This one inspired by a midnight call to a psychedelically painted bus parked outside a hotel. The bus was part of a documentary focused on marijuana and its legalization in California. My patient, along with some colleagues, had tried an “edible” that apparently had some punch. My patient was a long time connoisseur, but this one sent him stratospheric. When I arrived he couldn’t speak a word, and was sitting bolt upright just rolling his head with eyes clamped shut. A “bad trip” indeed. After a couple liters of saline and a little ondansetron (Zofran) for nausea he was back in the game; or a least back to speaking and able to describe some of his hallucinations. Amazingly, nobody was filming!

Red Flags:

• Elderly, pediatric, or generally frail
• Vomiting and dehydration
• Fevers and suspected infection
• Underlying psychiatric illness
• Chronic liver or kidney disease
• Suspected accidental or intentional overdose
• Head injured
• No previous history of hallucinations
• Alcohol withdrawal (delirium tremens)
• Hyperhydrated with straight water after a marathon
• Bad mushrooms mixed in? (amanita)
• “Dry as a bone, red as a beet, blind as a bat, hot as hades, mad as a hatter” (Google “anticholinergic toxidrome”), Jimsonweed, Benadryl, Haldol, atropine, benztropine…

Happy Words

• Breathing, walking, talking, peeing, pooping properly still
• “I took some LSD, edible MJ, ‘shrooms, peyote, ayahuasca, ibogaine…”
• “I was hallucinating, but I’m better now.”
• “I spent all night studying for my exam, and then started seeing shadows crawling up the walls.”
• “I took some Tamiflu, Ambien, Lariam… and had some wicked crazy dreams.”

Honestly, hallucinations in someone no longer hallucinating is not particularly exciting. And even for those who are actively hallucinating, the large majority resolve with supportive care. In the absence of other life threatening symptoms or red flags, just find a comfortable chair, dim the lights to whatever level feels best, tune in some soothing music, hydrate with dilute Gatorade, coconut water, or a water/saltine/applesauce combo pack… Then watch and wait. (And keep my kids far away.)

Most hallucinating folks I see in ERs have taken something. And many are well on the mend by the time they drift in or are delivered by ambulance. Our goal is to rule out bad things in the brain, and anything metabolic we can change. If the problem is ongoing, we’ll typically order head CTs, electrolytes, drug screens, and of course pregnancy tests for anyone with a nanoscopic chance for pregnancy. If we suspect infection, then lumbar puncture (spinal tap) may be in the mix as well.

Rarely we’ll order MRIs too, but never expect one emergently (nor desire one if you’re hallucinating!) One day MRIs may be as easy to order as CTs, but they’re still long, loud and mostly daytime studies.

As for therapies, IV fluids help if there’s associated vomiting. Plus they give a sense that something is happening as we wait for labs and CT results. Sometimes we’ll use sedatives or antipsychotics.

On occasion hallucinations represent the “first schizophrenic break” especially in a teen in the absence of overdose. But far more frequently they represent the brain and body needing some time to rest and metabolize.

As for legalized marijuana, as with all medicines, we here at Pre-R recommend you tread lightly. Thumbs up for legalization, letting sick people feel better, ending the war, skimming some tax revenue, letting a plant be a plant. Thumbs down for cannabinoid hyperemesis syndrome, and bad trips in parking lots.

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