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real seizure versus fake seizure


fiznat

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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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Fiznat wrote:

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.

If they were not pseudo sz. As far as the mother stating the sz lasted 45 mins its possible she did not recognize a postictal period, it may have only lasted a few seconds. In an emergency situation we know time seems like its standing still. We always hear what took you so long, even though we were there in 5 mins. So her over estimating the time, maybe.

We are not capable of determining who is faking and who isn't all of the time. You have to trust your judgment. In this situation I don't think you had a choice, you made your decision to treat them( I believe the right decision). This 17 year old deserves an Oscar. Weigh the risks and benefits. Benefits of treating this pt ...good. Risks of not treating this pt.....Bad.

The incontinence, frothing at the mouth, a conjugate gaze. For someone without a seizure disorder to mimic a sz to that extent, they left you know choice. I would question someone not treating this pt.

Lets see faking a grand mal seizure for 45 mins. Difficult

Throwing a temper tantrum. Easy

They both will get you ativan in the ER

So maybe she is real good at faking sz's, but not that bright.

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“Fiznat,”

You started the thread asking for advice and guidance. After receiving a number of helpful and informative replies you still weren’t getting it. Also based on your original post knowing you are a student; I tried to help you understand the difference, and provide you with the means to educate yourself. Here’s what I wrote:

To which you reply,

Okay I appreciate the links and all that, but I don’t 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..

Well as an experienced basic and a ‘medic student’ which you called yourself in your own first post in your own thread you stated;

““

Long post here but it was a good call' date=' 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.[/quote']

Your learning, and as such and as a basic who ‘may{I don’t know you but based on the content of your post and some of the things it lacks} have only received the minimums of P/E & H/P education of the grand sum total of a course of 110 hrs. You are not even remotely prepared to begin to make or assess whether one of your ‘Seizure’ pt’s is indeed having the real thing. Also, your post, made it seem as if you were the one performing the ‘assessment and ALS skills’ which may or may not be ok depending on what part of your program you are currently in, and or if your not in the appropriate portion could get you in ‘A BOATLOAD OF TROUBLE’! Alas, this thread isn’t about that so moving on…

I also further tried to explain and help you by stating and I wrote:

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Despite the fact that this back and forth crap is getting fairly ridiculous by this point...

You started the thread asking for advice and guidance. After receiving a number of helpful and informative replies you still weren’t getting it. Also based on your original post knowing you are a student; I tried to help you understand the difference, and provide you with the means to educate yourself. Here’s what I wrote:

I felt that your attitude in that post was condecending. I didnt jump down your throat right away, I only stated that I felt that your tone was a little rude. This part of the argument could have been resolved very quickly with a simple clarification of your meaning. That is, of course, assuming you didnt mean to come across as you did.

You are not even remotely prepared to begin to make or assess whether one of your ‘Seizure’ pt’s is indeed having the real thing

Of course I'm not. Nor did I ever claim to be. In fact, I went through the effort of posting this whole story so that I could get some insight on this very subject!

Yet, if you do understand the underlying, physiology, patho-physiology, etiology, and DDX of the D/O’S, which cause seizure activity and are able to perform and understand how to do a full P/E & H&P, than there would have been ways for you to ‘increase or decrease your index of suspicion’ as to whether your pt ‘was actually seizing’. If you don’t understand the preceding material then of course you wouldn’t be able to ‘tell’ real vs. fake!!

As impressive as your listing of elaborate (yet redundant) medical terms truly is, in the future you may come off as less arrogant if you were to point out specific errors in an exam rather than dump on the entire thing. Referencing 5000 links to the entire world's history and scientific study on seizures is not what I asked for, nor what any poster on this forum would likely find useful. There is a difference between an ancidotal, friendly conversation about in-the-field observations and a systematic study of internet resources. This forum, and forums in general, generally serve the former. To unload your 10 minutes worth of google searching on this forum says to me that you dont really care to have a conversation about a call, you would rather shove a new user off elsewhere into the depths of data: suggesting that he'd better absorb the minituae of the subject before he is worthy, in your eyes, to come discuss it. Its true, neither my knowledge nor experience are that incredibly deep at this stage in my education- but I know enough to ask the right questions- and I thought that is what I was doing here. Simply because I didnt cover every single detail of what you consider to be an accurate "P/E & H&P" doesnt mean that I cant come in here and ask for ways to make myself better. You pass off all that information you posted as if it were your own, although when it comes down to it I doubt you *truly* do much better than my partner and I did in the feild.

Furthermore, the REASON you are able to pick apart details from my assessment as factors which "increase and decrease your index of suspicion" is BECAUSE I POSTED THEM THERE. This was not an accident. You arent seeing things in there that I didnt see, you are simply calling me out for not stating the obvious. OF COURSE the patient's incontinence lowers the index of suspicion, OF COURSE the normal blood pressure and resp rate increase it. I included these details in my post because I KNOW they are necessary for a complete understanding of the patient's condition! What do you think, I mindlessly collect all of this data, remember it, and post it here for you alone to interpret it without any understanding of my own? How arrogant it is of you to assume that! I wrote the post in a manner so that members of this forum could read it, see the presentation, and make a decision on their own. A discussion of those competeting pieces of "evidence," is what I hoped would follow. ...And it did, mostly, except for you.

A.) You don’t know the standards of assessment, care, or protocols for a patient in your practice environment/area. ALL YOUR PATIENTS should be receiving the same ‘care’ from you.

Any EMS worker in the field who does not err on the side of caution for the patient's behalf is a dangerous waste of space. Never once did I suggest that this patient should be recieving any less care than what she got from us. All I was asking for, again, was some ancidotal observations that I could make in order to help me determine the reality of this patient's presentation. In fact, it was YOU who suggested that this patient's treatment should have been altered:

If you recognized many of the very factors which would ‘raise your index of suspicion’ as to whether this patient ‘may or may not be’ having actual ‘seizure’ activity' date=' and someone still gave Ativan…what does that say about the care provided to said patient? [/quote']

(As you yourself stated: my "index of suspicion" should have very little effect on what treatment this patient recieved. Do you often change your treatment plan based soley on a "suspicion?")

Go ahead and pick apart our treatment if you feel it is necessary. The airway was patient and the patient was in no respiratory distress at any time during our care. You may practice differently, but I dont beleive that our approach to this airway was any different than what 99% of crews would have done in the same situation. I know what the books say just as well as you do, but the reality of the situation is that this is how things are widely done. Call it whatever you want, but people dont just go around popping in NPAs on every patient so that they can say they attempted something for the airway. A NPA is NOT a secure airway, nor was it completely necessary for this patient. ...But if it makes you feel better to point out what you think are errors, please feel free.

Your text is already in all-bold, I really dont think the caps lock is necessary at this point to get your ideas across. Whatever floats your boat, though.

The point of my comment to which you are responding here is that the tachycardia could be EITHER from these increased metabolic demands that you mention following a real seizure, OR simply from the energy expended while trying to fake a seizure for 45 minutes! Once again, I am fully aware that a real seizure can cause (through various pathologies) tachycardia. I am ALSO AWARE, however, that a fake seizure could just as likely have caused the same presentation. The heart rate, therefore, is pretty useless on its own- and not worth singling out (as you did).

Obviously my "profanity" is not offensive enough to be censored on this forum. ...And I beleive my scattered use of this VERY light language pales in comparison to your arrogance and dismissive attitude. I am offended by you.

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"fiznat,"

Of course I'm not. Nor did I ever claim to be. In fact, I went through the effort of posting this whole story so that I could get some insight on this very subject!

As impressive as your listing of elaborate (yet redundant) medical terms truly is, in the future you may come off as less arrogant if you were to point out specific errors in an exam rather than dump on the entire thing. Referencing 5000 links to the entire world's history and scientific study on seizures is not what I asked for, nor what any poster on this forum would likely find useful.

Hence the links which would provide you with the majority of the information you would need to educate yourself, see what assessment items you should have done if you didn't, and the rest of the things I mentioned in my previous posts. if you don't understand that medicine has moved to evidenced based practice based on studies you need to get used to that quickly, this is why I directed you to soem of those journal sites. Also, in reading the articles they also often explain the phys, and patho-phys of the D/O being discussed, hence A LEARNING OPPRTUNITY FOR YOU! If you have trouble understanding this perhaps you should try another profession which uses finger paints as part of it's 'daily work'...

Yet, if you do understand the underlying, physiology, patho-physiology, etiology, and DDX of the D/O’S, which cause seizure activity and are able to perform and understand how to do a full P/E & H&P, than there would have been ways for you to ‘increase or decrease your index of suspicion’ as to whether your pt ‘was actually seizing’. If you don’t understand the preceding material then of course you wouldn’t be able to ‘tell’ real vs. fake!!

There is a difference between an ancidotal, friendly conversation about in-the-field observations and a systematic study of internet resources. This forum, and forums in general, generally serve the former.

Actually part of the purpose of the forum here in general in addition to 'field related anecdotal discussion' a number of us here try to provide other EMS clinicians with help, teaching, and the information which will help them be better clinicians, and more professional providers... It sounds like you are emulating a theory and position similar to anothe poster here "whit72," (try reading the 'glucagon thread) who also fails to realize that there is more to medicine than what you find in a BLS and or Paramedic text, and anecdotal stories are ok, but serve little purpose in either furthering the education of others, and have little to no effect on the realities of our job and the standards of care to which we are held.. many of us advocate a better educated, and better understanding of medicine across the board for our colleagues. Until you realize this, you will have a problem, and be part of what is wrong with EMS today and why we can't advance our profession and career to a position of 'respect' in the medical community at large.

To unload your 10 minutes worth of google searching on this forum says to me that you dont really care to have a conversation about a call' date=' you would rather shove a new user off elsewhere into the depths of data: suggesting that he'd better absorb the minituae of the subject before he is worthy, in your eyes, to come discuss it. [/quote']

No it is better for the poster and individual to know and understand the things I mentioned so that they will have a clearer 'idea' as to the who, how, what, why, etc.. their patient presented how they did. next, this will allow the individual to become a better provider. Sounds like your advocating continuation of the status quo and stupidity which runs rampant in our profession currently...

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Okay, I'm gonna step out on a limb here a big one and when I do it, I'll probably catch a TON of flack from you all as well as step on some toes, but anyway, I'm gonna say it.

GET OFF THE SEIZURE FIXATION !!!!!!!

First off, I'll tell you from personal experiences, not all seizures are as they seem. Depending on the type of seizure and area of the brain where it is coming from the person may not have your "typical" seizure. In class the subject of seizures is truly just glazed over, and well, all they think you will ever see is tonic clonic activity, despite the fact that there is over 60 different types of seizures. Here's a little education.

Absence - person has NO post ictal period, seems like they are day dreaming for brief seconds, may have hundreds a day characterized by rapid eyelid fluttering during the episode. May be induced by hyperventilation.

Complex Partials - impaired consciousness, may seem like they are doing purposeful activity like chewing, fumbling with clothes, but actually are not (process is called automatisms), may even seem to be combative if restrained. May last from a few minutes to several hours and the person may have several in succession called clustering. Typical come from the temporal lobe, but may come from any area. May progress into generalized seizures. Typically have warning called aura before hand.

Simple Partial - not impaired consciousness, isolated body part affected (may be finger, arm, hand, etc). May happen several times a day. No aura is usually present. Normally self limiting.

Generalized Seizures - full body tonic clonic activity usually synchronous on both sides, may be initial or from complex partial which has spread. May originate from any area in the brain. Post ictal time may be from several minutes to several days depending on severity and length of seizure. Corneal reflexes diminished or not present, fixed gaze with or without deviation, eyes typically open, mouth open during tonic phase, clenched during clonic, and patients are typically tired post ictally. However, IF the seizure initiates in the frontal lobe there may be little or no post ictal period, bizarre features like bicycling, thrusting, sexual like movements may be present, very difficult to control, activity difficult to detect via EEG without specialized equipment (ie specially placed electrodes), and are most likely to go into status. Patients are frequently combative during/after seizure episode.

There are several other variations of seizures, but this is just an overview. There is truly such a thing as pseudo seizures which are a stress response to the body as well as factitious disorder (munchausen syndrome) where the person fakes an illness to assume a sick role. Difference is people with pseudo seizures are not consciously faking the seizures, and normally have been treated with medications for epilepsy for several years prior to diagnosis. It is frustrating for them as they are trying to control something that is difficult to treat as there are few psychiatrist/psychologists willing to tackle it.

How do I know this? I myself went through the difficulty of being MISDIAGNOSED for over three years with multiple ER docs saying I was faking because I worked in healthcare and had knowledge of seizures which is common with those with pseudo seizures to have. However, after extensive investigation and an incident in which a deprivation of medication induced an episode of status which allowed them to video tape and EEG the event at the same time was it determined I was having epileptic not pseudo seizures. Now several years later after being treated appropriately, I am seizure free and live my dream of working in fire and ems, something I nearly lost due to people's lack of knowledge. I was treated rudely by medics who thought I was faking, even told to stop faking my some that I thought were friends of mine. It nearly cost me more than one job and I had to fight to overcome that stigma and even though I have been seizure free for a significant time now, it is something that is not easily forgotten.

Bottom line, yes I know it's frustrating, and I've had patients that I was fairly sure were faking, and we had big issues with that in our county, but if you have any doubt, treat them right and treat them well and with respect. You will not regret it, and even if they were faking for attention, for that minute, they were treated like a person. Now, let's let the issue rest shall we? A good site to visit is the epilepsy foundation of america's website and read their section on info for first responders. Browse the area and read the message boards. Site is www.efa.org Check it out

Oh, and the hormone which the level elevates following seizures is called prolactin. It increases with tonic clonic but not simple partials and is variable reliability in complex partials and absence seizures as it may or may not be increased.

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