The fine line between neurologic illness and being nuts

I just finished packing my bags to return to North Carolina after a great weekend in Cincinnati. I got to catch up with a friend from medical school, spend time with my parents who remain upset that I have no plans of getting married any time soon, and the Reds beat the Dodgers yesterday on a day that the Big Red Machine was commemorated.

Recently I finished a very rough stretch of night float. I found myself in some very difficult situations where preconceived notions and biases hindered my ability to care appropriately for patients.

About 1 month prior I was called to evaluate a patient who was 28 weeks pregnant and had intermittently complained of an intractable headache. She also started to have episodes concerning for seizures that were witnessed on multiple occasions by the nursing staff. The day team had evaluated the patient and expressed concern for either a venous sinus thrombosis or an infection such as meningitis. Plans had been made for the patient to undergo a brain MRI and EEG. Unfortunately it took over 48 hours to get these studies done. During that long 48 hour period, I was constantly paged during the night to evaluate the patient when she had seizures. By the time I made it to her bedside, she was no longer seizing, and was mostly unresponsive and fatigued. In the mean time, we increased the doses of her valium and keppra in an attempt to stop the seizures.

The patient was too agitated and obese to tolerated the brain MRI so she had to have general anesthesia/intubation to be put to sleep. Her MRI was normal. We were initially all out of EEG machines so it took 48 hours to hook her up to EEG. I was again called to evaluate the patient after one of her seizure episodes; but this time after reviewing her EEG it became clearer to me that her events were not seizures at all. I was able to say with some comfort that there was nothing to do but stand back and watch, and in the morning the patient could be reassured that she wasn't having seizures.  I could not say if she was faking her events or subconsciously having involuntary spells that looked like seizures, but it did not matter much to me around 2 in the morning as whatever she was having was not life threatening.  I can say that I was fooled though; a young pregnant woman who is having a terrible headache and new onset seizures could have any number of serious conditions including a cerebral venous sinus thrombosis, eclampsia, or meningitis; however in this case the patient had nothing concerning and the epilepsy attending agreed with my assessment the next day.


About one month later I admitted an elderly woman on dialysis who had recently had a fall and sufferred a small subdural hemorrhage who was also having seizure like episodes.  Her nurse told me the patient would shake her legs, moan in pain, and ask for pain medication for about 30 minutes. She felt the episodes were pseudoseizures. These episodes had been going on for weeks.  The patient certainly had some reasons to seize; her blood pressure was high, she recently recovered from a small intracranial hemorrhage, and dialysis can predispose patients to all kinds of metabolic derrangements. On the day of admission we made arrangements for the patient to get dialysis, and then start continuous EEG monitoring to determine if she was having seizures. Again it took about 36 hours for the EEG to be hooked up. I came back the next night around 8PM and during signout the patient started having her event. She started to shake her left leg randomly and complain of pain. 5-10 minutes passed. I looked at her EEG and didn't see a clear seizure. I decided to give her 2mg of morphine. Five minutes later the patient was still in pain. She started to move all of her extremities rhythmically. Her oxygen saturation dropped to the high 80s. I decided the patient was not seizing; she got her morphine. I checked back on the patient 10 minutes later and she was comfortably eating her dinner. I decided the patient was faking these events to get narcotic medications and when my shift ended at 9AM I signed out this information to the day team and went home to sleep.

The next night when I came back to work, the intern kindly informed me that I was absolutely wrong about the patient's seizures being fake. The epilepsy attending told the team that morning that the patient was having myoclonic seizures with a prolonged secondarily generalized tonic clonic seizure. I felt terrible, but there was a slight element of disbelief. I looked at the EEG from last night again. The patient shook her leg in pain for 5-10 minutes and I did not see a seizure. I continued to review the EEG and video recordings more closely and then about 15 minutes into the spell, the patient had the rhythmic movements of all 4 extremities. I am standing bedside on the video and watching the patient seize. At this point her EEG shows an obvious generalized seizure, but I did not see this last night. So I watched as the video showed me standing around while my patient was having a prolonged seizure; and I chose to do close to nothing because I was previously convinced the patient was doing this to get narcotics.  Playing back the moment in my mind is haunting and embarassing. I am standing bedside watching a patient suffer and I chose to assume she was faking it to get narcotics. I had not reviewed the entire EEG the night before and I suddenly wished I could go back 24 hours and do things differently.

Luckily my mistake did not result in any long lasting adverse outcomes to the patient. She had been having these seizures for weeks and previously no one was sure what was going on. I apoligized the next day to my team and attending for being so incorrect (I did not apologize to the patient, but her intern did). The patient's seizure medications were adjusted and she did better.  I think if I did not get the added history from the patient's nurse that she had drug seeking behaviors, I would not have misjudged the situation so badly. I'm sure my error will be reviewed in a morbidity and mortality conference; but the chief resident and attendings were forgiving. I am sure they too have all made similar mistakes during their training; and continue to occasionally make these errors (which on rare occasions I have caught). My error weighed on me for several days, but then I decided that life is too short to be unhappy and now I have let it go.