I'm finding that, more and more, "seizure" is being a catch-all term for literally any clinical phenomenon. Patients may be walking, talking, syncopal, actively having an MI, or all of the above – it's all considered seizure if it looks odd enough. In fact, just mentioning key words like "shaking" or "seizure" is often enough to prompt a neurology consult. Since seizures are a painfully heterogeneous phenomenon, this is not entirely unreasonable. But at the same time – and this should go without saying – most things are not seizures. Lately, some of the things that have raised concern for seizures have been a bit troubling. I feel like a bit of a jerk when I use terms like "neurophobia," but… well, see below.
A few weeks ago, I got a rather breathless call from one of the newer nurses in the ED, asking me to come help with a patient who simply would not stop seizing or fighting with staff (1). Not unkindly, I suggested that usually people are only able to do one of those things at a time. From what I could hear in the background, it sounded like a pitched battle at the moment, the sort of situation required Haldol + security, rather than Dilantin + me. But I knew this nurse; he's really nice, and he wouldn't have called unless he felt as if he had too. He also fell into that camp that believes that people generally operate by certain rules, and neurology is meant to explain all aberrations (2).
Still, it was early in the week, when you're still filled with the sort of free-floating good will that pushed you towards medicine in the first place. So like a saint gearing up to sling alms, I holstered my tuning fork and trundled over to the ED, where I was greeted by the sight of a tall, skinny gargoyle of a man in a hospital gown. He was covered in old tattoos and scratches of varying age, with dried blood sheeting down the side of his head. I could see the tendons in his hands as he clutched the the doorway of his ED room and screamed at staff. Occasionally, he would point people out individually with one accusing finger, and you could see white in all 360 of the degrees around his pupils. Being off to the side just a little, I could also see the bright, quarter moon of his butt cheek as he informed the ED physician that "I know you, motherfucker.(3)" I sighed. A little crowd had gathered, maintaining a sensible 10ft radius, and they all watched these proceedings with the sort of ghastly expectation usually reserved for Japanese dating shows and Nascar races. I considered quietly moonwalking back the way I came – but then I saw why they had called me over.
Mid-paragraph, he stopped. His teeth clenched and the cords of his neck stood out as he arched his head and neck back. He clenched his fists in front of him and looked very briefly like Bruce Lee warming up for a match. I had just realized that he was holding his breath when he squatted down to a half-crouch, his arms started to shake and his head rolled back – but he remained upright. I'm sure that, for the bystanders, it was very dramatic. To me, he looked like Bruce Banner forcing a BM and accidentally turning into the Hulk.
The nurse that had called me started to ask for more ativan, and I told him to hold it for now. I'd read the chart beforehand: this man had already had enough benzos to fell a rhino in heat; his serum seemed to be 30% gin; his UDS was a Whitman-esque celebration of recreational substances. Overhearing me, the ED resident nodded wisely and started to call for Versed and Dilantin instead. I waved that off too, with a sort of growing desperation. Were we all seeing the same thing?
Before somebody could talk themselves into administering a propofol drip with extreme prejudice, I walked over with my hands held up, as if to show that I was unarmed. I asked the patient, – still mid-squat, mind you – if he was doing alright, which was a ridiculous question. But he did look at my face mid-"seizure," which was more or less the point. I suggested we hang it up for a little bit and talk in his room, to which he snapped "This ain't my room, shit head. My room is the streets. (4)"
I glanced over his shoulder as if seeing the room for the first time. "Oh, yeah. Oh, absolutely the streets," I agreed. I've found that for these cases – cases with a high likelihood of ending in a scrum followed by 6 months of prophylactic anti-retrovirals – the best approach is to channel the serenity and bafflement of the cow as he crosses the intersection. So, we began to chat. He sat on the edge of (not) his bed while I asked stupid questions and checked stupid reflexes.
I can't say that I remember our conversation verbatim, but I do remember certain exchanges.
Me: (points to Saving Private Ryan-esque head wound) "What happened to your head there?"
Him: "How should I know?"
Me: "Well, do you remember what happened before, maybe? Did you fall? Were you in a fight? Did you wake up like that?"
Him: "Did you wake up like a bitch?"
Me: "Have you ever had seizures before?"
Him: "Everyone has seizures sometime, man."
Me: "I don't know about that, but, um, have you ever been on seizure medications before?"
Him: (looking at me scathingly) "No. I don't wanna get addicted to that shit."
Me: "Is there anyone I can call? Maybe someone that was with you, might be able to say what happened?"
Him: "Goddamn sand n-gger, you tryin' to call Kevin? You tryin' to call Kevin?!"
He kept repeating this last, louder and louder, as he stood up (5). For my own part, I backed out of the room, just as un-heroic as they come. And dear reader, I shit you not: as I back-pedaled, I heard another nurse warn everyone that "Here comes another seizure!" Why, if I hadn't been fleeing like a coward, I'd have had no words.
The patient came out right after me, his hands tearing at his hospital gown. In a blink, he had it off and wadded up into a loose ball, which he fired past my head at the nursing station. He stood there, naked and heaving, covered in bizarre tattoos – lots of faded blue dice on his forearms, harlequin masks, sundry big boobed devils on motorcycles, etc. But, more specifically and terrifyingly, he had a tattoo of a wolf howling, drawn en face in faded blue ink with orange eyes – and it was tattooed on his crotch in such a way that his penis seemed to emerge from its mouth.
This, I found, was my absolute limit. The bad consult I could handle. The swearing, insults and racism I could chalk up to hard living and neuro-chemical extremis. But the wolf? That had taken time and forethought. It was clearly the watermark of a personality that would take any AED's I started and return them to me rectally, before stealing my car keys. Security swarmed in, and I walked out.
As I did, I passed the hospitalist he was being admitted to, and she asked me if I would be ordering an MRI, Keppra, any of that.
I sighed again. "No, He's got PNES, chronic crazy and essential racism. Let's start with a head CT and an EEG, if we can get them."
"But he's still seizing," she replied, looking at the anarchy over my shoulder. I looked back to see him hulking out again, as no less than three burly rent-a-cops tried to bulldoze him back into his room. Blessedly, the crowd of bodies kept me from finding out if he had an erection.
"I don't think that's a seizure," I said, trying not to sound appalled.
"Yes, he's seizing. I see it," she replied, and she actually pointed, as if that would clear things up for me. As if she hadn't been clear enough, or perhaps in case I'd gotten confused and examined the clothed, 82yo woman one room over.
"Please don't take this the wrong way, but I don't think a seizure is what you think it is," I said, before shimmering out.
1) I don't get called to the ED very much, and that's by design. We actually have a few separate neurology teams. If there's a patient that needs to be dipped in rTPA, the stroke team comes running. If somebody woke up with a couple of burst pipes, the neuro ICU is standing by with soft voices and warm hands. If somebody is having seizures, or anything resembling one, the ED orders a Hellfire strike of benzos with one hand, while putting in a non-urgent consult for "prolonged post-ictal state" with the other. Given all of these heroes – who are likely doing kettlebell swings or one-armed pullups while waiting for the Commissioner to blaze the signal – there's really only a sliver of niche emergencies that would require someone like me. This was not one of those cases.
2) I tend to feel that the practice of neurology adheres to certain principles, while humanity – the species that yielded both Ska and Suge Knight – is a heaving mass of carbon and wild-eyed outliers, screaming into a void.
3) He did, as it turned out. They'd met during his last visit to the ED, during which he'd threatened to beat up the little old lady in the room next to him before leaving AMA. So, you know, believe your patient.
4) While he could have said it more nicely, he wasn't wrong. Besides, seizure aborted, right? I take my wins wherever and however I can.
5) I am demonstrably non-white, but didn't seem to be what disturbed him most. If you can categorize things like this, I would say that he was being more collaterally than primarily racist. He seemed more focused on my possibly getting in touch with Kevin. I never found out much about Kevin, but it's hard to imagine that they shared a cubicle wall at the NAACP.
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