My patient, an elderly woman with a warm smile and bright lipstick greeted me enthusiastically though I didn’t know if she remembered me from the day before.
“You know, they did a surgery on me yesterday,” she told me. “The doctor there, he was really surprised. You know why? What came out was tiny fish! Can you believe it, tiny little fish swimming!”
I saw a tube, a small hose, snaking from her lung through her gown all the way to the plastic box on the floor. The fluid in the box was blood, almost a liters worth.
“Oh?!” I said, picturing betta fish floating in the drain box, like an extravagant party table decoration for a strange medically-themed party.
“Yes! He said he had never seen anything like it before.” She shook her head.
Before I could ask her how it made her feel to hear about these fish coming from her body she had changed the subject. But I desperately wanted to know: had the fish come from fear? Did she see some odd beauty in the image as I did? Or perhaps she was simply a comedienne in her regular life, a trait now hidden in clouds of confusion by a long hospital stay.
I learned about delirium as a medical resident, how illness and the artificial hospital environment altered the routines that kept patients’ fragile minds and bodies functioning properly. I didn’t fully understand that temporary confusion until the long hospital stay after my own surgery. One dark night I began experiencing bladder spasms that left me howling in agony, a sensation that made the pain from the complex surgery seem trivial. I cried to my nurse to make it stop. It did, temporarily, when she unkinked my foley catheter, and then started right back up again. As it happened I could feel my mind slipping away to protect me from the physical sensations. Later, when the catheter was out I formed my own experiential if not evidence-based understanding of why removing foleys was part of the delirium prevention strategies I had learned during my training.
I wonder now how the delirious mind writes its stories. There was the man who was dying- though he may not have known it- who proudly described to me his side gig as a keyboardist in a cabaret. Maybe that was his dream job, or a hidden goal but it was never his reality. His partner told me that he had been a musician at his church, but never in a night club.
Then there was the stately woman with perfectly manicured nails, who when I came to see her was busily typing in numbers on her TV remote, attempting to call her daughter to bring in her makeup. I remembered that I got my hair cut and picked out new glasses right before my surgery as some kind of antidote to the hospital gown and lack of showers. I assured the woman that she was beautiful even without her makeup. She laughed at me, said, “Oh, no, I don’t think so!” When I asked her if I could help her to use the actual phone she couldn’t remember the phone number. A minute later she was again dialing her daughter on the remote.
My patient never brought up the fish again, though she did remain intermittently confused. Every time I saw her though, I thought of fish, the complex inner workings of the mind, and the pure imagination, wonder and perhaps fear it took to construct those thoughts.