real seizure versus fake seizure
Posted 01 July 2006 - 05:16 PM
My partner (ALS) and I (BLS, in medic school) responded to an "active seizure" yesterday, I'd like to see what you guys would have done differently.
On arrival we found a 17 year old female supine in bed in full tonic-clonic generalised seizure activity. The patient was nonresponsive to voice and pain (good, deep sternal rub). We noted the patient was incontinent to urine, frothing at the mouth with eyes in a fixed conjugate gauze to the upward right. PEARRL, not constricted or abnormally dialated. Skin was warm, pink, dry. Family on scene states (through a language barrier/translation) that the patient was in this exact seizing state for a full 45 minutes prior to our arrival. They said that this has happened once before, a month ago, and they assumed this would resolve on its own like it did last time. They denied, however, that the patient had any dx of any kind of seizure disorder. The patient is on no meds, and has no allergies.
We placed the patient on 15lpm O2 via a NRB, established an IV (18#, right AC). Blood sugar off of the IV was 108. Per protocol we gave 1mg Ativan IVP with no effect. A 2nd mg of Ativan IVP got the patient to calm down completely. Stair chair'ed the patient to the stretcher, to the ambulance. Got the patient on the monitor: sinus tachy at 137bpm. BP 130/74, RR 24. The patient began to seize again, so we decided to transport right away. Priority 1 to a local children's hospital. Enroute the patient got another mg of Ativan per on-line medical control, which again caused the activity to cease. The patient remained unresponsive for the entire time she was in our care.
As we were transferring the patient over to the ED bed, she began to seize again. The ED staff gave her yet another mg of Ativan, which again caused the patient to calm down. The hospital did a search for the patient's history in their own records, which showed that she had been seen at this ED 5 times in the past 2 months for the same presentation. She had a neuro consult a few visits before with no dx. It was written in the history that the seizures were assumed to be "fake." Around this same time, the patient opened her eyes at the request of her mother. She was still not answering questions, but was obviously alert and lethargic. It isnt clear whether the lethargy is part of a postdictal state, or from the 4 mg of Ativan she got over the last half hour.
In a converstation with the ED doc after finishing our paperwork, the doctor said that this particular patient was "apparantly very, very good at faking seizures," however there were things in her presentation that led him to believe that she was in fact faking. He claims this was obvious to him before even reading the history. His points were:
1) Her seizure motion was not bliaterally equal. The patient was shaking both arms, but they were seemingly at random and not in sync with eachother at all. The doc stated that "real seizures" generally present with bilaterally equal, or close to bilaterally equal tonic-clonic motion. I have never heard of this before.
2) Her motion was too purposeful. While she never accomplished any sort of task with this motion, according to the doc it was obvious to him that the motion was not genuine seizure motion, but rather a calculated, conscious motion. I dont know how he was able to determine this. She certainly looked like a real seizure to me.
3) Her mother's story didnt add up. A 45 minute seizure doesnt "just resolve" like the mother stated it did last time, and patients who have these seizures dont end up with no dx and no meds - which was the mother's story.
So I guess we were fooled. ...But I dont see how we could have avoided it here-- the patient was incontinent to urine, and was COMPLETELY unresponsive to pain. It really blows my mind that the patient could have been conscious and have NO reaction to the sternal rub or IV, nevermind urinate on herself. On top of that, it seems incredible to me that the patient was able to maintain these "fake' symptons for us with 3mg on Ativan on board. Youd think by that time she'd be completely snowed.
Anyways, I'd like to hear what experiences you guys have had with seizures. What kind of criteria/tests do you like to use to differentiate between real and fake seizures, and do you think there was anything that my partner and I could have done differently on this call?
Posted 01 July 2006 - 05:25 PM
Posted 01 July 2006 - 05:30 PM
dont beat yourself up on it.
Oh, I'm not really upset that she fooled us-- haha I'm actually pretty impressed. I thought it would be an interesting topic to discuss though, and perhaps there are a few other things we could have done/seen that would have helped us understand what was really going on... Also I'd like to hear what people think about the ED doc's points-- cause some (especially the first one) seem kinda odd to me.
Posted 01 July 2006 - 06:17 PM
Posted 01 July 2006 - 09:15 PM
Thats fine if you find this humorous your allowed, my concern is what became of her?
When you hear that it affects children thats my concern as it would be yours as the Individual (EMT/Medic)
So wining an oscar hmmm, so what if it was your kid, are you going to call their bluff?
It must be hard to deal with it but of course your not a psych major
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