Finding the cause of seizures can mean the difference between life and death
Tips to make sure that your doctor does not use dangerous shortcuts when assessing seizures and other general signs and symptoms
Sometimes a person will arrive at an emergency room or doctor’s office with classic symptoms that make it easy for the doctor to make a diagnosis.
For example, even most laypeople would recognize that facial droop and paralysis on one side, and having problems speaking, are textbook symptoms for stroke.
Other times, though, a diagnosis is not as straight-forward. For example, symptoms like pain, nausea, and vomiting, could be caused by a variety of medical conditions, some dangerous and others not as much.
The standard of care requires that doctors form and go through a differential diagnosis list to make sure that they figure out what is really causing the problem. In other words, when the doctor cannot make an immediate diagnosis, then he or she puts each potential different diagnosis on the list. The doctor then does tests, radiology scans (X-ray, CT, or MRI, for instance), lab work, or other assessments to rule out each potential diagnosis, and should start with the diagnosis that is most dangerous to the patient.
In my experience as a Texas medical malpractice lawyer, I have seen time after time when doctors were busy or lazy and did not go through the time-tested differential diagnosis process. These negligent doctors skipped through ruling out a dangerous, life-threatening diagnosis, and instead made the wrong diagnosis of something that was rather benign or not as serious.
Two cases come to mind.
In one case, a patient went to the emergency room of a major hospital in Houston’s Texas Medical Center with right-sided facial droop, paralysis on the right side, and the inability to speak properly. Instead of being diagnosed with stroke, she was discharged and told that it was a psychogenic reaction—in other words, it was in her head. A few days later, she was correctly diagnosed at another hospital as having had a major stroke.
In another case, a patient went three days in a row to emergency rooms in the Humble/Kingwood area, complaining of a severe headache that suddenly started, and with worsening symptoms including blurry vision and blindness in his right eye, and very high blood pressure. All three times, the doctors did not take the time to go through a thorough differential diagnosis, and instead treated him for headache pain and high blood pressure. After being discharged the third night in a row, this person had a severe stroke caused by an internal carotid artery dissection that completed clotted the blood vessel.
The cause of seizures must be carefully diagnosed
Status epilepticus is a medical condition where a person has a single epileptic seizure that lasts over five minutes, or multiple seizures within five minutes without returning to normal in between the seizures. It is a pretty frequent occurrence, accounting for about one percent of all visits to emergency rooms.
The differential diagnosis for status epilepticus is extensive, and required the doctor to go through all of these possibilities before settling on a diagnosis.
Toxins. Status epilepticus can be caused by cocaine, methamphetamines, alcohol withdrawal, and tricyclic antidepressants. Doctors typically treat these with medications.
Central nervous system tumors. Tumors can cause increased intracranial pressure (pressure inside the cranial cavity of your head) and lead to herniation (part of your brain is squeezed across the skull). Doctors will typically order a head CT without contrast to see if a neurosurgeon needs to get involved immediately.
Stroke or bleed. Strokes may need to be treated immediately with the clot-busting drug tPA. Both strokes and brain bleeds cause irritation in the brain and can also lead to increased intracranial pressure that a neurosurgeon may need to deal with promptly.
Low electrolytes. Low sodium (hyponatremia), low blood glucose (hypoglycemia), low calcium (hypocalcemia), and low magnesium (hypomagnesemia) can all cause status epilepticus seizures. The doctor will treat these conditions with certain IV fluids. Depending on how low the electrolyte levels are, these can be serious, life-threatening conditions that require carefully-monitored correction.
Infection. A central nervous system (CAN) infection, such as encephalitis, herpes encephalitis, and brain abscess can also be the culprit for this type of seizure. They each have different medical treatments.
Eclampsia. A final potential diagnosis, that is sometimes overlooked, is eclampsia, or seizures in a woman who has pre-eclampsia. Pre-eclampsia is a pregnancy-related condition, which can be present in pregnant or post-partum women (those who recently delivered a baby), characterized by high blood pressure and high levels of protein in the urine. If the mom is still pregnancy, the OB/GYN may need to deliver the baby by emergency C-Section.
What can you do to promote differential diagnosis safety?
While your doctor is the expert, always remember that you, as the patient, are a co-captain of the healthcare team.
First of all, do not worry about knowing each potential diagnosis that should be on the doctor’s differential diagnosis list for a certain condition. That is the doctor’s job. There are some telltale signs, though, that the doctor is trying to take an unsafe short-cut to diagnose and treat you. Here are some:
(1) If you go to the emergency room and they want to discharge you after a short period of time.
(2) The doctor tells you the diagnosis before he or she even hears from you what brought you to the hospital or office.
(3) The doctor is overly rushed, rude, or abrupt.
(4) You are treated with a large amount of pain medications or sedatives, which can cloud the ability to tell what is wrong with you.
(5) The doctor gives a mental health or psych diagnosis, like an anxiety or panic attack, when you have no history of mental health issues.
(6) If you are at an academic or teaching hospital, and a new doctor (resident) makes a diagnosis that seems odd to you, and you have not even been seen by a fully-trained (attending) physician.
I do not mean for the list to be exhaustive or authoritative, but this gives you a pretty good idea.
If you find yourself or someone you care for in this situation, you need to speak up and essentially call a time-out. You need to be assured that the doctor went through the correct process before coming to a conclusion on the diagnosis.
If you have doubts about the proposed diagnosis, respectfully tell the doctor that it just does not make sense to you and ask him or her to walk you through the differential diagnosis process. Of course, the doctor may be right, but on the other hand, may have missed the mark.
Ask questions about what else could be causing your symptoms. Ask if there are any tests that could be done to make sure. If the doctor seems defensive or dismissive of your concerns, you can ask the doctor or nurse for a second opinion by an attending physician.
We are here to help
We know that a botched diagnosis can be life-changing. Painter Law Firm’s Houston medical negligence attorneys are available to discuss your potential case. Call 281-580-8800 to set up a free consultation.
Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.
On 4/1/2018, the new law will end the current practice where doctors can secretly enter a DNR order against patient and family wishes [...]read more
This article was originally published in the September/October 2017 edition of "The Houston Lawyer" magazine [...]read more
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This article was originally published in the September/October 2017 edition of "The Houston Lawyer" magazine
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