The Johnston Sign, Or: I Think My Patient is Faking

It is a dark and stormy night when you are dispatched to a downtown fast food restaurant on the report of chest pain. You arrive to find the restaurant manager explaining how the patient was homeless and had stretched a cup of coffee across several hours. But he had been quiet, inoffensive, and mellow so the employees had decided to let him hang out. "Now that it's closing time he has heart problems," he finishes with an eye roll.

You approach the patient and ask what's going on. The patient is sitting in a chair, holding his right fist against his sternum in a precordial salute. His eyes are squinted closed and his head is rolling from side to side. He whispers his response, 
"My chest hurts…"  
When you ask other questions, he declines to answer. 
"I can't talk anymore...  It hurts so bad I think I'm dying..."

His vital signs are normal. His speech is whispered, but not breath dependent - he speaks in full (but quiet) sentences. His breath and tracheal sounds are normal, as is his oxygen saturation.  His skin is warm, pink, and dry. The 12-lead ECG shows a normal sinus rhythm without ST segment, T wave changes, or ectopy.

Johnston Sign. Squinty eyes, whispering in full sentences, rolling head, occasionally going limp for no reason, and an overly dramatic presentation that does not match objective findings. This is the Johnston Sign.

Soccer player, on the ground, writhing in extreme agony.  Johnston Sign.
(By Thomas Sørenes via Wikimedia Commons)

The Johnston Sign was created years ago (by me, after an irritating night) to explain a patient who was dramatically faking. There are no objective signs of a problem.  Everything matches a bad actor on a poor TV show. Most patients haven't seen as many sick people as you have. The closest they come is to see an actor (who probably hasn't seen many truly sick people either) play sick on House, ER, or Grey's Anatomy. You have the advantage, because you've seen how people actually present when they're fixing to die.

Experienced medics know that dyspnea is an issue of volume – but inspiratory/expiratory volume, not auditory volume. Even severely dyspneic patients don't whisper; they can only get one word per inhalation but you can hear the one word. Chest pain has nothing to do with squinty eyes. Dizziness doesn't result in rolling your head around.  Spontaneous episodes of limpness? Please.

Faker!  The patient in the scenario doesn't want to go out in the cold and would rather go to a warm ED!

It is never that simple in EMS. I am very sorry to admit that the Johnston Sign sucks as a diagnostic or decision-making tool.*  Fakers sometimes aren't faking, sometimes they aren't bright enough to complain about their actual problem, sometimes they are poor communicators, sometimes they think you won't believe them so they build it up, the list goes on and on.

There are five main variations** of behavior that can fall under the umbrella term of "faking medical problems." Three are real mental health issues requiring diagnosis, care, and treatment by a competent professional. One is a diagnosis of exclusion that prehospital providers are ill-equipped to determine.  The final one is dangerous and embarrassing - it doesn't even approach EMS Rule #2: Look cool.

• Conversion disorder/Functional neurological syndrome: Mental health disorder in which stress presents as neurologic complaints like seizures or blindness. There is real suffering here.  Not faking.
• Somatic symptom disorder: Mental health disorder with real complaints such as pain, nausea, rashes, dizziness, and such. The cause or severity of the complaints can't be easily assigned to a medical diagnosis. These patients can be very frustrated with the inability of medical science to find a solid, treatable diagnosis. Again, there is real suffering here.  Not faking.
• Factitious disorder/Non-accidental illness: Mental health disorder where people badly want to be a patient, so they induce or feign illness. Being a patient means that they get care, nurturing, and sympathy. So they are gaining something, but not anything tangible or physical. Keep in mind that these patients can sometimes induce real illness by doing things like mainlining aquarium water. Not faking.
• Malingering: This is not usually thought of as a mental health disorder. Malingerers are seeking tangible material gains like analgesic drugs, a warm place to stay, avoiding jail or work, and those kinds of things. They invent symptoms and complaints to facilitate those benefits. By assigning the malingering label, you are saying that you are positive that the patient doesn't have any of the thousands of other possible medical diagnoses.  That ‘diagnosis’ stays in their medical record, affecting their future care, so you’d better be sure before you curse someone with that label.
• Real problem you incorrectly thought was being faked: The issue here is that people can spark your Johnston Sign sensor either through inventing problems where there are none, or through exaggerating real problems. Outright invention of complaints is actually more rare than you think.  People usually add complaints to their symptoms, overdramatize their problem, or otherwise exaggerate their real problem.  Sometimes they may not tell you their real problem, worrying that you may find it to be dumb and not help them.

The problem with separating all of these out is that it can't be done in a fast food restaurant, no matter how badass a medic you are. Separating malingering from real problems requires testing, imaging, and exams that are not available in the field. Even with those tools, experienced professionals with years of post-graduate medical education find it difficult to differentiate. 

The other problem is that even when you land on the malingering diagnosis, it is difficult to separate it into those who are inventing an imaginary problem and those that are exaggerating a real problem.  Invention is rare.  Exaggeration can be because patients don’t believe their problem will be seen as “serious enough,” that their problem is believable, their problem is a big problem but it isn’t medical, or even that their problem has been evaluated and the outcome did not meet the patient’s approval.  But there is a real problem there, even if it is exaggerated. 

My advice to you is to not worry about outing fakers.  You will never throw the bullshit flag and get a confession (I’ve tried, trust me - people just dig in).  The simplest solution is to assume there is a problem there. It may not be what they are complaining about. Search out and solve their problem, whatever it is.  It’s not like your pay will be docked for taking unnecessary patients to the ED, right?  What do you care - solve the issue.  If the issue is medical, I can start the process of getting the problem solved.  If the problem is that it is cold outside, I can solve that one too.  If the problem is that they want nurturing and sympathy, I can solve that one as well.  If they want a note to get out of work, I will write a note that they called 911. At minimum, knowing what their real problem is makes for a more accurate hand-off report.  "This is Fred, he's 40, and it's absolutely frigid outside so he wanted to go indoors…" 

When I suspect someone is faking or exaggerating a problem, I talk to them about it.  Bluntly and directly.  Something along the lines of: “I want you to understand that I am here to help you, no matter what problem you are having.  The way that you’re presenting your chest pain to me doesn’t match how I’ve usually seen chest pain in the past.  Whatever your issue is, I will help fix it.  I would like to hear you tell me about what is really bothering you, so I can help you…”  Once you make the promise to help with their problem, follow through with your vow. If they continue with chest pain, they continue with chest pain.  It isn’t a big deal – I can treat chest pain without ECG findings pretty easily. Make your treatment appropriate to your subjective and objective findings.

*Feel free to use the Johnston Sign as a descriptive tool to explain how a patient was presenting in a dramatic fashion, but use extreme caution considering it as a diagnostic tool. Never validated, never tested, unlikely to be…
**I should probably hyperlink to more information about each pathology, but you can search Wikipedia, WebMD, emedicine.com, or whatever your go-to medical source is as well as I can…