Monday, October 11, 2010
Epilepsy: Difficult Judgements.
A case of epilepsy is in my experience the most searching test of a physician's skill. This case is perhaps an extreme example, but the management of epilepsy is never easy.
Gail was 19 when she first came to my out-patients' clinic. She was a student at a local college.
She had suffered two major epileptic fits two days before, a Sunday. On the Friday before she had drunk to considerable excess at a party, so much that she could not remember how she had got back to her student lodgings, and she had stayed in bed most of Saturday.
As a young child she had suffered a number of fits, indeed she had a substantial folder of hospital notes generated during attendances in the paediatric department. Extensive investigation at age 5 had shown only minor anomalies on the electro-encephalogram. She had taken anti-convulsant tablets until the age of 12, but had then stopped, having been free of fits for 3 years. A repeat electro-encephalogram at that time showed no abnormality.
Off treatment she had had no more fits until the recent events. Until Saturday she considered herself to be a normal, healthy, active young woman.
Her big interest was her 500 cc motor bike. She belonged to a local motor-cycle club, and spent most of her weekends out with them. Indeed she had come to the hospital on her motor-cycle, arriving in leathers and helmet.
Examination and a set of routine tests were unremarkable. A repeat electro-encephalogram and a CT scan were each reported normal, but those results took several days to come through.
Two important issues had to be considered immediately.
1. Should she take anti-convulsants again?
2. Should she continue riding motor-cycles?
Anti-convulsant treatment is not simple. Anti-convulsants reduce the fit frequency; they do not guarantee that no more fits will occur. Anti-convulsants have a long list of side-effects, notably sedation. Gail was at college, preparing for exams. Her academic performance could well be impaired.
The drunkenness was an obvious aggravating factor. What was the risk of further fits if she took no medication but avoided alcohol, fatigue, noise, flashing lights, excitement? Probably low, but not negligible. Just 4 days had passed since the party, and 2 days since the fits: she had to be considered still at some additional risk for several days more.
I decided to recommend a 1 month course of phenobarbitone: a 30 mg. tablet at bedtime for 2 weeks, then a 15 mg. tablet for 2 weeks more.
Phenobarbitone has the advantage of long duration of effect. A single daily dose aids compliance; a bedtime dose means the worst of the sedation is during the night.
Phenobarbitone increases the metabolism of hormones and drugs. It can interfere with the effectiveness of oral contraceptives. I warned her of this; she blushed, she wasn't on the pill.
She took the tablets as prescribed. She had no further fits and stopped medication at the end of the month.
But what about the motor-cycling? I advised strongly she should not do it: I had a duty to advise her to inform the Licensing Authority. That might well mean losing her licence for a minimum of 2 years.
I also advised she should inform her insurance company, which would risk loss of cover.
She became very upset. This was her main leisure interest; her friends were in the motor-cycle club; if she couldn't ride she couldn't meet them. Tears flowed, tissues were passed.
I recorded my advice in her notes, and in my letter to her general practitioner.
I saw her for review several times over the next 3 months. No more fits occurred during this time, but she continued riding her motor-cycle, not informing the licensing and insurance people.
I repeated my advice at each visit, but she did not heed me. She reassured me she was very careful with alcohol, avoided fatigue, and felt very well.
Still I was worried. She was epileptic. Further fits were unlikely, but not impossible.
I had visions of a fit causing an accident. On her motor-cycle she was a serious risk to herself, and, even worse, to other people. Supposing she crashed into school children at a bus-stop?
Did I have a duty to inform the Licensing Authority myself, without her consent?
I had a professional duty of confidentiality; did I have a public duty of protection?
Eventually I sought the opinion of the Regional Hospital Board's Solicitor. His advice was unequivocal. My duty was to Gail: I must advise her, and record that I had done so. It was Gail's responsibility to inform the relevant authorities. For me to do so would be a serious breach of professional confidence. On his advice I sent to Gail by recorded delivery a letter explaining the issues raised by her relapse and advising her that she a legal duty to inform the Licensing Authority, and that she must also inform her insurance company.
She did not reply, and failed to come to further appointments: I never saw her again.