Epilepsy: A story untold (I)

Things always happen for a reason. Or so we are told.

However, no matter how hard I tried, I just could not think of a befitting reason for my encounter with the young man I met earlier in the day. He had come into the consulting room, accompanied by his father. The patient was a young handsome boy in his early twenties who was currently (at the time) training to be a pilot in one of the flying schools in Nigeria. He was in his second year and was doing well according to his father. It was easy to detect the note of pride in his father’s voice as he narrated to me how becoming a pilot was his son’s lifelong ambition. The father was also a retired pilot and Adam* was his third child. Their common passion for flying and all things related to aeronautics had solidified their father-son bond and it was hardly news, when he admitted that Adam was his favourite child.

The reason for the hospital visit was simple: The school had called his father and requested for a thorough medical check-up for Adam. Why? I asked. There had to be a reason he was singled out of his peers for this exercise. His father, who was previously talkative suddenly became quiet. He stared at his hands, his shoes, the drab, peeling paint of the clinic walls, anywhere, but at my face. Finally, Adam spoke up.

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‘They say that I fainted.’ He said in low tones.

Realization hit like a ton of bricks. I tried to probe him for more details but he seemed blissfully ignorant. All he remembered was that he was in class with his mates receiving lectures when suddenly everything went black. Later, he woke up in a hospital bed feeling exhausted. His body hurt all over and he realized he had urinated on himself. That was a week ago and since then there had been no repeat episode.

The story still did not add up and so I turned to the father and looked at him squarely. ‘Do you want to add anything?’. He sighed heavily and began to speak; the school authorities told him that his son had a seizure. He was in class when he suddenly fell from his chair and his whole body started shaking uncontrollably. The other students reported that he lost consciousness as he did not respond to his name and had to be rushed to the hospital when he did not stop seizing for more than two minutes. Adam had some bruises on his limbs from the impact of the fall and seizures. His father was adamant that this was Adam’s first episode. There was no past history of febrile seizures in childhood. Other questions asked to determine other causes of seizures; a possible head injury, features of a brain tumour etc were all denied. I quietly documented my findings and requested for the appropriate tests.

The elephant in the room was of course the issue of his schooling. Both his father and I knew that the boy’s career was at stake but we were reluctant to discuss it. I wanted to see the results first and also do some background reading on aviation laws. Epilepsy is a clinical condition that is often hard to diagnose properly at first. Before labelling a patient with epilepsy, certain criteria have to be fulfilled.

Adam returned three days later; this time with both his parents. His parents were divorced and his mother had since remarried. Her son had reached out to her and she wanted to be part of his management. He had suffered another seizure the night before and had to be rushed to the emergency ward. She admitted that he had had two episodes of seizures as a child due to high temperature. His father, being a pilot at the time, was absent and did not know. They had been discharged from the hospital by the time he (Adam’s father) returned. No structural abnormality was detected on MRI and all the other blood tests were negative. However, the EEG showed some abnormal brain activity. For confirmation, I sent the EEG result to the neurologist and asked that they return the following day.

After several discussions with the Neurologist, the diagnosis was as I feared. Epilepsy is defined by the WHO, as having two or more unprovoked seizures. It is one of the world’s oldest recognized conditions, with written records dating back to 4000 BC yet it remains one of the most stigmatized conditions of all time. Epilepsy is a chronic, non-communicable disease that is difficult to cure and can sometimes span the entire lifetime of an individual thereby negatively impacting a person’s quality of life.

One seizure does not signify epilepsy as up to 10% of people worldwide have one seizure during their lifetime, hence my original apprehension. However, Adam’s history showed that he had two seizures so far in a span of two weeks, abnormal brain activity and a past history of childhood febrile seizures. There was no manipulating the evidence; the results would be documented and sent to his school via email as requested. The boy broke down in tears.

Epilepsy is unequivocally disqualifying for all flying duties. A single unprovoked convulsion may be sufficient to constitute a diagnosis of a seizure disorder for military purposes. The Federal Aviation Administration, in its guide for medical examiners, requires that all disturbances of consciousness without satisfactory medical explanation of the cause as well as seizures be reported and will be subject to FAA approval. In the US, decisions are sometimes individualized based on the circumstances, condition and seizure control in a patient. For example, if a patient has been treated for years and is seizure free for the past five years, his license may be renewed but with limitation to the type of aircraft. Additionally, if a pilot is seizure free for 10 years and does not require anticonvulsant medication for the last three years, then he or she can re-apply for medical re-certification.

In other countries, Nigeria included, epilepsy is often given a blanket judgement. It is a disqualifying medical condition and therefore not subject to negotiation. In simpler terms, Adam would simply have to find another career.

As you can imagine, it was a difficult conversation to have with him and his parents. What made it more herculean was the fact that there is no known cause of epilepsy. Sometimes, without any structural abnormality, the electrical activity of the brain can just misfire and a person starts to seize. Science is still trying to come up with a better reason than ‘village people’. I tried my best to counsel them, to offer a possible reason, but even I knew that my words were lacking. In the end, I switched to religion because as doctor, we sometimes wear different caps. Physician on Monday, Preacher on Tuesday, Arbitrator on Friday. Na so e be.

As expected, the school suspended his education on medical grounds and encouraged him to go for treatment. He is currently on medication and has been seizure free for eight weeks now. Sadly, he is yet to come to terms with his illness and still believes he will get better and return to flying school.

Some reasons, only the Almighty knows.