All Patient Stories have been de-identified to protect their identity & personal health information
I was recently talking to a patient who had experienced a lifetime of seizures. During the conversation, she disclosed to me she was struggling with depression. Through more discussion she expressed increasing thoughts of ending her life.
Not just did we help connect her with a support system, but we helped her by changing the seizure medication she was on because it had a known side effect of increases thoughts of suicide in about 13% of adults taking that medication. Taking the time to talk to her about her mental health struggles allowed us to change her medications, which also had the effect of practically saving her life. The typical seizure medication Keppra (Levetiracetam) has been found to causes this side effect and it with just a change in her medication to lamotrigine she began to surpass those thoughts of self harm.
See "SANAD II: Dear Levetiracetam, the Honeymoon Is Over" commentary by my physician mentor Dr. Bermeo-Ovalle, MD who wrote about this love/hate relationship physicians have with Keppra (Levetiracetam) the first go-to medication for individuals with focal seizures. This particular seizure medication has the possibility to exasperate feelings and emotions especially for those who have an already high risk or predisposition of another mental health condition.
I love what this physician said to the patient: just like the seizures are a physical representation of misfiring in with your brain so are emotions and unhealthy thoughts; they are just the misfiring in the brain, so we must treat the thoughts just like we treat the Seizures.
Through either changing the dose, adding an additional medication, or switching to a different medication completely, one can have a significant impact on an individuals' life.
Make sure you always have at least one person you trust, and tell them if you are ever experiencing any emotional challenges especially not wanting to live anymore. Also, connect back with your doctor because you never know if these thoughts are from a change in a medical condition or a medication side effect. Suicide hotline: 988
The "Altered Mental Status" Patient
We had an elderly Spanish speaking female patient who had gone back-and-forth between psychiatry, neurology and her internal medicine team and we no one could determine why she had such an altered mental status. Initially we called it "delirium from a UTI," but giving her anabiotic didn’t fix her mentation. We then considered it to be an impact from low glucose, so we fixed that too, but it just barely changed how she acted. Some called it schizophrenctive disorder because she said there was a fire on the ground a couple days and because she had a history of depression. Some days she would go catatonic, was frozen in place, and would just stare at you without talking or moving. Other days she was able to answer questions and would repetitively say the same word “Esto, esto” which means “this, this. ” eventually we realized she was talking about her catheter or IV tube being in her way.
One day we decided to remove her urinary catheter to see if she would be able to start peeing on her own. However after three hours her bladder had almost 700 mL seen through a bedside ultrasound. I told her that we would need to insert the catheter again unless she was able to urinate on her own. She looked at me in distress and said "Mira Mira" "look look" but no urine would come out of her. We tried an doing an MRI of her spine and brain but there was not a reason we could see of why she was unable to urinate on her own and was retaining urine.
Then one day she began to refuse to eat. She would pierce her lips and placed her face to the side every time the nurses or CNAs would try to feed her or give her medicine. Even the Speech therapist could not get her to talk with the interpreter over the iPad. However, when I spoke to her in Spanish, and held her hand, sometimes she would talk in two or three word sentences and be able to express her needs.
Finally when her husband could get off work he came to visit her, this was after almost a week of her being in the hospital. He told me she had been like this before after his own father died. In that situation she "acted like a baby" and wanted help with all her activities of daily living (ADLs). I asked what happened right before she started acting this way and he responded that his mother now had died, and he was trying to hide it from her, but of course she eventually found out and began again to act in this altered way.
Possibly she held in her urine, and barely talked to us because she didn't know or trust the caregivers nurses and doctors around her. To note, her neighbor in the same hospital room told me the patient spent all night talking her ear off about how she doesn’t want to talk or eat and just wants to die. Suicide hotline: 988
The body reacts to trauma in different ways. Some people might cry when they get sad news, others might become angry and express their frustration through physical violence . It is possible that for this patient she acted like a child and wanted to be comforted when she heard the news. However, she did not know how to properly express that emotion and her trauma response was to freeze and become altered. Her subconscious knew that she would receive the support if she didn’t walk, talk, or eat. She was not trying to do this on purpose. Holding in a bladder of over double amount of urine would be very painful and most likely would eventually leak out on its own. Her brain was just freaking out and her pain was expressed through an altered mental status.
A middle aged man with metastatic cancer in his brain, lungs, and liver came into the hospital with bacteremia (bacteria in his blood) from his chemotherapy chest port becoming infected. When I asked him if he smoked he said he had quit 15 years ago to live a better healthier life right before his two young girls were born. He expressed that even though he quit smoking that long ago he still got cancer and was close to the end.
I told him that there are many kinds of lung cancer and his was not directly caused by smoking. He couldn’t believe it and stated “never in all the years I have dealt with this has anyone told me that!! All this time I have been blaming myself.” I responded “there is no reason to blame yourself. Nothing you did or didn’t do made you deserve to have cancer. “
We both began to tear up when I continued, “you did not cause this and it is not your fault. Unfortunatly, the world just isn’t fair”
No one deserves to have a health condition, especially metastatic end stage cancer. There are always things that one can do better with their health, but it is not fair to blame yourself. Life happens, and no one chooses to become sick.
To be continued with more patients as my M3 year progresses...
1. Bermeo-Ovalle A. SANAD II: Dear Levetiracetam, the Honeymoon Is Over. Epilepsy Currents. 2022;22(1):18-21. doi:10.1177/15357597211052129