Gary Small & Gigi Vorgan Read online

  To help me remember the various physical causes of psychological symptoms, I had come up with my own mnemonic for some of the more common ones—“WHHIMP.” Each letter was the first initial for a medical cause of delirium: w was for Wernicke’s encephalopathy, due to brain damage from chronic alcohol abuse. The h’s stood for a hypertensive crisis (extremely high blood pressure causing an acute drop in brain blood flow) or hypoglycemia or hyperglycemia from an imbalance in blood sugar. I reminded me that intracranial lesions such as strokes, tumors, and bleeds could be the culprit. M was for meningitis and related infections of the brain and meninges, which coat the brain; and p was for poisons, certainly high on the list of possibilities in a young person who might be experimenting with recreational drugs.

  Jane Doe coughed suddenly, and we all jumped. She was looking straight at me now but still wasn’t talking. I moved my index finger from left to right in front of her face, but her eyes didn’t track it. I snapped my fingers in front of her eyes and got no response. When I suddenly clapped my hands, she flinched and blinked, so I did get some reaction. I ordered a CT scan to rule out a brain tumor or hemorrhage.

  Her low-grade temperature could mean an infection, but she lacked the neck rigidity that was typical of meningitis. Her complaints about the heat and her nudity suggested possible heat intolerance due to an overactive thyroid, which the blood-screening tests would rule out. We needed a urine sample for a toxicology screen, but no way was she going to pee in a cup. She would have to be catheterized. To spare her the humiliation of two burly security guards holding her down, Judy shuffled us guys out of the room and enlisted the help of two female interns to catheterize her. She also drew blood for screening laboratory tests to make sure the patient didn’t have anemia, a thyroid disorder, or some other chemical imbalance that might be altering her mental state.

  As I waited for the lab results, I decided to take another stab at an interview. The guards and I walked back into room 6, and I could tell that Joe and Carl were looking forward to seeing me get nowhere again. I tried to be casual with the patient and offered her a cup of orange juice. She finally seemed to respond to me. She slowly raised her hand for the cup. She took a small sip at first, then quickly gulped it all down.

  “It looks like you were pretty thirsty,” I said. The staff smirked, anticipating yet another useless round of questions, but the patient’s demeanor seemed to change—her blank stare was replaced by an inquisitive look. She scanned the room; her body tensed; her brow furrowed.

  I felt like maybe we were getting somewhere, so I continued in my light tone, “Maybe we can talk now.”

  Ms. Doe suddenly sat straight up and became aware of her scant attire. She wrapped her hospital gown tightly around her body and asked, “Where am I? Who are you? What the hell?”

  I could sense that the team was impressed. I should have felt cocky that my astute, relentless, and well-timed interview skills had finally cracked this obstinate naked-lady case. I should have been proud that in my role as a psychiatrist, something I had said had actually gotten this delirious, mute woman to talk like a normal person. I mean, sure I had gone to school and read some books and aced some tests, but here I was in the real world, playing doctor, and I actually fixed somebody. Unfortunately, I had no idea what I had said that worked.

  The patient held out her cup and said, “More.”

  In an instant I realized it was nothing I’d said but something I’d done that got her to talk. More precisely, it was the orange juice. And that cup of OJ was also the key to what caused her bizarre behavior. Her blood sugar had obviously crashed, and she had been suffering from acute hypoglycemia.

  Responding to the patient’s anxiety about her skimpy hospital gown, I asked Judy to get her a pair of scrubs to put on and escorted the security guards out of the room while Judy helped her change. I returned with another cup of orange juice and sat in the chair next to her gurney while she drank it. She was calmer now.

  Again I told her I was Dr. Small and asked her about herself. Her name was Katie Genaro. She was nineteen and lived with her parents above their popular family bakery in the North End. She worked part-time as a waitress while taking acting classes and doing Equity theater whenever she could get a part.

  I moved the conversation along to find out more about the cause of her delirium. “Katie, do you have any medical illnesses?” I asked.

  “Why do you want to know?”

  “Because you were brought to the hospital tonight, delirious. You’d been walking in the street babbling, and you only just now came out of your delirium when you drank some orange juice.”

  “Shit. It’s my stupid diabetes again. I probably didn’t eat enough breakfast before taking my insulin shot.”

  “So this has happened before?”

  “Once or twice. I don’t always get my insulin right, so sometimes I get light-headed and sweaty,” she said.

  “How long have you had diabetes?”

  “I found out about a year ago.”

  Diabetics don’t make enough of their own insulin—the body’s natural hormone for moving sugar from the blood into the body’s cells for energy. If somebody injects too much insulin after not ingesting enough sugar or carbohydrate from a meal, her blood glucose level can take a quick dive. Because sugar is the brain’s main source of energy, Katie’s low brain-sugar level plunged her into an amnesia-driven delirious state, which the orange juice instantly cured, making her sane once again. It wasn’t a huge psychiatric achievement, but I had given her the right treatment—even though I didn’t know it at the time.

  “I couldn’t believe it. I mean, I’ve always been such a health freak.”

  “Being a health freak is a good thing, but it won’t help you control your diabetic symptoms if you don’t stay on top of your blood-sugar levels. You’re playing with fire, and if you’re not careful, it can kill you.”

  “You sound like my mother. She’s always accusing me of messing with my insulin so I can stay thin for acting parts. How ridiculous.”

  I noticed that she was very slender and wondered if it really was so ridiculous. “I certainly don’t mean to sound like a parent. I just want to be sure you know the facts about diabetes. When you get it at your age, it’s usually inherited,” I said.

  “Well, my aunt got diabetes when she was about forty, but she was overweight and worked in Dad’s bakery.”

  Judy came in with a sandwich for Katie and handed me the lab results. As I suspected, Katie’s blood-glucose level had been forty-five—well below the normal range.

  “Katie, I want you to meet Judy; she’s been taking care of you tonight. Judy, this is Katie Genaro. She lives with her parents in the North End. You know Genaro’s? That’s their family bakery.”

  “Oh my God.” Judy swooned. “Your father’s biscottis are my downfall.”

  “Thank you for the clothes and stuff. I’m sorry if I acted all crazy.”

  “Don’t worry about it, sweetie. You came to the right place. I’m just outside if you need anything.”

  I hoped Judy would take my cue about Genaro’s and get in touch with Katie’s parents. They were probably worried sick over their daughter’s whereabouts and would come pick her up.

  “Katie, you were standing on your head when I first got here.” I avoided mentioning the naked part so as not to embarrass her further.

  She laughed. “Oh my God, I take yoga and sometimes I do headstands to relax.”

  Katie started eating her sandwich, and I stepped out to the hallway to write up my notes. Her headstand appeared to be psychologically insignificant, and I also thought she should have an endocrinologist and nutritionist consult on her diabetes management. Judy told me that Mr. and Mrs. Genaro were on their way. After about ten minutes, I checked back in on Katie, who was resting on the gurney with her hands covering her face.

  “What’s the matter, Katie?” I asked.

  She wiped the tears from her face, “My whole life is a mess. I can’t handle
this diabetes thing. I’m trying to be an actress and pay for my own acting classes, but there’s just no pleasing my mother.”

  “What do you mean?” I asked.

  “What happened tonight will just be another disappointment to her. That’s all I seem to do,” she said. “She thinks being an actress is a joke, an excuse to skip college and be a waitress all my life. And it’s ironic because she used to be an actress too.”

  My pager went off with my next emergency. I could see that Katie was going to be a much more complicated case than just an E.R. consult. I felt like moving on—I’d had my orange-juice victory, and if I stayed, I’d have to get involved and wrapped up in Katie’s family and medical issues. A part of me wanted to quit while I was ahead. I wasn’t sure I could be the psychiatric hero in her next set of problems, and I already had a great story for the coffee room. But I knew at some level that to become a better psychiatrist, I needed to stay and face this challenge. So instead of dashing off, I muted my pager and said, “It must be really painful when your mother doesn’t support your career.”

  My comment reopened her floodgate of tears. I handed her a tissue and let her cry for a while.

  “It’s true, Dr. Small. It’s incredibly painful. Nobody ever seems to understand that.”

  “Katie, I think it would be helpful if you had someone to talk with about your feelings. Maybe you and I could meet later this week. Would you be willing to do that?” She nodded yes and the door suddenly swung open. A woman around forty and her tall, balding husband rushed in.

  “Katie, we were so worried about you. We didn’t know where you were or what happened to you.” Mrs. Genaro threw her arms around her daughter, who looked annoyed and uncomfortable.

  “Mom, I’m fine. I had another problem with my insulin, and this is Dr. Small. He helped figure it out…he’s going to be my psychiatrist.”

  “What?” Katie’s mother said. “You don’t need a psychiatrist. You’re not crazy.” Mrs. Genaro looked at me. “What’s going on? What is Katie doing here?”

  I hesitated to respond. I had just established a doctor/patient relationship with Katie, and I wanted Katie to know that whatever she told me was in confidence. On the other hand, this had been a medical emergency and her parents were clearly worried. While I was mulling over my options, Katie rescued me.

  “I’m here because my glucose got too low.”

  Mr. Genaro spoke for the first time. “But sweetheart, the emergency room again?”

  “I didn’t eat enough breakfast and got confused, so they brought in Dr. Small. I’m fine now.”

  Her mother wasn’t satisfied. “But why didn’t anyone call me?”

  “We did, Mrs. Genaro, as soon as we could,” I answered.

  “Well, that wasn’t soon enough. I ought to sue this hospital.” She turned to Katie, “And you’re grounded, young lady. You obviously can’t handle your insulin and a silly waitress job at the same time.”

  Katie winced at her mother’s criticism. “You can’t ground me, Mother. I’m almost twenty.”

  “As long as you’re under my roof, I can do whatever I want.”

  “Look, honey,” Mr. Genaro said to his wife. “We found Katie and everybody’s all right. Let’s just go home and settle this tomorrow.”

  I handed Katie my card, and Mr. Genaro and I left room 6 as Katie’s mother helped her change into the clothes she had brought. Outside the room he thanked me for my help. Before I left the E.R., I made sure that Judy gave Katie follow-up information about managing her diabetes.

  As I headed back to the coffee room, I noticed that the E.R. was quiet now. I was exhausted and decided to lie down on the couch and rest my eyes for a moment.

  “Small. Wake up. You look like shit.” It was morning and Mike had just arrived for work. I had slept through the night, and my next shift was about to start.

  “What time is it?” I asked.

  “It’s time for a shower, man. You’re disgusting.”

  He handed me a cup of coffee, and I went off to the call room to shower and change. The rest of the day, I fought the chronic fatigue that always followed a busy night on call. If I kept moving, I was all right, but if I sat down too long, I had to focus on keeping my eyelids open or I’d nod off. Today, on-call hours are limited to ensure that residents don’t experience this level of fatigue while dealing with patients.

  My mind kept going back to Katie Genaro’s unusual presentation in the E.R. The emotional issues she was struggling with were complex. I wasn’t sure I had enough experience to really help.

  FRIDAY WAS MY OUTPATIENT-CLINIC DAY, AND KATIE was scheduled for an afternoon appointment. I had finally graduated to my own assigned outpatient office. Even though it didn’t have a window, there was a worn upholstered chair, two metal chairs, a small coffee table, and all the other necessary trimmings including desk, phone, and tissue box. I hung a few diplomas on the wall and put some psychiatry textbooks on the shelves behind my desk to make it look official.

  I had already worked with a few psychotherapy cases, but I still felt awkward getting total strangers to trust me and open up about their innermost secrets in fifty-minute sessions. I wished I had a cheat sheet that fit in my palm so I could refer to it when I didn’t know what to say.

  The clinic’s secretary buzzed me on the intercom to announce Katie’s arrival, and I went out to meet her. She was wearing jeans and a sweater and looked like any other pretty, blond, nineteen-year-old struggling actress.

  We sat down in my little office, and Katie began. “So how does this actually work? I see there’s no couch, so do I sit here and talk while you take notes? Or do you ask me questions, or what?”

  “Basically, we just talk about your feelings and discuss what’s going on in your life.”

  “Okay,” she said.

  “Well, how’s it going with your blood sugar?” I asked.

  “Fine. I’m taking care of it, but my mom won’t stop nagging me about the other night. She says I screwed up and almost killed myself. She actually thinks I did it to get attention.”

  “Well, you have ended up in the emergency room several times,” I said.

  “They were all accidents. I wasn’t trying to get attention. And even if I was, it wouldn’t matter.”

  “What do you mean?” I asked.

  “All my life I’ve tried to please her. As a little girl I helped out in the bakery, I got straight A’s in school, I took dance lessons twice a week, and she hardly even noticed. When I told her I wanted to be an actress, I thought she’d be happy for me.”

  “What happened?” I asked.

  “She got hysterical. She said I was ruining my life by not going to college and getting a real job.”

  “But you told me your mother was an actress too.”

  “Yes, but she gave it up when she married my dad and got pregnant. Now she works in the bakery. I know she’s not happy.”

  “That may well be, Katie, but whether it’s accidental or intentional, when you don’t take care of your diabetes, it definitely gets a rise out of your mother.”

  “So you’re saying I do it on purpose too?” she asked.

  “No, but sometimes we do things that feel accidental even though they serve a purpose.”

  “But it’s such a bummer going to the emergency room,” she said.

  “True, but it sure gets your mom’s attention.” She didn’t respond, so I continued. “How do you feel when your mother doesn’t support your career?” I asked.

  “Angry, misunderstood…She says I’m bound to fail as an actress just like she did and she’s only trying to save me from the pain and rejection.”

  “Maybe that was her experience of it, and in her way she’s trying to protect you.”

  Katie snapped, “What? Are you working for her? This is my life and she just won’t see that. I think she’s jealous of my career.”

  I was struck by how quickly Katie got angry and realized that she had taken my last comment as unsupportive of he
r. I went back to my imaginary cheat sheet. “Why do you think she’s jealous?” The question seemed to bring her back to me.

  Katie took a deep breath and said, “Last year I was in a big play at the Colonial Theater. We were doing Bram Stoker’s Dracula. Even though I had a bit part, it was a major theater and I was really excited. I got tickets for my parents on opening night.”

  “Sounds great,” I said.

  “It was, but…” She appeared sad and looked away.

  “But what, Katie?”

  “Every time I came onstage, I could see my father sitting next to an empty seat. My mother claimed she had a headache and couldn’t make it.” Katie started to cry, and I pushed the box of tissues toward her. “She just couldn’t stand to see me have any semblance of success.” She blew her nose and cleared her throat. “Maybe I am getting sloppy with my diabetes to get her attention, who knows?”

  I felt like we were getting somewhere, but I wasn’t sure which direction to go in. Katie’s relationship with her mother was the hot button here, so I had an idea, “How would you feel about your mother joining us for a session?”

  “I don’t think she’d come. She thinks shrinks are for psychos.” She paused, looking thoughtful. “But you know, it’s not a bad idea. She needs therapy more than I do. I’ll let you know.”

  The following week the E.R. was remarkably quiet. On Tuesday afternoon, we had finished up with the morning walk-ins and there were no more patients. Mike Pierce and I went over to the corner sub shop for a sandwich. After paying, we took our lunches outside and found a bench.

  “I heard about that naked headstand lady you saw last week. What happened with her?” Mike asked.

  “I gave her a cup of orange juice and cured her. She had acute hypoglycemia.”

  “Way to go, Small,” Mike said. “Any follow-up?”

  “Yes, actually,” I said. “I’m seeing her in the outpatient clinic. She’s nineteen and has separation issues with her mother. She’s bringing her mother to the next session.”