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Judy led the way and placed the gown on the gurney. Carl and Joe took positions in the corners. I stood in front of the open door. Though I believed it was to block the patient from bolting from the room, I think now it was also, subconsciously, to allow me to make my own quick escape.
    The strength-in-numbers tactic seemed to work. Judy moved toward the patient and gently helped her down from her headstand, as if she was spotting a gymnast. Judy spoke quietly as she assisted her with the gown, “You’re so lucky to have those pretty blond curls.” She escorted Ms. Doe to the gurney and said, “Sit down, sweetie, and get comfortable.”
    I pulled up a chair and took a moment to observe the patient. Her hair was matted and dirty, and she had a butterfly tattoo on her ankle. “Can you tell me your name?” I got no response, so I followed with, “Do you know how you got here?”
    She mumbled something about how hot it was.
    “You’re right, it is warm in here,” I said. “Would you like me to get a fan?”
    Blank stare and no reply.
    “Is there someone I can call for you?”
    The patient twitched for a moment, and I thought she was finally going to say something real, but still nothing. Joe and Carl were clearly amused by my futile queries but stifled their laughter. I didn’t dare look at Judy.
    I was getting annoyed—I was trying to help this patient, not entertain the staff. After what seemed like an endless string of feeble attempts to get her to talk, I moved on to a physical exam and tentatively lifted her wrist to check her pulse. Her hand felt clammy. When I tapped her knees and ankles, her deep-tendon reflexes were normal. She wouldn’t cooperate for me to test her arm and leg strength, but other than a slightly rapid heart rate and low-grade fever, I couldn’t find anything physically wrong with her.
    I had performed hundreds of physical exams, but this was the strangest one yet. Not only was I onstage for the staff, but my patient’s mind was off somewhere else. Because I couldn’t get her to walk for me, I wasn’t able to check her gait, which might have revealed various brain problems—wide-based could mean hydrocephalus, shuffling could indicate Parkinson’s disease—but I did know that she was neurologically quite capable of standing on her head. I knew she was out of touch with reality, but diagnostically, I was stumped.
    People lose touch with reality for many reasons. Sometimes severe depression, stress, or trauma can push them over the edge and they escape into a distorted mental state that appears crazy to other people. But many mental symptoms, like psychosis, ultimately have a physical cause. In fact, many medical emergencies initially present themselves with only mental symptoms—delirium, confusion, depression, anxiety, psychosis, or panic attacks.
    To help me remember the various physical causes of psychological symptoms, I had come up with my own mnemonic for some of the more common ones—“WHHIMP.” Each letter was the first initial for amedical cause of delirium: w was for W ernicke’s encephalopathy, due to brain damage from chronic alcohol abuse. The h ’s stood for a h ypertensive crisis (extremely high blood pressure causing an acute drop in brain blood flow) or h ypoglycemia or h yperglycemia from an imbalance in blood sugar. I reminded me that i ntracranial lesions such as strokes, tumors, and bleeds could be the culprit. M was for m eningitis and related infections of the brain and meninges, which coat the brain; and p was for p oisons, certainly high on the list of possibilities in a young person who might be experimenting with recreational drugs.
    Jane Doe coughed suddenly, and we all jumped. She was looking straight at me now but still wasn’t talking. I moved my index finger from left to right in front of her face, but her eyes didn’t track it. I snapped my fingers in front of her eyes and got no response. When I suddenly clapped my hands, she flinched and