The man did not respond. No amount of verbal persuasion could make him lift his eyelids and the only noises he made were incomprehensible groans. He moved only to push away his loved ones and the hospital staff trying to look after him.
His wife said he didn’t speak English.
“What does he speak”, the doctor asked.
“Can you speak to him in Tokelauan for me?”
The doctor was startled by her response. “No?”
“I can’t speak Tokelauan.”
The doctor was perplexed. The notion of a married couple unable to communicate was unnatural, it just didn’t sit right. Mail-order brides excepted, the doctor could only recall one previous instance of a married couple without a common language. He thought back, to about three months earlier. While he was reviewing another patient in the emergency department he had overheard an exasperated doctor expressing her disbelief at the absurdity of a patient who couldn’t speak the same language as his wife. More details began bubbling up from the depths of the doctor’s memory. The previous patient had a headache. The doctor’s pulse quickened as he caught the scent of an elusive prey.
“Did you come to the ED a few months ago when he had a headache?”.
“Yes, the doctor said that it should get better. But he kept having them. He doesn’t like doctors and wouldn’t come back. The last few days he’s just been lying around doing nothing.”
“You said he only speaks Tokelauan. Did he use to speak English?”
“Yeah! You think I’d marry someone I can’t talk to!”
The Doctor rushed from the cubicle, reached for the phone and booked an urgent CT scan of the man’s head. The resus nurse was perched like a hawk beside the groaning man, ready to raise the alarm should his level of consciousness fall further. Meanwhile the patient’s old notes had arrived from medical records. The doctor skipped through the pages until he found the notes of a few months before. Sure enough the man had presented with a headache. He was described as a ‘poor historian’. The doctor also learned that the man sustained a concussion in a motor vehicle accident a few years earlier. He had had a head scan. The doctor tracked down the report. He caught his breath as he read, “there appears to be a tiny lesion contiguous with the meninges in the left temporal region”. In the conclusion of the report, the radiologist recommended that a repeat scan after an interval of a year should be to performed to check for any change in the incidental finding. That was four years previously. Since then the man had moved town and had never been to a doctor – until three months ago.
A few minutes later the doctor stood impatiently waiting in front of a monitor. The patient slid head first into the ringed hollow of the CT scanner. Radiation beams began slicing through his brain tissue and the monitor came to life. As the left temporal region came into view an impostor announced itself. A large complex tumor was squashing the speech centers of the man’s brain, so much so that the left hemisphere of his brain had begun to compress the right. The features of the tumor were consistent with a meningioma, and although it was large, there was every chance a surgeon could exact a cure by cutting the cancer out.
The man was soon intubated to protect his airway should his coma worsen. He was then sent on the three hour journey to the nearest neurosurgical referral center, to the people who could offer him the hope of recovery. The tumour was indeed resected and the man survived the opening and closing of his skull. What language or languages he spoke after he woke up, the doctor never knew.
Listen, listen to the patient’s story! He is telling you the diagnosis.JB Murphy
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.