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.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
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.
You call 911....let the medical professional make that determination. You have been given a ton of information to better understand the student...however this is NO WAY qualifies you to make decisions about her medical conditions. Even if they are "faked" seizures" are you willing to be responsible if something goes wrong?
Sje sounds like a complex patient and I don't believe the seizures are fake. They are atypical but not faked.
Your best action is to call 911 and let them sort it out.
This really does sound like a situation that is way to complicated for a lay person to work out…is a real seizure? If so, how long do I wait? Did she injury her head when she struck it on the pavement? Heck, even as an RN who has witnessed seizures--real, fake, pseudo--I wouldn't feel comfortable trying to decide if it is bad enough to call EMS, especially given her otherwise complex medical hx. My opinion--if there is any doubt in your mind, call 911. If she is "better" by the time medics get there, then she can refuse. If she is not better, they can take her in. You don't want it to be your rear on the line if something really bad happens to this woman.
I *have* asked the student why she doesn't want EMS involved.
Basically, her story is that every time someone calls an ambulance, it means a doctor in the ED (she calls them student-sorcerers) will tell her that (a) they can't do anything about this right now, and (b) she should go see her neurologist ASAP.
And then, she has to wait two-three hours for someone to get around to discharging her. That's unless the "student-sorcerer" in question is particularly inexperienced, in which case he'll want to cover his behind by admitting her. She has also told me that every time an ambulance is called, it costs her more than a day's wages.
And so her rule of thumb is: do not call an ambulance unless it's obvious that I am severely hurt, my seizure has lasted longer than five minutes, or I've had multiples on the same day, while you were watching.
The question, for me, remains. You are all now saying that this situation is too complex for a non-medical person to adequately judge. Does that mean I go against her wishes every time? Does it mean I call an ambulance no matter what? Or is the rule of thumb that she has given me a solid one? And if it is, then how do I know what "severely hurt" means?
Once, after she'd had one of her seizures at our school, she was home for two weeks because she had aggravated her ruptured spinal disk and couldn't walk on crutches, nor push the wheelchair by herself. She told me that her back had gotten worse, but not how it had happened. Thinking back, though, I remembered how she'd held her breath while we put her back in her chair that last day at school, and how she couldn't pick up her backpack when she was ready to go home, because she couldn't bend that far (something she otherwise has not trouble with).
If I'd asked her, then, whether she needed to go to the hospital, I'm pretty sure she would have said no. But she's the type to tough it out in silence; not scream bloody murder for a hangnail, like some other people I've had in my class over the years. In the end, even when she's awake and alert, it seems difficult to know when to pull the alarm, in her case.
So I'm left asking you guys: do you think her "rule of thumb" for when to involve EMS is a good one? Should I follow it, in the name of respecting her wishes? Or should I just call 911 every time, like some people have already suggested?
Specializes in Critical Care, Med-Surg, Psych, Geri, LTC, Tele,.
Quoting Grodo: "The question, for me, remains. You are all now saying that this situation is too complex for a non-medical person to adequately judge. Does that mean I go against her wishes every time?"
Yes. As nurses, we are trained to protect our own liability by contacting EMS. That way, she can refuse treatment herself. If you don't call EMS, you can be held liable for a bad outcome. The only alternative is if an MD writes an order stating 'do not send to hospital unless "this that or the other' occurs." If an MD isn't willing to write that order, then you shouldn't get in between.
I was also wondering if she has any cognitive impairments/mental disabilities? I know many bright people with CP, however, this may not always be the case.
CYA, if you have a letter from her neurologist about when to call, and one from her releasing you from liability for not calling except in those 3 instances, then you could consider not calling. Otherwise... follow your gut and CYA.
I was also wondering if she has any cognitive impairments/mental disabilities? I know many bright people with CP, however, this may not always be the case.
Oh, no. She is without question one of the brightest people I've ever met.
She joked once that she probably knows more about medicine than many first-year residents do. I believe her. She basically never takes notes in class (apparently writing is slow, and painful in the long run), but she remembers everything. We are night school (teacher education), but she went to university too. I believe she even has two degrees. She currently works as a computer programmer.
I just wonder how she's ever going to be a teacher, if all these seizures are real ...
As a person who has real seizures that don't look at all like seizures, questioning the veracity of her seizures is incredibly offensive when, by what I just read in your OP, she seems very much like the real deal. It is the job of EMS to rule out faking. It doesn't mean they think she is.
I hope to god if I walk (yes, I said walk) into an ED or request medical help (yes, have a conversation) while I am having uncontrolled seizure activity, people actually believe me. Judgment doesn't rule out faking. An EEG does.
Grodo, in my experience, it is rare that someone admits they have pseudoseizures (a.k.a. Conversion disorder). Families often become quite defensive that their child's seizure is "real" and cannot possibly be a psychological problem.
You do not have to be incontinent with a seizure. You do not have to have an extended recovery time. In fact, you can be fully conscious and still have a seizure. Simple partial seizures may manifest as just a feeling of déjà vu. Myoclonic jerks can be a seizure although many of us experience normal sleep myoclonus--or jerking of our extremities as we drift off to sleep.
Some people have intractable epilepsy or difficult to treat seizures. They have failed many medications but continue to have seizures. This might be the reason your person doesn't want the squad called. She may know that there is not much they can do for her and doesn't want to incur an additional expense for a ride to the hospital to hear so.
I don't know what this young lady has but I do know that epilepsy is often misunderstood. It is still a stigma so many people don't want to share that they have it and will go to great lengths to hide it or minimize it.
I appreciate you wanting to find out more information. The Epilepsy Foundation of America is a great resource for information and training.
Thank you for adding this to the conversation. I have left temporal lobe epilepsy and when I say the "E" word, people assume I'm going to fall down in a tonic-clonic, biting my tongue off, choking on my tongue and start channeling the spirit of the devil or something. I'm able to function completely while having them, although if I have a lot of them simultaneously, speaking takes a great deal of effort (it's exhausting) and I lose random nouns and short term memory. But that's it. I feel blessed to have it that "easy" and my heart falls to pieces thinking how hard it must be for a young lady like the one described in the OP.
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 subconsciously.
To the last paragraph, yes. The presentation depends completely on where in the brain is getting what, basically. Her speech areas may be effected the least, gross motor movements the most. You just don't know unless you have a neurologist do and interpret an EEG (which WILL differentiate between pseudo and the real thing). In my experience and short lived nursing practice, you can never expect epilepsy to look the way you expect it to look. It's different for everyone.
I believe, going by my newly gained knowledge of different types of seizure activity, that your description of walking into an ER while having an active seizure, means your seizures are (sometimes?) simple partials.
My student has generalized seizure activity (tonic-clonic attacks): something I had seen before in my grandson. That previous experience predisposed me towards expecting the same thing in someone else. This student's seizures seem different, though, not so much during, but definitely after. As I've said before, that threw me off.
I can see now, though, that as you say, it is not my place to judge. Moreover, I've had responses here from people who have experience with clients who have both CP and epilepsy, making me see that the two conditions can influence each other and create something "weird", which even the EMT may never have seen before. I no longer think this person is faking her seizures. But to be honest, that doesn't put my mind at ease. It makes me more scared for her than I've ever been.
My apologies to you, Ixchel, if my initial post, and maybe some of the ones after, have offended you.
As nurses, we are trained to protect our own liability by contacting EMS. That way, she can refuse treatment herself. If you don't call EMS, you can be held liable for a bad outcome.
I don't for a minute believe that she would ever go to court trying to blame us for the consequences of one of her seizures. if she'd been the type to do that, I'm sure she would have found a reason and a victim already. That said, I don't know her parents or brother or sister. If it went really, really wrong, they might pull the trigger on legal action.
I will look into your suggestion of having an MD put down some bright-line rules for when we do and do not call EMS.
Esme12, ASN, BSN, RN
20,908 Posts
Sje sounds like a complex patient and I don't believe the seizures are fake. They are atypical but not faked.
Your best action is to call 911 and let them sort it out.