I'm teaching nursing fundamentals right now, and one of the things I tell my students over and over again is the importance of observation. Assessment and inspection are two of the fundamentals of Fundamentals. I tell them the job of nursing will never get boring if you think of each patient as a mystery. "Try to be like Sherlock Holmes (yes, they still know who that is, much to my joy) or House (from the TV show) and solve the mystery". No matter what your patient says, I want you to think, "What's really going on here?" I'm going to tell you a true story (names and relationships have been changed to protect the innocent). It has a beginning, a middle, and an end, but I am leaving off the end, for now. Because I believe you can solve this mystery, I really do. So read on, and see if you can unravel the Mystery of The Dog in a Fedora.
My Cousin Ruth
It's been a few years since this happened, and it concerns my cousin Ruth. I hadn't seen her in a few years - we live on opposite ends of the country, but out of the blue she called to ask if she could come to live with us for a few months. She was 18 and living a vagabond life, driving around the country in a PT cruiser with her dog, Mavis, exploring, meeting weird people, and working odd jobs. She had just finished picked oranges in Florida, and was looking for a break from living rough until a job opened up for her on the west coast picking apples. We weren't happy with our nanny, and I loved the idea of connecting with actual family, so we agreed she would stay for a few months and keep and eye on our four children, taking them places, keeping them safe, and bonding.
The version of Ruth who showed up on our doorstep was thin for her 5'9" frame. She had cropped her hair short and dyed it purple. She has piercings and tattoos in odd places, but is a smart and very funny girl. I've known her all her life, and I trust her, despite her appearance. You might think from the description that Ruth is into drugs and alcohol, but I believe her when she adamantly denies using any mind-altering substances, because she lost her father at a very young age to suicide. Ruth is my cousin by a second marriage, and before her mom married my uncle, her dad had been an addict with a diagnosis of manic depression. When she found out he had killed himself, she hadn't seen him in years, but she had memories of him coming home drunk and high.
The kids adored her, probably because at the time she was staying with us she was just a really big kid herself. One of their favorite things to do was take a fresh pack of markers and draw all over each other. I would come home from work and find Ruth with a pink mustache, lovingly drawn on by my 5 year-old daughter. I never knew what each of my four kids would have on their arms, backs, legs and tummies when I arrived home. One day it would be cartoons of dogs and cats, another day it would be an entire Shell Silverstein poem. We all thought it was hilarious, and it washed off in the bath. Ruth did a great job entertaining my kids, but a less than great job with the other duties of a nanny. She didn't wash the dishes, the guest room looked like a bomb had gone off in her suitcase, and the kids toys were always everywhere but in the toy box. You make exceptions for family members because you love them.
But, Something Isn't Right
As time went on however, I began to notice how tired RUTH seemed to be. She would sleep until 5 minutes before I needed her to watch the kids. She would go to bed the moment I got home. The kids started talking about how she was too tired to play. A neighbor called me one day to report my 2 year-old son was wandering in the front yard, alone, without any pants on. I called Ruth, who answered promptly, saying in a quiet voice that she was sitting down, leaning up against the front door frame, too tired to walk around with the little guy. His lower extremity situation was normal for him - he was a staunch nudist. It would have surprised me if his pants had been ON, but I was worried that the kids weren't getting the care they needed to be safe.
That evening, after the kids went to bed, I knocked on Ruth's bedroom door. A faint murmur let me know she was awake and I entered the guest room. After moving aside a pile of clothing, I sat on the bed and said, "Ruth, what's going on?"
She was quiet for a long time. Finally she mumbled "I'm just so tired...all the time."
"Are you not sleeping?"
"I feel like all I do is sleep, but it's never enough." I know teenagers need a lot of rest and sleep, but when it interferes with activities of daily living, my nurse radar goes up. I did a visual scan of Ruth and the room. She looked tired, with dark smudges under her eyes, and her skin was pale, but she was always pale, favoring the goth lifestyle of no sun at any time. I observed no signs of drug or alcohol use, but those could easily be hidden.
"Is this normal for you? I mean, I haven't seen you in a few years, maybe this is how it is all the time?"
She started chewing her lip, and looking at her chewed fingernails she said, "I feel like it's been for the last few months. I used to do stuff. I used to ride horses. I picked all that fruit."
That was a good piece of evidence. She had successfully picked fruit all Spring - keeping a very physical job that was probably based on quotas.
"What's changed?" I was trying not to pry too much, but it had to be done.
"I went off the pill a while a go, and I've been bleeding a lot, on and off for a while now."
Now we were getting somewhere! Sexually active, recently stopped birth control. "Are you bleeding a lot?" She shrugged and looked away. I could tell she was embarrassed. She shook her head indicating a negative.
"Well you could be a little anemic, maybe you could try eating some spinach or broccoli. Heck, I could fry you up some chicken livers." She smiled at that, which was nice to see.
"I'm a vegetarian, remember?"
"We've got to figure something out - you have to be able to keep the kids safe, right? Do you need a few days off?"
"No, I'll be OK. Sorry. I've probably just got a cold or something."
"Keep me posted OK? Let me know if you feel worse, and just keep talking to me, OK?"
I left her then, sure that she went right back to sleep. I was worried about her. Her voice seemed flat and she didn't look like her usual cheerful self. Since depression runs in her family I wanted to keep an eye on her mood as well. "Ruth is her own person, as I am sure you know. Once she left home, she didn't want any more mothering. You know about as much as I do at this point." My aunt Nancy said in response to my phone call that evening. No insight was going to come from Ruth's mom, then.
A few weeks went by, and I could tell Ruth was really trying, but I could also see that she wasn't feeling any better. She seemed listless, and tired, and had even stopped coloring my children. She was never one to chat much, but now she was practically silent. I decided to head into her room for another fact-finding mission. "So it seems like you aren't feeling any better. I see how hard you are trying. I'm worried about you. Are you feeling down?"
As before, there was a long silence before the answer. "I'm having some weird thoughts."
"What kinds of thoughts?"
"I don't know. Just bad thoughts."
"Ruth, you have to tell me what's going on. It's my job as someone who loves you to get you to open up. Please talk to me."
Ruth took a deep breath and then said in a voice so quiet I could hardly hear her, "I'm seeing things."
That wasn't what I was expecting. "How do you mean?"
"When I lie down to go to sleep, I see lights on the ceiling. They move around. It's actually pretty cool."
I didn't agree with that statement. "You're not taking anything, no drugs, no alcohol?"
"Gross, no!" finally she showed a little spirit. She continued, with a small laugh in her voice. "There's a gray cat."
"A grey cat." I repeated stupidly. We don't have a cat, much less a grey cat. "You've seen a grey cat around the property?
"No, it just appears in my room, or in the kitchen sometimes."
My whole body was tingling with this information. I was running through a list of things that could cause hallucinations, and none of them were good. Schizophrenia, tumors, brain injury, the list was not anything I wanted for my cousin. "I'm not sure I understand, Ruth. Are you saying you are seeing things that you know aren't really there?" I could see tears in her eyes as she looked away at the wall.
"Yeah, I know it sounds crazy. Sometimes your dog comes in and sits down and she has a hat on. She's wearing a black fedora on her head." I sucked in some air and tried to get a handle on my thoughts.
Etiology Of Hallucinations
After doing some research, I was surprised that hallucinations in children are more common than you might think. An article I read states that most children ages 9-11 have had at least one psychotic-like experience, including hallucinations. There is an eight percent hallucination prevalence rate in children, however they tend to be transient and resolve spontaneously. In 50-95% of cases, after a few weeks or months.1
Causes of hallucinations include many organic problems, which I list below, but there are also some environmental factors I was unaware of including stress and anxiety, as well as childhood trauma. A positive relationship exists between hallucinations and sexual, physical and emotional abuse, but not parental death.2 Hallucinations are also related to drug use3 (LSD, psilocybin/mushrooms, mescalin/peyote), and a link has even been found between cannabis use and schizophrenia. Those who smoke cannabis are five times or more are more likely to develop schizophrenia, and researchers have found that if you are prone to schizophrenia, you are more likely to try cannabbis.4
Organic causes of hallucinations
Charles Bonnet Syndrome and Anton's syndrome (both involve vision issues.)
Seizures (small, brightly colored spots or shapes that flash.)
Peduncular hallucinosis (infarct of midbrain,)
Inborn errors of metabolism
Creutzfeldt-Jakob disease (a fatal, progressive neurodegenerative illness from prions.)
Mood disorders (a significant relationship between hallucinations and suicidal behavior, those with MDD, and psychotic experience 14-fold increase in suicide plans or attempts.)
Heading To The Emergency Room
I will admit that I've seen things in the woods that I know weren't really there. I occasionally see things out of the corner of my eye after I've been running or biking for a long time. Once during an endurance race, I saw the little black dog I adored in college. She died many years ago, but we spent so many happy hours in the woods together. I don't think a trip to the ER is needed when I see things after pushing my body to its physical limits. Ruth, however needed to go.
I questioned her further, "You said you are having bad thoughts. Is that what you meant, the hallucinations? Or is there something else? Are you having thoughts of harming yourself?" I know she's a cutter - I had seen the marks on her thighs under the very short dresses she wears, but the marks looked old and I hadn't brought it up, not wanting to pry into her private life at the beginning of the Summer. Now it was time to pry.
Ruth replied, "I don't know."
"Well I don't know either." I said with exasperation. I got up, went around to her side of the bed and gave her an awkward hug. She obviously didn't want it, but I was in full mom mode. "Can you promise me you won't hurt yourself?"
Another long silence as I held her, and she did soften a little bit into the hug. She finally whispered, "No."
OK then. I have never had to take anyone to the Emergency Room before. I called first, and they said to just drive up and bring Ruth inside, through the same doors that people with open head wounds, gunshots, and overdose travel. I called Ruth's mom while I was on the way, and she agreed I was doing the right thing. We didn't talk long because Nancy wanted to get moving on buying a plane ticket to come be with her daughter.
Taking Ruth to the ER, not knowing if she would be admitted to the "psych ward" was one of the worst experiences of my life. Watching them wheel her away, not being able to protect her or keep her safe, and having to trust that the hospital would do the right thing - that was incredibly hard.
Lucky for all of us, it all turned out OK. They kept her for four, long days. After her mom arrived, she went and camped out at the hospital so she could be there for each and every visiting hour. I begged Nancy to bring me copies of all the lab reports. I wanted to get as much information as possible. We talked at least three times a day. I kept telling her what to ask, and imploring her to take copious notes. "If they see you taking notes, they'll take better care of her!" I shouted into the phone. I love my profession, and I love being a nurse, but I know how easy it is for well intentioned, highly trained healthcare workers to make an error. I was determined to keep Ruth as safe as she could be.
I'm going to stop here for a little while. I wonder what you think was going on with Ruth? I've given you the same information I had. I still feel so guilty for not figuring it out sooner. Why was my dog wearing a fedora? The rest of the story will be in part 2.
1. Hallucinations in Children, Adolescents: Psychiatric, Medical Causes, Assessments and Treatment | Psych Central Professional
2. Visual Hallucinations: Differential Diagnosis and Treatment
3. Common Hallucinogens and Dissociative Drugs | National Institute on Drug Abuse (NIDA)
4. Marijuana use and schizophrenia: New evidence suggests link