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Jacob Keller Medical Care Team and Medications

Jacob Keller's medical care was shaped by years of neglect, misdiagnosis, and systemic failure before it became anything resembling a coordinated system. His epilepsy went undiagnosed throughout foster care, where absence seizures were mistaken for daydreaming and myoclonic jerks were attributed to clumsiness or anxiety. His autism was invisible to a system that saw defiance, not neurodivergence. His mental health conditions accumulated behavioral labels—ADHD, Reactive Attachment Disorder, Oppositional Defiant Disorder—that masked trauma and foreclosed appropriate treatment. The first adult to actually see what was happening in Jacob's body was Julia Weston, who started him on anti-seizure medication at seventeen. The first adult to coordinate his care across specialties was Logan Weston, who became both his neurologist and his most trusted medical advocate.

By adulthood, Jacob's care required coordination across neurology, psychiatry, therapy, pain management, and ENT—a pharmaceutical and clinical balancing act complicated by conditions that interacted with and exacerbated each other. The challenge was never simply treating one condition; it was treating all of them simultaneously without one treatment worsening another.

Care Team

Dr. Logan Weston — Neurologist / Primary Medical Advocate

Logan served multiple roles that no single professional relationship could cleanly categorize: neurologist providing formal medical oversight for Jacob's epilepsy, partner in proactive care planning who understood both the clinical and personal dimensions of Jacob's health, and lifelong friend whose relationship predated the medical partnership by over a decade. Logan witnessed one of Jacob's first major seizures in high school, an event that became the catalyst for Logan choosing neurology as his specialty. Throughout their friendship and professional relationship, Logan documented detailed clinical observations about Jacob's seizure patterns, recovery needs, and approach to his own care.

Logan's professional assessment of Jacob as a patient: Jacob presented as a fiercely independent and deeply private patient who possessed exceptional insight into his neurological condition but maintained an unhealthy relationship with his own limits. He consistently under-reported symptoms to medical providers, overrode his body's signals of fatigue and impending crisis, and attempted to maintain a professional front unless explicitly told that honesty was required rather than optional. He responded best to medical care that centered his autonomy, maintained discretion, and employed direct communication without euphemism or sugarcoating. He did not tolerate condescension and recoiled from expressions of pity disguised as concern.

Logan emphasized a crucial distinction: Jacob was not noncompliant because of defiance or lack of understanding. He was scared—terrified of what his body did without his permission, deeply afraid of how people perceived him when his disabilities became visible, and profoundly disturbed by any loss of control over his physical being. The quality of information Jacob provided to medical professionals depended entirely on trust. If he trusted a provider, they received accurate, detailed data. If he didn't trust them, they encountered only the defensive wall of "I'm fine" and gained no real understanding of his medical state.

Annie Whitaker — Trauma Therapist (from high school)

Annie became Jacob's therapist during high school, making their relationship his longest-standing therapeutic connection—one that spanned from his teen years through adulthood. She specialized in foster youth trauma and was fluent in ASL, which allowed her to maintain communication with Jacob during his nonverbal periods without requiring him to push through the distress of forced speech. Their relationship evolved over the years from formal therapy into something that defied clean clinical categorization—Annie bore witness to Jacob's growth with a consistency that the rest of his life had rarely provided. She accommodated his nonverbal periods, never requiring verbal processing when his system couldn't produce it, and understood that Jacob's silence was not resistance but regulation.

Psychiatrist (Name TBD)

Manages the psychiatric medication component of Jacob's care—specifically the pharmacological management of Bipolar I Disorder and the interaction between mood stabilizers and his anti-seizure regimen. The psychiatrist works in close coordination with Logan on the lamotrigine dosing, since lamotrigine serves dual purposes (seizure control and bipolar maintenance) and adjustments for one condition directly affect the other. Also monitors for medication-related mood destabilization and manages the complex interplay between Jacob's BPD, C-PTSD, and Bipolar I—conditions whose symptoms overlap and whose treatments can contradict each other.

ENT / Otolaryngologist (Name TBD)

Manages Jacob's chronic sinusitis, which originated from repeated mold exposure in foster care housing during childhood. The sinus inflammation worsens during high stress, poor sleep, and immune compromise, and frequently triggers his migraines—creating a compounding cycle. Treatment likely includes nasal corticosteroid sprays, saline irrigation, and periodic courses of antibiotics for acute flares.

Julia Weston — Initial Prescribing Physician

Julia started Jacob on his first anti-seizure medication at seventeen, after recognizing that his seizures had gone undiagnosed and untreated throughout foster care. She prescribed levetiracetam (Keppra) initially, observed the devastating behavioral side effects, and switched him to lamotrigine (Lamictal). Julia's role as prescribing physician preceded Logan's formal involvement in Jacob's neurological care and established the medication foundation that Logan later refined.

Support Network (Non-Clinical)

Charlie Rivera: Logan's domestic partner, functioned as Jacob's primary emergency contact and provided trauma-informed support during medical crises. His own lived experience with chronic illness gave him intuitive understanding of what Jacob needed during vulnerable moments.

Elliot Landry: Jacob's personal assistant and, functionally, his daily medical manager. Elliot tracked seizure frequency, managed medication schedules, coordinated with Logan on medical concerns, carried rescue medication, and performed the constant environmental scanning—light levels, crowd density, noise, Jake's physical state—that kept Jacob functional in professional settings. Elliot's seizure response protocol was trained and refined over years.

Band Members (CRATB): All band members completed informal seizure response training for tours and performances. Each knew the protocol: time the seizure, protect Jake's head, do not restrain, turn to recovery position after convulsions cease, have midazolam accessible, call Logan if duration exceeds five minutes.

Touring Staff: Received education about Jacob's medical needs and emergency protocols, ensuring his support network traveled with him. Staff knew seizure response basics, Jake's medication schedule, his sensory triggers, and the communication hierarchy (Elliot first, then Logan) for medical decisions.

Medication Regimen

Anti-Seizure Medications

Medication History and Evolution:

Jacob's epilepsy went undiagnosed and untreated throughout foster care. His first recognized tonic-clonic seizure at age thirteen left a faint scar under his left eyebrow but did not result in comprehensive epilepsy management.

At seventeen, Julia Weston started him on levetiracetam (Keppra). The medication's notorious behavioral side effects—irritability, aggression, mood destabilization known as "Keppra rage"—proved devastating for a teenager already navigating C-PTSD, emerging bipolar disorder, and the terror of becoming his father. Julia recognized the behavioral change as pharmacological and switched him.

Lamotrigine (Lamictal) became Jacob's primary anti-seizure medication and remained so throughout his adult life. Lamotrigine offered dual utility for both epilepsy and bipolar I maintenance therapy—controlling his absence seizures, reducing tonic-clonic frequency, and stabilizing his bipolar cycling. However, lamotrigine could paradoxically worsen myoclonic seizures at moderate-to-standard doses, creating a constant dosing tightrope. The two most effective drugs for myoclonic seizures—valproate (which causes tremor, career-ending for a pianist) and levetiracetam (Keppra rage)—were both contraindicated.

Low-dose clonazepam was added as adjunctive therapy for the myoclonic component, given the limited options remaining after valproate and levetiracetam were ruled out.

Intranasal midazolam served as rescue medication for prolonged seizures, typically administered at approximately five minutes of continuous seizure activity, though Logan made judgment calls based on the specific characteristics of each event. Elliot carried the midazolam and was trained in its administration.

VNS (Vagus Nerve Stimulator) implant was placed in Jacob's forties when medication optimization reached its limits. The device provided an additional layer of seizure management beyond what pharmaceuticals alone could achieve.

Mood Stabilization

Lamotrigine served double duty as both anti-seizure and mood stabilizer for Bipolar I. Additional psychiatric medications were managed by Jacob's psychiatrist in coordination with Logan, with the primary challenge being that adjustments for seizure control directly affected mood stability and vice versa. Treatment-resistant depression alternated with manic periods, and the pharmaceutical balancing act was complicated by the number of interacting conditions—changes to one medication rippled across the entire regimen.

Pain Management

Jacob experienced debilitating migraines inherited from Ben, reliably triggered by camera flashes and bright performance lighting. He developed strategies for managing performances—heat packs before concerts, anti-inflammatories, careful positioning—but the toll accumulated. In his late forties, chronic pain and joint inflammation developed in his hands and wrists from decades of piano performance, in his knees and hips from postural strain, and throughout his back and shoulders.

His high pain tolerance, developed through years of managing migraines and seizure-related injuries, meant he pushed through agony that would sideline others. Pain medication specifics are coordinated through his care team with particular attention to seizure threshold interactions—many common pain medications lower seizure threshold, limiting options.

Sinusitis Management

Chronic sinusitis management includes nasal corticosteroid sprays, saline irrigation, and periodic antibiotics for acute flares. The sinus pressure frequently triggers his migraines, creating a compounding cycle that requires coordination between ENT and neurology.

Medication Interactions and Challenges

Jacob's medication regimen represents one of the most complex pharmaceutical balancing acts in the series:

  • Lamotrigine dosing tightrope: Controls absence seizures and bipolar cycling, but higher doses worsen myoclonic seizures. Too low and the absences break through and bipolar destabilizes; too high and the myoclonic jerks increase.
  • Seizure threshold sensitivity: Many common medications (including some pain medications, some antibiotics, and some psychiatric medications) lower seizure threshold. Every new prescription must be evaluated for this interaction.
  • Psychiatric-neurological overlap: Bipolar medication adjustments affect seizure control. Seizure medication adjustments affect mood stability. The psychiatrist and Logan must coordinate closely.
  • Sleep-seizure cycle: Insomnia lowers seizure threshold. Seizures disrupt sleep. Sleep deprivation triggers more seizures. Breaking this cycle is one of the primary ongoing management challenges.
  • Stress-seizure-stress cycle: Emotional stress lowers seizure threshold. Seizures cause emotional distress. The stress of anticipating seizures further lowers the threshold. This cycle compounds during touring, performance seasons, and personal crises.

Seizure Protocols

During a Tonic-Clonic Seizure

Jacob collapsed with minimal to no warning. The tonic phase brought full-body rigidity with an ictal cry—a moaning or exhaled grunt as air was forced from his lungs when muscles contracted. The clonic phase followed with convulsions lasting thirty to ninety seconds on average.

Postictal Recovery Timeline

Recovery followed a predictable pattern that those who cared for him had learned to recognize:

0-1 minute: Complete stillness, irregular breathing, glassy eyes. Could not respond verbally or acknowledge others.

1-5 minutes: Fuzzy return to awareness. Disorientation, garbled attempts at speech, nausea that often resulted in vomiting (postictal emesis occurred in approximately 60% of episodes). Occasional incontinence. Tongue/lip trauma from clenching.

5-15 minutes: Mental reboot continued. Lingering confusion, mounting frustration at cognitive fog, headache setting in with increasing intensity.

15 minutes-1 hour: Cognitive fog made concentration nearly impossible. He spoke in muted tones with careful word selection. Memory gaps about the seizure and immediately preceding events. Overwhelming shame about what his body had done and who witnessed it.

1-24 hours: Intense fatigue requiring ten to fourteen hours of sleep. Muscle soreness throughout his body from violent contractions. Occasional low-grade fever as system recovered. Emotional rawness that left him vulnerable and defensive.

Focal Seizure Presentations

Jacob's seizure profile included multiple focal types:

Focal aware (simple partial): Auras with déjà vu, metallic taste, and motor disruption in the left hand—the hand would move involuntarily, often in patterned flexion resembling scale patterns. Auditory distortion could occur, with sound going sharp or flat or developing a metallic ring. Jacob remained fully conscious during these episodes and could often mask them in professional settings, though the effort cost him. He tracked the auditory distortion as his personal early warning system—when the room started sounding wrong, he knew something was building.

Focal impaired awareness (complex partial): Consciousness clouded without full loss. Automatisms included repetitive hand movements (often resembling piano patterns), lip movements with tongue clicking, shirt collar smoothing, and a tuneless hum on a single flat note. These automatisms superficially resembled his autistic stimming but lacked the regulatory purpose of stims—Elliot learned to distinguish between Jake's body doing something for him and Jake's body doing something to him. Postictal nausea was common after focal impaired clusters.

Ictal fear: Raw terror generated by seizure activity rather than external threat. Indistinguishable from trauma-related panic to outside observers, and difficult for Jacob himself to differentiate. During sleep, ictal fear presented similarly to nightmares but without narrative content—pure sourceless dread without images or memories attached.

Rescue Medication Protocol

Intranasal midazolam administered at approximately five minutes of continuous seizure activity. Logan made judgment calls based on specific seizure characteristics—type, intensity, pattern within a cluster. Elliot carried the midazolam and was trained in its administration for situations where Logan was not present.

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