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Special Care

Mackenzie Fairbairn

Department of Dental Hygiene, Lane Community College

DH 222: Clinic

June 1, 2024
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In 2009, Eva received a diagnosis of focal partial epilepsy and complex partial seizures,

conditions that would profoundly impact her daily life. Prior to this diagnosis, she had endured

severe migraines, cognitive disturbances, and emotional changes for several years before doctors

at OHSU identified her condition. Over the past decade, her medical team has diligently worked

to manage her epilepsy through various medications and treatments. In 2022, following one of

her EEG sessions, they successfully pinpointed the origin of her seizures and ultimately decided

to surgically remove her left hippocampus. While this procedure has improved her seizure

control, it has also introduced side effects. Behavioral changes, including communication

impairments, verbal memory deficits, memory impairments, and executive function deficits, now

significantly impact her daily life.

Focal partial epilepsy, also known as focal onset seizures, originates from a localized area

of the brain, contrasting with generalized seizures that involve both hemispheres simultaneously.

The pathophysiology of focal epilepsy encompasses diverse etiologies, including structural

lesions, genetic predispositions, and functional abnormalities. Neuroimaging studies,

electroencephalography (EEG), and clinical evaluations are pivotal in delineating the

epileptogenic zone and guiding therapeutic interventions. Clinical features of focal seizures vary

widely depending on the affected brain region and may manifest as motor, sensory, autonomic,

or cognitive disturbances. Timely recognition and accurate localization of focal seizures are

imperative for tailoring treatment strategies and optimizing seizure control (Johns et al., 2021).

Complex partial seizures represent a subtype of focal seizures characterized by impaired

consciousness or altered awareness. Patients experiencing complex partial seizures may exhibit a

wide array of automatisms, cognitive deficits, or emotional changes. Intractable epilepsy, also

known as drug-resistant epilepsy, denotes a condition where seizures persist despite adequate
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trials of antiepileptic medications. The etiology of complex partial seizures with intractable

epilepsy encompasses multifactorial elements, including genetic predispositions, structural brain

abnormalities, and functional disturbances in neuronal networks. Comprehensive evaluation,

including neuroimaging, EEG monitoring, and neuropsychological assessments, is indispensable

for delineating the underlying pathology and guiding treatment decisions (Epilepsy Society,

2024).

Removing the left hippocampus can have significant implications for cognitive function

and behavior. The most prominent effect of removing the left hippocampus is memory

impairment, particularly in forming new memories. The left hippocampus is heavily involved in

declarative memory, encompassing facts and events. Patients may have difficulty forming new

memories after removing the left hippocampus, a condition known as anterograde amnesia. The

left hippocampus is particularly important for verbal memory, including the retention of words,

names, and verbal instructions. Patients may experience difficulties remembering verbal

information, impacting communication and daily activities. The left hippocampus is closely

connected with language-processing areas, such as the left temporal lobe. Removal of the left

hippocampus may lead to language deficits, including difficulties in understanding and

producing language and disruptions in semantic memory. The hippocampus is interconnected

with various regions of the brain involved in executive functions, such as planning, decision-

making, and problem-solving. Removal of the left hippocampus may result in deficits in these

higher-order cognitive processes (Kean, 2017). Patients who undergo left hippocampal removal

may experience alterations in emotional expression, mood disturbances, and difficulties in

regulating emotions.
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Eva is still undergoing treatment at OHSU for her epilepsy. The surgery has made a

substantial impact, and she has yet to have a seizure since. She is still regulated with many meds,

including Gabapentin, Lamotrigine, Levetiracetam, Lacosamide, Zolmitriptan, Clobazam, and

propranolol. All these medications are used for seizure prevention and migraine prevention.

Many of these drugs result in Eva experiencing extreme fatigue and dizziness. Due to this

complication, after each appointment, we make sure she is upright for a few before dismissing

her. Due to the dizziness side effect, I walk her to the bus stop to ensure she gets home without

complications. Eva also takes nystatin for dermatitis, sodium chloride for a deficiency,

magnesium for migraine prevention, multivitamin, and an antidiarrheal when needed.

After the removal of Eva's left hippocampus and the resulting behavioral changes,

adjustments are necessary for her treatment. Due to her memory impairments, Eva requires

frequent reminders about her appointments. It took me some time to realize this, but now I

remind her daily until the day of her appointment. Outside of clinic sessions, we've had many

discussions where I've noticed communication difficulties. Eva tends to interpret information

differently from others and prefers to be informed about everything. Because of these

communication challenges, I have taken on the role of primary communicator. Eva often has

numerous questions, and due to her difficulty understanding, I sometimes need to explain things

in multiple ways until she grasps them. Keeping the answers simple works best. When others

join the conversation, Eva tends to veer into tangents about her medical history, prolonging

discussions. I ensure the conversation stays on track and try to create a comforting atmosphere,

so she feels welcomed. In our next session, I plan to provide Eva with written post-operative

information that she can easily refer to, helping her remember important details. While it is

important to modify treatment as needed, it is important to remember people-first language

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(Bowen, pg. 929). At the end of the day, Eva is a person; she is not her diagnosis; she is just

someone who has to live with the difficulties of this diagnosis.

Due to her epilepsy, she's unable to hold a valid driver's license, necessitating either

scheduled rides or my personal pick-up for her transportation. As mentioned earlier, her

medications induce fatigue and often make her dizzy when seated for extended periods. To

ensure her safe departure after appointments, I assist her in sitting upright for a few minutes

before accompanying her to her transportation. Additionally, I keep a protein shake on hand in

case she feels the need for it. Another modification I've implemented in Eva's treatment is

maintaining a heightened sense of awareness. During our first anesthesia experience, she

attempted to swat my hand, prompting me to ensure she keeps her hands still or to hold them

myself. These occasional unusual behaviors may stem from her executive function deficits,

potentially posing unnecessary risks.

Eva's journey with epilepsy has been one of resilience and adaptation, marked by

significant medical interventions and ongoing adjustments to her treatment plan. From her initial

diagnosis in 2009 to the successful pinpointing of her seizure origin in 2022, Eva has faced

numerous challenges along the way. While the surgical removal of her left hippocampus has

improved her seizure control, it has also introduced new hurdles, such as memory impairments

and communication difficulties. Despite these challenges, Eva remains steadfast in her pursuit of

managing her condition, supported by her dedicated medical team and caregivers. As she

continues her treatment at OHSU, efforts are ongoing to optimize her care and ensure her well-

being, including tailored reminders, communication strategies, and transportation assistance.

Through perseverance and collaboration, Eva's journey serves as a testament to the importance of
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comprehensive care and personalized support in navigating the complexities of epilepsy

management.

Implementing modifications for Eva's treatment required careful observation, adaptation,

and patience. Initially, it was challenging to recognize the extent of Eva's memory impairments

and communication difficulties. However, through consistent interaction and observation, it

became evident that she needed frequent reminders and simplified communication strategies.

Providing written post-operative information was a proactive step that I believe will greatly

benefit Eva, as it caters to her memory deficits and facilitates easy reference. One of the most

significant lessons learned was the importance of adapting communication styles to

accommodate Eva's needs. Keeping explanations simple and straightforward helped ensure

effective communication and minimized misunderstandings. Additionally, maintaining a person-

first approach emphasized Eva's identity beyond her medical condition, fostering a supportive

and inclusive environment.

Moving forward, I plan to continue refining Eva's treatment approach based on her

evolving needs and feedback. Regular evaluations of her progress and challenges will guide

ongoing modifications to optimize her care. Implementing written materials and visual aids in

communication can further enhance Eva's understanding and retention of important information.

I aim to explore additional strategies to support Eva's emotional well-being and enhance her

quality of life. This may involve collaborating closely with Eva's medical team. Eva's journey

underscores the importance of personalized, multidisciplinary care in managing complex medical

conditions like epilepsy. By continually adapting and tailoring interventions to meet Eva's unique

needs, we can empower her to navigate the challenges of her diagnosis.

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References

Bowen, D. M., & Pieren, J. A. (2020). Darby and Walsh Dental Hygiene: Theory and

Practice.Elsevier
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Epilepsy Society. by. (2024, April 25). Seizure types. Epilepsy Society.

https://epilepsysociety.org.uk/about-epilepsy/epileptic-seizures/seizure-types?

gad_source=1&gclid=EAIaIQobChMI8syniai5hgMV1xGtBh3C0QLdEAAYAiAAEgKw

NvD_BwE

Kean, S. (2017, September 2). Emotional wellbeing Ted-Ed Series: What happens when you

remove the hippocampus?. Dynamic You. https://www.dynamicyou.org/emotional-

wellbeing-ted-ed-series-happens-remove-hippocampus/

Types of seizures. Johns Hopkins Medicine. (2021, August 8).

https://www.hopkinsmedicine.org/health/conditions-and-diseases/epilepsy/types-of-

seizures