Medically Unexplained Symptoms and PEM (Paediatric Emergency Medicine) presentations - Dr Armstrong - 11 Jun 2020

Sly Saint · Jun 30, 2020

London School of Paediatrics - HEE NHS UK

https://www.youtube.com/watch?v=Rst1NOu1szA

(I skipped the case examples)
youtube generated transcript:
pt1

think about what is
mus or also known as PP so there are
multiple terms used to describe the same
issue the one that's most common used in
the UK is probably
medically unexplained symptoms it's also
known by some people as perplexing
presentations and in
creasing in the literature but more so
overseas in the UK it's known as bodily
distressed disorder and so these are all
interchangeable terms and sometimes
you'll heard of it referred to as a
functional disorder the most important
thing is there's no one pattern of
symptoms this can affect any organ
system or more than one organ system and
the hallmark of mus is that the symptoms
that an individual describes are not
fully explained by physical examination
or investigation what's really important
and something that occasion gets lost in
mus is that the symptoms the patient's
experiencing are absolutely 100% real to
them they are frequently distressing an
anxiety inducing both to them their
family and indeed the clinical team who
treats them because they committed why
the Chaves have no symptoms apologies
for the fire alarm in the background
hopefully I won't have to evacuate talk
um what is it not well it's absolutely
not malingering and that's very important to
understand and people sometimes get
labeled as faking their symptoms because
we can't explain them medically but
actually when you look at the literature
on these young people they are
absolutely not malingering it's not
exactly the same as fabricated or
induced illness but women come back and
talk about the overlap a little bit
later the talk in terms of the other
things that some that it used some
people may have heard of somatoform
disorders and it's a little bit pedantic
that if you're talking to mental health
colleagues this is distinct from em us
the difference between em us in
somatoform disorders is that in
somatoform disorders something is
physically wrong with you so for example
you have ankle pain and what happens is
the patient become psychologically
fixated on that real symptom to the
point where it becomes overwhelming so
it's an over-exaggeration of symptoms
due to psychological fixation for a real
condition as opposed to mus where there
isn't accurate information for symptoms
and organic illness well the distressing thing is that if
you look at the adult studies about four
to ten percent of adults with presumed
mus do eventually turn out to have an
organic diagnosis and I think that's the
other thing that's really important when
you're treating a possible mus you have
to keep in mind because some of them
will turn out eventually to have a rare
or unsuspected disorder which does
explain everything so what do we know
about mus

well we don't know very much
about mus in children young people
specifically there is quite a lot of
research in adults but not as much
that's been explicitly done only on a
pediatric population some so you suggest
up to ten percent of children will get
some medically unexplained symptoms at
some point in their childhood and that
sounds a lot but remember that a child
who has a nonspecific tummy pain which
is a well recognized common presentation
general Pediatrics could potentially
fall into the category of medically
unexplained symptoms in the literature
what you find is that most mus is
managed by self care approximately 30%
of adults with mus a suit primary care
support and in frontof draw acute mus is
managed in primary care body one percent
of adult patients with mus will seek
second to care support however this 1%
are often very frequent attenders of
second tear frequent users of services
and frequent requesters of tests and so
they come to people's attention it's
possible if it goes for this a slightly
higher on children but we don't have any
published evidence and supports this so
what happens to people with mus so as
you can see and although the majority of
people with mus and this is adults again
do recover within 12 months
I'm not insignificant percentage will
continue to have ongoing symptoms for
all the 12 months and that is higher air
in things like elegy than it is in most
fierceful at all we don't have the
figures for children but we know it is
possible for these children to go on
with long-term symptoms.

so what can you do to help for these young
people who you suspect may have mus well
the good news is there is some guidance
available and currently available is the
Royal College of Psychiatrists and experienced symptoms in children and
young people which is published in all
this 2018 and that is freely available
to Google and I've linked it at the end
of the talk in the resources slide at
the end of this presentation the Royal
College of pediatrics and child's health
has a new guideline which is due for
publication very soon I confirmed with
the college it is due out but I don't
have an actual date for publication at
this point in time but keep watching
this space there are some basic
principles when dealing with children
with possible mus the first thing is to
really think about it early so always
have in the back of your mind that
anyone presenting with unusual signs and
symptoms could mus be part of the
differential and it's important to be
open with children young people and
their families about the possibility of
mus as soon as you consider it and I
would list it in the normal list of
differentials and assuming I will be
explaining the possible medical
differentials and the reason for that is
the best way of managing these young
people is by parallel investigation
management strategies.

so it's not a case of we do all the medical things and then
we hand you over to psychiatry and walk
away we talk from the very beginning
about the importance of involving the
mental health teams in managing young
people with possible mus
so this talk is obviously specifically
around management and PGD is part of our
Penn week so probably the most important
thing is to recognize that you might be
dealing with a young person with MUS
and obviously D is different to the ward
and outpatients you get to see people
for a short period of time and it isn't
always apparent about early stage this
is kiram us but there are some things to
look out for so look out for frequent
attenders pre-competitive medical
presentations not so much with injuries
and another thing to account for is the
tense in multiple places what's
sometimes known as hospital shopping so
yes they've been to your department
three times but actually mum also
mentions that they've been to different
number two hospitals in the local area
and they've been seeing the GP and maybe
they've seen something outpatients at
another hospital and maybe they've seen
somebody privately but essentially a
pattern of people looking for an answer
when they can't find one because people
can't give them a straightforward answer
there's often quite significant mismatch
between the anxiety the child noon
person or their family and the medical
concerns so a lot of these symptoms are
not what we would consider red flag
symptoms they're ongoing and they're
chronic and they're annoying but they're
not normally immediately worrying but
that isn't always mirrored by the family
and often the reason that is by the time
you're seeing them in the emergency
department they may well have seen
several other people in several of the
places and being told there's nothing to
worry about but the symptoms are still
present and that leads on to the next
thing which is often you get to the end
of the consultation and you find there
is expressed or hidden dissatisfaction

so you'll experience the family that
everything's fine there's nothing to
worry about and the looks you're getting
clearly tell you that they're not happy
about it and what's important actually
that one is this explore with the family
why they're not happy about it and what
their concerns and expectations are from
a junior perspective these cases can be
quite complex and I think the most
important thing is if you think you're
seeing in running that might have any us
for these reasons or for some of the
things we've talked about and then it's
important to escalate early to a senior
doctor to discuss the best way of
managing them so things you can do in
the emergency department it's to be open
and non-judgmental as we talked about
it's really important to make it clear
that
mus is not malingering or fabricating it
is dealing with symptoms that we cannot
explain with a standard organic model
it's really important to acknowledge the
child in young person families distress
it's very tempting to say oh it's
nothing to worry about without actually
acknowledging that is disabling or
painful for the young person what you
can do is be reassuring about the
diagnosis you can exclude and one of the
phrases that I often use in the emergent
part is to be reassuring about we know
there's nothing immediately dangerous or
worrying and clearly there's something
that needs addressing but it doesn't
need to happen today and we don't need
to admit you to do it and really what
you're looking for is a pathway to
ongoing care that practically doesn't
involve admission or returning to the
emergency department so this is where
things like urgent review clinics if you
have access to them are really important
discussion with your inpatient
colleagues discussion with primary care
sometimes you do still need to provide a
safety net because members children will
end up having orgasms you can introduce
a holistic body mind link concept the
young person to do that things not to do
so really really importantly not to
minimize or ignore the symptoms they are
real to the patient also try not to over
investigate or admit if alternatives
exist these young people often have very
weird and wonderful symptoms and it is
tempting to assume that something really
serious is going on and just throw the
entire laboratory at them if not half of
radiology but actually all that's doing
is reinforcing that there is something
dangerous going on the we haven't
detected yet and that that's reinforced
by this concept of not focusing on
getting a specific specific diagnosis as
an alternative to MU S but actually
thinking of mus as being the diagnosis
and this is where having something
senior to have that conversation can be
helpful some of these young people will
end up getting admitted and the three
cases I've talked about all ended up
being admitted for different reasons
what's really important is as soon as
suspicion of mus for an inpatient then
you need an earlier senior review
preferably elite consultants and they
need to grow few things they need to
come up with a list of appropriate and
proportionate list of differentials
investigations and specialty referrals
and there is a fine balance to be struck
between not under investigating because
we don't want to miss something but also
not over investigating so a sensible
discussion that bit eginning about which
tests are appropriate and then if
they're all normal that actually we
don't need to do any more tests it's
really important that there is a lead
clinician who will oversee case
management and communication with
children young people in their families
because these cases by their definition
are difficult to explain what's
happening and if different people tell
the family different things that just
exacerbates the problem and you want to
link to your local cams or pediatric
liaison team and then probably led by
the senior you want a no discussion and
the first thing to actually explore what
they think is going on do they have any
theories about the symptoms that they
have any belief systems around a health
or ill health and - they have people in
the family who have experienced
something similar but different it's not
uncommon to discover for example in a
relatively early stage and some of these
medically unexplained symptoms that a
beloved relative has recently had a
significant diagnosis of a similar organ
system and it's really important to
introduce the concept of mus or P P at
an early stage if you think it's part of
the differential don't surprise families
with it at the end of a period of
investigation

introduce the concept of the mind-body link and set out a plan
with the children and young people about
what tests you're gonna do and actually
it's good to be clear at the outset that
you are doing these tests in the
expectation that the tests will be
normal what families don't like is where
the Toolman will do this tests and then
we tell all that's normal okay well
we're doing other tests oh that's normal
and all we're reinforcing is we don't
know what's going on actually it is a
positive thing we think this is mus we
are ruling out the other things and once
we've ruled them out we don't need to do
any more tests and early joint working
with cows and PLT is really helpful and
even if the family haven't yet bought
into the diagnosis of mu s and P P then
talking some about the importance of
managing the uncertainty in the symptoms
is an important part of engagement with
cans or PLT outpatients well it's all a
bit more relaxed it's the same as
inpatient care but there's less urgency
to manage it in a single consultation
it's still however important to induce
the possible of a diagnosis at the
beginning not at the end and where the
facilities exist then the best way of
managing these is joint clinical
consultations with somebody from PLT or
Cam's in the room with you and the
patient and joining together to manage
the patient and it just highlights the
joint nature of this condition the
investigation there's a question there
do you find that cans appear too happy
too involved so yes I find they are
often happens well my experience of
working with them is absolutely if I go
to them as a clinician I say I think
there's a really high likelihood this is
mus we're gonna do this test and this
test and if they're normal it's really
looking like mus then they will
definitely want to get involved they'd
rather not sooner rather than later so
that needs us onto cams and PLT so
they'd like to be involved early but
even before the presence of your mental
health colleagues you as pediatricians
can still explore some things with the
family and the Chan young person it's
really important to get a good
chronology of the child's symptoms and
to compare that with what was going on
when the child's life at the same time
and one of the phrases that I learned
from working with PLT colleagues was to
consider the entrances and the exits
into a young person's life who's come
who's left who they left at they moved school have
a loss to close friends as a grandparent
died as a parent spit-up has a new step
parent arrived as a new step sibling
arrived these are all big events in
children young people's lives and it's
really important to have them documented
my chronology alongside the symptoms
because that's what allows you to start
making links as to what might be
potentially leading as mus
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Sly Saint · Jun 30, 2020

pt2

think about stresses at home at school with friends

do you explore the possibility of

safeguarding concerns so there isn't an

intrinsic link with safeguarding mus but

there's an overlap some children who are

being abused will turn out to present

with mus because they can't vocalize

their concerns and so they present with

mus but not everybody is but it's

important to clarify and ask and ask

without the parents presence if at all

possible that are they are they say is anyone

hurting them doesn't have to be in

school area term it could be in school

it could be over the Internet

we still need to get documentary

evidence we've asked that and you can

use some screening tools as one called

arc ads which is a revised children

anxiety and depression scale and again I

put the link in the resources at the end

of this talk we talked about useful

scripts and this is taken from the RCP

psych guidance on managing mus and I'll

just let you read the screen for a

couple of minutes so this is about how

you introduce to a child young person

and their families the link between the

mind and body and the importance of

involving cams or PLT in the process

early on and not waiting until we've

exhausted all of the possibilities

before we get to this point other things

that I'd used with younger children and

then us can present from very young is

to talk them through the impact of their

emotions on their body and so for

example even some news young as seven or

eight will understand the concept that

if you're having the best there you can

think of and you stub your tool you

probably won't be bothered if you

stubbed your toe but if you're having a

really bad day and everything's gone

wrong and you stub your toe then it

will feel really miserable because it's

another really miserable thing that's

happened in a miserable day and actually

that's that's an approach that quite

young children can begin to grasp but

how our bodies experienced physical

symptoms is absolutely influenced by our

state of mind and it's just a way of

opening the people up to the concept of

the link between the mind and the body

so we said we talked about mus and FII

so fabricated and jus stillness is not

the same but there are some parallels

and sometimes there can be a little bit

of blurring between them n fi I

explicitly the care is that Ponce is the

person responsible for health seeking

behavior so in general fi is seen in

younger children whereas in mus

it's the individual themselves who's the

prom prime reason for seeking of health

and generally therefore they're a bit

older but it is true that young children

who were subject to fri can transition

to all the young children and people

with mus
so she's been brought up where

your mother is consistently reinforcing

this concept of you holding the sick

role from a very early age they're not

surprisingly just because you're the one

making decisions you probably are going

to default to the same mindset around

sick role that you might have had when

you were younger

just a reminder XII is not a single

thing there's a spectrum and the green

to red is sort of the risk to the child

from how the family approach fri this is

taken from daniel Glaser's FII handbook

which the royal college of pediatrics is

produced which is also in the resources

pack and so you started with the most

benign form of foi which is essentially

over anxious parents who are worried

about their child symptoms and will

consult

multiple people to try and work out

what's going on and will hospital shop

and there's clear parallels here between

this and what we're talking about with

in the u.s. in general this is amenable

to reassurance calm explanation and

careful managing and there's very little

risk to the young person in general or

the location children can end up over

investigated the next type type ii is a

bit more complex this is where parents

have fixed health beliefs around why

their child or young person is ill and

this can occur as a result of a

breakdown communication between

professionals or maybe due to

pre-existing health beliefs it might be

related to relatives or friends who have

similar issues and these are more

challenging for professionals because

the parents really hold

beliefs in the way that's not easily

open to challenge they are a set of

things beliefs in the same way as a set

of religious beliefs or political

beliefs and it's quite difficult

sometimes and again this can definitely

lead to a significant breakdown and

working relationships between parents

and carers and therefore hospital

shopping and reinvestigation at the

instigation of the parents these are a

bit more concerning and they often do

need a safeguarding input finally we get

to type 3 which is the most worrying

this is where the parents are actively

fabricating and falsifying signs and

this is what we would have originally

thought of as Munchausen's by proxy if

you go back 20 years and this is the

most worrying it it can absolutely lead

to harm to the child these are the

parents who give a baby salt or

administer insulin to their child or to

definitely hurt them you know I don't

know one child where the mother booked

them into Edie with a painful wrist and

then while they were waiting the scene

took him into the toilets wrapped his

hand in a towel and hit him with a

hammer to make sure that when he was

seen there was definitely something to

be managed so these are really worrying

and and then type four is sin a bit

different this is where so in type three

the parent does not have a recognised

mental diagnosis mental health diagnosis

but is acting for unclear reasons and in

tight for the parent is suffering from

explicit psychiatric illness normally

some form of psychosis where they have a

delusional belief which leads them to

harm the child these are actually

incredibly dangerous to children but not

because of active malice on the part the

parent the parent is ill and needs help

and but there are cases where parents

have sadly murdered their children as a

consequence of their absolute psychosis

and then again FII similar to talking

about the father

mus some of the children will turn out

to have a true organic illness and type

5 in F&I in Dinah Glaser's

classification was where actually the

parent was right there was something

wrong with the child and although they

were labeled as having health care

seeking behavior actually they were

currently advocating for their child's

needs so how does Isabel up with mus

well in Fri safeguarding is based around

either neglect when the care is not

meeting the child

person's medical needs and this is

really type 1 and type 2 where there's

either at overanxious or fixed health

beliefs and from a seagoing perspective

the parent is acting what they perceived

to be the child's best interests but

isn't necessarily acting what we will

receive the child's best interest when

you get to the physical abuse or non

accidental injury then that's the active

fabrication that's the type 3 in the

type 4 where you actually got active

harm happening the child your results of

the FII in mm UX it's much more complex

because clearly the locus sits with the

young person not their carer and we've

already talked about the fact that it's

the child young person who's

experiencing these very real symptoms

however it doesn't mean that there's no

rule for safeguarding then us so we can

still consider the possibility of

neglect

if the carer is not acting in the trail

during person's best interest so if they

are supporting the young person in

insisting on more tests or Hospital

shopping or not really engaging with the

mental health component then that can be

a recent thing about safeguarding um and

as we've said there is a link with abuse

as one cause of mus
.............

the majority get better often without us

being involved at all so children with

nonspecific double pain will often just

get better some cases won't fully

resolve but they'll reach a stage where

the young person can manage their

symptoms so they don't impair function

and and this might be talking about some

that IBS where you know they work a way

to live their life without it causing

them problems about 1% of people

presenting with them us will have

assistent symptoms this is young people

my adults where if you don't manage them

carefully they remain at risk of

reaction it card from their health

seeking behaviors and what's important

about this is that looking at these

patients can be a real challenge for all

the staff involved staff can feel

frustrated because this isn't making

sense to them and we like to fix things

as doctors and nurses and allied health

professionals so if it's not working for

us than weeks feel frustrated we can

feel inadequate or a sense of failure

for the exactly the same reasons and

actually back an often lead to anger

when you put those two things together

and particularly when people start to

talk about malingering and fabrication

and falsification and it's really

important you don't transfer these

feelings on to the young person or their

family and actually it's really

important to use opportunities like

MDT's to allow staff to talk about their

feelings safely and talk about their

sense of frustration and anger when

looking at these young people otherwise

it can come out in the consultations

with the Italian person and the guide

from the royal culture of psychiatry has

a really really helpful top tips from a

Chan young person families perspective

and that's what the next two slides are

so these are what families have said to

medical staff

don't make us finger

for being an inpatient and this is what

they're saying is it comes across be

honest from the outset talk about the

fact that mus is a differential and it

means that we do know what's wrong with

them so mu s doesn't mean we throw in

our hands or than God we don't know it

means this is how we look after children

who present with this sort of problem um

don't tell them the child is making it

up well it's all in the head I hope we

wouldn't use those terms these days but

it does cause problems when it's clearly

not just ill in their head their

experience is achill symptoms and we

talked about importance of the whole

chronology and the importance of the

parent family and their emotional state

talk to them about the fact their pain

is really real it's not that it's a

fabricated pain and don't um there's

nothing wrong with them and send them

home with a child in the worst physical

Ambition this is goes back to our

managing these children Edie we we

should try not to admit them but

sometimes you have to in all three cases

I presented ended up being admitted

because they'd reached a stage where the

family couldn't manage them at all

very clearly the importance of

communication and this is a particularly

a problem for bigger hospitals with

multiple specialities these patients if

you're not careful can get bounced from

specialty to speciality to speciality

and nobody's holding the reins and

that's why it's really important to have

a single overriding person in charge of

the case and as they said make sure one

doctor is in charge so any questions

happy to take them on chat or take them

orally if people want to unmute

so the next slide after this has got the

resources on it

these are challenging patients and I

think that's for the most important

things to take away from it one of the

things I would say is watch out for a

patient who you actively avoid be that

in the emergency department you know oh

I saw in the last two times I don't go

back and see them again

they're just painful they say the same

thing or with also you're doing

inpatient work the patient who literally

reorganizes the ward around so you might

always start in bed one but just so

happened this patients in bed one and so

instead you start at the other end and

work your way backwards because it's

just too painful to go and see this

patient and if you've got patients like

that who are making you feel frustrated

and acquits

annoyed then actually start thinking

about should we be pushing down the mus

pathway because that's a big link from

my perspective between those two things

so question about what are the

alternative missing so yes absolutely

review clinics are an option I think

which clinic depends on your local set

up and it's very difficult to be

didactic without knowing how your

individual unit focuses that's why an

early discussion with a senior is the

best way forward because they'll know

the best

local policies so in my hospital I would

get them into our urgent PD general

pediatric review clinic rather than

bringing them back to a needy with you

clinic because actually a needy really

isn't going to get them much further

forward what they're gonna need is

engagement with a general pediatrician

who can manage the case and organize

those appropriate and proportionate

investigations and referrals if need be

any other questions see from the numbers

that people are beginning to drift away

do you find that the majority usually

discuss something and so I would say the

minority disclose specific abuse or

trauma it's often it can be relatively

minor things and this is why the

importance of entrance and exits is is

really interesting so a different

patient that had an 8 year olds who got

persistent hiccups for new organic cause

and actually when you went back through

technology they've started the day after

she was told a beloved aunt was

emigrating now that's not something you

would expect an essay Trigger mus but

there was a very clear link and actually

when you were able to start talking

about missing her aunt and how she would

keep in touch and hiccups began to

resolve so it doesn't always have to be

abuse or trauma it's something that for

the child or young person is relevant to

them I talked about the factors often

the diagnosis it's really common that

you know somebody comes in with

recurrent chest pain air and you find

that there are you know a grandparent or

an animal has had recent heart attack

that's really common and there's a lot

of anxiety of course the problem is that

often the anxiety is multi-generational

so you may well find the parent is

anxious about they're their own parent

who's just out of heart attack and now

their child is complaining of chest pain

and not surprising the entire family is

just caught up in this big anxious whirl

so other questions what are your tips

for safety netting if there are already

red flag symptoms so the the RCP psych

guideline has a specific set of red flag

symptoms that definitely merit a

discussion with a senior I didn't go

them all on the slides because it would

have taken about another six slides but

I can definitely direct you look at that

and if you're getting red flag symptoms

and that should be discussed with your

senior about how you safety net them how

do we untangle that all the lack of

posture yeah so we don't know Corbin's

knew we wouldn't find out for a while I

think it goes back to the thing about

being open and honest and saying to the

young person this might be related to

coverage some post.
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so chronic fatigue

syndrome has an overlap with MUS but is

not exactly the same and I think I would

look at how you look at the two

somebody's asked about ours conversation

family can be difficult for juniors and

the best way to deal with them.
so I go back to you need to talk to senior and
even out of hours you would have a
senior you can talk to and they should
help you with a script to talk to the
family um I think the important things
are it's reasonable to say do you know
what your symptoms are and not clearly
one thing or another and this is a few
of the things it might be and I'm going
to talk to my boss and think about what

we can best do in terms of helping you

get to the base of what is going on and

if you've had experience with mus then

it's perfectly reasonable to bring that

into the discussion I wouldn't do it for

the first time without understanding a

bit more about how it works and this is

definitely one to sit in with somebody

more senior when having that talk to

learn that the best ways of having that

conversation with family it's easy to

get it wrong and for the family to take

away the concept that you're telling

their child is making it up and you have

to be very careful in how you phrase

that the scripts that we that we put up

and the ones that are in the RCP psych

guidance are quite useful for that

anything else from anyone okay

now that's the resources page so that's

the medically unexplained symptoms in

children young people from the Royal

College of psychiatry

there's the fabricate induced illness by

carers from the rar cpc-h and the

archives which we reference the revised

children's anxiety and depression scale

is available online as well and that's

referenced in the Royal College of

Psychiatrists
guidance
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chrisb · Jun 29, 2020

"what's really important
and something that occasion gets lost in
mus is that the symptoms the patient's
experiencing are absolutely 100% real to
them they are frequently distressing an
anxiety inducing both to them their
family and indeed the clinical team who
treats them"

he seems to be treading on thin ice here. So, they are not real or need not be considered real by others. Whatever "real" may mean.

Invisible Woman · Jun 29, 2020

I read an account once of a young rheumatoid arthritis patient. She was a pre teen when her symptoms started. They seemed a bit vague at first and gradually worsened.

Naturally she was distressed. She was being left behind & felt left out me her friends and classmates as she couldn't keep up.

Then she was ambushed at an outpatient appointment by therapist who sat her down and asked why she didn't want to go to school, why she was struggling to make friends.

It was the ultimate betrayal for this kid.

The cruelty of being disbelieved and the problem made worse by the very people she thought would try to help her. The additional cruelty of being accused of not wanting to do the things she so desperately did want to do.

Eventually, the diagnosis of rheumatoid arthritis was made and an explanation for her symptoms became clear. There was never an acknowledgement of the harm the therapist or team caused.

I wish these people would assess how many people experience the same thing as this youngster.

I wish they would assess the long term damage caused by having faith that those who are supposed to help and support you will ripped away.

rvallee · Jun 29, 2020

Why is there mention of PEM in the title when it is not discussed (as far as I can tell, too rambly to read all)? This is the exact same substance as any alternative medicine guru: null and void. I don't get it, it's entirely devoid of anything relevant to the actual needs. I would actually feel like I would be wasting my time less than this if my job were to watch actual clown shows all day.

Lot of waffling without substance. Just someone who likes to hear the sound of their voice "explaining" the "unexplained" spooky ghost sounds followed by thunder.

Hoopoe · Jun 29, 2020

I also thought it was about postexertional malaise and that it was nice that hospitalists are becoming aware of this. But the cases didn't fit ME/CFS and then he presented his psychosomatic belief system.

MatthiasRiem · Jun 29, 2020

In this case, it seems 'PEM' abbreviates 'Paediatric Emergency Medicine'.
Also explains the bit about keeping the patient out of the emergency room in the future...

wigglethemouse · Jun 29, 2020

Sly Saint said: ↑

youtube generated transcript:
Click to expand...

@Sly Saint When you grab the transcript, is there an easy way to remove the time stamps, rather than deleting one by one?

rvallee · Jun 29, 2020

MatthiasRiem said: ↑

In this case, it seems 'PEM' abbreviates 'Paediatric Emergency Medicine'.
Also explains the bit about keeping the patient out of the emergency room in the future...
Click to expand...

Hmmm. Still odd considering this very rarely presents to emergency, those kinds of symptoms are almost universally handled by GPs. Well, more like not handled but whatever this is where it doesn't happen.

Sean · Jun 30, 2020

Invisible Woman said: ↑

Eventually, the diagnosis of rheumatoid arthritis was made and an explanation for her symptoms became clear. There was never an acknowledgement of the harm the therapist or team caused.
Click to expand...

If they were honest compassionate professionals they would openly acknowledge and apologise for these kind of mistakes, and learn from them. Without being asked or forced to.

Sly Saint · Jun 30, 2020

wigglethemouse said: ↑

@Sly Saint When you grab the transcript, is there an easy way to remove the time stamps, rather than deleting one by one?
Click to expand...

yes; when you bring up the transcript in upper rh corner there is another 3dot menu and it says 'toggle time stamps'

DigitalDrifter · Jun 30, 2020

chrisb said: ↑

is that the symptoms the patient's
experiencing are absolutely 100% real to
them
Click to expand...

In my experience that's just gaslighting when it comes to ME, they don't treat you as if your symptoms are real.

rvallee · Jun 30, 2020

Sean said: ↑

If they were honest compassionate professionals they would openly acknowledge and apologise for these kind of mistakes, and learn from them. Without being asked or forced to.
Click to expand...

How then could it be maintained, as is repeated ad nauseam as a mantra, that no harm come from conversion disorder? Which is of course deliberate, a full accounting of the outcomes would have all of it cancelled in a heartbeat. It's a scam, you can't maintain a scam and face the truth at the same time.

So everyone lies. Most probably unwittingly. But they are licensed professionals and they lie, to themselves, to us, about us and to the world. With Enron-style creative accounting of hiding the losses and amplifying gains that are mostly an illusion. Actually Enron was small-time fraud compared to this, and far less lethal.

But the circle jerk goes on spinning. How else would Freud spin in his grave if not turned by the cyclone of hot air coming from the spit of woo?

wigglethemouse · Jul 3, 2020

Sly Saint said: ↑

yes; when you bring up the transcript in upper rh corner there is another 3dot menu and it says 'toggle time stamps'
Click to expand...

Thank you.

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Medically Unexplained Symptoms and PEM (Paediatric Emergency Medicine) presentations - Dr Armstrong - 11 Jun 2020

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