Convulsions

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May 16, 2014 by The Jailhouse Doc

The jail induces convulsions of all kinds, be they epileptic seizures, panic attacks, pseudoseizures, malingering, or nauseated dry heaves induced by mystery foods that have induced large swaths of our population to discover that they have severe allergies to soy.  Allergies to soy that cause nausea, vomiting, gas, dizzy spells, chest pain, heartburn, passing out, weakness, shortness of breath and diarrhea, among many other ailments.

Convusions are such a common occurrence, that a stadium worthy wave of eye-rolling tsunamis its way from nurse to MA, to provider, to dental assistant, to correctional officer at the news that a medical emergency has been called,….. for a seizure.  The stretcher and medical supply bags are gathered and schlepped down the mouse maze of hallways, stopping here and there to wait for doors to be magically unlocked by the eyes in sky.  Sometimes I wonder what would happen if a patient was truly coding and couldn’t be reached because we were stuck waiting for doors to be opened!  But no,.. most medical emergency calls have been for seizures, and as I said, it’s such a common occurrence that it hardly merits expediting our convoy’s movements.  This is because “seizures” are such a common occurrence, and the patients most frequently do not present with “classic” seizure symptoms including a postictal state that it doesn’t take long to start wondering if people are faking.

Convulsions are a mystery to me, an annoyance to others, an affliction to many, and a coping mechanism for still more. 

This is a typical scenario: the officers on duty are insistent that a seizure has occurred, because to any member of the non-medical public, any sort of collapse with any sort of shaking constitutes a full blown seizure.  The medical team arrives to find the patient sitting in a chair, responding to questions, stating that they just had a seizure, perhaps looking a little dazed.  Or perhaps they are breathing but non-responsive to voice commands, but avert their gaze from a penlight pupil exam, or hold their breath when an ammonia capsule is popped under their nose.  Or perhaps they are truly in a postictal state, confused, incontinent,. They are brought to the medical floor for examination and treatment.  Most of the time, their vitals are normal, they recover, they go back to their unit, regardless of what sort of seizure it was.  They follow up in chronic care, where perhaps a their blood is drawn to ensure their seizure meds are at the correct levels, and adjusted if necessary.

I would rather not become jaded, at least not until I’ve worked here at least a year (just kidding,..) so I feel like rolling my eyes and leaving it at “they’re faking” is unsatisfying, ethically dodgy, and,. well,.. boring.  When I try to step back and look at the big picture of a patient’s life, the possible social realities of their world at home, the reality that they are incarcerated and all the stress, shame, disappointment and angst that follows, I find that the complex way all of these things intersect and create a perfect storm lends itself to unorthodox coping strategies, where healthy coping strategies have not been developed.  And I’m not totally off my rocker in these ponderings.

Pseudoseizures, to our knowledge, are nonepileptical convulsions that have a psychological cause, not a neurological cause.  The CT scan of the head is normal.  The EEG is normal.  The labs, the vitals,.. all normal.  And yet, something is clearly wrong.  This is complicated by the fact that a certain percentage of people with pseudoseizures also have true epileptic seizures.

How many people are on heavy seizure medications without proven epileptic seizure disorder?  I don’t know.  But I wonder.  It really begs the question, what drives people to convulse, whether its conscious or not?  After all, these episodes used to be called “hysterical seizures” back in the day, after all, as early scientists struggled for answers to explain the difference between epileptic fits and other convulsive episodes.  It doesn’t take much medical sleuthing to realize that the medical community remains woefully lacking in good data, understanding, comprehensive treatment plans and give-a-rip when it comes to treating pseudoseizures.  The stigma of mental illness extends into this realm; we have compassion for someone with epilepsy, but a patient who has convulsions related to a personality disorder?  Or PTSD?  Or an anxiety disorder?  They are clearly doing this on purpose for attention, and they’re wasting our time.  Sometimes this may be true, but there must be space at the table for those whose convulsions are the result of serious psychological illness.  Yet, we all know that the behavioral therapy needs of our country are seriously lacking in resources, trained professionals and program availability.

Bring this all back to the jail setting, I really do think it’s a perfect storm.  Patients, plucked out of dysfunctional communities in which drugs, abuse and violence tramples on all semblances of opportunity, plopped down in a jumpsuit in a hot cell, with virtually all control and freedoms taken away, uncertainty swirling about when and if one will ever be released, the pervasive thoughts of loved ones, frequently children farmed out to foster families or elderly parents, the stigma of knowing that one will always have a “record,” the disappointment of cycling in and out of jail,… the frustrating of falling back off the wagon, the anxiety of wanting a cigarette every second of the day, the feeling that the road to success and a happy future disappeared into a Florida sink hole taking all hopes and dreams with it, the sense of “otherness,” “badness,” the tangible separation and subsequent feeling of humiliation between the inmate and noninmate which doesn’t exist out in the real world but is as screaming loud as the orange jumpsuit inside the facility,.. the inability to go to bed when you want, eat what you want, have a freaking salad,…. all of these things compile together and erupt like Old Faithful.  Can we really be surprised that someone in this reality may not have the coping mechanisms of goal setting, reframing, self care, finding humor, systematic relaxation strategies, positive re-appraisal?  to name a few?  I mean, who are we freaking kidding??  I would probably convulse too.  And that’s why I am challenged to have more compassion, and spend more time trying to read through what little research we have in regards to pseudoseizures.  Perhaps people really are using these physical jerking motions as a nonverbal strategy for expressing the pent up stress and overwhelming emotions triggered by their situation.  I mean, it’s not hurting anyone (well sometimes it does but that’s another matter involving the body habitus of the patient involved and lack of mechanical lifts in the jail setting with which to safely get someone off the floor…)

We have a great team of mental health professionals at my facility who work their asses off, but it does seem, like most medical professionals, their time is really limited, and their strategies are often also limited to medications, rather than other therapeutic techniques that require a lot of time and effort on the part of the patient and the provider.  As well as a long term relationship, and in the setting of a jail, you just don’t have that luxury.

So I guess we’ll keep medicated pseudoseizures with seizure meds until legally responsible guidelines are released that say otherwise, and the mental health team will continue medicating people with mental health meds, because I don’t know of any patients with pseudoseizures that don’t also have a mental health diagnosis,. at least at our facility,.. and I will keep showing up when a convulsive episode is happening, and make sure they don’t hurt themselves.  And we will continue on this way until we have good alternative strategies.  And I will try not to feel irritated every time I’m called to these episodes, to both honor my own oath of compassionate care, AND honor the difficult realities of my patients’ lives that have brought about their medical conditions.

Sources, because I’m not entirely irresponsible, and I only trust medscape.  And wikipedia. But I’ll only cite medscape.

http://www.medscape.com/viewarticle/431278_1

http://www.medscape.com/viewarticle/498175_2

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