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.
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.
Specializes in Complex pedi to LTC/SA & now a manager.
Get guidelines in writing whether from facility nurse or treating physician such as timing, description of seizure activity, time, when to call nurse/EMS.
Don't assume she won't sue. (Or her estranged family) if injury occurs
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?
Call 911 every time. You may think she nor her family will ever sue...it only takes one smooth talking lawyer to convince her or the family that they can take you or the facility for millions of dollars.
CYA...and being a bright person she we will realize that she either (a) accepts multiple ambulance rides to the ED or (b) goes to her neurologist to try to get a better handle on things.
As a side note, she really does need to have more respect for the professionals in the ED. "Student sorcerers?" The attending, with a consultation to her neurologist, makes the decision on whether she stays in the hospital, not some witch doctor. She knows more about medicine than most first year residents? Umm, no, just stop right there.
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?
You are overthinking this. The answer is simple. If she has a seizure, call 911. Her wishes are pretty much null and void when she has an altered level of consciousness. Are you willing to risk her life or your employment and bank account over this? No? So call an ambulance. It is the right answer barring further guidance from a person qualified to give medical direction.
As a side note, she really does need to have more respect for the professionals in the ED. "Student sorcerers?" The attending, with a consultation to her neurologist, makes the decision on whether she stays in the hospital, not some witch doctor. She knows more about medicine than most first year residents? Umm, no, just stop right there.
To be fair, I don't think she really believes this. I think it's become a running joke between her and some of her friends/confidants. It's pretty clear that she hates hospitals, and she's willing to avoid them at all costs. But when the ambulance actually showed up Wednesday, she was cordial with the people manning it, even when they at first refused to take her wheelchair with them.
I do believe, however, that she knows more about herself and her own medical conditions than most first-year residents do. In line with your colleague's comment on paramedics who don't really know how to treat complex pediatric patients, it wouldn't surprise me if beginning doctors aren't nearly as well-informed about the exact effects and consequences of certain conditions as the people who are actually living with them.
it wouldn't surprise me if beginning doctors aren't nearly as well-informed about the exact effects and consequences of certain conditions as the people who are actually living with them.
That goes beyond just beginning doctors. Even experienced medical professionals cannot totally understand how a chronic disease affects a given individual's life. We can make generalizations, we can know some of the typical responses to a disease…the exacts effects are different for each person and touch each person's life differently.
That goes beyond just beginning doctors. Even experienced medical professionals cannot totally understand how a chronic disease affects a given individual's life. We can make generalizations, we can know some of the typical responses to a disease…the exacts effects are different for each person and touch each person's life differently.
No doubt. But I mean things like how spasticity affects movement, and that it can cause muscle and bone contractures in the long run. That is something I only discovered yesterday, after someone here had told me to go read about CP and related conditions. But I'm an educator, not a medic. And the medic who loaded my student into the ambulance on Wednesday seemed incredulous when she said she couldn't stretch her knees out all the way. He asked her three times.
Now, it is perfectly possible that most doctors do know that kind of stuff. But I'll tell you, I have long QT syndrome, for which I have regular follow-up appointments with a cardiologist. When I asked that person if my husband could get an appointment with him too, seeing as our PCP thinks there might be serious arteriosclerosis, he referred us to a different person.
I'm not saying he's not competent at what he does with me. He may even be perfectly competent to tackle both my and my husband's conditions, and there may be an entirely logical medical or practical reason for him not to take us both. I'm just saying that in a system where one cardiologist doesn't always fully grasp what the other is doing (or one neurologist, or one orthopedist, or ...) ... well, it may not be so hard to gather better knowledge of a specific condition, which you happen to be suffering from, than most doctors out there ...
I imagine, for instance, that cerebral palsy is one of those things that requires an interdisciplinary approach not available in very many places. Given that, I'd find it unsurprising if most of the bright people with CP knew more about their own condition than your average ED doctor. The same might be true for epilepsy. Which still doesn't mean that patients can be trusted to treat themselves all on their own, of course. Just that, when they are adults and of average or above-average intelligence, they are probably an invaluable resource in making decisions about what to do, when a doctor who specializes in this stuff is not immediately available.
Ok, I have read all of the posts on this thread. First, thank you to enuf_already for being the first person to acknowledge that "pseudoseizures" are NOT the result of the person faking it. Pseudoseizures are the result of serious mental illness, it is not someone seeking attention. That said, I do not believe that is what is happening with the OP's student.
I don't see anything weird with any of the behaviors the OP describes in her student. Do you have any idea how annoying it is to be taken to the ER in an ambulance after having a seizure when you have epilepsy, spending hours rotting in a room while nothing is done other than some drug levels checked (and since it's not a true trough, the results are more or less pointless) and then finally being discharged and having to find your own way home? I do. Fortunately I haven't had a seizure in over 11 years but, before I had my brain surgery, I had seizures every day. Sometimes my post-ictal periods were so bad that I woke up in my bed in a towel with no recollection as to how I got there/the last thing I remembered was getting out of the shower and other times, I had a seizure in the middle of a test and kept taking the test. Just because the student recovers faster than the OP's grandson did does not mean anything. No 2 patients are the same. And I completely believe her about the cost of an ambulance. Those things are expensive, many insurances don't cover the full cost and if her plan has a deductible, she could be out a few thousand dollars on one ride.
The student has cerebral palsy. People with cerebral palsy have an increased incidence of epilepsy. Epilepsy affects between 1-3% of the general population but between 25-35% of those with CP. I don't see any reason to disbelieve the student. There is nothing abnormal, OP, about the fact that your student has never bitten her tongue during any of the seizures you've witnessed nor that she has never been incontinent. In fact, research has shown that urinary incontinence or lack thereof is a useless diagnostic indicator when evaluating seizure vs syncope vs psychgenic non-epileptic events. I've had 1,000s of seizures in my life and never once bit my tongue or was incontinent.
It's generally not necessary to call 911 every time someone with epilepsy has a seizure. General guidelines are to call 911 if the seizure lasts longer than 5 minutes or if injury or respiratory compromise occurs. If you're unsure, I agree to err on the side of caution but as the student said, there literally is nothing to be done in an ER for someone with epilepsy who had a seizure that self-resolved. The most annoying ER trip I ever had, I was taken out of my college dorm in the middle of the night, taken to the closest hospital (that I wouldn't allow to touch my cat with a ten foot pole), had the ER staff tell me they needed me to take a pregnancy test, had them tell me that they didn't believe me- "you're 19"- when I told them it was IMPOSSIBLE for me to be pregnant because I wasn't sexually active, had them send me to the bathroom by myself where I promptly fell off the toilet and had another seizure, had them do an unnecessary CT and then come in all proud of themselves saying "we found something in your right temporal lobe"... yup, that's the tumor I told you I have that's being resected in three weeks. Honestly I don't know how long that seizure lasted and my RA/friend did the right thing by calling for help but unless a patient is actively seizing when they arrive at the ER, it's unlikely that the trip is necessary.
It sounds like the entire education center would benefit from some education on epilepsy. Contact your local Epilepsy Foundation. Their HOPE (Helping Other People with Epilepsy) program offers community education on epilepsy. The general public's lack of knowledge about epilepsy has been deadly in the past.
Why don't you suggest she get a tegretol level drawn to see if the medication is at a therapeutic level??? Perhaps the level is subtherapeutic and she would still be having seizures if that is true. It is interesting how she has picked the major systems to have problems with, so no particular type of recovery?? More emphasis on being sick and disabled!!!
Why don't you suggest she get a tegretol level drawn to see if the medication is at a therapeutic level??? Perhaps the level is subtherapeutic and she would still be having seizures if that is true. It is interesting how she has picked the major systems to have problems with, so no particular type of recovery?? More emphasis on being sick and disabled!!!
If she has intractable epilepsy, it won't matter if her levels are therapeutic or not. Unfortunately some people can never obtain seizure freedom in spite of medications, surgeries, or the ketogenic diet.
Even people with well controlled epilepsy can be prone to breakthrough seizures when their body is stressed. This can be from lack of sleep, illness, or stressful situations.
It sounds to me like this young lady is actually trying to do the best she can with the diagnoses she's been given. OP, as others have said, I'd see if the young lady would be willing to have her neurologist provide written guidelines regarding when to call the squad. If not, you are obligated to call when she has a seizure for her safety and your protection
Pseudoseizures are the result of serious mental illness, it is not someone seeking attention. That said, I do not believe that is what is happening with the OP's student.
At this point, neither do I.
I don't see anything weird with any of the behaviors the OP describes in her student. Do you have any idea how annoying it is to be taken to the ER in an ambulance after having a seizure when you have epilepsy, spending hours rotting in a room while nothing is done other than some drug levels checked (and since it's not a true trough, the results are more or less pointless) and then finally being discharged and having to find your own way home?
That is pretty much exactly what the student said to me, the first time I asked her why she prefers not to have EMS involved. Sarcasm included.
The truth is, in many situations it would just be easier for *us* to be able to call an ambulance and be done with it. This woman has no family nearby. She has a few emergency contacts, but there's no telling as to whether those people will be available at any given time. She's explained *that* to me, too. She can't expect anyone to stay home all the time, waiting for that one phone call that may or may not happen. Otherwise, what would be the point of her leading an independent life? She might as well have someone come with her everywhere, then. And two seizures a month is a lot, I guess, but not enough to entirely give up your independence over. I get that.
It sounds like the entire education center would benefit from some education on epilepsy
That, I will not disagree with. Thank you for your suggestion. And tank you for your story!
It is interesting how she has picked the major systems to have problems with, so no particular type of recovery?? More emphasis on being sick and disabled!!!
I realize now that I may have come in here with a very unfair characterization of my student, but I feel like this one is even more unfair. She is not the type of person who milks her disability and/or illness for all that it is worth. I would say, on the contrary.
In the two and a half years that I've known her (training is spread over three, here, for working students), she's told me a few times that her medication had been changed because it was affecting her in some way that had an impact on her functioning in class. It seems they were experimenting? I think it might very well be true that her seizures do not respond to medication as well as expected. I do know that before she came to us, she used to have more than two seizures a month, so perhaps the medication is helping a little, but not enough.
In any case, when I thought she was faking, I thought she might be doing it due to some kind of psychological need (i.e., getting the nurturing and attention that she seems unable to obtain for herself any other way, seeing as she has no family nearby, and her social network appears to be thin). I never thought it was because she wants to cast herself in the sick role. She is, in many ways, more independent (and fiercely defends her right to be seen and treated as such) than many perfectly healthy people I know.
Esme12, ASN, BSN, RN
20,908 Posts
Never ever assume someone won't sue.