It’s difficult for any of us to grasp what it must be like to have to flee your homeland due to violence or persecution. I struggle with the conflict of knowing that the most human parts of us are drawn to sheltering those in need, while also recognizing that unvetted mass migrations have real economic and political repercussions. Mavrovouni refugee camp encapsulates some of this poetically. Beautiful blue water meets the allure of land in the distance as naval patrol boats make themselves felt, donning European colours. While the medicine was oftentimes uncomplicated and our clinic was well supported by higher level structures, I am not naive in recognizing that Lesvos is the creme de la creme of asylum camps. Healthcare is accessible, NGOs provided legal advice, the camp is fenced but not a prison, and asylum seekers are free to walk the streets of nearby Mytiline and enjoy the spoils of Greek lifestyle. There are far worse shores to arrive on.

Still, migrants bear the scars of their violent journeys, on their skin or in their soul. On the second week of my attachment, a boat capsized with the coast guard nearby and seven people drowned, including the parents of a child that now walks alone in unfamiliar land. The only difference between his story and mine is that I got to be born somewhere else. The psychological impact of these sagas is life-altering.

In the field of medicine, especially the humanitarian space, we often inhabit a junction between the realms of physical and psychological health. Inexorably connected, when lived trauma runs deep enough, these two entities become one in the same. I bore witness to this several times during my attachment.

The first was a camp visit some three weeks into my attachment. The complaint was abdominal pain in a woman who was in such bad shape she couldn’t get out of bed to come to the clinic. This time my interpreter was Bagher, a soft spoken and articulate young guy from Afghanistan who worked with us as a Dari interpreter. He and I got on well. It was just after nightfall when we pulled up in the car to a block of tents near the end of the first section of the camp.

Walking into the tent I saw a woman, probably in her early or mid-thirties laying in bed. She looked uncomfortable. As I came closer we found that she was an Arabic speaker, not Dari. This meant that Bagher would have to phone back to the clinic for another interpreter to walk out and meet us, leaving me without translation to do my consult. Examining the patient, her belly exam had some tenderness above the area of her bladder, and otherwise she didn’t have anything discernible wrong with her. Her vitals signs reflected those of someone who was in pain, nothing more, and she didn’t look overly septic.

Getting one of our Arabic interpreters, Noor, on speakerphone, I was able to probe some more questions. The pain had started suddenly in the last hour, it was cramping, and didn’t seem to move anywhere. Additionally, she had no other symptoms: diarrhea, urine changes, recent vaginal bleeding, skin changes, shortness of breath, or cough. The patient’s concern was that this could somehow be related to an IUD she had placed three years prior. She told me her pain was so intense that she couldn’t sit up in bed.

With Noor’s help on the phone I gave her what I had in the emergency bag for pain. In truth though, with such a nonspecific exam and a known IUD in there, the only way to definitively say what was going on would be with some imaging of her abdomen. Sure, I had my handheld ultrasound with me, but visualizing an IUD perforated uterus was not something I knew how to do. My suspicion that she was having something serious like a ruptured bowel was low, but with this much pain it warranted an evaluation in hospital. This, after all, was not truly a resource limited setting; we had access to the state hospital exactly for this reason, and as much as I like to handle things on my own, the right move for her would be to get a diagnostic ultrasound or a scan.

‘So, this is what I think we should do,’ I began. Noor’s voice translated from my palm. Her husband was in the room with us as well and we were all in agreement.

Next, I called my medical coordinator, this night it was Christos, an exquisitely affable Greek with earrings and buzzed hair.

‘Tell me Juan my dearest,’ he said.

So I told him.

‘I trust in your judgment,’ he said. ‘If you think this is the right thing to do then we will do it. However I will tell you that getting an ambulance in the camp for things that are not acute chest pain or more clear cut emergencies sometimes takes time, so you will likely be waiting maybe up to thirty minutes.’

‘If that’s how it is, that’s how it is,’ I said. ‘When you call though, tell them I have an acute abdomen. They will know what this means.’

‘Excellent of course. We will send someone as soon as we can,’ he said.

Right, I thought. Back to my patient.

Keeping an eye on her vital signs, I sat with her. She wasn’t very engaging with me, failing to meet my eye and providing quite minimal interaction. It seemed like her pain was getting worse, but her behavior began striking me as rather odd. She then started getting restless, squirming about in the bed. After a minute or so she chilled out and closed her eyes as if to sleep. Her vital signs remained rock steady throughout. We waited for a few minutes, and something just didn’t seem right. I looked back down at my patient and gave her a shake.

Her eyes remained closed, breathing comfortably.

I gave her another shake, and then squeezed her trap muscle on her shoulder.

Still nothing.

Now I dug my knuckles into her sternum and shouted.

No response.

Opening her eyes and using my penlight, her eyes were rolled back, dancing.

In all likelihood this was now a seizure.

I opened up the medical kit behind me and started fishing for something to abort seizures. In the process I called Noor again and put him on speaker and relayed to the husband and now the patient’s mother who was in the tent what was happening.

‘I worry she might be having a seizure,’ I told them. ‘Has she ever been diagnosed with seizures before? Is she on seizure medicine?’

As I told them this, the husband walked across the room and planted himself on top of his wife, chest to chest. I found it strange but then the mom started speaking.

‘She has done this before,’ the mom told me through Noor, nodding towards her daughter. ‘A few times now since we left Syria. She was seen by doctors before and they told her it wasn’t seizures.’

Now, the patient was waking up, and starting to make noises. They were groans, she sounded agitated. I turned my head towards her for a second and I caught a punch that knocked off my glasses. She was thrashing now, violently and uncontrollably smacking and flailing. Her husband held her down and she tried to push him off. Her movements were what we call ‘purposeful,’ she grabbed, pushed, pulled, kicked, and flailed in all directions. It was horrible to watch and very intense, especially for her family, but this is not what seizures look like. She thrashed and thrashed for a few minutes like a woman possessed; I had no success convincing her husband to let her flail undisturbed as he tried to keep her from hurting herself. After a few loud minutes, she ran out of steam, and again appeared to drift off to sleep. I watched and waited with family as the cycle repeated twice more before she seemed to calm down a bit and kept her eyes open. Getting the chance to sift more deeply through the emergency bag, I found a rectal suppository of a medicine called midazolam, a benzodiazepine which can help abort seizures. Right as I found it, Noor arrived at the front of the tent and was introducing himself.

‘Noor,’ I said. ‘She’s started having some seizure-like activity, very dramatic and destructive. I have a medicine here that can abort seizures if that’s what is happening, but it is given rectally through the rear end. Can you help me tell this to the family?’

A look of hesitation came across his face.

‘I don’t know man,’ he said. ‘I can ask…’

As he started explaining the paramedics poked their head into the tent.

‘Right never mind, let’s get her moved,’ I said.

She was well behaved now, and while still failing to meet my gaze, was cooperative in sliding from the bed onto the stretcher. I gave handover to the paramedics and she was off in their hands with her husband, looking alright.

Bagher, Noor, and I took a moment to decompress before walking back to the car.

‘Well that was intense,’ one of them said.

‘I am sorry about the exchange we had in there,’ Noor said. ‘I can just tell you from knowing the culture there is no chance in hell that guy would have let you put a suppository in his wife. Even from the moment I came in and asked who he was, the way he answered me, I could tell. I should have still asked right away though.’

‘That’s a fair point Noor I appreciate that,’ I said. ‘The whole thing was a bit strange. It wasn’t that convincing for a true seizure but actually seemed more likely non-epileptic seizures. Midazolam can kind of help with either.’

The distinction between true seizures and non-epileptic seizure events is a really deep rabbit hole and grey area in medicine. True epileptic seizures are a byproduct of groups of neurons (brain cells) going on the fritz and firing signals uncontrollably. This can happen for any number of reasons: drugs, a hit to the head, disease in the brain like infection or inflammation that can alter the function of cells, the list is long. Depending on where these neurons are firing, they can sometimes involve only certain parts of the brain (focal seizures) or spread to include the entire network of brain cells (generalized seizures). The specific things people do when they have seizures is usually related to where in their brain they are having them, which is why different people have different looking seizures. Some patients can also have events that make them behave similar to how patients behave with true seizures, but when you measure their brain activity, their brain cells are firing normally.

This does not necessarily mean that non-epilectic events are people ‘faking’ seizures. It just means that these events in front of us are not the consequence of abnormal brain activity in the way that true epileptic seizures are. This is important because it means that people who are having non-epileptic seizures will not benefit from being on anti-seizure medicines, and I have seen many patients who are put on seizure meds that don’t work, with increasing doses and more pills with no improvement, only to be successfully diagnosed years later with non-epileptic seizures, meaning that all of the side effects from the medicines were pointless. The most common cause of non-epileptic seizures is typically unresolved psychological trauma, or some form of undiagnosed psychiatric disease. This population, asylum seekers and refugees, is at a very high risk for that.

Our lady’s behaviour before, during, and after my arrival seemed more in line with non-epileptic events, especially if she had done this before and was evaluated by a neurologist who chose not to start seizure medicines. Could her abdomen pain be real, and that could have triggered this? Maybe. Could her abdomen pain also be some part of a greater manifestation of psychological disturbance? Also possible. I couldn’t definitively say without putting her on brain electrodes and recording the activity during one of her events.

I thought about her case more with me after work and over the coming days. Should I have committed to my intuition and maybe called off the ambulance? I don’t think so, especially given how traumatic her episode was and her pain. Still though, I think I had to keep in mind psychological trauma as an underlying risk factor in this group more than I would otherwise. My very next shift two days later brought another chance.

It was early in the evening, still light out. I had been seeing patients for about an hour. Between cases I would sit outside writing notes between the medical container and the main registration tent. That’s where I was when I heard Jelmer, one of our support crew volunteers at the check-in desk, calling for help.

‘Medic! We need a medic!’  

I got up and darted into the tent through the curtains into the main waiting area. I saw a full waiting room, and to my left was Dr Anne, one of my Dutch colleagues, knelt down next to a young man laying flat on the bench, stiff as a board, clenching his teeth and aggressively hyperventilating.

‘I think he’s having a seizure maybe?’ Jelmer said. ‘He came in here with a friend, seemed fine and then suddenly started doing this.’

His support crew teammate Lars was now ushering people out of the tent to clear the room.

‘Anne, what do you need?’ I asked.

‘He has a good pulse, I am watching him,’ she said.

‘Let me get the vitals gear,’ I said.

After grabbing the kit I now knelt down close to her. Looking at our patient, he was young. Mid-twenties at most, with a beard and no moustache. His jaw was contorted, grinding his molars, exhaling with an intensity that whistled through his teeth. Trembling fists at his sides locked him rigid, and he was unresponsive to any touching or shouting. His eyes were also clammed shut, with no chance to get a penlight in there. I had a feeling I knew what this was.

‘We will keep everyone else outside the tent and do registration from there,’ Lars said behind me. ‘Are you going to call an ambulance?’

‘Let’s hold on that for a moment and see where this goes,’ Anne and I said together.

In tandem, Anne and I collected his vitals. His blood pressure and heart rate were both high, as expected. His intensity started to soften over the next few minutes, his muscles loosened and his drowsy eyes opened as he came to.

Also still in the waiting room were two other young men, who turned out to be his friends. One of them came to be seen for a runny nose, and the patient himself just came along for company. Through one of the interpreters they told us he had a history of events like this, and was seen by a battery of doctors in Iraq and Türkiye for the last few years. Nobody had ever put him on medication. They said these episodes happened every few months, and that most recently he had one that lasted over three hours and had to be sent to the hospital right here from Mavrovouni camp.

Anne stuck around for a bit, and actually had a patient waiting for her by appointment, so as our friend settled she left us and I stayed. Once the patient was out of his drowsy stupor, I was able to sit him up and ask some questions. Slowly, the mist in his eyes cleared and he became a normal person in front of me. He told me his name, which we’ll say was Mo (fake name, rest assured), and where he was from, Syria. I even learned that he liked futbol.

‘I am from Argentina,’ I said.

‘I love Messi!’ he answered.

Then I started a neuro exam. First I had him say the days of the week backwards. Then I had him follow my finger with his gaze. He started okay, and then his eyes dropped and his expression went blank.

‘It’s going to happen again,’ one of his friends said.

Eyes still open, Mo’s colour drained, and he turned white as a ghost. His mouth tried to word something and then his posture buckled and he slid backward onto the bench. Between myself and the friends we caught him and put again flat on his back and Mo gradually tensed up and started hyperventilating. Again, his fists tightened and he went rigid. It was how you might expect someone to look if they were having a vivid nightmare fighting monsters in the dark. In some ways, I suppose he was.

He did this once or twice more, coming back intermittently. After the third episode, while he was awake I gave him a tablet of a benzodiazepine to calm the nerves. That seemed to help him stay out of the events, although it did make him a bit woozy.

After a good ten minutes with no events, I walked him and his friend to my consultation room. I learned some more details of his story. These events usually came with a headache at the back right side of his head, which is also the site of where he was hit in the head when he was a boy. However, the events themselves started many many years later, after the war in Syria. He left Syria and was an asylum seeker in Iraq for some time, and his events were worked up extensively including electrodes on his head. He started seeing a talk therapist in Iraq with good success, at his best going a period of two years event free. Over the last year or so however, the events had come back, happening every few months. He never had any of the stereotypical seizure movements: tongue biting, urination, or whole body rhythmic shaking. Based on what I saw and heard, I didn’t think any more workup was warranted at this time.

What I did think he could benefit from, was some more talk therapy, so I asked Shiri, our staff psychologist, to come say hello and see if we could get him in for some therapy. They agreed on a date for a first session just in a few days.

As he walked out of the exam room he thanked me and reached out for my hand. As I did, he pulled me in. I thought he was going for a kiss on the cheek, but instead he whispered in my ear.

‘Vamos Argentina,’ he said.