Filler

Homage to delirium

I recently started a fellowship in geriatric medicine at a large academic facility, and it was with some trepidation that I saw the list of my patients for the next two years"dean of this," "professor of that." Fresh from residency in a community based hospital, I felt as if these figures from medical school clinical examinations had come back to haunt me.

And then "professor of that" was admitted to hospital. I spent some time with this retired medical school dean, when he entertained us with his past glories. I did not expect him to succumb to a delirium so shortly after admission. Perhaps part of me failed to accept that a great academic figure could so rapidly become just like the other frail, grey souls struggling with reality in their hospital beds.

As we rode the wave of his fluctuating mental state his failing heart incited a pharmaceutical tug of war as evidence based medicine conflicted with a need for simplistic prescribing. I wanted to hurry him back to his familiar environment. Despite it all, some of the old magic was hinted at. I chuckled as he bullied the new interns into obtaining unnecessary investigations for the slightest symptom.

And then he sank deeper into confusion. The attending physician's eyes registered great concern, and I knew then that I wasn't alone in feeling some sadness in seeing a great member of our profession slip.

"But I must get to Hopkins," he cried, his delirium in full force, "I must deliver this paper. My son's making the arrangements, you have met him I believe," introducing me to a white wall. To those walking past his room he was like any other frail old man teetering at his walking frame like a branch swaying in a cruel breeze. Inside, however, I was witness to a strange and compelling discourse. The turbulent sea of his thoughts had whisked him to a lecture hall distant in place and time. His walker was transformed into a podium by his delusions; he sprang to life, restored to his former professorial glory as lecturer as he addressed the hallucinoform crowd.

My initial instinct was to redirect him back to reality. On the other hand, to bask again in the academic limelight seemed to be therapeutic for him. While ensuring that he didn't topple over, I did little to end his grand delusion. I was privy to an experience akin to hearing Dr Parkinson lecture me on "the shaking palsy."

If I have learnt anything from my experiences with the professor, it is that delirium is more than just a confused patient. It is a state unique to the individual that draws on the entirety of his or her life experiences. As such, I have a clearer understanding that though delirium can be easily diagnosed, it is rare that we are given the chance to contextualise the abnormal thought processing. Perhaps if we knew our patients' passions in more detail we could understand what lies behind the manifestations of their confusion. A great man can still be a great man in the presence of an acute confusional state, and it is this knowledge that gives me joy in caring for patients in their twilight days.

And now as I pass the chief resident's office on my way to rounds, I dwell for an instant by my patient's photograph labelled "Housestaff 1935-6" and wonder if I will be lucky enough to have my delirious ramblings impact on someone so deeply.

Craig J Wilson, fellow in geriatric medicine, Duke University, Durham, NC, USA. 

We welcome articles of up to 600 words on topics such as A memorable patient, A paper that changed my practice, My most unfortunate mistake, or any other piece conveying instruction, pathos, or humour. If possible the article should be supplied on a disk. Permission is needed from the patient or a relative if an identifiable patient is referred to. We also welcome contributions for "Endpieces," consisting of quotations of up to 80 words (but most are considerably shorter) from any source, ancient or modern, which have appealed to the reader.