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 avoiding 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, Circulation 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 what is known in the business as 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.
the reveal:
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 of conciousness, passive 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.
the ignore:
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 the lack of attention 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,  seems totally appropriate or necessary 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.
Don’t forget the faking pain signs… Wadells test…
The sound of an I.O. drill works well, too!
We had a patient come in courtesy of the ambulance one night shift. He had a lot of alcohol and in all attempts to rouse him we could only score a 3-4 GCS. Now the EN I was working with was a little concerned about his wellbeing. I suggested after doing the whole nipple torture etc. that we try the guedels. Now the EN is keen to learn so I talked her through it. She then proceeded to place the guedels, at this point the patient arose from his slumber. After a few minutes the EN thought we should have a little fun, and told the patient that I the male RN had lost my ring whilst doing the routine PR exam. At this point I wished we had a video camera as the patients facial expression was priceless. He then proceeded to check that all his bits were in place and unaltered. Needless to say the patient was now out of danger. He ended up been a nice fellow who appreciated our unique sense of humour!!
I think over at Shroom’s blog, he had a possum patient who was miraculously cured after Shroom had requested (in such a way that the patient could hear), “the really big brain needle”.
The last possum I encountered “woke up” when my colleague walked into the room and suggested (in all sincerity) that if he was that unwell he’d need a urethral catheter.