Sunday, January 9, 2011

3-year-old girl with seizures

Some weeks ago in our rural Indonesian clinic, we saw a small girl of about three in the late afternoon. Her concerned parents brought her in because she was having a seizure during a fever. It was a quiet little seizure, and perhaps it didn't much worry them at first. She didn't jerk or turn blue or flail dramatically. She just lay limp and insensible, left hand twitching and eyes gazing to the left.

How long has she been having this seizure? we asked them.

Since morning, came the answer. Oh, no.

A seizure that lasts longer than a few minutes--the definition varies from 5 to 30 minutes in some texts--is called status epilepticus, and it's a different ballgame from the more benign self-limited fever-related seizures that little kids sometimes get. Seizing for longer than a few minutes can cause brain damage.

Our physicians stopped the seizure quickly with rectal diazepam. But she didn't recover. Instead she lay comatose, barely responding to painful stimuli like a firm rubbing of her sternum. Basic tests found no obvious explanations of her seizure other than the fever, and no obvious cause of the fever. Treatment for the most likely bugs was begun, but within minutes of her seizure stopping, she began posturing--a sign of grave brain damage. Having reached the limit of the clinic's capacities, the physicians decided to transfer her to a nearby hospital. Her prognosis for resuming a normal childhood is grim.

Though it's a completely different situation, this tragedy reminded me of Anne Fadiman's superb book The Spirit Catches You And You Fall Down. It's about of a clash of cultures--Laotian Hmong and Western medical--and how a failure of communication between a pair of well-meaning immigrant parents and a group of equally well-meaning doctors led to a little girl's suffering a devastating and seemingly preventable seizure. It's brilliantly researched and presented. I read this book before beginning medical school and it's one of the few books in my adult life that I've reread many times, because it fascinates me that cultural differences can lead to so absolute a failure to communicate.

In our case, the failure is not one of person-to-person communication; it's hard to pinpoint and blame is hard to affix. The tragedy here is in part from her parents not bringing her in sooner because they didn't realize how dangerous an extended seizure can be. Or so I speculate, across a language barrier--there may also be factors like lack of access to transportation, concerns about expense, not realizing there was a clinic they could go to, and so on. But if I'm right and it was a simple lack of alarm on their part, then this episode underscores how much medicine a layperson in a developed nation can learn simply by having access to the media. TV dramas, radio programs, newspaper articles, storybooks, all of these over a lifetime teach people the seemingly obvious fact that things like seizures or sudden paralysis or terrible chest pain need to go to the hospital right away. We aren't born knowing these things, and in areas where this knowledge isn't floating around, maybe people don't know it. Maybe her parents didn't know it. And what looked to them like a quiet little seizure turned out to be seismic.

1 comment:

  1. Heartbreaking story. And a brilliant commentary on how important access can be to recognizing the warning signs of serious illness. More on this, please!