I am nervous. I sleep poorly. I’ve survived four on-calls since starting psychiatry in July. I know very little. In August, Marie, the emergency department nurse, pages me at 3:00 a.m.
"We have an agitated man—possibly DTs."
I leap from bed fully dressed and rush to emergency. I’ve never assessed a case of delirium tremens. I am a wreck. Matthews, the 6-foot, 4-inch-tall medical resident, tosses me the chart.
"He’s fine," Matt says. "He’s all yours."
I scan Matt’s scrawl. "But he has a facial laceration. Didn’t you suture him?"
"Look, Rubens." Matt shows me a tiny scratch on his arm. "He hit me. He stinks."
Matt stomps off to the intern’s residence. I grow jittery, but Marie’s face softens. "The patient just threatened to kill Matt. You’ll do better." I thank her, pour some coffee, and prepare for disaster. Matt prefers orthopedics—either a leg is broken or not. He has no time for people who are broken inside. Nightly I read Kaplan, yet feel I know nothing.
Matthews wrote, "Unpleasant, filthy man, 45. Medically stable. Refer to psych."
In a dim room, I see an orderly, a security guard, a wild-haired man pushing an intravenous pole. The patient shakes and sweats profusely. Blood seeps from his brow and covers his beard. His skin is sunburned. He wears a winter coat but is barelegged. A dirty tan covers his calves. I’ve never inhaled such a stench. I need a gas mask. I rub my eyes and want to flee. Yet I stay.
I read that Matt administered intravenous fluids, thiamine, diazepam, and vitamins. I brighten the light to see more. "Shut the lights!" the man yells. "Look at them bugs!"
I read his name. "Mr. Ray Glover?" He starts. With savage hair, the coat, and the pole, he looks like a leper. "I am Dr. Rubens, the psychiatry resident. Can we talk? Mr. Glover, what brought you here? Where are you?" Glover checks the walls and the ceiling.
"You tell me, doc," he whispers. "Walls are bugged." I ask him what’s on the walls. "Centipedes," he says. "Say, are you a real doctor?"
"I am a real doctor," I reply feebly and ask, "Mr. Glover, why are you here?"
"I’m a killer," Glover says. "I told the doc I’d kill him. He didn’t like me." Glover staggers into the hallway. He is 6 feet tall, my height. His stench trails behind. The guard and orderly follow us.
"What do the voices say?" Glover replies that he murdered someone. He is bad, guilty.
"But you are Ray Glover," I say.
We return to his room. I flick on the examining light and check his wounds. Marie enters. We remove his clothes. A scale of dirt and excrement covers his skin. The stench overpowers us. "Here is a needle to quiet the voices. OK?" He nods. Marie slowly injects diazepam, 10 mg. He is febrile, shaky, slightly hypertensive. I am unsure what to do next. Softly Marie says to wash him. Together we wheel him to the bath with the orderly and guard. We put on surgical gloves. We clean his wounded body twice. Layers peel off. Scars are on his back. We check for infection, scabies. "Please find his records," I ask Marie. "Call the police, the psychiatric wards." Marie leaves. I dry Glover. I see hardened scars. I give him green hospital clothing. He swears at voices. I reassure him but feel edgy. The bath draws us near; he is under my skin. I feel his furtive terror. I call my staff psychiatrist. Dr. Berlin says Glover’s history and presentation suggest delirium tremens. "But there’s more," I say. Berlin tells me to check his neurological status and drug use and rule out medical illness.
"I’ve done that, sir," I say. "Suppose he doesn’t settle? I’ve never seen anyone so jumpy. I’m missing something. This is my first case. I have no experience with DTs."
"We all have a first case, Dr. Rubens," Berlin says. "Tell me, what worries you?"
"I worry I’ll make a mistake. Maybe he killed a man. Maybe it’s not a delusion?"
"It’s possible. Get him to tell his story," Berlin says. "I better come over, right?"
When I return, Glover mumbles about killing Glover. "Go on," I say. I suture. Marie sighs and sponges his brow. "Years ago, I had a fight," Glover pauses, "with my dad."
Marie pulls me aside. "He has a criminal record. I can’t find a psych history yet."
Glover tells a story of boozing for months then drinking nothing for a week. I administer another 10 mg of intravenous diazepam slowly. I recall Victor and Adams’s chapter on delirium tremens—confusion and hyperactivity after alcohol withdrawal. Fifteen percent of the cases end fatally; I fret more. At 4:30, Berlin enters. His gray age settles me but silences Glover—the opposite effect.
"It’s DTs," Berlin says, sardonic. "He trusts you." Berlin taps me and leaves.
An hour later, Glover says, "I need to confess." He drifts, impossible to follow. His dad tortured him. He speaks as if from far away. "The tractor cut his head off—no accident. I went to prison for Ray senior." I feel dread and a sickening curious thrill.
"Years ago, in August, I killed him." Glover nods. "Better keep me here."
"He left prison last year—free," Marie confirms. "Never drank before. Strange?"
We admit Glover. I see him on the ward each day. Days later, his delirium clears. I make process notes. Dr. Berlin, a former army psychiatrist and psychoanalyst, listens. He discusses Glover’s anniversary reaction—his trauma, guilt. Glover served time for killing his father in a fight—that is true. "Read Sophocles’s Oedipus Rex and Freud. Oedipus’s father was an abuser. Oedipus murdered his father. That legacy is in all of us, don’t you think?"
Later that week, I have a terrifying dream. I have murdered and buried evidence. When I awake, I feel guilt, shame. I want to hide but tell my supervisor. He nods calmly.
I see Berlin each week and Glover each day for confession.
Address correspondence and reprint requests to Dr. Ruskin, Mount Sinai Hospital, 600 University Ave., Toronto, Ont. M5G 1X5, Canada; firstname.lastname@example.org (e-mail).