Episode 44:

Unconscious Bias in Healthcare and Seizure Management

In this episode, we are going to be talking about the continued unconscious bias by medical professionals and you’re going to learn about different types of seizures and seizure management.

SHOW NOTES

Unconscious Bias in Healthcare by Medical Professionals

Unconscious bias describes associations or attitudes that unknowingly alter one’s perceptions and therefore often go unrecognized by the individual, whereas conscious bias is an explicit form of bias that is based on one’s discriminatory beliefs and values and can be targeted in nature.

Healthcare professionals, if asked, might say they try to treat all patients equally and may not believe they hold negative attitudes about patients. However, by definition, they may lack awareness of their own potential unconscious biases, and their actions may unknowingly suggest that these biases are active.

In 2017, the Agency for Healthcare Research and Quality issued its 15th yearly report on health care quality and disparities, as called for by the medical institute in 2002. It found that while some disparities had gotten better, many remained. The most recent data available showed that 40 percent of the quality measures were still worse for blacks than whites. Other groups fared worse as well. Measures were worse for 20 percent of Asian-Americans, 30 percent of Native Americans, and one-third of Pacific Islanders and Hispanics¹.

Results of this review suggest that implicit bias against Black, Hispanic/Latino/Latina, and dark-skinned individuals is present among many health care providers of different specialties, levels of training, and levels of experience².

At the beginning of the human immunodeficiency virus (HIV) epidemic, the high prevalence of HIV among gay men led to initial beliefs that the disease could not be transmitted beyond the gay community.

Conscious bias has manifested itself in severe forms of abuse within the medical profession. One notable historical example is the Tuskegee syphilis study, in which black men were targeted to determine the effects of untreated, latent syphilis. The Tuskegee study demonstrated how conscious bias, in this case, manifested in the form of racism, led to the unethical treatment of black men that continues to have long-lasting effects on health equity and justice in today’s society³.

A number of experiments support her claim. One study showed that physicians whose Implicit-association test (IAT) tests revealed them to harbor pro-white implicit biases were more likely to prescribe pain medications to white patients than to black patients. Another study administered an IAT test to physicians and then asked them whether they would prescribe thrombolysis—an aggressive, yet effective treatment for coronary artery disease—to patients presenting symptoms for coronary artery disease. The experiment revealed that physicians with whom the IAT tests revealed harbor anti-black implicit biases were less likely to prescribe thrombolysis to black patients and more likely to prescribe the treatment to white patients.

Solution?
More standardized care, but it needs to be adhered to by everyone

 

Seizures and Seizure management

Epileptic seizure: A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements or feelings, and in levels of consciousness. If you have two or more seizures or a tendency to have recurrent seizures, you have epilepsy.

Non-epileptic seizures (NES) or dissociative seizures are different from epilepsy as they have a different cause. If you, or someone you know, have been diagnosed with non-epileptic seizures it may be helpful for you to identify the type of seizures that are relevant to you and how you feel about them. Non-epileptic seizures (NES) are not caused by disrupted electrical activity in the brain and so are different from epilepsy.

 

Types of seizure

  • Focal onset aware seizure
    • When the seizure begins on one side of the brain and the person has no loss of awareness of their surroundings during it, it is called a focal onset aware seizure.
    • When people have focal aware seizures, they are fully awake, alert, and able to recall events during the seizure. Some are “frozen” during the seizure, so they may or may not be able to respond to others during the seizures. Overall, these seizures are brief, usually lasting less than 2 minutes.
    • There can be different variations of these seizures.
      • Autonomic: abdominal discomfort or nausea which may rise into the throat (epigastric rising), stomach pain, the rumbling sounds of gas moving in the intestines (borborygmi), belching, flatulence, and vomiting.
      • Emotional: seizures that arise in or near the temporal lobes often take the form of an odd experience. One may see or hear things that are not there. One feels emotions, often fear, but sometimes sadness, anger, or joy.
      • Motor: convulsive movements. Jerking typically begins in one area of the body — the face, arm, leg, or trunk — and may spread to other parts of the body.
      • Sensory: Some focal seizures consist of sensory experience. The person may see lights, hear a buzzing sound, or feel tingling or numbness in a part of the body.
  • Focal onset impaired awareness seizure
    • When the seizure begins on one side of the brain and the person has a change in their level of awareness during some or all of it, it is called a focal onset impaired awareness seizure.
    • A common brain region where focal seizures can originate in the temporal lobe. During a focal dyscognitive seizure originating from this brain region, the person stops and may have a blank look or empty stare. S/he will appear unaware of the environment and may seem dazed. The individual may manifest any of the following “inappropriate” automatic behaviors:
      • chewing movements
      • uncoordinated activity
      • meaningless bits of behavior that appear random and clumsy including picking at their clothes or trying to remove them
      • walking about aimlessly
      • picking up things
      • Mumbling
  • Focal to  bilateral tonic-clonic seizure
    • These seizures are called focal to bilateral tonic-clonic because they start in a limited area on one side of the brain and spread to involve both sides. This is different from a generalized onset tonic-clonic seizure, which starts on both sides of the brain.
    • These seizures may look dramatic. They start suddenly and the movements can be strong or forceful.
  • Absence seizure
    • An absence seizure is a generalized onset seizure, which means it begins on both sides of the brain at the same time.
    • In an absence seizure, epileptic activity occurs throughout the entire brain. It is a milder type of activity that causes unconsciousness without convulsions. After the seizure, the person has no memory of it.
    • An absence seizure begins and ends abruptly and without warning. It consists of a period of unconsciousness with a blank stare. It may look like the person is daydreaming. The person may lose muscle control and make repetitive movements such as:
      • chewing movements
      • rapid breathing
      • rhythmic blinking
      • slight movements or tugging at clothing
    • They are more common in children
      • Tonic-clonic seizure
        This type of seizure (also called a convulsion) is what most people think of when they hear the word “seizure.”
      • During a generalized tonic-clonic (formerly grand mal) seizure, electric discharges instantaneously involve the entire brain. The person loses consciousness right from the beginning of the seizure.
      • The tonic phase comes first.
        • All the muscles stiffen.
        • Air being forced past the vocal cords causes a cry or groan.
        • The person loses consciousness and falls to the floor.
        • A person may bite their tongue or inside of their cheek. If this happens, saliva may look a bit bloody.
      • After the tonic phase comes the clonic phase.
        • The arms and usually the legs begin to jerk rapidly and rhythmically, bending and relaxing at the elbows, hips, and knees.
        • After a few minutes, the jerking slows and stops.
      • Increased pressure on the bladder and bowel may cause wetting (urinary incontinence) or soiling (fecal incontinence).
      • The child may bite the tongue, which may cause bleeding.
  • Atonic seizure
    • Muscle “tone” is the muscle’s normal tension. “Atonic” means “without tone.” So in an atonic seizure, muscles suddenly become limp.
    • Part or all of the body may become limp. The eyelids may droop, the head may nod or drop forward, and the person may drop things.
    • If standing, the person often falls to the ground.
    • These seizures typically last less than 15 seconds.
    • People may get injured when they fall. Head protection, such as a helmet or other protective gear, may be needed.
    • These seizures are also called “drop attacks” or “drop seizures.”
  • Clonic seizure
    • “Clonus” means fast stiffening and relaxing of a muscle that happens repeatedly. In other words, it is repeated jerking. The movements cannot be stopped by restraining or repositioning the arms or legs.
    • Clonic seizures are rare. Tonic-clonic seizures, involving stiffening followed by jerking of the muscles, are more common.
      rare and most commonly occur in babies.
  • Tonic seizure
    • Muscle “tone” is the muscle’s normal tension at rest. In a tonic seizure, the tone is greatly increased: the body, arms, or legs become suddenly stiff or tense.
    • A person may be aware of or have only a small change in awareness during a tonic seizure.
    • They usually happen during sleep and usually involve all or most of the brain, affecting both sides of the body.
    • They are short, usually less than 20 seconds.
    • A person may fall if standing when a tonic seizure starts.
  • Myoclonic seizure
    • Myoclonic (MY-o-KLON-ik) seizures are brief, shock-like jerks of a muscle or a group of muscles. “Myo” means muscle and “clonus” (KLOH-nus) means rapidly alternating contraction and relaxation—jerking or twitching—of a muscle. Usually, they don’t last more than a second or two. There can be just one, but sometimes many will occur within a short time.
    • Even people without epilepsy can experience myoclonus in hiccups or in a sudden jerk that may wake you up as you’re just falling asleep. These things are normal.
    • In epilepsy, myoclonic seizures usually cause abnormal movements on both sides of the body at the same time.
    • Consciousness and memory are not impaired.
  • Gelastic and dacrystic seizure
    • Gelastic and dacrystic seizures are focal (or partial) seizures that start in an area at the base of the brain called the hypothalamus.
    • Gelastic seizure is the term used to describe focal or partial seizures with bouts of uncontrolled laughing or giggling. They are often called laughing seizures. The person may look like they are smiling or smirking.
    • Dacrystic seizures are focal or partial seizures when a person makes a crying sound. They may also look like they are grimacing.
    • The emotions (laughing or crying) are often forced and the person can’t stop them from happening.
    • Most people don’t feel happy or a sense of well-being during a gelastic seizure. The opposite may happen – they may feel scared or a loss of control. Some people may feel anxious that they will laugh at a socially inappropriate time.
    • Usually a person is aware of what’s going on around them during these seizures.
  • Febrile seizures
    • Children aged 3 months to 5 or 6 years may have seizures when they have a high fever. These are called febrile seizures and occur in 2% to 5% of all children. There is a slight tendency for them to run in families. If a child’s parents, brothers or sisters, or other close relatives have had febrile seizures, the child is a bit more likely to have them.
    • Sometimes the seizure comes “out of the blue” before it is recognized that the child is ill. A fever may begin silently in a previously healthy child. A seizure can be the first sign that alerts the family that the child is ill.

Diagnosis

  • A brain wave test, also called an EEG (electroencephalogram), to look for changes in the brain’s electrical patterns that are related to seizures.
    • The EEG shows patterns of normal or abnormal brain electrical activity. Some abnormal patterns may occur with a number of different conditions, not just seizures. For example, certain types of waves may be seen after head trauma, stroke, brain tumor, or seizures.
  • Blood tests, to look for certain medical disorders.
  • a CT scan or an MRI scan to look for abnormal areas such as a tumor or infection.
  • Other tests also might be recommended, such as a lumbar puncture (also called a spinal tap), EKG (electrocardiogram, to check the heart), or a sleep test.

Treatment

  • Drug therapy is the most common treatment for epilepsy and is usually tried first.
    • Diazepam (Valium) , lorazepam (Ativan) and similar Benzodiazepines such as clonazepam (Klonopin)
    • Effective in short-term treatment of all seizures; used often in the emergency room to stop a seizure, particularly status epilepticus
      topiramate, gabapentin, levetiracetam, lamotrigine, and divalproex, clonazepam.
    • Anticonvulsant drug level testing can help a physician control a person’s seizures by monitoring the presence of medication in the bloodstream.
    • The bloodstream is the pathway that leads medication to the parts of the brain where seizures begin.
    • Side effects
      • alteration of behavior
      • drowsiness
      • lethargy
      • dizziness
      • unsteadiness or
      • skin rash
  • Surgery: different types of resections of the seizure causing the area.
  • Neuromodulation is another option. This therapy involves using a device to send small electric currents to the nervous system.
    stimulating nerve cells can release substances that change how the cells act or help them go back to their normal state.
    • Vagus nerve stimulation (VNS) is a type of neuromodulation. It is designed to change how brain cells work by giving electrical stimulation to certain areas involved in seizures.
      • The vagus nerve is part of the autonomic nervous system, which controls functions of the body that are not under voluntary control (such as heart rate and breathing). The vagus nerve sends information from the brain to other areas of the body. It also carries information from the body to the brain.
    • The RNS® System is similar to a heart pacemaker. It can monitor brain waves, then respond to activity that is different from usual or that looks like a seizure.
      • The system can give small pulses or bursts of stimulation to the brain when anything unusual is detected. This can stop seizure activity before the actual seizure begins. Or it could stop seizure activity from spreading from a small focal seizure to a generalized seizure.
      • The RNS® System is designed to work in 3 key ways:
        • Monitor brain waves at the seizure focus, all the time – even during sleep.
        • Detect unusual electrical activity that can lead to a seizure.
        • Respond quickly (within milliseconds) to seizure activity by giving small bursts or pulses of stimulation. This goal is to help brainwaves return to normal, even before it could turn into a seizure.

For some people, the first symptom of a seizure may be an aura. An aura is actually a focal seizure with retained awareness and is experienced as a particular sensory or experiential phenomenon (such as deja vu).

  • Common aura descriptions:
    • butterflies in the stomach
    • flashes of light
    • odd noises (e.g. buzzing in the ear)
    • strange smells (e.g. burnt toast, rotten eggs)
    • a powerful emotion
    • Dizziness

The period after the seizure is referred to as the post-ictal state. During this time, the person will need to rest. It may be difficult to wake him/her or get any response from him/her during this time. After a seizure, the person may feel fatigued, confusion, and disorientation, which may last from five minutes to several hours or even days.

During seizures outside the hospital, the person should be laid on their side to prevent aspiration. The tongue has to be monitored so it does not rollback. AED just in case, while the ambulance comes.

If you like this episode…

Then You’ll Love These Too!

Episode 48: Why Do Nurses Get Injured?

Episode 48: Why Do Nurses Get Injured?

In this episode, we will talk about sleep hygiene, why it’s important to your health. On the current health news, we will discuss hospice, how waiting too long to use hospice care can make suffering at end-of-life worse.

read more
Episode 47: Why Sleep Hygiene is Important

Episode 47: Why Sleep Hygiene is Important

In this episode, we will talk about sleep hygiene, why it’s important to your health. On the current health news, we will discuss hospice, how waiting too long to use hospice care can make suffering at end-of-life worse.

read more

© 2019 Cup Of Nurses. All Rights Reserved.

Don't Miss A Beat

© 2019 Cup Of Nurses. All Rights Reserved.

Pin It on Pinterest

Share This