Casebook: To look and not to see...the “too-normal” EEG

The mother placed the one-year old girl gently on the exam table. The child had seizures since early infancy. She was on medicine, but all it did was make her sleepy. So the family gave her the additional supplements and tonics: bush tea (containing Phenobarbital), honey (blessed by a preacher) and saffron water (sent by relatives from the old country). All to no avail. The parents appeared resigned to their fate. I was just another stop on the way to nowhere.

The girl was utterly charming. Tight curls framing a cherubic face. Clear complexion, a pretty lace dress and new shoes covering her tiny feet. Something was missing, though. She had a blank, expressionless gaze. No noises, no interest. She made no effort to move around, not even when I tickled her. Every few seconds, she would startle to an unseen stimulus, flailing her arms off the bed. No cry, no fuss. She turned her head away as the worried mother made futile efforts to feed her.

Another challenge, another opportunity. I looked through the chart. An EEG report indicated the child had normal brain waves. A couple of pages of the tracing were included with the report. I was impressed by how normal the EEG appeared: too normal to represent the brain waves of the child lying before me. I asked the family to repeat the test. The following week, the family returned with a tracing that appeared identical to the first study. Something was amiss. I decided to check the machine on which the EEG had been performed.

To my surprise, the default settings on the machine had been set to display only normal brain frequencies!! What I was looking for was not visible with the preset filters. When I reset the filters, the full picture emerged. The screen was filled with chaotic, abnormal patterns that indicated a serious form of childhood epilepsy. The first EEG showed the same patterns. The “too-normal” EEG was in fact, severely abnormal. What you see depends on how you look.

It was time to get to work-a year had gone by, a year with a “hidden” diagnosis, a year of inappropriate medications. We switched medications, stopped the sedating supplements, and I asked the family to come back in a few weeks. Before the follow-up visit, a health worker brought news: You will not believe your eyes, Doc.

The girl that returned was a new person. She was smiling, making lots of baby sounds, blowing bubbles. Big, bright eyes lit up when she engaged her parents’ attention. The muscle jerks were few and far between, and subtle enough that she could sit without support for a while. The child was making up lost time, fast. A month later, she was walking on her own.

Filters hide reality. But if one knows how to look, miracles unfold everyday. Welcome to Paradise.

To market, to market…, where the locals shop

There are two kinds of shopping in Paradise. The stuff that you take back with you, and the stuff that you use on island. You can find out about the former in travel brochures. I’m writing about the latter. If you want what the islanders produce, go where the locals shop.

Saturday mornings are the best time to check out The Market. Situated in Charlotte Amalie, Market Square’s newest addition is the renovated Sanderilla Thomas Bungalow. The old structure collapsed in 2003 after being struck by a tractor trailer-it took over a million dollars and 4 years to rebuild it using the original roof in a new steel-reinforced design.

Get an early start - the market opens at sunrise. Vendors line the streets with homemade jams and jellies, spices and sauces. Fresh seasonal produce is plentiful and priced to sell quickly (It takes a day to go from raw to overripe in the tropical heat) Tropical fruits and vegetables are usually smaller than the mainland counterparts, but the deep colors and concentrated flavors are a treat for the senses. Talk to the vendors if you see something unusual, and you will get a story and a recipe to go with your purchase.

Harvesting the best of land and sea, the French community (or Frenchies, as they are known locally) carries on the traditions of early European settlers. Seasoned divers even go free diving for lobster off the ocean floor. Fishermen sell fish off the dock. Seafood sells quickly, so the early shopper gets the best catch of the day. Beware of ciguetera toxin in the large reef fish. It is safer to buy pellagic fish (free-ocean swimmers, like tuna) or the catch from the north side of the islands.

During the week, roadside stands and carts sell local produce all over the islands. It is not unusual to see a car stopped in the middle of the road, while someone makes a quick purchase (or waits for a stray goat or chicken to cross the road).

What if you miss big-city shopping? There are no shopping malls in Paradise. If you need household supplies, you simply can’t do better than K-Mart!! It’s enough to make you go postal, and order from a catalog.

Civil Servicitis: He not in

I first heard the term civil servicitis at a regional conference. The common symptoms: a government position that guarantees a job, but not a service. That’s not entirely true, but one has to first recognize the condition before finding a solution.

There a person for each function, and a function for each person. Sharing functions is hazardous to job security, or so the thinking goes. This often leads to stalemates, especially if one wishes to expedite a process. I got a first-hand experience of civil servicitis shortly after leaving for Paradise.

After walking a set of papers several blocks between the personnel office and the police department, I arrived near lunch time. The security officer (there’s one at every building entrance) was only letting a few people sign in before closing for the day-at noon!! I made the initial cut. A security clearance and a walk through metal detectors brought me to the documents window. I paid the cashier for the required services, and went to the next window for fingerprinting. It was still ten minutes before noon, there was no one waiting, but this was the civil service. We close at noon. I’m leaving for lunch, come back tomorrow. There was little civility or service, so I had to back-track and make a fresh start. I chatted up another worker who knew someone in the department where I was to work, and things fell in place. I walked out with a set of fingerprints, only to find the personnel office had closed for the day. As I left the premises, I noticed the two crossing guards-one at each side of the two-lane road. Just another day in Paradise.

The government is the largest employer in Paradise, with a third of the workforce in civil service. There are 19 paid holidays, along with impromptu days-off for carnivals, election days and other civic events. As the number of retirees rises steadily, the pension plan is straining to meet the defined-benefit pension obligations. How about the employees? If you ask for service: he not in!! A private-sector worker informed me that the government’s function was to provide jobs, not services. As far as the he-not-in dilemma, his antidote: call in and ask to leave a long message. The person usually shows up at the other end or you get a contact number.

My suggestion: Show how to make things easier. I came up with a formula that works (sometimes) as a remedy for civil servicitis:

Lot of work in a lot of time: Hard Work
Lot of work in a little time: Smart Work
Little work in a lot of time: Hard Time