Its All About the Circle

by Robert J. Lanz, LCSW

(I’m finally recovering from chemo-brain and found these great resources outlining what social workers do in the Emergency Department:)

www.coreyrichardsonspersonalblog.blogs

www.hospitalsocialwork.wikispaces.com/Role+of+the+Social+Worker+in+the+Emergency+Room

(They don’t explain the “how,” which is what I do here.
“How” is the art of social work.  
– Bob)

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One of my patients died-well, a lot of my patients died-many, if not most of them, were my patients because they were about to die or already had. At that point I guess, the family/friends/survivors left behind became my patients. This is the story about such a patient and the twisted and turning circumstances that lead to an old friend in a church. A church in the desert.

In the beginning, it was the distance from the desert to the big city that made me suspicious. I’m already a little suspicious by nature, having lived on the wrong side of the law for some time and then later carrying a probation officers badge trying to help out delinquent kids who always thought they could fool me. I was too experienced and too suspicious.

Working in the ER is slightly less likely to push my suspicion buttons than working in juvenile hall, but only slightly. Everyone working in the ER knew just about everyone lied about sex, drugs and money and how that foreign object got up their rectums. I wasn’t always so jaded about these things, suspicious but not jaded, and I always tried to give patients the benefit of the doubt, although that naturally faded over time and with experience. I never got used to the idea that someone had actually gotten away with lying to me either in the confines of a detention facility or a medical one. I take it personal. After all, I am a mental health professional with degrees and licenses to perform various types of family and individual assessments and therapies. And I was being paid to do what was in the best interests of the patients even if they didn’t know it or like it.

In any case, there is a subset of medical scammers, and scammers are just more sophisticated liars with a more devious plan, that fooled almost everyone. If fact with these guys, it is part of their diagnosis if they are able to confabulate a believable story and fool almost everyone. The non-DSM literature refers to these patients as Munchausen’s Syndrome patients, apparently named after the infamous Baron Von Munchausen, some old European guy who went around the country like Bernie Madoff fooling people vigorously and believably for an extended period of time. Munchausen patients do the same, except, for the baron the desire was for personal aggrandizement while the Munchausen patients just want to become patients, a very different pathology.

In the DSM they aren’t actually referred to as Munchausen’s, that would be too colloquial. Maybe they have a rule about diagnosing someone who has a movie made about them like the Baron did. There is no James Dean syndrome but there is a narcissistic personality disorder and there is no Ted Bundy syndrome but there is ,well, you get the idea.

The ‘M’ word has been replaced by the ‘F’ word, as in factitious. I’ll quote the DSM so as to give an official ring to one of  the most interesting diagnosis, the one that so engrossed me that I ended up being the hospital know it all on the diagnosis and did some interesting consultations because of it. Usually the consultations came at the tail end of a vexing and troublesome admission where the diagnosis of Factitious Disorder was considered last rather than first after about a hundred grand had been blown on testing and treatments. With my background they were the perfect foil for my suspicious nature.

Anyway, per the DSM, Factitious Disorders are characterized by physical or psychological symptoms that are intentionally produced or feigned so as the faker can become a patient in the hospital for an extended period of time where he or she can be the center of attention and drama. The motivation is an intense need to assume the sick role. The DSM description hardly gives justice to the full depravity inherent in the diagnosis. If you want to know more about this incredible diagnosis, you’ll have to take my  class or go to Google. Suffice to say there is NOTHING these people won’t do to become a patient. NOTHING. They will inject horse urine to create festering wounds. They will douche with a caustic substance. They will eat spoonfuls of salt in time for their lab draw then drink liters of water in time for their next lab draw. Don’t get me started. Just remember the part about NOTHING they won’t do to become patients. Be suspicious. The reason they get away with their behavior so long is that no one believes someone would do all the crazy things they do until all other possibilities are ruled out. By then, the damage has been done. Incurable. Don’t try to fix them. Try to catch them in the ER and do not let them get admitted.

A suspicious guy like me looks for patterns and it didn’t take long for me to figure out what these guys had in common-all the information I need to start my assessment was on the face sheets of their medical charts. They were almost never local. They never had private insurance. They didn’t have a local doctor to call. They had a dramatic presenting problem. Of course not everyone with these demographics was a Munchausen, but every Munchausen had these demographics.

So this old guy comes a hundred and twenty miles in an ambulance from the high desert passing several great hospitals along the way. He has no medical insurance. He has no local doctor. My radar starts buzzing. Pretty dramatic I’m thinking and he doesn’t look like he is having a medical emergency. I’m getting ready to hear a big story but before I put my foot in my mouth I’m going to do a quick fact check. I pulled the ambulance guy aside and asked about the patient.

“Hey, why did this guy come all the way down here from the desert?”

“Said he read about you guys.”

“He doesn’t have insurance. How are you guys going to bill him?”

“He paid cash out front. He owns a big truck business up there.”

“You know the business? You know that’s him?”

“Well, he paid cash. But I’ve never seen him before. We think its him.”

Pretty dramatic I’m thinking.

The patient got settled, had his vital signs taken and openly stated he came to be admitted and didn’t know any doctor on staff. He did have some minor irregularities on his EKG and would have to get admitted to have that worked up. If a Munchausen’s gets admitted, he’s upstairs and out of my zone and most likely unless I have some pretty solid evidence, he would get away with the scam, if it was a scam.  I’d have to know more before he entered the  “upstairs” system.

“Wow” I said to the old guy. “You came a long way.”

“Yeah. I read a lot of good things about your hospital. I wanted to get treated here.”

“What do you do up there in the desert? I used to ride my dirt bike up there near where you live. Of course I was a lot younger then.”

“Still riding?”

“Too many crashes. With age you get the cage. I race off road cars now.”

“Hmm. Race where?”

“Baja races. Vegas. Some local desert stuff.”

“Big Stuff.”

“Yeah. Pretty expensive. I raced with a small slow team.”

“But you raced,” he laughed.

“Yeah. I raced.”

“I own High Desert Trucking. We sponsor a couple of guys.”

Oh geez, was this guy just playing off me or did he really own High Desert Trucking? I knew his race team but didn’t know anyone on it personally.
He pulled out a business card and sure enough, High Desert Trucking.

“Come up to my room some time if it ever gets slow down here. We’ll do some bench racing.”

Bench racing is what racers do when they aren’t actually racing. It is a highly evolved art of bragging and stretching the truth and reliving truths that usually don’t need much stretching. It’s reliving your race memories in a crowd. If you race the Baja, you’ve got stories.

“I’ll do that.”

That’s how I became friends with Jake. That would be the rich guy Jake-not the Munchausen Jake. That would be the Jake who made a sizeable donation to the charitable funds department of the hospital. I guess Jake wrote a note to the CEO as I got a card from the CEO thanking me for taking good care of Jake. Apparently Jake made some of the donation in my name. See why it is a good idea to not put your foot in your mouth? Got to be careful with those Munchausen face sheets.

Jake came back to the hospital a couple more times over the years and always called down to the ER to see if I would come up and bench race with him a little. Once I let him take me to an expensive steak dinner, sort of a violation of the hospital rules but after all, he did make that sizeable charitable contribution.

One morning back home in the high desert his family found him dead in his bed, passing peacefully in his sleep just like we all would like to do. They invited me up for the funeral, out there in the desert not far from where I used to ride my dirt bike.

Of course I went. Of course I got up and made a big speech to a crowd of a couple of hundred friends and family. Sort of social work bench racing I guess. I was well received and afterwards several people came up and talked to me and told me Jake had told them about our bench racing sessions. Very cool day I’d say.

Remember I wrote previously about having lived at a ski resort in Utah? It was another life up there. I owned a bar and was the bartender from Hollywood. That’s all anyone knew about me. No use blabbing about having carried a badge. That was another life too.

One of the guys  who worked for Jake came up to me and called me out.

“Flaco? Is that you?”

How I got the name Flaco is another story from another time but my bar’s name was Flaco’s Cantina.  Mexican theme of course.

“Yeah. That’s me Jimmy.” I said to the guy who used to drive the snow groomer at the resort where the bar was. He was a good and steady customer but I didn’t bring it up. That was a long time ago. He had a new job and so did I.

“Nice speech Flaco.”

Another big circle completed. Good social work, another notch on the Everything Else list….

Dividing line

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About robertjlanz

Author and health care professional.
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