Paula had altered mental status; the possibility of an encephalopathy was never looked at.

Paula knew 20 years ago, when she woke up in distress, that she was not depressed. She had altered mental status [a sign of encephalopathy]. Paula had no words to describe it then. She knew that what she was experiencing was different than anything she had ever experienced in her life and she knew that something was physically wrong.

Paula had altered mental status [a sign of encephalopathy ] and she immediately thought to herself; I hope I am not sent to a psychiatrist; if they do-I am finished. Of course she was dispatched to a psychiatrist after 3 weeks of suddenly being completely incompetent and weird at work. Everybody noticed and it was so embarrassing for Paula; everyone knew she had lost her sanity. No one knew what to do, what to say. They looked as scared as she felt.

If Paula had been given a quick mental status test, she would have failed because her memory was so disturbed. I gave her a digit span test at one time and found that she could remember 5 random numbers out of 7 forward, and only 2 numbers backward. No wonder she could not do her job. Paula also lost her words; she could no longer remember word like “altered mental status ” and she wracked what little brain power she had left to try to communicate that she was not able to function intellectually at her baseline. But she had no words to explain. And doctors were not prepared to hear, they preferred that she be sad, depressed instead of partially demented or silently delirious [same thing really].

Paula remained in a state of altered mental status for over a year. And during that year her doctor believed her to be depressed not insane. She tried over and over again to tell him [when she remembered to try] but he would not help her to communicate. He asked open ended questions instead of focused questions. He refused to give her a mental status test when she asked.

He certainly did not measure her vital signs. He did not see that her breathing was depressed along with her altered mental status. He did not know the peripheral or central causes of encephalopathy. He never thought of getting her emergency internal medical assessment and care; and emergency medical assessments do not measure minute ventilation, they do not assess altered mental status properly and they do not give arterial blood gas tests as a precaution, to see if acid base of the blood are causing the altered mental status that they never assess.

It was truly a nightmare! Paula was really scared, beyond the crazy chronic distress which accompanies respiratory pump failure [for good reason].

How many people like Paula become disabled and ill like this? A lot! And none of them get proper medical attention, instead they are sent to psychiatrists who do not dispense medical attention, merely sedatives and psychotherapy. And they often leave people stuck in their disability from their hidden-in-plain-sight encephalopathy.

What is encephalopathy mean again? Encephalopathy” means damage or disease that affects the brain. It happens when there’s been a change in the way your brain works or a change in your body that affects your brain. Those changes lead to an altered mental state, leaving you confused and not acting like you usually do. Encephalopathy is not a single disease but a group of disorders with several causes.…..The symptoms you have depend on the type and cause of your encephalopathy, but some of the most common ones are: Confusion Memory loss Personality changes Trouble thinking clearly or focusing.

And why didn’t anybody think of encephalopathy when Paula exhibited all of those symptoms?

There is no good reason.

Certainly there should be a algorithm that helps identify encephalopathy when it occurs, especially during a first episode. Instead, doctors assume that the problem is psychiatric and true medical care is never given. This seems like neglect to me. Medical neglect.

This is how doctors missed Paula’s encephalopathy from ventilatory pump failure. This how doctors missed an attack of hypercapnic encephalopathy.

And all because no one measured her 4 major vital signs. No one counted her respiratory rate or her minute ventilation. No one checked for acid base disturbance of the blood [even though they are relatively common and all result in mental confusion]. No one understood that reliance on basic blood tests and pulse oximetry can be misleading and offer false hope and leads to diagnostic error.

The biggest reason for the neglect is that patients with altered mental status cannot say that they have altered mental status; their altered mental status prevents them form being able to explain it. So doctors should always use an algorithm to make sure they NEVER miss this diagnosis.

And they should check for hypercapnic encephalopathy in all mentally ill patients, because I think it is more common than one realizes.

Altered mental status is a very serious and complex syndrome which demands a lot of medical investigation in order to prevent major chronic disability.

The only thing that kept Paula from having a long term disability, and possibly never recovering her mental and physical health was Kraepelin’s book on manic depressive insanity and me.

And that should not be the case.


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