THCB

Status Epilepticus

flying cadeucii

The girl seizes. Her body torques and twists and jerks about like a snake trapped on an electric fence. She flops back and forth on the gurney before us, her pale forehead glistening with sweat, her brown hair wetted black from the effort of muscle contractions that threaten to tear apart her tiny frame.

Trauma Room Two is silent save for the gluck-gluck-gluck of her gagging as her jaw and teeth grind and bang together out of control.

This.

Is.

Seizure.

Her body screams with each shimmy and shake.

Her father stands next to me. He strokes her head with trembling fingers, running them through her damp hair, trying to keep the strands out of her grimacing face. His fingers move in time with the rhythmic nod of her skull as the tonic-clonic seizure ratchets and cranks her body. I take a deep breath. I start my chant.

Break seizure break.

Break seizure break.

I say it in my head, I say it in my bones, I say it in every part of me, keeping time to her dance.

Break seizure break.

I need to stall. I need to wait. I need to ride this out. The medicine will work. I just have to give it a little more time.

I look over at her father standing next to me as he gazes down at his thirteen year old daughter. Written across his face is a sadness so deep, so dark, so complete that even I can feel it in my deadened chest. Its claws jerk and tear away at me with each awful buck of her body.

Break seizure break.

Break seizure break.

I repeat it in my mind. Again. And again. And again.

Her skin turns a pasty grey as her oxygen level falls. Her brain is forgetting how to breathe. If I give her sedation and put a tube down her trachea to breathe for her, I will not know if she is seizing. But if I do not, well, she may just stop breathing forever. It’s a catch-22, a rock and a hard place, a lose-lose bet with a stacked deck in the casino of the Titanic as it careens into an iceberg.

But choose I must.

Her dad watches, petting her head, waiting. I know she has bad seizures when I see how calmly he sits with his sadness, watching his only daughter disappear in front of him. He does not panic, he does not cry out, he too has seen hundreds, maybe thousands of seizures, maybe even more than I. But unlike me, each one takes another piece of his daughter. They carry her away, little by little, to that other place out beyond the horizon we cannot reach.

Break seizure break.

Break seizure break.

My gut begins to twist. My breath becomes shallow. My hands begin to shake. Maybe this is the one that will never stop. Maybe this is the campfire that precedes the forest fire that burns down all that stands in its path. I know I have to stop it now or it will burn through this girl, leaving nothing behind but a smoldering, empty shell.

I look up at the clock, the green digital numbers stand unchanging, as if painted onto the wall. I have four medications dripping into her arms as fast as they can go. I have given round after round of drugs through the IV, trying to extinguish these roaring flames before me.

I swear the clock lies, but it has only been one minute since the last dose. One sixty second burst of time. One little tiny slice, of a slice, of a slice. Time respects no one inside the Trauma Room.

I have to ride it out a little longer.

I look at her mom. She stands back, a blank look on her face. I know that look. She has been drained and drained again, seizure after seizure, until finally, one day, there was nothing left to drain.  She looks to have departed somewhere else. I can’t say I blame her. A person can only spill so much sadness before they run dry.

Break seizure break.

Break seizure break.

The digit on the clock blinks to a new number. It now has been two minutes. She is dusky, almost blue. I draw up another dose, ready to fire. I tear open the intubation equipment, ready to dash in to the house before it burns to the ground.

But the seizure breaks. The fire extinguishes.  All movement stops. The absence of her shaking suddenly feels unbearably loud. I notice the monitor again, beeping along with her racing heart. I know her breath is coming.

Just wait.

Wait.

Wait.

Her oxygen levels fall further, triggering another alarm on the monitor. The alarms now call back and forth like two panicked, drowning dogs. No one moves in Trauma Two though the air fills with a cacophony of their almost unbearable cries.

I see her mom. She stares blankly ahead, oblivious to the noise. It occurs to me maybe she is making a grocery list in her head for later. Maybe she is trying to remember whether it was Tuesday or was it Wednesday when she last went to the store. Or maybe she is not thinking at all, she is just empty.

The ER nurse across from me makes eye contact. We look at each other. She knows what I know. Wait. We nod to each other subtly. The breath will come.

I look back at her dad. He stares at his daughter, trying to will her to breathe even though he knows by now he has no power over any of this. But try he does. I see it in his face. He has not been drained, not yet anyway. Life is drilling him full of holes as fast as it can, adding another big one today.  I see he does not shy away from the horror like most. He is going to fight this to the bitter end, no matter the cost to himself or his sanity or his soul.

A desperate gasp bursts forth from the girl, interrupting my thoughts. It is followed by another. And then another. Her brain is remembering to breathe. Her oxygen level rises, her skin pinks up, she starts to move. The medicine or the chant worked, I never know which one does what anymore.

She opens her eyes. She sees her mom. Mom gives a little smile but her daughter’s eyes stay blank. They jerk around erratically, looking for something, someone. They see me, the nurse, the room, the alarms and monitors, all of which she holds her eyes to for a second as her brain struggles to understand what she sees… no, not this, not this, not this.

She sees her dad. Her eyes stop. He is crying, as he must have done ten thousand times before and will do another ten thousand times more. I watch as her eyes stay fixed on her father’s face like a distant beacon through the fog in her head. Little by little she guides herself back by his steady light. We all watch as his daughter starts to return before us, the snake that possessed her slithering away back to some distant and dark place.

She stares at her father. And then it clicks who he is and why he is crying. She smiles a gentle smile at him. He takes her hand.

In that brief moment I see why he fights so hard.

At least five seizures a night, every night, for eight years, they tell me. They came out of nowhere. No family history, no medical problems, just one day they started, and they have not stopped since. Every test, every drug, every specialist has been visited and tried and then tried again. They have been told there are no specialists left to see or drugs to try.

I put a hand on her father’s shoulder and stand there, feeling somehow unworthy to be in the presence of such a raw and exposed soul. I know only too well that in this business it is foolish to hope, but I find myself saying a quiet prayer to some God I once knew…

Just this once

Just this once

Save this one.

Philip Allen Green, MD is an emergency physician based in Walla Walla, Washington.

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KL LanceLawrence A. Liebshcer, MDWilliam Palmer MD Recent comment authors
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KL Lance
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KL Lance

Beautifully written, compassionate, and heartbreaking. This is what killed my brother, in his fifties, fifteen years ago.

Lawrence A. Liebshcer, MD
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Lawrence A. Liebshcer, MD

Beautifully written. Uncanny accuracy in describing the parents…and the emotions of dealing with a seizure, the standing by and hoping. And fearing. Thanks for publishing.

William Palmer MD
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William Palmer MD

Sounds as if it is time to do some DNA sequencing. See genetics.emory. edu. “There are about 140 genetic syndromes with seizure activity.” Some acquired mutations can do this also.

Maybe you could treat something with iRNA? from a research lab?

Wonderful writing. Thanks for this.