Epilepsy

I was in another training session for First Aid (with the Red Cross) today and we were discussing causes of unconsciousness and talked about Epilepsy. After a friend suggested to me and as I've had a fair bit of experience dealing with Epilepsy, I decided it would be my next post! As there's so much to say about Epilepsy, I'll focus on my experiences with epilepsy, but will provide basic information about other types.

Epilepsy is a complicated condition - once again one not fully understood. Sometimes damage to the brain is detected and this is believed to cause the seizures (or "fits"). This is Symptomatic epilepsy and an example would include a lady who had become epileptic after suffering head trauma (a patient who's consultation I sat in on while on Work Experience). However in other cases, epilepsy occurs with other conditions, such as learning disabilities (all my other experience dealing with epilepsy comes under this category). The learning disability hints there is some sort of brain damage, however no brain damage can be found. This is Cryptogenic epilepsy. In many cases, no obvious cause for the seizures can be found - that is, no brain damage. Seizures occur when neurones in the brain are disrupted, which causes the electrical impulses to cause the seizures.

There are many types of epilepsy. These are divided up into Partial and Generalised Seizures. The type of seizure depends on how much of the brain is affected. In Generalised Seizures, most or all of the brain is affected and, not surprisingly, in Partial seizures, only part of the brain is affected.


Partial Seizures
Partial seizures can be simple or complex. In simple partial seizures, the person will be conscious throughout the duration of the seizure, and so will remember it. In complex seizures, the person is unconscious for the seizure and can display unusual behaviours.

Generalised Seizures
There are 6 types of Generalised Seizures: Absences, Clonic, Atonic, Tonic Clonic, Myoclonic and Tonic. My experiences so far have involved Absences and Tonic Clonic seizures - so I'll focus on these in a minute. In Myoclonic jerks, the person experiences twitches as if being electrocuted. When these jerks persist and the person usually becomes unconscious, then they are experiencing a Clonic seizure. In a Tonic seizure, your muscles suddenly contract, which can cause you to fall over. In an Atonic seizure, the muscles relax, causing the person to fall to the ground.

Absences are very common and are seizures I have witnessed multiple times! During an absence, the person loses consciousness and appears to be daydreaming (which is why a lot of the time these seizures are missed). During a seizure, the person will not respond and will stare into space. Clients I work with who experience absences don't respond to name or any sort of visual stimulus (e.g. waving a hand in front of their eyes), have dilation of the pupils, cyanosis of the lips and can drop their head into their chest and blink rapidly. These seizures have also appeared to cause sudden changes in behaviours and the mood of the client, however do not always. When an absence occurs, the general approach is to quietly call their name until they come back round, especially as they can be disorientated after an absence.

Tonic Clonic seizures are what most people commonly associate with an "epileptic fit" and it is the most common type of seizure in people with epilepsy. Contractions and twitches cause the person to fall to the floor and jerk. This can involve banging their head, biting (it has been known for a person to bite their tongue very hard during a tonic clonic) and jerking their arms and legs. These normally last for up to 5 minutes, but vary depending on the person. In my experiences, they have lasted between 1 and 4 minutes. After a Tonic Clonic seizure, the person is normally fairly tired and will lay down for 10-45 minutes to recover. During a seizure, it is important to remove as many hazards as possible (without putting yourself in danger). Examples of this may include moving furniture to avoid the person causing injury to themselves or removing any objects that could cause injury. If possible, some people also put a soft object, such as a pillow, underneath the person experiencing the seizure's head in an attempt to prevent damage from repeatedly banging their head of the floor. Common drugs to be administered for Tonic Clonic include Diazepam (either rectally or through injection) and Buccal Midazolam (squirted onto the inside of the cheeks in the mouth). Thankfully, I've never had to administer either of these so far!

Status Epilepticus is where the person remains unconscious from a seizure for more than half an hour. This can be a single seizure or multiple (clusters). Medication is normally administered when this occurs or and ambulance is called as there is a risk of brain damage from a prolonged seizure.

While there is no cure for epilepsy, some people do seem to "grow out" of this condition. Most people learn to cope with it and the effects on their lives vary. For example, depending on your last seizure, you may or may not be eligible for a driving licence. AEDs (Anti-Epileptic Drugs) are prescribed to try to lessen the frequency of seizures.

There are multiple triggers, many of which are more common than the stereotypical "flashing lights" (photosensitive epilepsy), such as stress, blood sugar levels, dehydration and lack of sleep.

Co-amoxiclav + other things!

This week I had an incident at work where a client showed extremely challenging behaviour and ended up biting me badly on my shoulder. I went to the minor injuries and was prescribed anti-biotics for a week to help prevent any infections. Since I hadn't heard of "Co-amoxiclav", I decided to look it up and see what I could find:

It's an anti-biotic in the Pencillin group and is used to treat many infections, including infections in the abdomen, kidneys, urinary tract, sinuses and more. It is a combination of Amoxicillin Trihydrate and Potassium Clavulinate. Like many anti-biotics, it works by interfering with the cell walls of bacteria, and causes holes to appear in the bacteria, causing them to die because they can't control the substances moving in and out of the cell (such as the cytoplasm). Like most medicines, there are side effects of Co-amoxiclav, such as diarrhoea, vomiting, dizziness and jaundice. Thankfully I haven't experienced any of these, but they can occur after finishing the course of anti-biotics!


Another thing that interested me this week was in Biology, where my teacher ended up getting side-tracked onto talking about high tension pneumothorax. This can be caused by several things, but he focused on small punctures of the lung, rather than the other types that can happen in the elderly and smokers or due to large punctures, such as a broken rib, stab wound or gunshot wound. His example was how some people's lungs can have a pinprick puncture when taking off in an aeroplane, due to the changes in pressure (where the volume of air increases/decreases depending on whether you're ascending or descending). This tiny puncture means that air from inspiration can enter the pleural space (chest), but is stopped from getting back into the lung. Essentially, the space outside the lungs fills up with air and can cause difficulties for breathing and circulation. My teacher also said how the windpipe is forced to the other side of the body by the air. It can become life-threatening and needs intervention immediately. This is done by essentially letting out the air from the pleural space with a valve-like mechanism.


I've also started reading another book called "Bad Science" by Ben Goldacre. It's really interesting so far and exposes all the fakes and frauds in big pharmaceutical companies and really emphasises how we can be made to believe anything through statistics.

"Complications" by Atul Gawande

Recently I’ve been reading (something I don’t get the chance to do a lot of the time!) a book called “Complications” by Atul Gawande. I had Awards Evening vouchers (I won Key Stage 4 awards for Contribution to my House, getting good GSCE grades and Computing) that I had to buy a book with for my prize. This book was recommended on many sites for prospective medical students and so I bought it! It’s written by a surgical resident in the US and contains many key ideas to being a doctor, which are presented through his personal anecdotes. It’s a brilliant book – very well written by anyone’s standards – and especially good for people interested in medicine. I’d recommend it to anyone!

In this book, many interesting and complex conditions and medical treatments are discussed. These include blushing and how this can be prevented by a surgical operation, the feeling of nausea, how and why people feel pain, operations to force people to lose weight, biopsies and more. The book also focussed on aspects of being a doctor, other than the actual conditions, such as when “good doctors go bad” and the possible role of robots in future.

I’ll start with a few of the conditions I found particularly interesting:

 Necrotizing Fasciitis

This is a condition I read about in the last chapter of the book (and is the freshest in my mind!), but I remember being especially fascinated by this lethal bacterial infection, partly because it’s so hard to diagnose and that we don’t know that much about it. This is caused by A Streptococcus, the bacterium that normally causes nothing more than a strep throat. However, some strains have evolved to become far more dangerous – such as this one. It is not known where exactly the bacteria come from, especially seeing as how cases of necrotizing fasciitis have developed from reported scratches (on any part of the body), after surgery, abrasions and even from punches on the arms. What I found most frightening is there are cases where no cause for infection has been found.

So what can this terrifying bacterium do? Well the press have nicknamed it the “flesh-eating bacteria” and this isn’t untrue! It invades deep under the skin (unlike cellulitis, which necrotizing fasciitis is often misdiagnosed as) and consumes any tissue it finds at a rapid rate. This leaves the tissue grey, foul and gangrenous. Without early surgical intervention, fatalities are shockingly common! Thankfully, this is a rather rare condition; however that also means it is often misdiagnosed. When the diagnosis of necrotizing fasciitis is confirmed from a sample of the infected area, the patient is taken into surgery, where all the infected tissue must be removed. This often means that limbs have to be amputated. In the case in the book – the lady with the infection went into surgery and survived with only the muscle in her leg removed. She went back to work in an office eventually and after a while could walk as well.

Sudden Infant Death Syndrome (SIDS)

This condition was particularly interesting to me because it’s another mystery to medicine. SIDS is a condition where babies die with no apparent cause of death. In a similar way that types of autism can be diagnosed as “Pervasive Development Disorder – Not Otherwise Specified”, SIDS is another diagnosis essentially meaning “we don’t really know”. In a case in the book, eight babies from one mother were diagnosed with SIDS. It is described how the pathologists can find no cause of death and so put “Undetermined” in the report. It reminded me of a case I read about in the news a few years ago, where a healthy young man dropped dead suddenly – a condition that is very rare and seems to cause people to suddenly die. This mystery fascinates me, although eventually the woman in the book admitted to counts of first degree murder by smothering her children in their sleep. In this case, there was a logical, fairly simple answer, but how do we know this is always the case?

Moving more on to the experiences Gawande showed in the book: one that particularly caught my attention, and is also fairly disturbing, is how common Anxiety and Depression Disorders are among doctors. A frightening  proportion of doctors (according to Gawande’s statistics) have disorders such as Depression and alcoholism. This of course could make them unsafe to treat patients and in “Complications”, Gawande tells of a doctor he knew who started off as a fantastic surgeon, but exhaustion and Depression ended up in him losing his licence.

Gawande also talks about diagnosis and the difficulties in diagnosing. The process is meant to be a purely factual one and he went on to say how the treatment for a patient should be decided by a mathematical process that determines the likelihoods of the possible outcomes of the diagnosis and of each treatment, however he said doctors have to make decisions in the heat of the moment, when a patient walks in, when something goes wrong in an operation or when a patient takes a sudden turn for the worse. They use their gut instinct; however Gawande also said how this can be influenced. For example, in the case of necrotizing fasciitis (see above), Gawande had experienced a case of this fatal bacterium merely weeks before. He described it as one of the worse cases he’s ever seen, the patient ended up dying after his organs started failing after they operated to remove the infected tissue that had consumed much of his tissue on the left side of his torso – the back and shoulder muscle, the abdomen, etc. This previous case had meant that the diagnosis was fresh in his mind and also something he didn’t want to see again. Had this previous patient not have been admitted, Gawande thinks he may have missed the correct diagnosis on the woman who eventually survived.

This book explores many issues of being a doctor and I would thoroughly recommend it to anyone, whether they’re interested in medicine or not!

In other news, today I attended my second training session with the Red Cross. We’ve covered how to lead sessions to peers and I’ve volunteered to train younger year groups in First Aid – I look forward to posting about this training and the sessions I end up running!