24 / 7 . But when I took his history , he said first they thought he had fainted , then they decided he had had a seizure . He had been on maneuvers in the summer in Georgia , after a week of intoxicated leave . He said he stood up , felt dizzy , thought “ Oh shit ” and fell over . He did not remember falling and did not protect his landing . He hurt his shoulder and his buddies said his legs jerked . His sergeant had a kid with seizures , and he called it a seizure . Earl was eventually drummed out of the service , even though he never had an abnormal EEG . He had not had cardiovascular testing .
We did stand up , sit down and lie down vital signs – all absurdly healthy and normal despite recent drinking . We got him in line for a CT scan – normal . He was great on the ward . He helped the old guys and made fun of everybody nonstop , all day and all night . He had an EEG : normal . He had a stress treadmill at the insistence of the resident and over the objections of the attending : he went over 10 minutes , all fine . The attending sneered . He walked in straight lines and practically did card tricks with fine motor testing . He agreed to a spinal tap – normal . He finally got an echo to rule out hypertrophic cardiomyopathy ( the resident was friends with the cardiology fellow ) – normal .
Meanwhile , Dr . Jack , our incredibly brilliant chain smoker of an attending , had told us from the beginning he had never had a seizure . He ’ d simply fainted and had myoclonic jerks . His diagnosis , said Dr . Jack , was “ Misconduct !! Showing up practically drunk in the heat in Georgia , that ’ s all that is !!”
It fell to me to try to set the record straight . Dr . Jack signed a letter on official VA letterhead that said in essence , “ They Wuz Wrong . Give this man his life back .”
He had continued his disability benefit ( 100 %) and was working some in a garage , she said . A real nice guy , she said . Had kids and all .
The VA people had taken the original diagnosis and carved it in stone . Not even the letter from our eminent and omniscient attending had changed their minds .
I think of how this man must have been yelled at by endless generations of interns . “ Why is your Dilantin level low ?” Surely someone down the line would have insisted on giving him medicine .
The wrong diagnosis can be very hard to change . The wrong diagnosis can wreak havoc over time , rendering people uninsurable , dogging them at every step . Removing that diagnosis can involve multiple specialists in multiple clinics or states ; reams of claims data as your employer changes your insurer willy-nilly ; warring opinions at every turn . The hapless , thoroughly disillusioned patient may never have the time or means to pursue this . He or she might get unnecessary tests and treatment , over and over again .
The wrong diagnosis is dangerous . Seeing polka dots is not . Be willing to tell the patient that “ We don ’ t know yet what you have . But you do not have what they said you have .”
Sometimes , you never know a final answer . But you have not supplied a wrong one , and that ’ s what counts .
Dr . Barry is an internist and Associate Professor of Medicine ( Gratis Faculty ) at the University of Louisville School of Medicine , currently retired and mulling her next moves .
I do not know if you have had to wrangle with the VA , but it ain ’ t a fair fight . At the time , as a sleepless intern , I was limited to textbooks . They offered few ways to distinguish seizing from fainting-with-muscle-jerking ( we now think that the fewer the muscle jerks plus a sudden complete loss of muscle tone both point toward fainting , not seizing ).
The good news , I told Earl , was that he did not have a seizure disorder . I explained why . But the problem , said Earl , was now he had this disability benefit from having had a seizure . No you do not , I told him . We have removed that diagnosis from your record with this letter and in our chart and – truly – this is good news . No seizure meds . You can drive !
I did his discharge summary , emphatically pointing out the total lack of pathology and the removal of any diagnosis of seizure . I sent him home on no meds and told him to drink less . I was very glad for him .
Two years later , a fellow third-year paged me from the VA . “ Why is this guy asking for seizure meds ?”
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