Author: Murtagh, John
Billy was one of those patients who haunts every practice. Completely self-indulgent and doctor-dependent, he was reliant on every drug that would help blot out reality: alcohol, pethidine, morphine, amphetamines and (in those days) Relaxa Tabs. His medical records carried the somewhat elitist diagnosis of Munchausen’s syndrome – an unfortunate label that eventually was to affect his management adversely.
Aged 38, Billy was an almost comical looking man of short, obese stature, who tended to communicate with a staccato of almost inaudible grunts. Nevertheless, there was something appealing about this harmless roly-poly Dickensian character.
He would present with a dramatic episode of abdominal pain (invariably in the evening) at our surgery or the casualty department of the teaching hospital, where he virtually had a mortgage on a surgical bed following an appendectomy and a cholecystectomy. He appeared to be a world authority on the symptoms and signs of acute pancreatitis.
We were convinced that the strategy of treating his abdominal pain in hospital with a nasogastric milk drip was providing effective because his visits were now infrequent. Billy was, however, seeking comfort from his Relaxa Tabs despite many visits to drug treatment centres.
I will never forget that day, 17 year ago, when Billy presented in the morning complaining of the eternal abdominal pain: ‘It’s the worst gut ache I’ve ever had, Doc’. As he sat in front of me, like a melancholy bullfrog, my imagination drifted fiendishly and most unprofessionally to the scenarios of Ian Fleming’s novels in which trapdoors under chairs lead to tanks of sharks, crocodiles or (best of all) piranha fish.
Eventually poor Billy was dispatched, unhappily clutching a prescription for an antacid. I was not exactly overjoyed when he reappeared at 11 pm claiming he had been treated at the hospital casualty department. Yet, for once in this life, Billy looked genuinely ill. Examination of his abdomen revealed more than his usual guarding and tenderness: rebound tenderness was widespread and he had extreme pain on rectal examination. Could Billy have a real organic problem?
He was admitted to hospital where the surgeon, doing yet another laparotomy, was greeted with an intra abdominal ‘sewer’ due to a perforated small bowel. Floating on the faeces were two toothpicks and several pieces of silver (Relaxa Tabs in their foil covering).
The postoperative course was stormy and eventually Billy died. Every time I think of this loyal patient and great character. I feel guilty about those fantasies of dispatching him in to a tank of piranha fish.
While recognising the obvious lessons it is important that doctors realise they should acknowledge their own feelings and emotions but not permit them to cloud their rational management of patients, especially when they are most vulnerable (that is, tired, stressed or angry).
-Another trap: Familiarity can breed contempt.
Billy was a classic case of ‘Munchausen syndrome’ which is hospital admission by deception often without convincing clinical signs or abnormal investigation. Diagnosis requires a high level of suspicion and then skillful confrontation, counselling and management.
I often recall the wise counsel of an experienced country general practitioner who offered the follow: ‘No matter what the circumstances, always examine your patients, never talk about them and never become emotionally involved with them!’
NICE quality standards describe high-priority areas for quality improvement in a defined care or service area. Each standard consists of a prioritised set of specific, concise and measurable statements. They draw on existing guidance, which provides an underpinning, comprehensive set of recommendations, and are designed to support the measurement of improvement.
This quality standard covers the initial management of self-harm and the provision of longer-term support for children and young people (aged 8 years and older) and adults (aged 18 years and older)who self-harm.
The term self harm is used in this quality standard to refer to any act of self poisoning or self injury carried out by a person, irrespective of their motivation. This commonly involves self poisoning with medication or self injury by cutting. Self harm is not used to refer to harm arising from overeating, body piercing, body tattooing, excessive consumption of alcohol or recreational drugs, starvation arising from anorexia nervosa or accidental harm to oneself.
A wide range of mental health problems are associated with self harm, including borderline personality disorder, depression, bipolar disorder, schizophrenia, and drug and alcohol use disorders. People who self harm have a 50 to 100 fold higher likelihood of dying by suicide in the 12 month period after an episode than people who do not self harm.
Document Type: Research Article