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I sensed a commotion rippling across the emergency room. near the entrance, a man sporting a surgical mask and pajamas was pacing like a tethered ferret. It was 2 a.m., but as a rule most patients don’t wear their PJ’s to the ER. Something was strange about this one. Heading over, I watched as Claudia, the intake nurse, tried to coax him into the triage chair. He sat for a moment, stood up, then plopped back down.

“I need to see your expert,” he spat out. “I have to do this quickly.”

“Do what, sir?” Claudia asked.

The patient sprang up. “I can’t feel my legs. I can’t breathe. Where’s your expert?”

His wife walked calmly over from the registration desk.


“John was hospitalized uptown four days ago,” she told me. “It started then just like it did tonight, with a headache and confusion.” The 
spinal tap done uptown had shown a high white blood cell count, indicative of infection, but all the cultures were negative. John had stayed in the ICU and gotten better overnight—a surprise for the uptown staff, who then diagnosed viral meningitis. (Meningitis is an inflammation of the meninges, or lining of the brain and spinal cord, usually caused by bacteria or a virus; bacterial meningitis can be life threatening, but viral meningitis usually acts more like a passing flu.) In line with that diagnosis, they’d sent John home.  “Yet just before bed tonight he had a headache, then woke up babbling again,” his wife explained.

Now I turned to the patient himself. John looked about 40. He stared at me with a vacant, intense glare that reminded me of someone high on angel dust. The disturbing gaze cinched my first impression: This patient was suffering from altered mental status, the catchall term for “malfunctioning brain.” That meant his brain could indeed be under siege by a virus resulting in meningitis; the inflammation and any associated virus causing his confusion could have gone away without treatment. But there was no explanation for why it had returned. What had they missed uptown?

I glanced at John’s vital signs. Blood pressure, pulse, breathing rate, and temperature were all normal. That was interesting. Viral meningitis usually causes a fever and accelerated heart rate.

I turned to the patient again. “What happened tonight, sir?”

“It’s all right, darling,” the wife said soothingly. “This is no worse than last time.”

“No fever, vomiting, or new medications?” I asked.

She shook her head.

“I can’t stay,” John said in a rush. “We have to go.”

“First can I make sure you’re OK?” I pleaded. “It really would be better if you stayed,” I said in my softest please-don’t-make-me-tie-you-down voice.

“See? The doctor is very nice,” the wife implored.

“How about we get you in a comfortable room?” I offered. “It has a TV.”

My first-year student, Stacy, materialized; she was there voluntarily, her idea of fun being an overnight in the ER.

Together we shepherded John into a room. We had to move quickly; altered mental status in an otherwise healthy patient mandates a head CAT scan to rule out bleeds and tumors and a spinal tap to check for meningitis and encephalitis (inflammation of the brain).

John, surgical mask still in place, kept popping out of the room.

“What are you going to do?” he demanded. “I need the expert. A neurologist!”

His wife laid her hand on his arm. He stopped talking and calmed down. I told him we would be running tests, but in light of the mega workup he’d gotten uptown, I questioned whether they would show much at all. The safest approach lay straight up the middle: First rule out immediate life-threatening things, then rethink.

“OK,” I told Stacy. “Go in there and get more detail: Fever? Headache? Nightmares? Travel? Hearing voices? The weirdest part is how he got better, then bang, bad again. I’m counting on ya, kid.”

For a few minutes, all was calm. Then Stacy came trotting out of the room.

“Dr. Dajer, can he have water and an Advil? He has a headache.”

“Sure,” I started saying. Then I stopped.

Advil?