Blog #77: DRIVING PRIVILEGES, PAYING YOUR BILLS AND MORALITY: DRIVING AND THE EXPERIENCE OF A NEUROLOGIST

                 

WASHINGTON, Dec. 7, 2016 (UPI) -- The driver of a Baltimore school bus that hit a car and a transit bus last month, killing six people, including himself, had been involved in at least 12 other crashes in the last five years, the National Transportation Safety Board said Wednesday.

The investigative agency released a preliminary report on the Nov. 1 crash Wednesday, which detailed the incident and the medical history of the school bus driver. "The school bus driver had a history of hypertension, diabetes, and seizures. In the past 5 years, he had been involved in at least 12 crashes or incidents while operating a school bus or personal vehicle," the NTSB report said. "In addition, the week before the crash, paramedics were called ... because the school bus driver was experiencing what witnesses described as a seizure."

The report also says the school bus driver held a medical certificate denoting a medical condition but it had not been filed with the state motor vehicle administration.

I practiced clinical neurology in the state of California. California, Delaware, Nevada, New Jersey, Oregon and Pennsylvania are the only states that require physicians to report people who have been diagnosed with epilepsy to the local official health officer. Knowing that driving privileges are at risk often creates a barrier between the doctor and the patient. Doing the right thing, the moral thing, can be difficult for both parties. Patients often threatened me to not send in a report. “Are you going to pay my mortgage, Doc? If I have to quit my driving, I’ll be in the poor house. You better not send that in.” Many leave in anger.

Specifically, The California Health & Safety Code 103900(a) (2010) states: “Every physician and surgeon must immediately report to the local health officer individuals 14 years of age and older whom they have diagnosed as having a disorder characterized by lapses of consciousness.” Reports made because the physician acted reasonably and in good faith and believed will serve the public interest, the doctor shall not be civilly or criminally liable.

However, it is NOT the physician who decides if any particular patient should drive or not; it’s the official motor vehicle agency—with guidance by special medical panels. My experience has been that not all epilepsy patients have their driving restricted. If the patient and the doctor report that the seizures occur only during sleep (“nocturnal seizures”) the DMV often allows driving. But, periodic medical follow/up and reports to the DMV should show no seizures are occurring. The DMV decides how long a person must be seizure-free? Seizure-free 6 to 24 months is a routine observation period. 

Doing the right thing, the moral thing, can be difficult. I have followed patients whose licenses had been revoked for 6-24 months and then restored because they have been seizure-free. However, occasional follow-up visits have consisted of this scenario: “Are you taking your anticonvulsant medications as prescribed?” “Oh, yes, Doctor.” “Have you had any seizures?” Some have said, “Would you have to report to the DMV?” When I respond, “Yes,” patients have told me, “No, Doctor, I’ve been fine.” The doctor and patient are thus deprived of the opportunity to improve care by changing dosages or medications to give better seizure control. If the doctor fails to report to the health official, the physician is liable for damages by accident victims.

I have learned of news reports such as, “The driver lost control of his vehicle that jumped the curb and crashed into a group of people on the sidewalk.” As a neurologist dealing with epilepsy that affects one of every one hundred people, my response would be, “I hope it’s not one of my epilepsy patients.” What else would cause drivers to lose control? Alcohol? Drugs? An epileptic black out?     

In the other 44 states that don’t require doctors to report their epilepsy patients, it is hoped that patients will cease driving on their own and/or will report themselves to their DMVs. How many individuals report themselves? We can sympathize with their moral dilemmas. “Are you going to pay my mortgage if you stop me from driving, Doc? Will I kill myself or others?”

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Blog #76: Recognizing Epileptic Seizures Is Not Easy

            I gave a presentation: IS IT A LEARNING DISORDER, A HEARING PROBLEM, AUTISM OR EPILEPSY? to school psychologists in Newport Beach, California, last month in order to raise epilepsy awareness. These are all prominent reasons why children fall behind in school work. Correct diagnosis is the key to greater life-success. 

            Three million American children and adults are living with epilepsy. Millions more are touched by their epilepsy including: family members and friends, educators, counselors and health providers. They all need to be alert to the symptoms of “non-convulsive epilepsy.” 

More education is needed. The general population has little awareness of this condition. 

            Typical presentations of unrecognized epilepsy include individuals complaining that they just can’t keep up in their work and/or studies. A complaint of sudden, brief, confusion spells suggests possible non-convulsive seizures. These seizures can last seconds or longer. Medical and psychotherapy professionals don’t usually put an epilepsy possibility at the top of their diagnostic considerations. Complex partial seizures and petit mal, or “absence” non-convulsive epilepsies do not exhibit obvious convulsive limb shaking, tongue and lip biting and loss of bladder/bowel control. I often hear the lament: “No one knew what was wrong with my nephew for the longest time. They thought he had a learning disorder. They finally diagnosed epilepsy.”

            Clues for non-convulsive seizures causing mental difficulties and mental slowness are derived from observation of the individual. Sudden facial expression changes suggestive of staring, loss of contact with their environment and not responding to questions, or losing train-of-thought all put forward the possibility of non-convulsive epileptic seizures. Most reliable for diagnosis is to have family and friend-observers test the person during apparent mental blank outs or sudden, inappropriate, “spacey,” quizzical facial expressions. During this time observers should ask the person to perform some action in order to test intact consciousness. Ask the person to: “put your right thumb on your left ear,” or “stick out your tongue and lift your right leg,” etc. During such a spell they won’t do it. Brain scans, EEGs and other laboratory tests are often normal and can’t be relied upon to diagnose epilepsy.

            In my clinical experience, the observer’s report may be the only “data” the neurologist gets to consider this non-convulsive epilepsy diagnosis. A trial of antiseizure medications can be prescribed despite all the negative formal testing. The non-convulsive epilepsy diagnosis is supported if medications minimize or stop these “little” spells.

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Blog # 75: More Evidence: Epilepsy Surgery is Safe and Very Effective

            When a brain abnormality can be documented to be the site of origin of intractable epilepsy, surgical removal of this area is a highly effective treatment. The procedure can decrease the frequency of seizures, or even stop the seizures entirely. Continuing anticonvulsant medications after surgery is usual but not necessarily in every case. 

            In a recent study, 15 epilepsy centers in France followed 207 patients over five years.¹ The surgical group consisted of 119 patients; 88 were in the medical group treated only with anticonvulsant medications. Effectiveness was defined as 1 year without a seizure.

            Sixty-nine percent of patients in the surgical group but only 12.3 percent of the medically treated group were completely seizure-free during the second year of follow-up. After five years 76.8 percent of the post-surgery group and 21 percent of the medically treated group were seizure-free.     

            If seizures are disrupting your life, especially complex partial seizures, I encourage you to ask your physician if surgical treatment is appropriate. It can possibly be curative. Surgical treatment should be considered early in the course of your epilepsy after it is clear that your medications fail to produce satisfactory control.

  

1.       M-C Picot, A Jaussent, D Neveu, et.al. Cost-effectiveness analysis of epilepsy surgery in a controlled cohort of adult patients with intractable partial epilepsy: A 5-year follow-up study. Epilepsia Oct. 2016; 57: 1669-1679.

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Blog #74: New Studies Reveal High SUDEP Risk of Death in Poorly Controlled Epilepsy

 

     SUDEP (Sudden Unexplained Death in Epilepsy) is not rare. These individuals with epilepsy are found dead without evidence of having had an associated convulsion, i.e., there is no sign of incontinence or tongue biting or thrashing.

    New studies reveal sudden death is more common, dangerously more common, than previously thought. One-third of people with epilepsy continue to have some seizures despite adequate treatment with antiseizure medications. These individuals’ epilepsy is referred to as “poorly controlled” or “uncontrolled” epilepsy. Their risk each year of SUDEP is 1/150. The risk is particularly high in those whose uncontrolled seizures are the tonic-clonic type. Among epilepsy patients whose seizures are well-controlled, i.e., no seizures while on treatment have a risk of SUDEP incidence of 1/1000. ¹             

      What should you do to lessen your risk of SUDEP? Take your medications as prescribed to hopefully decrease the likelihood of having a seizure as it’s more common among those with poorly controlled tonic-clinicepilepsy. Discuss SUDEP with your doctor. You may have to bring up the subject as many physicians are hesitant to discuss possible “bad” news.

      For more information about SUDEP I invite you to read my blogs at LanceFogan.com, titled:  #13: Sudden Unexpected Death During Seizures; #30: Should Doctors Discuss SUDEP with Epilepsy Patients? #57: Sleeping on Your Stomach Increases Risk of SUDEP; and #68: Epilepsy, Risks to a Long Life and Mortality.

1) LJ Hirsch, EJ Donner, EL So, et. al. Abbreviated report of the NIH/NINDS workshop on sudden unexpected death in epilepsy. Neurology 2011: 76 1932-1938

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Blog #73: Epilepsy and Autism Association and Risk

            Individuals with epilepsy are at increased risk of symptoms of the Autism Spectrum Disorder (ASD), especially if the epilepsy appears in childhood. Among individuals with epilepsy in a recent study, 1.6% of them compared with 0.2% of controls were diagnosed with ASD. Individuals with epilepsy were therefore at increased risk of future ASD. Further, ASD is more common in the siblings and offspring of individuals who have epilepsy, suggesting a shared cause. The risk in the offspring was particularly high in mothers with epilepsy. Epilepsy was also associated with a prior diagnosis of ASD. ¹

            Autism is a neurodevelopmental disorder. The Autism spectrum is wide-ranging. It varies from severe to very high functioning behavior. The spectrum comprises Asperger’s syndrome—which is on the higher-functioning end of the autism spectrum―to childhood disintegrative disorder and the pervasive developmental disorder. Autism Spectrum Disorder affects the child’s development and learning. It is generally suspected by behavioral variances as compared with their peers around age three.

            Symptoms of ASD include difficulty with social interaction, impaired verbal and nonverbal communication and repetitive behaviors, such as rocking, pacing and repeating actions and words. The spectrum is characterized by hypersensitivity to external stimulations, such as noise and being touched. A common clue of this in young children can be folding down their ears in an attempt to block-out noises.

            Some form of autism affects one out of every 68 kids and it affects more boys than girls. The number of children diagnosed with autism spectrum disorder is rising, but it is not clear whether the increased frequency is due to better detection and reporting of the disorder or due to a real increase in the number of cases, or both.

1. Sundelin HEK, Larsson H, Lichtenstein P, et al. Autism and Epilepsy. Neurology 2016; 87:192-197. 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Blog #72: A New Study: If, and How, Dogs Predict Seizures

I welcome this fascinating new study. Epilepsy Ireland, previously known as Brainwave – The Irish Epilepsy Association prior to 7 February 2013 – is a charity in Ireland. It provides support, information and advice to people with epilepsy.  Epilepsy Ireland was founded in 1966, and is based in Dublin, with nine regional offices throughout Ireland.

My Blog # 9 on LanceFogan.com, September 12, 2011, “Can Dogs Alert Patients Prior to a Seizure?” discusses dogs—some trained and others seemingly with an inborn uncanny ability to predict seizures, often hours before the seizure. For example, the dog will walk in front of a patient on a sidewalk to stop the human from stepping off the curb of a street into danger perceiving a seizure will soon occur. This happens even before the person has an aura or the seizure. Dogs will lie on the patient’s chest to warn the person to stay in bed―a seizure will soon happen.

On July 14, 2016, Epilepsy Ireland alerted its followers that Queens University Belfast will research this topic. Volunteers with epilepsy are sought to enter the study whether they own a dog or not. The researchers also want to enter people into the study with epilepsy who live with a dog. Information is queried about the dog and how the dog reacts if the person has a seizure.

The study is part of a PhD project undertaken by Neil Powell, PhD-student and supervised by Professor Peter Hepper of the Queens University School of Psychology. They can be contacted at: n.powell01@qub.ac.uk and p.hepper@qub.ac.uk.

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.