the absent cat was noted?”Gloria nodded a bored yes.  She was still distracted, making little eye contact.  “You know fevers, I get them all the time Jackson.”

“Cooper . . . it’s Dr. Cooper.”  The interview continued.  She had been having some burning with urination as well.  She indicated the past history of many urinary infections, somehow always related to her cat’s health it seemed.  Jackson finished up a few questions for the patient, excused himself and made his way to the nursing station. 

Jackson looked for the patient’s old chart which would indicate any prior medical visits or hospitalizations.  Filed in an old gray file cabinet in the S’s was an empty folder labeled with the patient’s name.  Ms. Sands had never been seen before.  He looked at the ongoing in-patient hospital chart.  Her urine had an E. coli bacterium in it.  The bacteria was sensitive to the IV antibiotics that the patient had been on for one week.  He looked at her vital sign record.  For the last two weeks a daily temperature fever spike of 102 to 103-degrees Fahrenheit was recorded.  If in fact she had a urinary tract infection, any associated fever would typically be resolved with adequate antibiotics in less than three days.  Given her urine culture and IV antibiotics, she should have been without a fever at this time.  Complicated UTIs with either a kidney abscess, or obstruction of the ureter, the tube connecting the kidney and bladder, could explain the persistence of fever.  He would check her x-rays and present the patient to his attending physician.

#

 They met each early AM five days a week in one of the classrooms at the university, complete with rows of metal folding chairs, an old wooden podium, and a huge urn of brewing bitter tasting coffee.  Lee W. Hickok, MD. poured himself some in a Styrofoam cup with LWH carved into the side and walked to the front of the room.  “Hello, I’m Lee W., and I am an alcoholic.”  The man was in his forties, with dark brown hair highlighted on the temples with gray and wearing round glasses. He was dressed in a brown plaid sportscoat topping another pair of distinctive cowboy boots, shiny black and snakeskin in construction. He went on to introduce the meeting, speaking with a suggestion of a southern accent.   “We have business this morning.  Teddy is going to make the report.”

A large male nurse dressed in a white tunic stood and approached the podium.  “Hello group.  I am Teddy and I am an alcoholic and a drug addict.”

“Hello, Teddy,” the audience recited in unison.  

The man began a presentation of local fund-raising activities for that month.  He reported as a treasurer, mentioning monies coming in and going out.  Karen was next, a neatly dressed woman of fifty or so, in a conservative skirt and high-heel shoes.  “God grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference.”  An Alcoholic Anonymous meeting then proceeded with mention of the twelve steps, and a short testimony about his life of alcoholism from a tall black cafeteria employee.

After a short break, Lee W. Hickok returned to the podium.  “Well, ya’ll, you have the unfortunate distinction of having myself to give the long testimonial.  I am Lee W. and I am an alcoholic.” “Hello Lee W.”“I stole my step-father’s Dr. Crow’s bourbon whiskey and drank each day under the porch when I was twelve.”   Lee W. took a handwritten notepaper out of his pocket, balled it up and threw his prepared talk across the room for effect.  “He beat me, quite a bit for that and anything else he could think of.  Drinking, I can honestly say, was the only thing that brute handed down to me.  Soon, I couldn’t live without it.  I drank daily and frequently, heck I drank all the time, really since that day.  She was killed in front of me, my Mother.  She had taken me away from him in the dead of night.  They were fighting again; he was a rough one.  He broadsided us at the intersection.  I still see her dead eyes and blood soaked face in my dreams.”Lee W. described a life of alcoholism, carousing and drugs.  At one point he withdrew himself from the alcohol, treating the resulting DT’s or delirium tremens with an IV and valium.  His sobriety did not last.  “I was sober on and off for just a year after that.  Drinking again, it became my tool.  I am a surgeon, and not proud to say I was drunk during my medical practice and most of my surgeries.  I dabbled with cocaine and tried to kill myself after my wife Amber left me last summer.”  Lee W. held up his healed forearm laceration for all to see.“I am sober now for fourteen months.  It has been 421 days now.  But for God, I would not be here today.  My life is truly one day at a time.”

#

He was just leaving the meeting when his pager went off.  “This is Dr. Hickok, I was paged.”“Lee W., it’s Jackson.  Are you the unlucky attending on call today?”“Hell yeah.  Y’all got something for me?”  Lee W.’s life was so refreshed now that he was sober. He looked happy for the phone call, like he was anxious for a medical problem to solve.“Just three consults.  I need to present them to you, though.”“Can y’all meet me in my office?”Lee W. Hickok was a newly appointed associate professor of urology at the University Medical Center in northern California.  The university was a private institution, well respected as a leader in modern American medicine.  His office, however, did little to reinforce the importance of his position.  It was a cramped, crowded eight by ten-foot room, the door opening into the department’s small kitchen.  An IBM XT personal computer and a large dot-matrix printer filled an old oak desk which dominated the room.  Jackson arrived as the attending urologist was just opening the office door.  “Grab us a couple of coffee’s my fellow tee-totaler.  And remember fondly as you pour it of adding just a drop of the good stuff, for me.”Jackson turned and moved to the coffee urn in the resident’s office.  He wasn’t quite sure about the Texan’s last remark.  Yes, Jackson was a tee-totaler, a recovering narcotic addict.  Lee W. was supposedly a sober alcoholic.  Last year, during Jackson’s surgery internship he had drank with Lee W. in that same office and yes, he had added a shot or two to the man’s coffee on more than one occasion.  Guess he is just reminiscing, he thought.  

Before he left with the coffee, Jackson quickly opened his attaché case.  He grabbed the prescription bottle and shoved it into his white coat pocket.Lee W. was sitting back in his office chair, his black booted feet up on the edge of his cramped desk.  A smiley logo screen-saver circled harmlessly on the computer screen.  Jackson handed the porcelain cup to the man, and pulled a cardboard box full of books over, sat and drank his coffee.“Did you freshen this up for me?”  Lee W. sipped the hot brew loudly, a sly smile on his face.“Yeah, Lee W., sweet amber just as you like it.”  Jackson put his cup on the edge of the desk.  He reached into his pocket and pulled out the prescription bottle.  He shook out two oval white tablets and threw them into his mouth.  “You want a couple?”Lee W. placed his feet on the ground.  He had a curious look on his face.“Here, they’re just Tic-Tacs!”  Jackson shook a couple of the breath mints into the Texan’s hand.  “I keep this bottle.  It helps.”  He went on to read the prescription on the bottle.  “Percocet . . .dispense one-hundred.  One or two orally every three to four hours as needed for pain.  It’s dated June 23, 1982.”

“One year ago, I see.  Jackson, these are the most delicious Tic Tacs.  You’re a strong man, my friend.”The disposition of two of the consult patients were decided in Lee W.’s office.   Mr. Simpson was a 75-year-old black male with wide spread metastatic prostate cancer on the internal medicine service.  He was suffering with horrible pain from the boney spread of his cancer.  Dr. Charles Huggins won the 1966 Nobel prize for his revolutionary finding that removing the testicles and any source of testosterone in patient’s like this put the great majority into a temporary remission.  Jackson would arrange an OR time this week to perform a bilateral orchiectomy, a surgical removal of the man’s testicles. Kenny Tobias was a six-year-old male boy with leukemia.  He was on the oncology service and receiving chemotherapy.  He had a problem with nighttime wetting, or enuresis, however.  “Should we start him on Tofranil, Lee W.?”  Tofranil was an oral medication that relaxed the bladder.   Taken at bedtime, it was effective commonly in enuresis.Lee W. reached to his desk drawer and withdrew a xeroxed medical article.

 “Here’s what we’re going to do for that child, y’all.”  He tossed the article into Jackson’s lap.  Highlighted in yellow was the article’s title: Treatment of Persistent Enuresis with Desmopressin Nasal Spray.  “It’s new, Y’all.  It’s also called DDAVP or desmopressin.  It is a nasal spray that cuts down on the kidney’s production of urine at night.  It has much less side-effects than Tofranil.

”Lee W. wanted to go and see the UTI patient with persistent fever, Gloria Sands.  Her problem was that she continued to spike daily fevers after seven days of intravenous antibiotics.  “She relates this fever to the death of her cat, Lee W!  The cat’s name was Mr. Whiskers.  She found him dead on the kitchen floor, and she has had a fever ever since.  There is something peculiar about her, however.  Sort of distracted.  Just a touch odd, I think.” 

At the patient’s door Jackson handed the vital sign sheet to the Lee W.  “See,” Jackson said pointing to the graphic tracing of her temperature.  “She spikes a 102 to 103 fever each day at three PM.  You know, Lee W., now that I look at this again, that’s just after shift change!”  Lee W. looked at his watch.  “That’s in thirty minutes Jackson.  Let’s go see her.”The bedside curtain was drawn when the two made their way into the patient’s room.  The television was blasting a daytime soap of some sort.  The room was dark, all lights turned off.  Jackson pulled back the curtain slowly.  “Ms., Sands, it’s Dr. Cooper.”  “Stay out, you troll!” the patient yelled.  Jackson had already pulled the curtain.  Before the two was the patient, sitting with the head of the bed drawn up.  She was busy fumbling with her left arm and IV site.  Jackson grabbed her arm.  She was just in the process of injecting a syringe into the injection port of the intravenous line.  He removed the syringe and stood looking at the woman, incredulous

.“That’s mine, Jack!”  The patient was roused, she quickly stood at the bedside and wrestled Jackson for the syringe.  Jackson grabbed both arms of the thrashing woman.  Lee W. stepped beyond the woman and reached into an open bedside drawer.  Within was a specimen cup of clear fluid.  In the bottom was debris, brown and green leafy material.The woman started crying.  “That’s my stuff now leave!  Rape!  Rape!”  The woman stomped her feet jumping back into the bed.  She pulled the sheet over her face.  “Leave me alone you rapists.”Two nurses hurried into the room.

 “Dr. Hickok, what’s happening?”Jackson and Lee W. left the crying woman with the nurses.  They moved to the hallway and eventually sat in the nursing station.  “That’s stool,” Lee W. said.  He held the container up to the light shaking it gently, the debris in the bottom now dispersed through the liquid.  Jackson took the container from Lee W.  He compared the syringe to the fluid in the specimen jar.  The two looked identical.  “What the heck?”“She injects her own stool into her IV.  There is your source of fever, Jackson.”“Munchausen, she’s a Munchausen, Lee W.!”

Baron von Munchausen was an 18th century German officer who was known for embellishing the stories of his life and experience.  Munchausen syndrome is the most severe type of factitious disorder in which a person repeatedly and deliberately acts as if he or she has a physical or mental illness when he or she is not really sick. Munchausen syndrome is considered a mental illness because it is associated with severe emotional difficulties.  Gloria Sands left the hospital quickly.  She refused to sign her against medical advice (AMA) forms.  Knowing the course of Munchausen syndrome patients, her appearance in other medical institutions with identical claims was likely.  

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