Last week a 5 year old boy was admitted to the Pediatric Research Ward. He was feeling weak and tired for 3 days when he started complaining of headaches. His mother felt his forehead, thought he had a fever, so gave him a fever-reducing medicine. The boy laid down for a nap and an hour later his family found him in the middle of a seizure. It lasted about 3 minutes. He woke up 10 minutes later, sleepy and confused.
At the local health center his rapid malaria test was positive. After the healthcare worker gave him some anti-malarial medications, he felt a bit better. He was sitting up and talking when he abruptly stopped, entering a second seizure. He did not wake after the second seizure. The staff in the health center gave him some anti-seizure medication. By this time, it was almost 11 p.m. As travel at night in Malawi is ill-advised, he remained in the health center, unmoving and comatose.
Early the next morning an ambulance brought the boy to Queen Elizabeth Central Hospital. In the Emergency Room he was deeply comatose with a temperature of 39.8°C (103°F). Immediately after arrival he had several short seizures. The child received a second dose of an anti-seizure medication. His mother and a nurse shifted him onto a rolling stretcher to begin the 10 minute trip to the Pediatric Research Ward.
Shortly after departing the boy started having another seizure. The people pushing the stretcher quickened their pace. When they arrived on the Research Ward the boy’s convulsion continued. The team examined him quickly, inserted an intravenous line, gave him phenobarbital, and the seizure stopped. The admission team finished their examination and the child began the process of being admitted to the Ward. These procedures include an EEG (brain wave test) to see if electrical seizure activity is ongoing, even if the physical seizure has stopped.
The EEG technicians rapidly hooked the child up to the EEG machine, turned it on, and summoned me to the bedside. The child was in non-convulsive status epilepticus. “Status epilepticus” (“status” for short) is when seizures occur repeatedly without the patient regaining consciousness. When the abnormal brain electricity continues but there is no physical convulsion, this is non-convulsive status epilepticus. It is a medical emergency. The ongoing electrical seizure injures the brain. It needs to be stopped and non-seizure cerebral rhythms restored as quickly as possible.
I ordered a second anti-seizure medicine be added to the phenobarbital. The abnormal brain electricity on EEG continued. In the USA or Europe there are several other medications that can be given to stop non-convulsive status that does not respond with “normal” therapy. On the Research Ward we have only one other choice, ketamine.
Unfortunately, when we begin using ketamine to treat seizures in children with cerebral malaria, the outcome is usually the death of the child. This likely has nothing to do with ketamine, but with the fact that the malaria has profoundly affected the brain so that less powerful antiseizure medications do not stop the convulsions. Though we know the likely outcome when giving the drug, we still try it. I wrote about a typical experience with ketamine and patient outcome a few months ago (“Powerless”). The child about whom I wrote was neither unique nor rare. Three weeks later I treated a young girl with non-convulsive status epilepticus and was in the same Catch 22: if I do not give enough medications, the continuous seizures will kill the child, but if I continue to give them medications to stop the seizures, the drugs will stop their breathing and the child will die.
Today, as I was treating this 5 year old boy for his non-convulsive status epilepticus, I hoped that this time things would end differently. But hope was not my only emotion. I also felt dread. Dread that the Third Time was not a Charm. Dread that this boy, too, would die as I cared for him. Dread that I would hear his mother’s cry and see her face as her child left this Earth.
Later that day I asked my fellow physicians about this feeling. To my surprise it is a common physician emotion when treating people with illnesses that have a high death rate. “Vicarious traumatization” is being traumatized by the trauma of other people. It often leads to guilt and can result in post-traumatic stress disorder. Dread is a common physician emotion accompanying vicarious traumatization. As physicians we do our best to steel ourselves against poor patient outcomes. Sometimes, though, I find it challenging to do so.
Concurrently with my feelings of hope and dread, I thought about how unfair this boy’s situation was…. A child in the USA receives a ventilator and optimal care. A child in Malawi dies.
Concurrently with my feelings of hope and dread, I thought about how unfair this boy’s situation was. In the USA, if a child was in non-convulsive status epilepticus, I would admit them to an intensive care unit. They would receive a wide variety of medications. If the medication suppressed their breathing, they would be put on a ventilator. This boy, living in Malawi, had none of those luxuries. There are four anti-seizure medications available. If he stops breathing from either the seizures or the drugs his life is over. A child in the USA receives a ventilator and optimal care. A child in Malawi dies.
At the child’s bedside, with all of this swirling in my mind, I ordered a bolus (a single large dose to increase the level of a drug in the blood) of ketamine and started an intravenous infusion. The boy’s EEG revealed that his brain was still firing off with continuous seizures. I repeated the bolus and doubled the infusion rate. No luck. I gave him a third bolus and turned up the rate of infusion to its maximum. The seizures stopped.
It was incredible. I had walked the tightrope between too little and too much medication and was still balanced. His brain responded after being in a continuous seizure for almost a day. I was elated, surprised, and relieved.
I always do my best for the children in whose care I am entrusted. Sometimes, despite doing my best, things turn out very badly. But not every time. I was happy I spoke to my colleagues and learned that we had similar rushes of emotions when dealing with life-or-death situations. In my opinion, physicians need to do a better job of self-healing. I believe the first stop in emotional health is to recognize, name, and think about the mixture of emotions within us when we deal with these issues. While treating this 5 year old boy for his non-convulsive status epilepticus, I was uncomfortable. After thinking and writing about my experience, I believe I know why. Physician, Heal Thyself.
