How can someone know if he is really sick? Life-threatening illness in the emergency department is often like the Supreme Court Justice Potter Stewart's assessment of pornography: we know it when we see it.
But for most people, in most situations, sorting out true illness can be difficult. Many healthy folks cycle through EDs for nothingitis because they are anxious about disease, while some very unwell people stick it out at home in full denial or stoically convinced that they can will themselves better. Others get so worked up with worry that they cause their coronaries to spasm them into right into a cardiac cath lab while others just can't understand why their chest aches so deeply when they walk up stairs.
What's the difference between a mind that causes illness and one that can detect sickness early? This would seem to be an important question not only for emergency medicine but also for every single living and thinking “patient” in the world. As EPs, we've all seen scores of panicky patients who have initiated their own domino effect of self-inflicted pathology. Take, for instance, the worried hypertensive who takes his blood pressure reading at home again and again until it reaches an ischemic stroke climax.
Admittedly, patients seem much better at causing their own illness than at sensing it before it occurs. But some people out there can reliably predict when they are getting ill, and I find this intriguing. Do we as humans have a muted and under-recognized sense of our own sickness? Could our patients serve as their own triage nurses with better recognition skills? Phone advice lines are great, but wouldn't it be nice if our patients had a reliable sense of sickness, an epiphany of medical impairment. Skeptical? Well, consider some examples. Let's start with the “aura.”
The aura that “precedes the headache of migraine is very mysterious.… [T]here is a process of intense activity which seems to spread, like the ripples in a pond into which a stone is thrown.… The most frequent among the many forms is that of a small star near the fixing point; it enlarges towards one side, its rays expanding into zigzags,” wrote British neurologist Sir William Gowers in the British Medical Journal in 1906. Dr. Gowers was fascinated with the aura, so much so that he just couldn't help himself from describing it in exquisite detail.
“The most frequent prodroma is visual, as you all know. It is so characteristic as not to lead to confusion with epilepsy. But its features should be noted. The most frequent among the many forms is that of a small star near the fixing point; it enlarges towards one side, its rays expanding into zigzags, often coloured — the 'fortification spectrum.' Within it vision is dimmed by bright scintillation. It becomes faint when it has almost reached the periphery, and ends in various ways which are not relevant to our present object.”
Auras, as we know, are also common in people with epilepsy, and come in a wide variety of forms — a kaleidoscope of lights, the smell of burnt toast, the sound of a public address announcer booming — and may occur seconds to hours before the onset of a headache or seizure. The aura is an extremely reliable indicator of impending symptoms for a patient with epilepsy or a migraineur, far more accurate than routinely available clinical evaluation or testing. Absent continuous fMRI or EEG monitoring, most would consider them a gold standard of disease prediction. But we don't really understand where auras originate. We assume, of course, that they are associated with excitation of specific cortical areas preceding the onset of more generalized processes, but have not been able to actually capture the neural circuitry of this process.
Is it possible then that auras are a prominent manifestation of an innate mental ability to detect illness, a sense and premonition of sickness?
Consider some other health-related premonitions. As EPs, most or all of us have had some experience with a patient who accurately predicted his own demise. I asked the partners in my department about such premonitions of death, and all but one had a story to share. The one who demurred gave this response, “Ugh, no, but I can tell you about the thousands of anxious patients I've had to talk down from the ledge. I hope you aren't going to turn this into a column.”
Well, with apologies to Dr. Nau, I am. I can recall a patient of mine, a reasonably healthy middle-aged man with a small spontaneous intracerebral hemorrhage caused, I initially reasoned, by poorly controlled hypertension. This man was neurologically intact, not on anticoagulants and had no evidence of mass or aneurysm on imaging. It seemed like he would do just fine. Nonetheless, we prepared a transfer to a neurosurgical center for observation.
My patient, stable and asymptomatic prior to transfer, asked me in a quite of matter-of-fact manner, “I'm gonna die, aren't I?” I assured him that this was not likely and that we were just taking a precaution, but he was convinced. “I'm gonna die,” he said once more, softly, right before being loaded on the transport stretcher. And, in fact, he did die, just a few hours later, from multiple new bleeds caused by a rapidly progressive cerebral vasculitis.
A colleague tells a story of an aunt who suffered for months with headaches and dizziness of unknown etiology. She became convinced that she was going to die after many visits to her doctor and failed treatments. She was so convinced, in fact, that she began preparing and freezing dozens of meals so her husband would eat well after she passed. Ultimately, her cerebral aneurysm was diagnosed just shortly prior to rupture. She did not die, but was right on about being on the verge.
This is not a rich topic in the literature, but some evidence supports the premonition of death as a real entity. It is not uncommon for pregnant women who miscarry or otherwise lose a pregnancy to experience a premonition beforehand. A survey of women who suffered a stillbirth in the second trimester or later found that 64 percent reported some premonition that their child was unwell.
Joseph Ngeh describes one such premonition in the in-hospital death of an elderly patient in a 2003 letter to the Journal of the American Geriatrics Society: “The patient's family had arrived by then. Although distraught, they showed no surprise at hearing about the patient's sudden death. During our conversation, I sensed that they had expected this to happen. Remarkably, the daughter-in-law volunteered that, when they visited the patient at 9 p.m. earlier that night, a mere six hours before the patient's first cardiopulmonary arrest, the patient had held her hand and mentioned that he would ‘die tonight.’”
Premonitions of death are also common in trauma patients. A 2009 survey-based study by Miglietta and colleagues of 302 members of the Eastern Association for the Surgery of Trauma found that 95 percent of respondents reported encountering patients who expressed premonition of death, and 50 percent agreed that patients expressing such premonitions had a higher mortality rate. Fifty-seven percent also agreed with the belief that patient willpower affects outcome while 44 percent were on board with the notion that patients had an innate ability to sense their ultimate outcome after injury.
Such “evidence” must be considered in the light of its limitations. Recall bias is obvious; surely many pregnant women and trauma patients thrive and recover despite premonitions to the contrary. We must also distinguish premonition of death from the ancient Chinese phenomenon of hui guang fan zhao, also called a Lazarus premonition. Screenwriters have made liberal use of this scenario for decades: the transient revival of the dying person before death. This situation is clearly different because it is not so much a premonition as it is the recognition of a process, like a song in its last chorus, that is nearly complete.
And, of course, absent a biologic explanation, it's impossible to prove that humans have an innate sense of sickness. I would argue though that we should not be overly skeptical. We accept that animals may intuit when they or others are ill. Remember Oscar the cat (featured in the New England Journal of Medicine in 2007) who correctly foretold the deaths of more than 50 patients in a nursing home, curling up with them within hours of their death? We also accept that certain animals, and my recently departed black lab was one of these, will innately put themselves out to pasture near the time of their death (in the case of my lab, this did not work, because my wife kept carrying her back inside from the bushes).
It seems biologically and intuitively plausible that we humans have an innate sense of sickness. I think we can all agree that such a skill could be quite useful; wouldn't it be nice to have as much faith in the word of a patient who has intuitively predicted the onset of an AMI or stroke as we do with an epileptic aura? It sure would save us EPs a lot of stress, not to mention unnecessary testing.