Friday, March 14, 2014

March 12

Don't get confused. I title my posts the days the events happen unless I forget :) I bet you though I abandoned this blog again....ha ha I haven't :)

Sometimes at work, i get a little uncomfortable with the way my Attendings (the big bosses) handle certain cases and the decisions they make.  Of course every physician in training has experienced this at some point or another. And I am sure there are decisions I make or suggests that make others cringe.
Anyhow, I am in the epilepsy clinic this month and we have a patient with epilepsy who is complaining of increased seizures. She describes her current seizures as being different than the ones we have been treating her for all these years. With these new ones she is walking down the street or doing a chore and then all of a sudden her body freezes and she can't move a limb (she has even dropped dishes when this happens). They last for less than a minute and then she can move again, she does not lose consciousness, get confused or convulse. In fact, when these events happen in a public place like work, she tells her coworkers that she feels dizzy and needs a minute so that they don't look at her weirdly for suddenly freezing in place ( i.e. she does not really feel dizzy). These events are happening daily. She has been under a lot of stress with running her own business, and after she was diagnosed with epilepsy less than 5 years ago, she went through a divorce. Her family and kids live out of town, so she relies on friends for moral support and the bottle. Yes, for months now she drinks a bottle of wine from the time she gets off work till when she goes to sleep every single day.

So for my non physician friends...there are a couple of red flags to her story:

1) New seizure type in the setting of stress that is not responding to her medication
2) When thinking about the parts of the brain that seizures come from (cerebral cortex), they work in two ways most commonly: a seizure from one side of the  brain causes symptoms in the opposite part of the body (so right side of body seizure is coming from your left brain) and so when a seizure affects both left and right sides of your body, then similarly both sides of your brain is affected  (we refer to this as generalized) and you lose consciousness or have altered awareness and confusion. So for what she describes where her entire body freezes and she can talk to a coworker....yeah...very suspicious for pseudoseizures or non-epileptic psychological spells
3) A bottle of wine a day is a red flag for anyone's health even the french and italians :)

So you know what we did? (well what my attending did) He increased her seizure medicine and then wrote her a new prescription for ativan (also known as lorazepam) to take as needed when she feels these events. I raised a few objections; why are we giving benzos to an alcoholic? Can't a mix of the two stop her breathing? Also, last I checked benzos were addictive and a person can even have withdrawal seizures from them? Also, why increase her seizure meds when these new spells do not fit with epilepsy and cant we monitor her in the hospital or get an ambulatory EEG that she can wear at home to monitor these for a few days. He said the addiction data on the benzos are exaggerated and   no need to bring her in or get more testing if the increased seizure meds work.

And so I left for the day baffled....I had suggested to the patient privately that she tries to get a therapist or psychiatrist or AA or something to help her with her obvious depression (she got tearful 3 times during my interview with her), I can only pray she heeds me, but since my Attending did not reinforce that I will be really surprised if she follows through.....

That being said...I am about to sip on lots of wine alone :)