I came with a question I've been asking myself for a few days ... maybe someone here can help.
I work at an adult education center (disclaimer: not a nurse!).There is a studentl there (age 28) who regularly has seizures. I've only seen it happen a few times in the 2+ years that this person has been with us, but she says that it actually happens quite often (1-2 times a month). She has always been quite adamant that we not call an ambulance when a seizure hits, so we never had until now. This past Wednesday, though, she had multiple seizures in relatively rapid succession, and that time we did call an ambulance.
By the time the ambulance came (about fifteen minutes after we called, since they had a bit of trouble finding us), the student was talking in full sentences and appeared extremely tired, but otherwise OK. It may have been another five minutes or so between her having the seizure, and us deciding that we were going to make that call.
Among other things, the ambulance crew asked her what medications she was on, and she said Tegretol. I happen to know this is an actual anti-seizure med. My grandson took it for a while.The ambulance crew asked me to describe what had happened, and I did, as best I could. In hindsight, one of the most striking things, to me, was how this student repeatedly struck her head against the pavement.
After a while, though, one of the paramedics began asking me questions I hadn't really expected. Like whether she had talked or sat up while seizing. It seemed to me he was implying that the seizure might be fake. I did a bit of internet research and found, on this forum among others, that some people apparently do, in fact, fake seizures for attention. The thing about this student is that she seems more bothered than pleased when people hover over her.
But then again, that paramedic got me thinking. There are a few things that seem weird about this situation. Like for instance: she is a crutch walker and an occasional wheelchair user. I have never witnessed her having a seizure while on crutches; always in the chair. And I don't often see her in the chair. Being in the chair means that she won't fall to the ground abruptly, even while having a seizure. Also, I witnessed my grandson having a tonic-clonic seizure twice, and both times, it took him at least an hour to come fully out of it. With this student, it's fifteen minutes at most. What seems especially weird to me is that she's always trembling all over her body after a seizure (not right after, but within minutes, as she tries to get back to work). Aren't her muscles supposed to be exhausted and therefore limp?
If she is indeed faking the seizures, I'd like to know. If attention is what she's after, it seems to me we souldn't be giving it to her anymore. Maybe then the fake (?) seizures might stop.
@dishes: That could be true. But her elevated muscle tone gets much, much worse after she's had a seizure. Under normal circumstances, she has almost no impairment in her upper limbs. Not that I notice, anyway. And she herself has said that most of the time, she's able to use her hands and arms normally. She can do things like write in longhand for an hour, if she needs to. But after she's had a seizure, suddenly she's no longer even able to pick up her own coffee mug. That just seems ... well, weird, to me.
Specializes in Complex pedi to LTC/SA & now a manager.
@dishes: That could be true. But her elevated muscle tone gets much, much worse after she's had a seizure. Under normal circumstances, she has almost no impairment in her upper limbs. Not that I notice, anyway. And she herself has said that most of the time, she's able to use her hands and arms normally. She can do things like write in longhand for an hour, if she needs to. But after she's had a seizure, suddenly she's no longer even able to pick up her own coffee mug. That just seems ... well, weird, to me.
Hypertonicity and increased spasticity is not unexpected post ictal in a person with cerebral palsy. Perhaps you need to learn more about CP and related conditions? What you describe is not uncommon in a CP client with epilepsy it can be an expected post ictal state not "wierd". A client with dyskinesia or spa tic cerebral palsy is most definitely NOT going to have the same post ictal or seizure presentation as an otherwise typical child with epilepsy. If you saw the odd reactions from medics if I have to cal. 911 for one of my medically complex pediatric patients and the standard protocol treatment they received you would be awestruck
Actually, the person I am talking about is an adult, and she seems to have no family. Of course everyone has family, but you know what I mean: estranged from her parents, no partner, no children, and even her brother and sister live far away and aren't consistently in the picture. That's one of the things that made me suspect attention-seeking behavior in the first place. It does not seem like she has a great support system in place. She needs to be getting the love from somewhere, right? We are as good a source as any.
After doing some more due diligence (I admit that my first search was mostly limited to fake seizures, but now I've been looking at real ones too), I know that the spectrum of seizure disorders is pretty wide, and it includes many types of "strange behavior" that I wouldn't have seen as any kind of seizure before I posted this topic here. This particular student told me her seizures are tonic-clonic epilepsy, though. And because my grandson has the same type of seizures, I expected the same, or at least a similar presentation. Her quick mental recovery, coupled with protracted physical impairment (trembling, stiff limbs) threw me off.
I suppose you were trying to say that what I'm seeing in this person could very well be legitimate epilepsy? If so, thank you for letting me know. It has changed my outlook, and I'm sure it will change the way I handle the next seizure I witness, even if only unconsciously.
Grodo,
I really do appreciate your willingness to learn about seizures and epilepsy. You are correct that even two people with the same type of epilepsy may not present exactly alike. A generalized tonic-clonic seizure can either start as a generalized seizure or a partial seizure that spreads or secondarily generalizes. Remember that our brains are not exactly the same and how and where the impulses spread can affect how the seizure looks and the after effects.
You mentioned something about this young lady having CP and other health issues which could impact how she appears (shaky) after a seizure. We have people who have Todd's paralysis after a seizure, which can appear as if they've had a stroke. How long it takes to resolve can vary from person to person. I've witness some ugly seizures with a quick recovery and mild seizures with prolonged recovery.
People with epilepsy are also at an increased risk for comorbidities such as learning disorders and mental health issues. So you see, given her life circumstances, she could have epilepsy, a mental health disorder and a need for attention because she is lonely. She could also be faking it but until proven otherwise, it sounds as if taking her seriously until proven otherwise is the best and safest option.
You have to remember that no 2 brains are exactly alike. That's good because that helps to make us who we are and not a carbon copy of our neighbor. At the same time, it makes solving many neurological issues challenging.
I appreciate the comments from people who have experience with clients who have both CP and epilepsy.
I am just a teacher, not a medical professional. But knowing these things puts what I've seen in perspective. I consulted the Wikipedia page on cerebral palsy, and after reading that, I remembered that my student once told me she has spastic diplegia. So if elevated muscle tone is a normal post-ictal thing for someone with spasticity, I suppose that's another "weird" element I can discard as potentially indicating a fake seizure disorder. The thing is, the EMT who picked her up Wednesday also said it was weird. But I suppose, as per JustBeachy's comment, that not all EMT's know how epilepsy affects spasticity, and vice versa.
Specializes in critical care, ER,ICU, CVSURG, CCU.
i had a darling patient that would fake seizures for attention........in the mist of a seizure at an outing she managed to not loose control, drop or crush a choclate cupcake.....i made statmen "her name"........you can not have a seizure in the sun, you must move under a shade tree, she stops seizure, and moves to shade spot, and then finished her seizure.....never loosing the cupcake :)
Specializes in Complex pedi to LTC/SA & now a manager.
You have no idea how little EMTs know about CP and developmental disabilities.
I had a toddler in status epilepticus who had a brain injury, essentially blind, respiratory issues. We called EMS because none of the extensive treatment protocol drugs had any effect. She oxygenates well at 0.5-1L
O2. Ems put on a non rebreather. She was a cutie and the one EMT was visibly distressed that she wouldn't ( couldn't) look at her or the stuffed plush she was shoving in her face. They went bonkers when we fixed the oxygen to a more appropriate level. EMS is trained by protocol. Some do not do well when faced with atypical variants such as being conscious and verbal post ictal but shivering and hypertonic spasms. At 28, she may not want 911 called if typically stable because she just want to deal with bring accused of faking because her seizures are not the same as others who are otherwise "normal". The more you post the more I suspect this may be the case.
CP is as a result of brain insult/damage and manifests before age 3. There is spastic (di or quad),dyskinetic , mixed. They may be hypertonic, hypotonic or mixed tone. (Such as hypotonic trunk, hypertonic limbs ). A person with CP may have learning challenges or be cognitively intact. They may be medically complex/fragile or otherwise healthy. Many individuals who have CP were born prematurely and may have suffered a stroke or brain bleed before, during or after birth. It's most definitely a spectrum condition. It's very common for those with cp to have a form of epilepsy also.
Asking questions and discussing your concerns is only going to help you care for her better.
Asking questions and discussing your concerns is only going to help you care for her better.
Well, if I should respect her wishes *not* to be confronted with EMS in most cases, then I would like to know when I *do* call EMS. If I ask the student, she'll give me some variation on "when I'm dead, running on half my normal blood supply, or blue in the face from not breathing."
To be fair, she did once tell me that medical intervention is warranted when a seizure lasts longer than five minutes -- a piece of wisdom I have found on various "how to deal with epilepsy" videos, too. But according to her, she's never had a seizure that lasted longer than five minutes, and I've never witnessed her having one that lasted that long, either.
So what, then? Should I be concerned when her post-ictal period lasts longer than normal, too? If so, how much longer? I also read that EMS should be called when a person has multiple consecutive tonic-clonic seizures without waking up in-between. I suppose that means being post-ictal, and then going straight into another seizure. No jokes about us being too fussy, in-between. OK, I can do that. But what about when she does wake up in-between, but still has multiple seizures within, say, the span of one hour? Is that cause for concern, too? Based on what I've read so far, it doesn't actually happen that often. Does that mean these seizures might be psychogenic, after all? And can the ED do anything about psychogenic seizures, or do I just give her what she seems to crave (i.e., attention)?
Follow the ed center's policy regarding when to call EMS. If there is no policy, request one.
We do have one. It states, literally: "Emergency Medical Services should be contacted in all situations that are deemed, by any member of the staff, to be a genuine emergency."
That still leaves me trying to assess what a genuine emergency is, in the case of a student with known epilepsy and various other medical issues.
Specializes in Complex pedi to LTC/SA & now a manager.
You are referring to status epilepticus. There is almost no post ictal stage between seizures. Many of my patients have drugs for seizure >5 min, if not resolved call 911.
Follow facility policy. You could always let her tell EMS she refuses care/transport.
We do have one. It states, literally: "Emergency Medical Services should be contacted in all situations that are deemed, by any member of the staff, to be a genuine emergency."
That still leaves me trying to assess what a genuine emergency is, in the case of a student with known epilepsy and various other medical issues.
No, because you are not qualified to make the assessment, as you've noted - you're a teacher, not a medical person. She seems to have complex issues as it is. It's not fair to put this burden on you! Err on the side of caution and call 911, period. You cannot go wrong that way. If the student wants to refuse, that's up to her.
A seizure is a medical emergency, that as a teacher one should not do a wait and see game. It can and does get out of control pretty quickly, you can lose an airway quickly, and the responsibility to the student is to seek medical attention.
If nothing else, the medication that she takes is not working if in fact she is having this many seizures. They are not controlled well.
This seems like a complex set of circumstances, and equally as complex medical conditions. Perhaps you should be having a nurse accompany all outings/overnights. Maybe to have a staff meeting where these seizures are addressed, and how to deal with them effectively.
And finally, have you asked the student why they do not want EMS called if they are actively seizing? That is the part that seems rather manipulative to me.
Grodo
18 Posts
@dishes: That could be true. But her elevated muscle tone gets much, much worse after she's had a seizure. Under normal circumstances, she has almost no impairment in her upper limbs. Not that I notice, anyway. And she herself has said that most of the time, she's able to use her hands and arms normally. She can do things like write in longhand for an hour, if she needs to. But after she's had a seizure, suddenly she's no longer even able to pick up her own coffee mug. That just seems ... well, weird, to me.