Nursing Intuition, Part 2: The Seizure Girl

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    All nurses have intuition. Sometimes it acts more like faith or an energy that takes us to the right answer well beyond reason. (This two-part series is connected to a giveaway in celebration of Nurse's Week, May 8-12. The Kindle download is free for all. Paperback versions require participation. Links and details follow the article.)

    Nursing Intuition, Part 2: The Seizure Girl

    “This is Rescue 89. We’re inbound to your facility with an eighteen-year-old female, postictal following a witnessed grand mal seizure. We’ve established a saline lock and have her on oxygen at two liters on a nasal cannula. Respirations 16, oxygen saturation’s 99%. She’s in a sinus rhythm with a rate of 86. Blood pressure, 132 over 74. We’ll be at your back door in about three minutes.”

    I'm the RN assigned to the trauma rooms directly in front of the nurse’s station. Barring some other life threatening arrival in the next two minutes, the seizure girl will be mine. Unless she's actively seizing when she rolls through the door, I'll likely be on my own for the first ten to fifteen minutes of her time here. I'm neither anxious nor excited. I've taken care of hundreds of patients like her, but each one holds a hint of adventure, a unique encounter that can go in unforeseen directions.

    “Hey, Randy, I heard the report you called in,” I greet the lead medic as they roll through the door. “Any other critical details you need to add?”

    “No, it’s fairly straight forward. She’s got a long history of seizures. We’ve run on her several times in the past few months. I put a saline lock in her left antecubital just in case, but we didn’t need to medicate her. You can see she’s pretty well back to normal. Her mother should be here any minute, and she can fill you in on what she saw.”

    As we lift Nicole across to the ER Stryker, I see that she’s alert, almost too alert for someone just coming out of a seizure. She's cooperative, functional, apparently uninjured, shy, and very attractive. There's no sign of seizure activity now. “Hello, young lady. My name’s Robbi. I’m going to be your nurse here today. We need to get you undressed and into a hospital gown.”

    Nicole balks. “Do I really have to go through all this again? I’m okay now.”

    “Yes, you’ve got to go through 'all this’ again. If you wanted a burger you should’ve gone to McDonalds. 'All this’ is what we do here. You wear the gown; we don’t.” I’m trying to strike an effective balance between fun and authority.

    Nicole’s mom rushes into the room, oozing with anxiety and melting into a rambling, disjointed account of the seizure that had prompted her to call 911. “She was just getting up from the couch. Her eyes rolled back in her head, and she slumped down. She kind of bounced off the couch and went all the way to the floor before I could get to her. She was shaking all over like always––her arms, her legs, her head, foaming at the mouth––then she tensed up, arched her back, and turned blue before she started breathing again.”

    Mom is flushed and sweaty; she's breathing hard and way too fast. Between the two of them, she looks more like a patient. If she blows off much more carbon dioxide, she’ll become one. “Nicole's doing really well,” I assure her. "How long did the shaking last?”

    “Maybe two or three minutes, but it seems like forever when it's happening. This has been going on for four years. We’ve been to three different neurologists. She’s had all kinds of CT-scans, MRIs, blood tests, EEGs––everything. But nobody can figure out what’s wrong or how to treat her.”

    I document Nicole’s history, review and update her medication reconciliation, draw blood from the saline lock, and send samples to the lab. I also assess Nicole for any injuries which may have occurred when she fell to the floor and started shaking. She denies any pain. There's nothing visible, not even reddened areas or a bitten tongue. Nicole appears to have made it through this one essentially unscathed.

    Nicole’s mom repeatedly interjects random tidbits about extensive testing and failed treatments. When she leaves the room to get something from the cafeteria, I’m alone with Nicole for the first time since she rolled through the door. As I move to the head of the stretcher, Nicole’s gaze suddenly deviates to the right and her arms start to twitch. I stop and watch. I can get help and medication in seconds if I need them, but I've seen a lot of pseudo seizures in twenty-four years of ER nursing. The shaking looks too organized and purposeful. I can't help doubting that this is the real thing.

    The deviated gaze intensifies, and the legs join the arms in rhythmic convulsions. Nicole clenches her teeth. Her breathing is getting noisy. She drools and blows bubbles with her saliva. Calmly, without saying anything, I pick up Nicole’s left arm by her wrist, noting that the shaking in the arm clearly diminishes as soon as I raise it. I position the arm a few inches over Nicole’s face and let go, following the general assumption that a patient with purposeful movement will avoid hitting herself in the face. Nicole redirects the arm just enough to cause it to drop harmlessly to the pillow beside her left ear. I do it again and get the same result. The test isn’t conclusive, but it adds one more piece to a mounting pile of evidence.

    I cross my arms, placing them on top of the padded rails as I lean over to watch. The shaking continues for about two minutes before easing rapidly and stopping altogether. In a matter of seconds, Nicole turns her face toward me, her eyes rolling back in her head briefly, as if she's having a hard time focusing, before clearly making eye contact.

    Most nurses see ourselves as partners in the quest for healing, knowing doctors aren’t well-positioned to learn what we can learn. They're spread too thin. It’s safer to imagine that medical problems are just medical, but there's always a story behind the illness. Good nurses find it, and good doctors listen to us when we do. Call it what you want to––impetuous, unprofessional or even arrogant––but something in Nicole’s eyes prompts me to go with my instincts. In those two seconds of eye contact, an intuitive surge of energy pushes me toward a huge gamble. I know this encounter will take a disastrous turn if I'm wrong, but the flash of intuitive insight compels me to take this risk. Staring Nicole down, I speak clearly, demanding an answer: “What horrible thing happened to you four years ago that made you act like this to get attention?”

    Nicole doesn't look away. Tears pool in her eyes. Her chin quivers as she chokes on the words. “I was raped.” She takes a deep breath and lets it out slowly. "I was raped," she says again, a little louder this time, as if she needs to confirm that the words have finally escaped. Then there's a long silence punctuated by a deep sigh.

    “Did you ever tell anybody?”

    Nicole shakes her head. “No. I couldn’t.”

    “So this is how you’ve cried out for help?”

    Nicole nods. She stares at me without saying anything else.

    I feel the girl’s pain all too well. Leaning closer, I squeeze Nicole's hand gently. “This is quite a load you’ve been carrying. I can see that it’s been very hard for your mother too, even though she hasn’t known what’s been hurting you. Would it be okay for me to tell her when she comes back?”

    Nicole nods again, clutching my hand hard as if she's clinging to the deliverance she’s craved for a long, long time. She cries. “It wasn’t my fault. I wasn’t dressed slutty. I didn’t do anything wrong to deserve it.” She takes the Kleenex I hand her to wipe her eyes and nose.

    I feel like I'm listening to a little speech this poor girl has told herself thousands of times trying to process her pain. “No. No, you didn’t do anything wrong,” I assure her. “Sometimes we're victims when other people choose to be mean or hurtful. Even when you don’t do anything wrong, you can still get hit with the fallout from the bad things they do.”

    When Nicole’s mother returns with her snacks and learns what transpired in her absence, she cries. “I’m so sorry, baby. All this time and all these treatments. . . . Deep down inside I thought it was something like this, but I was too afraid to ask.”

    “Wow," I'm thinking, “too afraid to ask––” I was afraid to ask too, at least in the way I did it. It was tempting to ask in a general way, like I usually do: “Did anything really stressful happened that might have caused your seizures?” My guess is that Nicole had been asked, maybe several times in four years of crying out for help. Maybe she just wasn’t ready to answer. Or maybe the question wasn’t pointed enough until an intuitive moment broke through her defenses. Even from here, Nicole’s path to real healing is challenging, but at least she’s on the right one now.

    For Part 1, go to Nursing Intuition, Part 1: The Visitor is . . . Dying!


    EDITED BY ALLNURSES TO ADD

    This two-part series includes a giveaway as part of the allnurses 2017 National Nurses Week 7 Days of Giveaways. You are invited to share your own intuitive "save" story as a response here. The stories with the top 10 "Likes" shared by the readers will receive a paperback copy of "Anonymous Complaint: A Nurse's Story." Those who share a story in response to either article will be included in the contest.

    ALSO
    - The author has generously sponsored another GIVEAWAY. Monday, May - Friday, May 12, FREE Kindle version downloads of "Anonymous Complaint: A Nurse's Story" by Robbi Hartford will be available on Amazon.com.




    Click here for your Free Kindle download available May 8 - 12. Tell your friends.
    Last edit by RobbiRN on May 7
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    About RobbiRN, RN Pro

    I'm an ER RN, the author of the book for the giveaway and this story is an adaptation from chapter 1. Thank you in advance to those who share your story. Happy Nurse's Week.

    RobbiRN has '24' year(s) of experience and specializes in 'ER'. From 'Florida'; Joined Dec '16; Posts: 106; Likes: 517.

    Read My Articles

    12 Comments

  3. by   spotangel
    Wow! Love it!
  4. by   calivianya
    The first "seizure" I ever saw was just like this one. Sixteen year old girl, supposedly collapsed at school... sat up bolt upright in the bed when I straight cathed her. I learned an I&O cath will interrupt a fake seizure every time.

    She obviously had a horrible STD. Very green down there. This was while I was in nursing school and it was time for me to leave for the day, so I didn't get to finish following up with her, but I always wondered why she chose to fake a seizure to get treatment, and exactly what else was going on with her.
  5. by   3ringnursing
    That story was just awesome!

    This patient really had been waiting for the right person to ask the right questions at exactly the right moment.

    So glad you were where you were at that particular moment in time to ask those questions. You have ensured this young lady will get the real helps she needs now.

    This story sums up exactly what being a nurse is all about. And it gave me a desperately needed smile too!

    Sherlock Robbi - good job nurse!
    Last edit by 3ringnursing on May 6
  6. by   RobbiRN
    [QUOTE=calivianya;9441278]The first "seizure" I ever saw was just like this one. Sixteen year old girl, supposedly collapsed at school... sat up bolt upright in the bed when I straight cathed her. I learned an I&O cath will interrupt a fake seizure every time.

    She obviously had a horrible STD. Very green down there. This was while I was in nursing school and it was time for me to leave for the day, so I didn't get to finish following up with her, but I always wondered why she chose to fake a seizure to get treatment, and exactly what else was going on with her.[/QUOTE

    Nothing like a Foley to change behavior.

    A huge percentage of what we see is psycho-social in origin. Even when the manifestation becomes a legitimate medical problem, it often started with unhealthy thinking: anxiety, depression, disappointment, sadness . . . even loneliness. Of course we have to start by treating problems as medical until proven otherwise, but it's a tragedy when we throw more and more pills at people when the pills obviously aren't working.

    Some people may wonder why I posted this story as an example of an intuitive save? Because a lot of nursing intuitive saves are like this, finding the real problem, and saving the patient from an ineffective course of treatment.
  7. by   Vanessawf
    Would love to read your book!
  8. by   RobbiRN
    Quote from Vanessawf
    Would love to read your book!
    If you submit an "intuitive save" story as a response here, your odds of getting one of the free paperbacks are excellent at this point. The Kindle version, readable on any device, will be free for 5 days starting Monday morning.
  9. by   Wvrnmedic
    My "Intuitive Save" started similar to the above. I'm a flight nurse and was called to a "pediatric seizure on a school bus". Upon arrival, it's a 16 year old healthy looking girl. She's minimally responsive and wrapped in multiple blankets on a warm September day. The medic in the squad states that she is post ictal, seizure witnessed by bus driver lasted about 2 minutes, she's been shivering so we covered her up. She has no previous history of seizures.

    I start my head to toe assessment and she seems post ictal, but something is just off. I proceed to remove her blankets and continue assessing her. She seems like she's trying to look at me, but her eyes keep drifting up and off to the right. I continue my assessment and try to get her to follow simple directions. I note that her right side doesn't seem to be moving at all, although she is trying to squeeze my hand with her left.

    I calmly look at her dad who is at the foot of the cot and tell him that we are flying her to a different hospital - for his daughter's best interests. He agrees, knowing it's a 3 hour drive for him. I explain it's a better choice than the closer facility and they will be better equipped to help her.

    My intuition that this wasn't just a seizure saved this girl's life. She was actually having a stroke. Turned out that she was born with a congenitally short superior vena cava and as she grew, it became compressed against bone, causing a clot formation that traveled to her brain. By recognizing the symptoms and taking her to an appropriate stroke center, she was able to have a clot retrieval surgery and recovered with minimal side effects. She later had to have surgery to remove a couple ribs to keep the vessel from further clot formation.
  10. by   Fallon03
    My Intuitive Save came to me triaged as a Level 4 acuity facial laceration. Working my day shift in the ED one day I pull back a patient who had come to the ED for a facial laceration after a fall. The patient was an elderly gentlemen and as I approached the patient the first thing I noticed was a gaping laceration that went from the corner of his mouth to midway across his right cheek. As he proceeded to lay on the bed , I asked what had happened. He began to tell me his story. He said he had been mowing his land with his tractor and when he got to close to the hill he knew it was going to roll. So, he jumped off preemptively. Immediately , I thought of two things. The first mechanism of injury and the second his age. Both I thought could contribute to further trauma then what I was visibly able to see. As we continued to talk, I found myself leaning more and more over the bed to make eye contact with my patient. His wife informed me it had happened almost two hours earlier and she had to drag him to the hospital because she couldn't get is cut to stop bleeding. It quickly became apparent that the laceration was the least of my worries. I asked the patient why it seemed he wasn't looking at me as I spoke. Then asked what he had struck as he jumped from the leaning tractor. Looking at the ceiling , his answer gave me chills. Softly he replied, " At first it was painful to turn my head , now it just seems like I really can't that my muscles are to tight. " I told the patient not to move and gave his wife the call bell . Leaving the door open I ran to the nurses station directly across from the room . I told the attending provider he had to come immediately to room 20 . As he ran to the room I grabbed a C Collar . We placed the collar on the patient as gently as we could and informed him he must not move as much as possible. The patient was then rushed for a CT exam. Once he returned to his room, I informed him and his wife that if my suspicions were correct things would move very quickly. We went about calling his daughter so she could come be with his wife. As I suspected , the patient had sustained a traumatic injury. He came back positive for a fracture of his C1 . I learned that day what a Jefferson fracture was. Transport arrangements were made immediately and what seemed minutes he was on his way to the shock trauma center in D. C. Months later I was working and the greeter came back to the nurses station and said I had a visitor. When I went to the lobby I was greeted by his wife. She had the biggest smile and gave me the tightest hug. She explained how he had been placed in a halo and was recovering quite well. She thanked me for looking past the laceration and listening to my gut. Because of me she said , "my love is alive." This was in my 14 year career one of my proudest and most satisfying moments.
  11. by   RobbiRN
    Quote from Wvrnmedic
    I start my head to toe assessment and she seems post ictal, but something is just off. I proceed to remove her blankets and continue assessing her. She seems like she's trying to look at me, but her eyes keep drifting up and off to the right. I continue my assessment and try to get her to follow simple directions. I note that her right side doesn't seem to be moving at all, although she is trying to squeeze my hand with her left.

    I calmly look at her dad who is at the foot of the cot and tell him that we are flying her to a different hospital - for his daughter's best interests. He agrees, knowing it's a 3 hour drive for him. I explain it's a better choice than the closer facility and they will be better equipped to help her.

    My intuition that this wasn't just a seizure saved this girl's life. She was actually having a stroke. Turned out that she was born with a congenitally short superior vena cava and as she grew, it became compressed against bone, causing a clot formation that traveled to her brain. By recognizing the symptoms and taking her to an appropriate stroke center, she was able to have a clot retrieval surgery and recovered with minimal side effects. She later had to have surgery to remove a couple ribs to keep the vessel from further clot formation.
    Another life saved. Great mix of intuition, strong assessment skill, and the assertiveness to divert to a more appropriate facility. It would have been easy to overlook the stroke symptoms with a cursory exam resulting in delaying access to definitive care. Beautiful story. Thank you.
  12. by   lauracare4u
    Sounds like a great read.
  13. by   StefiDee
    Wow! Would love to read your book!
  14. by   smartassmommy
    Loved the book. Thank you for making it available on kindle

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