You are called to a stranger’s home in the middle of the night. He’s complaining of stomach pain and clutching his mid-section. He’s able to tell you, using all the medical terminology he can, how severe pain is… but he won’t let you touch him to palpate the abdominal area. He says he is running a fever but won’t let you use that fancy no-touch digital thermometer on him. His insistence that you transport him to “another hospital” (certainly not the one closest to your area of service) and explanation of inconvenience or not trusting the doctors sounds just a bit… off.
You’re working the night shift and really don’t mind helping others in need, but considering how the “patient” is demanding transport to his specified hospital, he won't let you examine him, he’ll list his medications but says none of the bottles are handy, and then the symptoms seem to change just as you manage to rule something out… Wow, is this guy trying to pull a fast one on you? Just maybe, your patient IS suffering from a true “illness,” or a disorder known as Munchausen Syndrome? Munchausen is known as a fictitious illness, something that a patient truly feels is there, but is a mental disorder.
Doctors do need to rule out the possibility of a true physical illness before making the diagnosis of Munchausen, something that may be difficult to accomplish in the field. However, if you DO suspect that your patient’s condition is “phony,” documentation is of the utmost importance. Use quotes and write down the patient’s description of his symptoms. Be sure to gather as much medical history as possible; patients with Munchausen are usually not very forthcoming or honest but do try to get concise answers. Look for any signs of self-abuse or multiple surgeries like scars, and notice and list any medications present, as well as other substances which might be causing symptoms. And NEVER be confrontational.
If you feel that a child or other person being “cared for” is the victim of Munchausen-by-proxy, be especially careful with your observations and documentation. Munchausen-by-proxy MAY be a form of abuse and may be attention seeking at the expense of another person’s well-being. Child abuse, if suspected, needs to be reported to Child Protective Services; elder abuse should be reported to law enforcement. If you are going to make that accusation, be sure you have ALL your supporting documentation written down. In NYS, Emergency Medical Technicians are mandated reporters of child abuse; see http://nysmandatedreporter.org/ for detailed info you will need to know.
Prehospital clinicians should always do a complete assessment of all patients, even if it is believed that the patient is suffering from a factitious disorder. It is the responsibility of a clinician, with diagnostic tools, to ensure that the patient is not suffering from a life-threatening, treatable, or correctable condition. Ask yourself, “does the patient look sick?” If the answer to this question is yes, continue treatment and transport to the hospital. Pass along your findings to the hospital staff (include in your notes who you are giving your information).