Nina had been on the neurology ward for a week. Despite extensive brain wave monitoring and the usual imaging tests, no one was sure if this young woman’s “falling-out spells” were bona fide seizures. She had failed all anticonvulsant medications, and we were stumped. Having seen several episodes, I was struck by their quasi-erotic nature. Without ever hurting herself, Nina would dramatically slump to the floor, arch her back, and make suggestive humping movements. Between spells, her in-your-face “why cannot you diagnose me” attitude made the staff hate dealing with her. Although at least 5 percent of medically uncontrollable seizure patients turn out to be nonphysiologic (inelegantly referred to as “psychogenic”),Footnote 1 we gave her a half-hearted benefit of the doubt. Perhaps we were overlooking something not obvious on the tests.
One morning, right in the middle of rounds, she sauntered out into the hallway barefoot, her hospital gown half-undone, and asked when we would be seeing her. “Soon, but not now,” I told her, “We’ve got some new admissions to see first.” Nina made a glorious swan dive directly in front of the chart cart. Rather than give in, I indicated to the junior residents, interns, and med students that we needed to “keep moving.” Just as I steered the chart rack around her bucking body, the department vice chairman came around the corner, saw Nina, and rushed over to do a quick assessment.
“What are you doing just standing there? This is an emergency; she could die.”
I tried to explain, but he insisted that she have an immediate arteriogram. “Let us get her down to radiology right now.” Nina’s bucking stopped; she was now motionless and unresponsive.
Having difficulty catheterizing the femoral artery through a skin puncture, the radiologist opted for direct visualization. Without using any sedation or local anesthesia, he took a scalpel and made an incision in Nina’s groin, spread open the wound with two small retractors and threaded the catheter into the exposed artery. I winced; Nina did not flinch. Not the slightest change of expression even when the radiologist injected the dye—a procedure that normally feels like searing heat going through your head. I was alarmed at her lack of response and filled with guilt that I had doubted her.
After what seemed like an interminable wait, Nina still out cold, we gathered around the view-box as the radiologist put up the X-rays. “Absolutely nothing,” the radiologist said. “You’re looking at a text-book demonstration of a normal brain.”
“That’s not possible,” came a piercing voice; Nina was sitting up and staring at us. “There has to be something.” The clamped arterial catheter still hung from her groin.
The vice-chairman, humiliated at having been seemingly duped, was livid. “Young lady,” he said, his face nearly in hers. “You’ll have to leave the hospital. We are not going to put up with this kind of behavior.”
She shrugged, lay down on the procedure table, closed her eyes and folded her hands on her chest as though showing us what it would be like if she were dead.
I last saw Nina being rolled into the elevator in the discharge wheelchair. In her lap were her belongings, including a canvas carry-all bag and a potted plant. She flashed a royal smile and gave a slight wave of her hand. “Thanks,” she mouthed as the elevator doors closed.
A few hours later, I received a phone call from the local Veteran’s Hospital. Nina was in the ER with a flurry of seizures; the ER physician wanted to know her discharge medications.
“None,” I said. “There are no medications for what she has.”
“You discharged her on nothing? You must be kidding.”
Once again, I tried to explain.
“I should report you,” the doctor said.
“You probably should. Oh, and give Nina my best for an outstanding performance.”
The following morning, a woman from hospital housekeeping handed me a letter that she had found under the pillow while cleaning Nina’s room. It was an official notification from the U.S. Army. Two months ago, just before her seizures began, Nina’s husband had been killed in Vietnam. “We are sorry for your loss,” the letter concluded. On her admission history, Nina had told me that her husband was in Vietnam but said that he was “out of harm’s way.”
