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.”
“Got it,” I said. At the time I was a medical resident at a New York City public hospital, supervising an intern and a medical student. I knew that delirium, an acute confusional state, could result from just about any type of acute illness, or it could be a side effect of medication. And yet, I explained to my team, you could often guess the cause simply from the type of patient.
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 fine, 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.
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.”
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 global 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?”
