Medicine & Reality

The “Demented” Patient

“He ain’t right in the head”

“He ain’t right in the head” were the first words I heard from my patient’s companion.

I’d done my standard introduction. “Hello I’m Michael Burg, one of the doctors in the emergency department. How can I help you today?”

The patient didn’t speak. Although I knew from a quick chart check that he was 49, he looked older, quite a bit older in fact. The woman with him spoke for him.

Often, when I roll up on patients in the ED, a “blink moment”occurs. It’s my instant visceral sense of what’s up. As in, “sick or not sick.” Or sometimes, “danger, stay back a bit, danger!” Occasionally it’s a single word like, “pale!”

In this case my blink moment was “Howard Hughes.”

My patient looked remarkably like Howard Hughes. NOT the dapper lady’s man portrayed at the start of Aviator. We’re talking about the just-before-he-died, decrepit, straggle-haired, graying, dirt-under-the fingernails, broken down old man.

Remember, my patient was not old, just 49.

“How long has he been, uh ‘not right in the head’ as you mentioned,” I continued.

“Don’t really know,” her response.

“Oh, I assumed you were a couple.” I said.

“Yeah we are. But we ain’t been one long.”

“So what else do you know about this gentleman?” I queried carefully.

“I tol’ you. He ain’t right in the head” she issued, sighing, her eyes rolling ceiling-ward as though I might be the dumbest doctor west of the Mississippi.

I noticed that her “right” came out “rah-yuh-t” and her “head,” hey-yud.”

“Well it’s important to know these things,” I went on, hoping to bridge our looming cultural and communication chasm.

But the latter-day Ms. H. Hughes wasn’t having it.

She just stared at me. Waiting, I think, for me to do some “doctor shee-ut” and figure out Mr. H. Hughes problem and cure it, so she could get on with her day.

I tried a couple more questions, but all they did was broaden the gap between me and Ms. The patient remained silent.

“I tol’ you. He ain’t right in the head.” How many times do I have to tell you that shee-ut.” This was now being spat at me as though … ah weren’t rah-t in the hey-yud neither.

One last try, by me. “Are you able to explain how he isn’t right in the head? What does he do? How does he behave? What has changed from his usual? Anything?

I felt like a drowning man who’d just been tossed a barbell.

“I tol’ you. His HEY-YUH AIN’T RAH-T!”

And with that, Ms. H. H. checked out. As in, stonily refused to speak with me any further.

One of my old-school colleagues believes that “history leads to the diagnosis in 90% of cases, but the other 10% of patients come to our ED.”

In medicine, “history” is the recounting of the dysfunctions and their time course that leads patients to seek medical care. An easy example would be “I’ve had fever and a productive cough with chest pain for about a week.” This simple straightforward declaration might lead a physician to conclude pneumonia is the diagnosis. Or something along those lines. That’s how it’s supposed to go.

But there was nothing simple or straightforward forthcoming from either the patient or his love mate. I was working with either “His head ain’t right” or “He ain’t right in the head” and nothing more. All, and I do mean all, other details were absent. A bit like Mr. H’s presence in all this. He still hadn’t spoken, nor had he moved or looked up.

So I pressed on, and did a physical examination with a focus on neurological function. There was not much to find.

My patient was disheveled but his basic signs of life, his “vital signs,” like temperature and blood pressure, were normal. With direct questioning I was able to elicit his name. He had no idea about the date. His guess about location was vague. “Building” I believe was his speculation. He completely lacked insight as to why he was in the emergency department seeing me. He may have offered something like “because she said so” on this topic.

He walked and his limbs functioned but his gait was off, broad-based and shuffling with head down as though he needed to see the floor in order to navigate.

There wasn’t much else.

So, I did what doctors do and started my investigation, with labs and brain imaging, specifically a CAT scan.

And then I left the department.

That’s one of the joys of emergency medicine. Usually we get to go home at a predetermined time, end of shift. As some say, “Five o’clock comes at the same time every day.”

Before leaving though, I “signed out” this patient, and my many others. A colleague heard the story from me and assumed responsibility for further care. Part of my “sign out” went like this.

“He’s 49 but looks 79 and is decidedly not functioning normally. I have some ideas about what might be going on but he was my last patient of the day and the medical evaluation is in progress. Please check the labs and the CAT scan that I’ve ordered and take it from there.”

Then I added.

“Under no circumstances is this man to be discharged home. He is too dysfunctional, and there’s no one there capable of caring for him. Admit him to the hospital regardless of test results. You may need to expand his medical evaluation if you don’t have a diagnosis after what I’ve started.”

Sometimes s%$t happens. And that’s what happened in this case. I found this out several days later when I worked again.

All the tests I’d ordered were normal and the patient was discharged home with instructions to see his primary care doctor.

Thankfully, he was brought back to the department within 24 hours by his head-ain’t-right woman. Then, as is said in medicine, “a diagnostic procedure was performed.” He was admitted to the hospital for treatment.

In this case, the diagnostic procedure, the one that should have been done next in this patient’s evaluation sequence, was a spinal tap.

The patient’s diagnosis … lues (to be more precise, actually tertiary lues). Or, if you’re English, “The French Disease.” And if you’re French, “The English Disease.” Or, depending on where you’re from, the German, Polish or Turkish disease. “The pox.” The list goes on and on. It’s an old disease.

We know it as syphilis.

If I had to create a back story, this is how it would go.

Many years ago, Mr. H. had enjoyed, or maybe just had, a sexual encounter. A short while later a painless ulcer had developed on his genitalia. Whether he noticed it or not, it had simply resolved. Then after a time he may have developed a diffuse rash, salmon-colored, that would have involved his palms and soles. This too would have resolved on its own. Many years passed. Then Mr. H. began to decline.

The reason for his decline, the organism that causes syphilis had found a home in his brain and was gradually destroying it. That is why he had become a shell of his former self, a man who appeared aged, disheveled and dysfunctional beyond all reason.

So, when all you get is “his head ain’t right” then it ain’t right to rest until you figure it out. If you’re a doctor and you do stop short then you are the one who ain’t right in the head.

This story is dedicated to my son Shawn. He’s 25 now but he first heard this tale as a 7-year-old. He’s been urging me to write it up for as long as I can remember.

He is right in the head.