Everyone suspected that Paula was suddenly Insane

Everyone at her work noticed how different Paula was, how she was suddenly passive, incompetent, dazed, scared, different, strange, awkward, weird, ….suddenly everyone suddenly felt horribly uncomfortable in her company, …..something was “off” about her, she was definitely not even close to her usual self.

I got news for you guys….that is what “altered mental status” is. Everyone at work understood right away. They did not want to say it out loud [although I am sure the gossip mill was very busy].

No one seemed to know what to do. It seemed frightening somehow so, so, so strange, natural, eerie, upsetting,…..it seemed hopeless, I am not sure why. Everyone knew. Even Paula knew something was very wrong. But she was left helpless because she had no clue what was happening to her and she could not put it into words, because like poisoning,…it was an unfamiliar strange unpleasant state. Paula was uncomfortable in her skin and was zombie-like in her behaviour and that was truly freaky for everyone, Paula included.

Yet no one could define this, whatever “this” was as an altered mental state, although if someone has suggested that is was indeed an “altered mental state” I think everyone would then have agreed.

Also, no one knew quite what to do about it, how to help, who to speak to….instead people squirmed, avoided Paula or made fun of her in a mean way, like kicking someone when they are down.

Doctors, being human, and having no algorithm to help them, react the same way; you can see it in their eyes-they want to run away from a person in this natural state, although this is a primitive reaction and they cannot put their instinctive response into words.

It is like avoiding the dying; and altered mental states can be part of the dying process, so it is not a crazy response. But it is not a helpful response.

A helpful response might be to ask the person if they feel like their normal self; the person will most likely be able to respond to focused and directed questions. Confused people will have major problems answering open ended questions such as “what is wrong”? Clearly they do not know and clearly they are are confused and cannot say much anyway.

When dealing with a sick or injured person, the best approach is to physically examine them and to take their basic vital signs. Respiratory rate at rest is key because an abnormal rate [too slow, irregular] will clue you into physiology and let you know that the physiology is abnormal. Abnormal breathing rate at rest, especially suggestive of respiratory failure type 1 or 2 and altered mental status and mood will signal a serious physiological problem, potentially affecting the acid base properties of the blood. Abnormal circulation [lowered body temperature, vasoconstriction [cold pale extremities and lips, heart signs , raised heart rate and blood pressure] will obviously occur if respiratory failure of any kind is occurring. And respiratory failure can be silent-invisible – unfelt [except for distress and anxiety], if not measured carefully for one minute with a stopwatch. Pulse oximetry and HCO3 will tell you nothing if the lungs are fine but the ventilatory system is the problem. Pathophysiology is complicated.

to be continued………..


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