I was a virginal student nurse looking after this young dude, and I was worried. He had been dropped off at the ED by a *friend* after an afternoon of drinking that culminated in a ding dong argument. He was not responding to my attempts to rouse him.
I quickly notified the senior doctor on duty who wandered over. After leaning over and examining the patient for a few moments he glanced over at me, took hold of the mans left nipple and twisted it up to volume level 11.
Wide eyed the man sprang up in bed and, via remote nipple control, the doctor actually maneuvered him completely off the bed and into a chair.
“I think he was faking it.” And he left to look after sick people.
There are many reasons why people who present to the ED play possum. Ranging from withdrawing into themselves after a traumatic event, to attention seeking behaviors, to psychiatric illness, to attention avoidingÂ behaviours.
If your gut feeling is that your patient is feigning it, you are probably right. But you are not definitely right.
I remember looking after a young girl that I was convinced was a total hyperventilating, hysterical, attention seeking brat.
In fact she had a large brain tumor.
There are many potential causes of a decreased level of consciousness in your patient. Here is a mnemonic to help you remember them:
- A- alcohol, acidosis, anoxia
- E – epilepsy, environment
- I – insulin (diabetes)
- O – overdose
- U- uremia (metabolic), underdose
- T – trauma, toxins, tumors
- I – infection (sepsis)
- P – psychiatric disorders
- S – stroke (CVA)
So the short of it is, a patient playing possum should still be managed as an unconscious patient until a definitive diagnosis of pseudogenic coma can be made.
They should have a full neurological assessment (Glasgow Coma Score) and Airway, Breathing, CirculationÂ requirements must be anticipated.
Once you have stabalized the ABC’s there are a few tips you can use to determine if your patient is a possum:
the sternal rub:
Vigorously grind your knuckles against the patients sternum. This causes whatÂ is known in the business asÂ noxious stimuli, and will usually rouse the pretenders.
the finger press:
Take your pen and press it hard against one of the patients nail beds. This really hurts.
the hand drop:
With the patient lying supine. Lift their hand above their face at a distance of about 20-30 cm. And let it drop. A patient pretending to be unconscious will invariably readjust the trajectory so the hand falls away from their face.
the eye flicker:
Gently run your finger along the patients eye lashes. If they are bogus, their eyelids will tend to flicker.
Gently open the patents eyes. Any resistance to eye opening is a tell.
Once open, the possum may roll his eyes back up into his head until you can only see sclera (known as Bell’s phenomenon) or move around in short well defined (geotropic) tracking movements.
With patients who have a true decreased level ofÂ conciousness, passiveÂ eyelid opening is easy and is followed by slow eyelid closure. Blinking also increases in possum patients, but decreases in true coma.
The eyes of patients who are unconscious may have a neutral position or exhibit a roving gaze where the eyes slowly scan back and forth across the visual field.
One paper I read suggests holding a mirror up in front of the patients open eye and observing for a pupil constriction when they look at themselves.
Once you have finished evaluating your patient, place them in the recovery position and go about your business. Lack of interaction either drives possums crazy and they just have to take a peek to see what is going on, or theÂ lack ofÂ attentionÂ overwhelms them and they *wake up* in order to get a little interaction.
the wasabi woo-woo:
Save up those small packets of wasabi next time you have Japanese take away. Open the patients mouth and squirt.
I’m kidding, I’m kidding.
Actually, it is important not to be judgmental or to ridicule these possum patients. You are not going to score a bonus point for tricking them or catching them out.
The patient is behaving in a way that, to them, Â seems totally appropriate or necessaryÂ within their current situational experience.
The ability to maintain a compassionate and professional attitude towards their care will often result in a patient that ends up responding in a therapeutic way.
Trick them out, Â and you may simply end up with a bed full of trouble.