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real seizure versus fake seizure

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Posted · Report post

Long post here but it was a good call, so....

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?

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Posted · Report post

I would have treated this as a seizure too...dont beat yourself up on it.

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Posted · Report post

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.

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Posted · Report post

I have been reeled in by the best .........I have even tried to nominate some for an Oscar. I agree, sounds like they were good at presenting the s/s . It does take a lot of experience and understanding seizures to detect some of the fakers. Since there are so many seizure disorders I have been careful, trying to determine real ones from fake ones. Always err on the patent's behalf....

r/r 911

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I'M CURIOUS AS TO WHAT WAS THE THE PSYCHOANALYSIS OF THE 17YR OLD?

(Without Prejudice)

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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The etiology behind many patients who fake illness, not to be confused with Munchausen by Proxy.

[align=center:3812aee389]Munchausen Syndrome[/font:3812aee389][/align:3812aee389]

What is Munchausen syndrome?

Munchausen syndrome is a type of factitious disorder, or mental illness, in which a person repeatedly acts as if he or she has a physical or mental disorder when, in truth, they have caused the symptoms. People with factitious disorders act this way because of an inner need to be seen as ill or injured, not to achieve a concrete benefit, such as financial gain. They are even willing to undergo painful or risky tests and operations in order to get the sympathy and special attention given to people who are truly ill. Munchausen syndrome is a mental illness associated with severe emotional difficulties.

Munchausen syndrome—named for Baron von Munchausen, an 18th century German officer who was known for embellishing the stories of his life and experiences—is the most severe type of factitious disorder. Most symptoms in people with Munchausen syndrome are related to physical illness—symptoms such as chest pain, stomach problems, or fever—rather than those of a mental disorder.

Note: Although Munchausen syndrome most properly refers to a factitious disorder with primarily physical symptoms, the term is sometimes used to refer to factitious disorders in general. In this article, Munchausen syndrome refers to factitious disorder with physical symptoms.

What are the symptoms of Munchausen syndrome?

People with this syndrome deliberately produce or exaggerate symptoms in several ways. They might lie about or fake symptoms, hurt themselves to bring on symptoms, or alter diagnostic tests (such as contaminating a urine sample). Possible warning signs of Munchausen syndrome include the following:

Dramatic but inconsistent medical history

Unclear symptoms that are not controllable and that become more severe or change once treatment has begun

Predictable relapses following improvement in the condition

Extensive knowledge of hospitals and/or medical terminology, as well the textbook descriptions of illnesses

Presence of multiple surgical scars

Appearance of new or additional symptoms following negative test results

Presence of symptoms only when the patient is alone or not being observed

Willingness or eagerness to have medical tests, operations, or other procedures

History of seeking treatment at numerous hospitals, clinics, and doctors offices, possibly even in different cities

Reluctance by the patient to allow health care professionals to meet with or talk to family, friends, or prior health care providers

Problems with identity and self-esteem

What causes Munchausen syndrome?

The exact cause of Munchausen syndrome is not known, but researchers believe both biological and psychological factors play a role in the development of this syndrome. Some theories suggest that a history of abuse or neglect as a child, or a history of frequent illnesses requiring hospitalization might be factors associated with the development of this syndrome. Researchers also are studying the possible link with personality disorders, which are common in individuals with Munchausen syndrome.

How common is Munchausen syndrome?

There are no reliable statistics regarding the number of people in the United States who suffer from Munchausen syndrome, but it is considered to be rare. Obtaining accurate statistics is difficult because of dishonesty in representation. In addition, people with Munchausen syndrome tend to seek treatment at many different health care facilities, which causes misleading statistics.

While Munchausen syndrome can occur in children, it most often affects young adults.

How is Munchausen syndrome diagnosed?

Diagnosing Munchausen syndrome is very difficult because of the dishonesty that is involved. Doctors must rule out any possible physical and mental illnesses, and often use a variety of diagnostic tests and procedures before considering a diagnosis of Munchausen syndrome.

If the doctor finds no physical reason for the symptoms, he or she might refer the person to a psychiatrist or psychologist — mental health professionals who are specially trained to diagnose and treat mental illnesses. Psychiatrists and psychologists use a thorough a medical history and physical, laboratory imagery, and psychological assessment tools to evaluate a person for Munchausen syndrome. The doctor bases his or her diagnosis on the exclusion of actual physical or other mental illness, and his or her observation of the patient’s attitude and behavior.

Questions to be answered include:

Do the patient's reported symptoms make sense in the context of all test results and assessments?

Do we have collateral information from other sources that confirm the patient's information? (If the patient does not allow this, this is a helpful clue.)

Is the patient willing to take the risk for more procedures and tests than you would expect?

Are treatments working in a predictable way.

The doctor then determines if the patient’s symptoms point to Munchausen syndrome as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), which is the standard reference book for recognized mental illnesses in the United States.

How is Munchausen syndrome treated?

Although a person with Munchausen syndrome actively seeks treatment for the various disorders he or she invents, the person often is unwilling to admit to and seek treatment for the syndrome itself. This makes treating people with Munchausen syndrome very challenging, and the outlook for recovery poor.

When treatment is sought, the first goal is to modify the person’s behavior and reduce his or her misuse or overuse of medical resources. Once this goal is met, treatment aims to work out any underlying psychological issues that might be causing the person’s behavior or help them find solutions to housing or other social needs.

As with other factitious disorders, the primary treatment for Munchausen syndrome is psychotherapy (a type of counseling). Treatment likely will focus on changing the thinking and behavior of the individual (cognitive-behavioral therapy). Family therapy also might be helpful in teaching family members not to reward or reinforce the behavior of the person with the disorder, but often the person is estranged from his or her family.

There are no medicines to treat factitious disorders themselves. Medicine might be used, however, to treat any related disorder—such as depression, anxiety, or a personality disorder. The use of medicines must be carefully monitored in people with factitious disorders due to the risk that the drugs might never be picked up from the pharmacy or might be used in a harmful way.

What are the complications of Munchausen syndrome?

People with Munchausen syndrome are at risk for health problems (or even death) associated with hurting themselves or otherwise causing symptoms. In addition, they might suffer from reactions or health problems associated with multiple tests, procedures, and treatments; and are at high risk for substance abuse and suicide attempts.

What is the prognosis (outlook) for people with Munchausen syndrome?

Some people with Munchausen syndrome suffer one or two brief episodes of symptoms. In most cases, however, the disorder is a chronic, or long-term, condition that can be very difficult to treat. Further, many people with Munchausen syndrome deny they are faking symptoms and will not seek or follow treatment. Even with treatment, it is more realistic to work toward managing the disorder rather than to try curing it. Avoiding unnecessary, inappropriate admissions to the hospital, testing, or treatment is important.

Can Munchausen syndrome be prevented?

There is no known way to prevent this disorder. However, it might be helpful to begin treatment in people as soon as they begin to have symptoms.

© Copyright 1995-2005 The Cleveland Clinic Foundation. All rights reserved[/font:3812aee389]

Peace,

Marty

:joker:

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Posted · Report post

Just another point, her seizures weren't "obviously" fake if the ED staff felt the need to medicate her with another millgram of Ativan.

As far as the motor activity being equal vs non equal, I'm not sure I buy into that comment. People have isolated focal seizure frequently. There's no rule (that I know of) that says that all seizure activity has to be equal. Using the doc's theory, I'd be curious to have him explain a focal motor seizure.

Also a 45 minute seizue that really lasts the full 45 minutes would either leave the pt so hypoxic and/or exhausted that they would remain very lethargic.

All in all, it sounds like an interesting call.

Shane

NRMET-P

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Posted · Report post

It sounds in the initial call and actions that she was really seizing, but the seizure lasting 45 mins nonstop that would be a little troubling and having on before and lasting the same amount of time, and no meds that would rise some concern, but if I had any doubt I would just raised her hand above her head and drop it and if it hit in the face then, see passed and if not, and she continued to be unresponsive try a ammonia inhaler and it she can take that then either she is strong willed or you are probably dealing with seizure, but it seems that you guys/gals was right on target with your treatment.

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Posted · Report post

I recently had a call for a 17 y/o female in seizure. F.D. on scene stated she was in full seizure on their arrival, lasted a few minutes, then subsided. On our arrival, patient was unresponsive to pain and appeared postictal. According to F.D. patient has a history of seizures. I still believe I have run on her before for the same.

Upon getting the patient in the ambulance: monitor, vitals, etc. She started to have a seizure which started in the head and neck and gradually worked itself down through her torso with not a lot of extreme movement in her arms and legs.

Gave her 5 mg valium, then 5 mg more which cause the seizures to cease. While calling in the radio report to the hospital, the patient had another seizure. I advised the ED that I was going to go with Versed. 5 mg of Versed later, the seizure stopped.

Out at ED, one of the "old dog" nurses recognized her for a previous c/c of seizure.

I learned later that they were under the impression that she was faking all of the seizures and they were trying to GOMER her.

I have had others that were accused of faking, then lab tests confirmed that they did have seizures. (I can't remember what the test was for. Myoglobin?)

I really think that some EDs are too quick to call a seizure fake just because either they don't see the seizure, or the patient's seizure doesn't fit into their mindset of what a seizure should look like.

Ya do the best wit' watcha got!

G

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Posted · Report post

It's all about the drama.

My partner and I have been fooled, too. No big.

I first look for the incontinence. To be willing to fake that, you need to be good. I have seen fakers do that, though.

What gives it away is what is what you see when you are on scene. All family members, SOs, etc, will deny that there was stress prior to the seizure. But about 1/2 the time, the tension is so thick you can cut it with a knife. It's like walking into the set of a bad Mexican soap opera, or the Jerry Springer show.

The thing that makes me aware of fakers is that we have so many regulars with real seizures. Most are urban outdoorsman, domicile challenged. We have one who seizes, and drops to the ground. He has a huge head, so he is always injured, then flops around for a few minutes. He has a long, violent post-ictal state, which involves many members of the law enforcement community, and sometimes an extra ambulance or engine company to keep him and bystanders apart. He is very dangerous. Usually, when he becomes alert, he runs away. I have learned from watching during the seizure, and post-ictal phase. i know everyone is different, but it's still good learning.

If only they would take their prescriptions, and not sell them.

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Posted · Report post

I'M CURIOUS AS TO WHAT WAS THE THE PSYCHOANALYSIS OF THE 17YR OLD?

(Without Prejudice)

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

Actually, I do call their bluff and tell them to knock that sh*t off! ... after experience you can usually tell those of seizing or not. Past history, med's, and post ictal behavior. Check advanced neuro assessment, and treat accordingly. I respond to about 10 to 15 seizure calls a week about 4 or 5 are real. Yes, I have been dooped, no shame.. far as lab test myoglobin only shows muscle activity which will increase even if faking, an EEG is requires to document seizure activity.

Most all the psuedoseizures are dramatic, and try to remain conscious during their activity. Yes, there are types that have to deal with behavior, psych and yes they can be conscious.. but a lot of these have other symptamology and know about their condition.

Again, treat according real or fake....

R/r 911

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Posted · Report post

The lab test is a prolactin level, which is usually elevated for a short period after a seizure (about 15 minutes or so). Does it really matter is someone gets one over on you? It doesn't make you any less of a provider. As long as you are doing the right thing, then no big deal. So what if you just gave some junkie their fix. It happens to everyone at some point, reguardless of how much experience you have. Just be alert to it so you don't become their supplier.

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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

I would like to think that I would call their bluff. Obviously there is something seriously wrong with this young patient, be it some sort of medical pathology or be it psychological: the answer would never be to simply let it go and "hope it resolves," as it seems this mother was attempting to do. I do feel sorry for the patient, and I do wonder what exactly is going on with her if it is in fact psychological-- but to get this good at faking seizures requires practice, and practice to me means lots of neglect of this issue by the parents. At this point, I dont feel like the behavior should be reinforced by allowing ourselves to be taken into the act. If she is faking, she needs to cut it out.

Coincidently I actually am a psych major. Finished my double major in psych and philosophy at Boston University in 04. Suprise! haha :wink:

Just another point, her seizures weren't "obviously" fake if the ED staff felt the need to medicate her with another millgram of Ativan.

I was wondering about this as well, and I actually asked the same question of the doc in charge. He basically said that they "just gave it anyways to calm her down," presumably so that she would be easier to deal with for the ED staff. Psychs get ativan too, I suppose. heh

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Posted · Report post

As far as your treatment of the Seizure activity, I don't thing you could have done it any better. If its not obvious to you, your partner or the ER staff I would be willing to bet you were right. Of course there are a few people who are damn good at faking seizures, and even if they did fake it you won't be getting sued later on for it. Just remember, if it looks and smells like something...its usually true.

On another note, a patient doesn't have to be unresponsive, icontinent and having a full tonic clonic seizure to benefit from treatment. I have seen a few patients (however rare) that suffer from focal motor seizures usually after a stroke event that have no diagnosed seizure history. These patients usually are still able to talk but act disoriented and somewhat lethargic like a diabetic. Just keep alert and do your best!!

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Posted · Report post

Pseudoseizures do not necessarily a "faker" make. In fact it can be a somatoform disorder. Don't be so quick to assign blame.

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In the course I'm currently studying, we had a lecture a few weeks ago on seizures, here are a couple of points:

- there are four classification of seizures - partial seizures, generalized seizures, unclassified seizures and non-epileptic sezires (the last being your pseudoseizures)

- unclassified seizures are ALL seizures that cannot be classified because of inadequate or incomplete data and some that defy classification

- non-epileptic seizures have no organic cause and are usually psychiatric based

- may appear similar to epileptic seizures but there is no electrical discharge

- these can be due to panic attacks, inability to cope with emotional demands, post trumatic stress, no control over behaviour, manipulative attacks.

- activity is disjointed, non synchronous, non clonic, disco-ordinated motor activity, pelvic thrusting, back acrhing

- even though presentation is not the same as "normal" seizures they are still classified as seizures.

I was looking after 19year old female, presented with asthma, tachypnoeic, tachycardic, low SpO2, began to have a tonic clonic seizure, ABG showed respiratory and metabolic acidosis. Doctor persisted to tell us she was faking the seizure and it was a pseudoseizure, only because she was maintaing her own airway. However, she was unresponsive, had full tonic clonic motions, not responding to midazolam, and was in a post-ictal state for 2 hours post seizure activity.

A good way to tell whether the patient is putting it in is by brushing over their eyelashes, if eyes move under the lids, and they open slightly than it is a good indication that the seizure is fake.

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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.

I had to readdress this thread because there are several things just sounded hinky to me. First off Dr's point # 1 = B.S. Dr's point # 2 = absolutely true. Dr's point # 3 = first time seizure activity NYD would not have any anticonvulsives prescribed. Also, in my experiences the layman is notoriously bad at reporting mental status. They just don't notice the right things or ask the right questions to properly assess.

ERDoc,

I was always under the impression that there was no conclusive way to determine whether a seizure was in fact "real" or not, so I asked around. The consensus is that prolactin levels do not conclusively indicate a true seizure. Does "medical stamp collecting" ring a bell? It seems that at some point someone did a inacurate study, with poor controls and test group sizes and then published the results which were then dispproved. XYY chromosome anybody?

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Since you obviously need soem help with 'seizures...'

Okay I appreciate the links and all that, but I dont think it is obvious (or even true) at all that I need help with the basic definitions of a seizure. I'm asking specifically about treatment of potentially fake seizures in the field, not about what a seizure IS. I'm not sure if it is meant that way, but you're coming off kinda rude..

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Okay I appreciate the links and all that, but I dont think it is obvious (or even true) at all that I need help with the basic definitions of a seizure. I'm asking specifically about treatment of potentially fake seizures in the field, not about what a seizure IS. I'm not sure if it is meant that way, but you're coming off kinda rude..

"Fiznat,"

In order for one to appropriately recognize 'fake vs real' seizures, one must first UNDERSTAND, AND KNOW the underlying, physiology, pathophysiology, etiology, and DDX of the D/O, before you can even begin to make a 'decision' clinically as to whether your patient is 'actually' having a seizure or not. Since YOU asked I tried to help and it is evident based on your responses that you needed more information, and help with this. the links will get you started on this path, and if you need more help feel free to ask.

As evidenced by the following comment of

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?

It is clearthat at this point you aren't in a position to be judging as to what is 'real and or fake' hence the 'obvious' comment I made! An appropriate neuro exam and H&P-P/E would have given you the proper answer.

Good luck,

ACE844

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An appropriate neuro exam and H&P-P/E would have given you the proper answer.

I posted pretty much the entire assessment of the patient, was there something you see that was missing? I feel I covered most of (if not all, at this level) the pertanant information needed to make this kind of determination. Being that you are the only person that mentioned that my exam may be incomplete maybe you could tell me what else you feel I should have done?

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I posted pretty much the entire assessment of the patient, was there something you see that was missing? I feel I covered most of (if not all, at this level) the pertanant information needed to make this kind of determination. Being that you are the only person that mentioned that my exam may be incomplete maybe you could tell me what else you feel I should have done?

here's how to do an appropriate exam...your answer lies in there...

http://medicine.ucsd.edu/clinicalmed/introduction.htm

[web:8467d29db1]http://www.postgradmed.com/issues/2002/01_02/prego.htm[/web:8467d29db1]

ACE844

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"Fiznat,"

Here are some clues for you as requested as to some things that may 'tip ya off that this was 'fake'...' Certainly I noticed them based on what you posted. I'm not picking on you, just using you as an example...

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.

If the patient had been seizing for 45mins, she would have been grossly diaphoretic and either very pale or flushed, also possibly been apenic and or in arrest if it were truely' status sz'... Also, not necessarily a 'sign,' but she managed to stay in bed, and or continue to have this 'seizure activity' in a nice soft comfy place...Food for Thought, thats what alittle 'scene size up may do for ya'! Especially in this context...

We placed the patient on 15lpm O2 via a NRB,

You make no mention of placing an NPA or suctioning an airway which you clinically describe as unpatent and or potentially compromised!!

established an IV (18#, right AC). Blood sugar off of the IV was 108.

Her BS probably wouldn't be this high if she had 'actually seized' for 45 min as you stated..

Per protocol we gave 1mg Ativan IVP with no effect. A 2nd mg of Ativan IVP got the patient to calm down completely.

I bet, that would mellow me out too... Anyone else up for 2 free mgs of ativan?!?! ?? "hammer," I seems to remember you requesting soem awhile back, 'fiz' is givin the stuff out..! YEE HAW!!

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.

My heart would be about that much if I working that hard at faking too...! Her other V/s's are unimpressive, but hard to say with out a clearer clinical picture..

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.

Again, no mention of a search for other reversable causes and or airway management, trismus, etc...... Bet she had a gag though!! THIS IS BASIC STUFF...BASIC ALS 101

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.

Pt

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.

These were all things you should have picked up on as mentioned previously and you would have been aware had you done a proper H&P-P/E!!

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.

See above and the links I posted..again they should help... I think this is potentially quite a commn issue among inadequately educated medics... but thats just my .02, HLO.

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?

See above answer, these are just a few of the things I noticed...

Hope this helps,

ACE844

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Wow alright, "ace." Are you always this rude and condecending with new people on this forum? I beleive I was VERY respectful, phrasing my challenge to your initial post in the most unoffensive manner possible. It seems you, by comparison, have very few of the same qualms. What an arrogant ass you come across as.

If the patient had been seizing for 45mins, she would have been grossly diaphoretic and either very pale or flushed, also possibly been apenic and or in arrest if it were truely' status sz'... Also, not necessarily a 'sign,' but she managed to stay in bed, and or continue to have this 'seizure activity' in a nice soft comfy place...Food for Thought, thats what alittle 'scene size up may do for ya'! Especially in this context...

Thanks for the tip on scene size up, ace. I specifically mentioned that there was a language barrier between the responders and the people (mom) telling the story. I wrote this portion of the description of the case AS AN EXAMPLE of the questionable nature of the seizure. Food for thought.

You make no mention of placing an NPA or suctioning an airway which you clinically describe as unpatent and or potentially compromised!!

I did forget to mention it in the post, but did not forget to try this for the patient. She would not tolerate an OPA, and a NPA was impractical given the time we spent on-scene and the effectiveness of the 2nd ativan dose. The patient's airway was patent, and she was at 97%+ on the pulse-ox by the time we got her into the bus. My job after that was to drive the ambulance, so I cannot speak for what happened enroute to the ED.

I bet, that would mellow me out too... Anyone else up for 2 free mgs of ativan?!?! ?? "hammer," I seems to remember you requesting soem awhile back, 'fiz' is givin the stuff out..! YEE HAW!!

Again, as I stated: I am an EMT in medic school, my partner was the ALS. I did not give *any* ativan to this patient. Not to mention that it is our protocol (as I also stated) to give a 2nd mg of ativan if seizure activity isnt resolved after the 1st dose.

My heart would be about that much if I working that hard at faking too...! Her other V/s's are unimpressive, but hard to say with out a clearer clinical picture..

Damn straight its hard to say. Your comment on heart rate is totally useless: HR would obviously be elevated regardless of whether she was faking for 45 minutes, or seizing for the same amount of time.

Hear that ringing..thats the clue phone..Please do answer it, since we have missed anumber of other 'clues' presesnt.

Hey, ass. What happened in the ED happened AFTER our oppertunity for intervention had already passed. If she had opened her damn eyes on scene or in our bus, that most certainly would have changed our approach to this patient. Your post-hoc cherry picking BS truly is impressive, though. If only each and every one of us could have the insight to be able to pick apart patients based on their future presentations. Maybe someday I will reach that level. Ace.

These were all things you should have picked up on as mentioned previously and you would have been aware had you done a proper H&P-P/E!!

So I should have picked up on the fact that the patient's "seizure" motion was not equally bilateral? So you believe that this is an accurate indentifier of true seizures? Explain it to me. The rest of the doc's points WERE recoginzed by my partner and me, as I explined them in my original assessment of the patient. Still, the confounding factors of the language barrier and questionable hx are enough to err on the patient's side, no?

Hope this helps

If I havnt made it clear enough already, it has NOT. Nor do I really beleive you care whether it does or not. How about stop trying to make yourself look good, and simply answer the questions asked. I truly hope that this is a big misunderstanding, because I have been on forums for a very long time (even moderating on a large one), and I very rarely see such arrogance and condecending attitude towards a newer member from an older one. If I am still misunderstanding your tone, I do aplogize- but I quite seriously doubt it.

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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?

The only sure fire way to know if a seizure is real or fake, is to perform an EEG during the said seizure activity. Sure prolactin levels might be elevated, but what is it's specificity?

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