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Authors: Allan H. Ropper
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was clogged with a full battery of tests. To use another of Callie’s favorite expressions: Wally had been worked up “up the wazoo.” Many of the results were still pending, and some would take weeks to come back. In the meantime, I suggested getting even more esoteric and expensive tests. As Elliott never tires of telling me: “Hey, it’s other people’smoney. Don’t start believing it’s our responsibility to reduce healthcare costs.” To which he was quick to add: “Not for quotation, by the way. I can just see that on the front page of the Globe .”
It may sound trite to say that confusion is the most confusing syndrome in medicine, but it is. A confused person behaves in a way so foreign to common experience that it can be unnerving, even for professionals. It is an alternate state of being. Portrayals of confusion in popular culture—the town drunk, for example—may look funny, but in the case of a truly confused person, the sight of someone who can’t find his own mind can be overwhelming.
As a neurological entity, confusion is up for grabs. Any young researcher hoping to make a name for herself might consider starting a large-scale study of it. Or not. It could easily eat up a budding career. An understanding of confusion has yet to be operationalized in the way that stroke or neuropathy or Parkinson’s disease have been. It is not, technically, a disease, but a syndrome, a collection of problems. Clinically, confusion is defined as a loss of the usual clarity, coherence, and speed of thinking, but this description, while accurate as far as it goes, captures only a snapshot of confused behavior. In some patients, blood tests will reveal a metabolic cause that can be addressed: low levels of blood sugar, for example, or high levels of carbon dioxide. But as with many neurological conditions, there are no definitive tests for confusion. We have to rely on the clinical exam, the patient’s history, the story as given by family or neighbors, and any little clues we can unearth. A tinplate locomotive, for example.
On my first visit with Wally Maskart, he seemed fairly lucid, if not completely with it. After introducing myself, I got right down to business.
“You’re a model train guy, right? HO gauge?”
“No. O gauge.”
“Good. I’ve got to come see your setup someday. I have N scale and HO. A lot of scale buildings, too.”
“So do I.”
Wally was sitting up in the hospital bed. His face was ruddy, his gray hair plastered down and tousled by the recently removed EEG leads. He was a hunched, flushed, somewhat pudgy fellow, constantly short of breath, and thus incapable of speaking with ease or completing a sentence without pausing to inhale some of the oxygen coursing through the tubes under his nose. He had the appearance of a guy who was once physically active, if not robust, and was now deflated.
“What brought you to the hospital?” Hannah asked him, and he proceeded to tell the story of getting lost for five hours.
“So that’s where I screwed up, getting all confused again,” he concluded.
“This driving for five hours, you’d never done that before?”
“No. I knew where the place was. I’d been there before.”
“So where did you go?” she asked.
“I can tell you exactly what happened. I looked up MapQuest. On MapQuest there’s a big circle, a rotary, and you enter the circle, and MapQuest says bear right, and then bear right again. But what I actually did is take the second right and then bear right. So I missed the building, which was right there, and got three towns away.”
“Three towns? And that’s the only time that’s happened?” Hannah asked.
“Yeah.”
“You’re not confused now,” I said. “You’re very clear.”
“I am now. I told my wife, don’t worry, but I was three towns away. And I made it home alright without any problem at all. The only problem was when I told her let’s go home, she got teary eyed.”
“But that was three
It may sound trite to say that confusion is the most confusing syndrome in medicine, but it is. A confused person behaves in a way so foreign to common experience that it can be unnerving, even for professionals. It is an alternate state of being. Portrayals of confusion in popular culture—the town drunk, for example—may look funny, but in the case of a truly confused person, the sight of someone who can’t find his own mind can be overwhelming.
As a neurological entity, confusion is up for grabs. Any young researcher hoping to make a name for herself might consider starting a large-scale study of it. Or not. It could easily eat up a budding career. An understanding of confusion has yet to be operationalized in the way that stroke or neuropathy or Parkinson’s disease have been. It is not, technically, a disease, but a syndrome, a collection of problems. Clinically, confusion is defined as a loss of the usual clarity, coherence, and speed of thinking, but this description, while accurate as far as it goes, captures only a snapshot of confused behavior. In some patients, blood tests will reveal a metabolic cause that can be addressed: low levels of blood sugar, for example, or high levels of carbon dioxide. But as with many neurological conditions, there are no definitive tests for confusion. We have to rely on the clinical exam, the patient’s history, the story as given by family or neighbors, and any little clues we can unearth. A tinplate locomotive, for example.
On my first visit with Wally Maskart, he seemed fairly lucid, if not completely with it. After introducing myself, I got right down to business.
“You’re a model train guy, right? HO gauge?”
“No. O gauge.”
“Good. I’ve got to come see your setup someday. I have N scale and HO. A lot of scale buildings, too.”
“So do I.”
Wally was sitting up in the hospital bed. His face was ruddy, his gray hair plastered down and tousled by the recently removed EEG leads. He was a hunched, flushed, somewhat pudgy fellow, constantly short of breath, and thus incapable of speaking with ease or completing a sentence without pausing to inhale some of the oxygen coursing through the tubes under his nose. He had the appearance of a guy who was once physically active, if not robust, and was now deflated.
“What brought you to the hospital?” Hannah asked him, and he proceeded to tell the story of getting lost for five hours.
“So that’s where I screwed up, getting all confused again,” he concluded.
“This driving for five hours, you’d never done that before?”
“No. I knew where the place was. I’d been there before.”
“So where did you go?” she asked.
“I can tell you exactly what happened. I looked up MapQuest. On MapQuest there’s a big circle, a rotary, and you enter the circle, and MapQuest says bear right, and then bear right again. But what I actually did is take the second right and then bear right. So I missed the building, which was right there, and got three towns away.”
“Three towns? And that’s the only time that’s happened?” Hannah asked.
“Yeah.”
“You’re not confused now,” I said. “You’re very clear.”
“I am now. I told my wife, don’t worry, but I was three towns away. And I made it home alright without any problem at all. The only problem was when I told her let’s go home, she got teary eyed.”
“But that was three
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