In medical school, I had a professor who talked about the “TWUD” factor, i.e., “Time Wasted in Useless Discussion.” As he defined it, TWUD is the mathematical quotient of the time spent discussing a particular diagnosis on rounds, divided by the number of times it is actually encountered. As an example of a high-TWUD factor condition, the entity “arrhythmogenic epilepsy” was cited, whereas “bronchopneumonia” has a low value.

I was reminded of the former condition recently when I had the opportunity to care for a teenager who presented to a local ER following an apparent Rolandic seizure. That’s a type of focal or generalized seizure that occurs in sleep and generally is outgrown during puberty. With cardiac monitoring in the ER, she felt hand tingling, became nauseated and had a 7-second episode of asystole due to complete AV block, with near-syncope. On admission, her echo and MRI were normal, but her EEG showed an epileptogenic focus. There followed an interesting discussion about whether she needed a pacemaker. Suffice it to say, I implanted a VVI device (“To a man with a hammer…” you know the rest) and while asleep on the table, she proceeded to have a bunch more episodes of AV block.

Most of us have had the experience of finding long QT patients in pediatric neurology practices, often when ECGs are obtained prior to starting a new anticonvulsant medication. Interestingly, in the neurology world, there is an entity called “sudden unexpected death in epilepsy (SUDEP),” the existence of which begs the question of how many arrhythmia diagnoses are missed. Similarly, how many of our “weak and dizzy” fainters actually have a neurological diagnosis such as basilar artery migraine (another high-TWUD factor entity)?

Clearly, child neurologists and pediatric electrophysiologists share an interest in paroxysmal disorders leading to loss of consciousness, and we care for each other’s patients, sometimes unknowingly. Perhaps we should be talking to each other!

George F. Van Hare, MD, is the Director of Pediatric Cardiology at Washington University / St. Louis Children's Hospital in St. Louis, MO.