Good News Bad News

"Now, my dear, what brings you into the ER at this ungodly hour?"

It was 3am on a Monday morning and this is my post-midnight spiel, a sneaky way of trying to figure out if I'm dealing with a patient in genuine distress or otherwise. I've always found the answer to this question to be very revealing - the patient who irately says "well I couldn't sleep, I'd run out of my (fill in narcotic name) and where the hell else was I supposed to go?!" is quite different from the one who gasps "I think I'm having a heart attack!"

I like the midnight shifts. I've learned that patients who come into the ER at these hours are either 1) very sick or 2) very crazy/worried/depressed.

This patient, though, stumped me with her answer: "I decided to get in the tub yesterday morning," she cheerily said, "and I decided not to get out."

"Oh," I said, mostly because that was all I could think of.

"Yes," she said, "and I suppose when my son came by tonight, he was alarmed because I was still in the tub."

"Oh," I said again.

"Mmmhmmm," she said, nodding her wizened 80-yr old head.

Wondering if she had a history of dementia or anything that would put her into Category 2 (which I - bad, bad me - call "the crazies"), I took her family aside.

"Is she always like this?" I asked.

"No, doctor," her son said, worriedly. "Never. She lives alone, does everything for herself. When we got there tonight, she was seeing things too."

"Seeing things?"

"Yes, she said there was a little girl with a teddy bear standing in the door."

O-k-a-y...

I went back to my patient, and tried a different tactic. "Tell me," I said, "who's here with you right now?"

"My son," she said. "My daughter-in-law."

"That's right," I said. "Anyone else?"

"Well," she said, "there's somebody standing over there on the ceiling but I can't make out who it is."

Nonchalantly, I elicited more details from my patient about this upside-down person: wears glasses, stands on the ceiling, is female, and "can't make out if she's dressed".

Since there were no naked little female leprechauns prancing on our ER ceilings, she was quite evidently psychotic. But without a psychiatric history? It would be highly unlikely - though not impossible - for someone to never have had any sort of psychiatric problems in their lives only to develop schizophrenia in their 80s...

I ordered my usual investigations for delirium, waited for them all to get back, and, as expected, found nothing. Great. Back to square one: my patient sees things and makes strange decisions to sit in bathtubs for two days but I can't find anything else wrong with her.

"Why didn't you get out of the tub?" I asked.

"I don't know, my dear," she said. "Couldn't tell you. I did think about it, though."

I was desperately fishing for "medical" reasons not to get out of a tub. Was she weak? No. Faint? No. Ill? In pain? Having trouble breathing? Couldn't see? Afraid she'd slip? No, no and more no. She'd just "decided" not to get out after thinking about it.

So I did the last test I could think of: I called the radiologist and asked for a CT of her head.

The radiologist was unimpressed by my request. "It doesn't sound like a stroke," he said.

"Yes, I know," I said. "But she's not delirious, she's hallucinating and behaving strangely and I want to make sure there's nothing actually in her head, like a tumour."

"But her exam was normal," he said.

"Yes, I know," I said. "I know this is a very strange story."

He reluctantly agreed to do it, and two hours later, I had my answer:

"There seems to be a subtle tumour in the right frontal lobe," the radiologist said. "That would explain the hallucinating and strange behaviour."

When I went to give the family this "good news bad news" - good because there was a reason for the strangeness of my patient, bad because it was a tumour - they took it quite well.

In fact, my patient took it better than her family.

"Oh!" she exclaimed, chuckling delightedly. "That's just what I need, my dear - a brain tumour!"