Vital Signs by Anna Reisman
An older woman suffering from delirium
teaches a doctor to challenge first impressions.
Your admission is Evelyn Warwick, little old lady in distress.” The emergency room resident motioned toward a curtained area at the far end of the ward. “Completely delirious.”
We all agreed about Mrs. Warwick’s probable diagnosis. An
elderly woman with delirium at a public city hospital was likely
to be a nursing home patient with pneumonia or a urinary tract
infection. She might be dehydrated, or maybe she’d had a stroke
or a heart attack.
When I pulled back the curtain, I did a double take. Evelyn Warwick was a handsome woman with a neat gray bob like an elementary school principal, not a typical city hospital patient. Her pink
pajamas glowed against the starched white sheets. Mr. Warwick,
a silver-haired man in a tweed jacket, stroked her forehead with
a damp cloth.
I introduced myself and the team and asked how she was
feeling. She opened her watery blue eyes and stared far into the
distance. “I don’t know where I am!” she murmured in a clipped
British accent. “I woke up and my head exploded.” She looked
around the room in a panic and started to weep. “Where am I?
What’s all this?”
Her husband patted her hand. “We were on the QE2, darling.
Four days at sea since we left Southampton. We docked in New
York yesterday, remember? You woke up in the hotel…. You were
so upset.” Mrs. Warwick closed her eyes and sighed.
“At 3 in the morning, she bolted up and woke me in a fright,” her
husband continued. “She didn’t know where she was.”
She had no medical history of note and took only a daily vitamin.
She didn’t drink, Mr. Warwick told us, no more than a glass of white
wine with dinner. Except for a mild fever and a slightly rapid heart
rate, her physical exam was normal. Her blood and urine tests, so
far, were unremarkable: she wasn’t anemic, her electrolytes were
;ne, and she wasn’t dehydrated. An electrocardiogram showed no
evidence of a heart attack. She’d had a normal chest X-ray, and a
CT scan of her brain hadn’t shown any sign of a stroke or tumor.
The initial results of her spinal tap were normal too.
I laid my hand on hers, which was warm and sweaty and jittery,
and asked her if she had felt any different in the last few days. Her
eyes popped open and darted back and forth. “I don’t know, I
don’t know where I am!” she said, her face creased with worry.
“You’re at a hospital,” I reminded her. “We’re going to help you
feel better, I promise.”
Mr. Warwick scratched his head. “She did say she felt a little
under the weather. Nothing out of the ordinary.” He watched his
wife turn her head from side to side and ask again where she was.
“Last night we had a late dinner at the hotel,” he told me. “She
had some broth, a little salad, half a glass of wine. She didn’t have
much appetite, a bit of a headache. Didn’t think much of it, after
such a long journey.”
So far, her symptoms and test results hadn’t given up any clues.
I left the room, hoisted a few textbooks over to the doctor’s station,
and started to read. We’d ruled out the most common causes of
delirium, but I wanted to make sure I wasn’t missing anything.
Then I came upon a syndrome I’d never heard of before:
transient global amnesia. TGA, I read, usually occurs in older
people and often produces a brief period of anterograde amnesia,
the inability to form new memories. Patients often ask about the
date and place again and again, and they sometimes experience
headache and nausea. Even though TGA is rare—each year, it
affects up to 32 per 100,000 people over age 50—and is typically
brought on by strenuous activity, I realized it might explain Mrs.
Warwick’s symptoms. Maybe the long voyage had been too much
for a 65-year-old woman. If this really was TGA, she should be
better within 24 hours.
I paged my intern and student and we went to get a snack from
the vending machines. I told them about TGA and they agreed
that the diagnosis made sense. But when we got back to the ER,
a nurse waved us over urgently. “I just paged you,” she said. “Mrs.
Warwick’s temperature spiked to 103 and she’s hallucinating, very
agitated. I don’t know where the husband is.”
We rushed back to the bedside. So much for transient glob-
al amnesia. Mrs. Warwick was thrashing around on the bed as
though possessed. Sweat poured down her face, and her blood
pressure had skyrocketed. “She just pulled out her IV,” the nurse
explained. “She needs restraints, OK?”
“Fine.” My heart thudded in my ears. I couldn’t think. Mrs. War-
wick cursed and hollered gibberish as the nurse wrapped restraints
around her wrists and tied them to the bedrails.
Someone was tapping my shoulder. “Shouldn’t we give her
some benzos?” Jeff, the medical student, was asking. I took a
deep breath and refocused. I explained that in most cases of
delirium, benzodiazepines—antianxiety medicines that include
diazepam (Valium)—can actually worsen symptoms. Instead, I
asked the nurse to give her haloperidol (Haldol), an antipsychotic
that can safely calm a delirious patient.
The Haldol wouldn’t take effect for at least 30 minutes. I feared
that Mrs. Warwick would go into cardiac arrest or have an arrhythmia or a stroke or be overwhelmed by infection, and I didn’t know
what else to do. We were going nowhere with our diagnoses while
my patient was plummeting downhill.
Leah, the intern, interrupted my frantic thoughts. “I keep thinking this looks like DT,” she said. “Though I know it can’t be…”
DT is an abbreviation for delirium tremens, a life-threatening state
that affects 5 percent of people withdrawing from alcohol. People
with DT are disoriented, sweaty, and febrile, and they sometimes
hallucinate. Dangerous cardiac arrhythmias and respiratory failure
can lead to death. A century ago, 37 percent of people with DT
died; nowadays, due to better treatment, it is about 5 percent.