Nuts

There were no patients to be seen when I walked down the hallway to get a cup of coffee. But when I returned to the nurses’ station, Heather, one of the regular night nurses, was holding a chart and looking at me, quizzically. “You have to see this guy,” she said. “I don’t have a clue what’s going on.”

That may sound funny. Of course, I have to see all the patients. But the nurses pride themselves in their patient assessments and they want to be able to tell me the diagnosis. As much as I try to get them to stop doing it, they attempt to give the answer instead of just giving me the facts. It’s not that I don’t want to know their opinion. I just don’t want to know their opinion before I see the patient and get biased. You can really put on the blinders and miss something if you go in expecting only to confirm the nurse’s impression. So I found it rather refreshing for her to admit that she didn’t know what was going on. Now, I thought, let’s see if I can figure out what really is going on.

As I entered the room, I was surprised to find a skinny middle-aged man contorted in such as way as to appear that he was al- most tied in a knot. He was flexed at the waist with his chin down on his chest, even though his eyes were locked in an upward gaze. Remarkably, his left leg was almost over his head and neck. And both arms were stiffly extended into his groin with left hand actually shoved inside his pants.

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My first impression was that the man was having a dystonic reaction. He had the unusual blank face of someone who had been on chronic antipsychotic medication. Sometimes patients with dreams of grandiosity or paranoia forget to take their meds for a while. Then they try to make it up by taking extra pills. The excess meds gives them the typical muscle contractions that make them appear to be tied in knots. Dystonia, locked up muscles, though serious, is easily treated. I can heal this with a simple shot of Benadryl, I thought. I’ll order the medication, cure the problem and be out of the room in less than two minutes. Then just sit back with a cup of coffee. The nurses will think I’m a genius. No, I thought further. You can’t be smug. You do that and they will be looking to take you down a notch. No, you have to be subtler than that. You have to just reappear, put the chart in the orders rack, and appear busy. If they’re talking, they will stop and say something like, “Boy, that didn’t take long.” But don’t take the bait and start bragging about how easy the diagnosis was. You have to just let it sink in.

Unfortunately, however, that wasn’t it. As soon as I spoke to the patient my own visions of grandiosity quickly melted as he relaxed his upward stare and looked down as he easily raised his balding head.

“Hello, I’m Doctor Plaster. What can I help you with?” I started somewhat disappointedly.

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“You?…help me?” he said reversing the question. Then he made a face at me like a little old man without teeth. He puckered his lips so much that it looked like they were out past his nose. I hadn’t seen that since I was a little boy. Dickey, my friend, could do that. When we went to the swimming pool he could push his lips out so far that he could shut off the openings to his nostrils. It was cool, just like the porpoises. I was jealous because I had to hold my nose to go under water. It wasn’t until I saw this man that I realized just how stupid he looked. “It was an Act-o’God,” the patient said rousing me from my memories. “I’ve been prayin’ about it. And nuthin’s happnin’” Then he made the Dickey face again.

I consider myself religious. So, unlike some of my colleagues, I don’t always think that religious references are a sign of mental instability. But, I had to admit, this guy was starting to look like he had a few screws loose. “What was an act of God?” I probed.

“My vast friends,” he said, squinting his eyes and looking off into space making his Dickey face. “I went to Harvard,” he said somewhat triumphantly.

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I wasn’t sure whether he was a street guy and just delusional or maybe he was one of those “Beautiful Mind” types who actually went to Harvard and just snapped. Regard- less time was starting to drag and I needed to cut to the chase.

“Have you been having feelings of depression lately?” I asked. “Have you had any thoughts of hurting yourself?” At least I would know if he was a potential admission.

“No!” he almost shouted. “Do you think I’m crazy?”

We obviously had a difference of opinion on that matter.

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He went on to try and explain but it wasn’t making sense to me. I wasn’t sure if I was just tired and not understanding him. But the more he explained the situation the more confused I felt. I could feel the conversation starting to wander. Finally in desperation I went back to my starting point. “So…what CAN I do for you?” I said slowly.

“My vast friends, my vast friends!” he shouted now. He was starting to get frustrated with me. “I thought you said you’re a doctor.”

Now I was getting frustrated, too. “What’s wrong with your friends?” I shouted back. “Are they chasing you?” Maybe he’s paranoid, I thought. “Are you seeing people? Are you hearing the voices of your friends? Are you receiving messages from the dead?” I shouted the questions in rapid succession. I felt like I was on a game show and the clock was running out.

“Are you nuts, doctor? What are you talking about? I want you to look at my vast friends.”

And at that he resumed the position he was in when I entered the room with his arms between his legs. But this time he reached into his under shorts and pulled out his scrotal sac. He had a hold of his testicles with such a grip and pulled the sac so far away from his body that I reflexively winced.

“Whoa, there!! You are going to pull them off.” Recoiling from the sight, it finally dawned on me what he was talking about. “Oh, you mean your vas deferens, part of the spermatic cord to your testicles.”

“Yeah, that’s what I said,” he shouted, obviously relieved that he was finally being understood. Then he made that face again. “I thought you guys knew about this stuff.”

Now he was making me feel dumb. I put on an exam glove and examined his scrotal sac. And to my chagrin, there was a swelling of his vas deferens. It could have been due to a resolving epididymitis, or just from chronic squeezing. Or it could have been a rare tumor. In any event, it was not an emergency. I was relieved to finally communicate, but frustrated that I couldn’t fix the guys problem and look like a hero to the nurses. However, one thing was for sure; I wasn’t going to get to the bottom of the problem tonight. I would just have to arrange a follow up with an urologist.

I began explaining what I knew of the problem, trying to reassure him as much as possible. But the more we talked the more disjointed his speech became. He was not just hard to follow. He had flight of ideas. I was not misunderstanding him. He was descending into a word salad. I was not the one in the room that was crazy. There was a larger problem here than his “vast friends.”

“Sir,” I began. “I think that you are having a little trouble organizing your thoughts. We have some special doctors here who…”

Before I could say anything further he stuffed his testicles back in his pants and jumped off the bed. “You don’t know what you’re talking about doc,” he said with complete clarity as he started for the door.

I contemplated my options. He wasn’t suicidal or homicidal. He wasn’t even homeless. He needed help but he didn’t want it. At least not from me. He was out of the room and headed for the door before I could get out the AMA form. It was use- less to stop him.

“You were sure in there a long time,” said Heather when I got back to the nurses’ station. “What was wrong with him?”

“His nuts,” I mumbled.

“He’s nuts?” she fired back. “Is that all? I could have told you he was crazy before you went in there.”