Nursing Intuition, Part 2: The Seizure Girl

RobbiRN, RN

"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!

Nursing Intuition, Part 2: The Seizure Girl

About RobbiRN, RN

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