If he has lost a self—himself—he cannot know it, because he is no longer there to know it.”. from― Oliver Sacks, The Man Who Mistook His Wife for a Hat and Other Clinical Tales
Most of the medical literature puts the responsibility of knowing if one is confused on the patient. The patient is asked to tell a doctor if they become confused. Doctors seem not to understand that confused patients, often cannot tell anyone that they are confused- because they are confused. “If he has lost a self—himself—he cannot know it, because he is no longer there to know it.”. from― Oliver Sacks, The Man Who Mistook His Wife for a Hat and Other Clinical Tales
A mildly confused patient may look normal, and may be able to answer simple questions, but they may not be able to spontaneously tell anyone if they are confused. They may not even recognize that they are confused- just as they may not recognize that they are experiencing difficulty breathing. Even worse, the patient may suddenly become passive, which may mask their confusion and lack of energy..
The patient is expected to respond to open ended questions such as “so what brings you here to day” in order to convey their medical problem. And that is the main thing, of course, that they cannot do. [“because he is no longer there to know it.”].
So many mildly confused patients go undetected. Just because no one will think of measuring their respiratory rate and simply assumes that they have become unhappy.
This is what happened to Paula. No one expected or understood that anyone can suddenly become mildly confused. So everybody missed it. She even managed to tell the doctor; he dismissed it. At the time she was in a state of despair. She would never remember to tell him again. He would never be able to help her.
In the end, this was a good thing. If anyone had guessed that Paula was confused [meaning quietly confused] they would have panicked, thrown a few treatments at her and given up on her if they didn’t work….or they might have killed Paula with incorrect treatments and not realize what they’d done…or they would have prevented her recovery by using drugs to calm her without restoring her baseline intellect.
Doctors need to understand the signs of mild confusion and learn a clear and simple emergency protocol; for example, every patient is now asked for their name and their address and phone number in order to make sure the right treatment is given to the right patient and no mistakes are made. Mildly confused patients will not remember their personal information, except for their name.
Paula knew her name but not her phone number and maybe not her address. She did not know this. Closer observation of her general appearance would have been useful [she had lost weight, her skin was grey, dehydrated, her extremities pale and cold, and she could not speak more than a couple of words at a time, [she did not look well]. She looked downright toxic. Because she was physically ill, not because she was sad. Sadness does not cause this.
The next step would be to measure her vital signs [especially respiratory rate and depth- to get her minute volume]. Nobody measures respiratory rate …even though it is the most sensitive of the vital signs to physical illness;
see the blog on Insanity; What does it feel like., where I quote:
Respiratory rate is the sentinel and arguably most important vital sign because its normal values are breached before those of other vital signs in nearly all states of clinical decline. …………Changes in respiratory rate are often the earliest warning of sepsis, systemic inflammatory response syndrome, shock, and respiratory insufficiency, among others. In these conditions, abnormalities in respiratory rate first herald the need for additional patient assessment and rapid intervention to prevent further decline and unexpected cardiac arrest.
Once abnormal [slow or too fast] respiratory rates are noted along with mild mental confusion, arterial blood gases are required in order to manage the metabolic dysfunction safely.
Every doctor should be aware of this emergency protocol for possible metabolic problems causing mental confusion in neuopsychiatric and neurological patients who go to the emergency room.
Every doctor who sees ambulatory patients should also be aware of what to do.
Advanced emergency first aid is preferable to panic, dismay and wrongheaded thinking and treatments.