Pt faking seizure

[STXmedic]

Type it in word, then copy and paste.

And a cardiac rule-out isn't somebody who needs to be seen over PNES? Explain? Are they that severe as to warrant back-seating somebody with a potential acute coronary syndrome?

 

[Dada Simba Detuned]

You are assuming that I am choosing to be your patient...

which is not usually the case. I let someone call an ambulance about 3 weeks ago voluntarily because I had a noro-virus type of infection and could not stay hydrated and needed IV hydration.

The rest of the time OTHER people call and my choices are to comply or be "Section Twelved" (in MA). My PNES scare people and/or they have potential liability concerns that require them to call 911 as part of their job. So I comply because I basically have to or I get committed. I don't CHOOSE to get in the ambulance unless I'm told I will be taken against my will if I don't comply.

Simba

Pretty much this- what do you want from the health-care system, and why do you even go to the ER if 'conventional' treatments like benzos simply make it worse? What do you expect the ER to do for you? What do you expect me to do for you?

I'll show up. I'll listen to you if you're conscious and cooperative. I won't really care if you're associating me with some unknown 'trauma', because I won't be causing any, nor will I be assessing your genitals in any way other than a quick "incontinent y/n?" fashion. I have no problems letting you try and sign an AMA in the midst of your non-seizure contortions on the ground if you're willing, nor do I have a problem with transporting you to ER-triage or a bed with no interventions other than the LifeStare in place if you want me to do that (after all, you have a non-life-threatening, documented, visible condition for which conventional therapy doesn't help). I will ask you to stop contorting with my Verbal Versed and ask you to exercise the self-discipline you should have to avoid making dangerous thrashing movements. I will even give you some valium or versed to help you calm down if you ask me for it, if that's what you want. I give it for anxiety quite often, and it usually helps. I don't even need to use a needle if you don't want an IV or IM injection.

If you're uncooperative and CAOx4, I don't have to take you if you don't want to go. That's not a problem.

If you're wanting to go and you are uncooperative and/or dangerous to yourself and others...that's where we have problems. I'll take you, but it's going to be on my terms. You're going to end up non-harmfully restrained if you decline chemical sedation with a rational reason. If you don't convey a rational reason or you're simply unsafe, then you will be sedated for your (and my!) protection.

Yes, this is tough on you. It's also tough on us. I don't like being forced to cater to the whims of a tiny segment of my patient population who uses their medical history as an excuse to be aggressive towards me and my partner, nor do I particularly like people who try and clog up ERs needlessly for known non-life-threatening conditions that they know the ER can't manage. You'll never know it though- I'll treat you with the same courtesy, respect, and action that everyone else gets.

I ran a conversion-disorder patient last month. 16 y/o F, semi-controlled movements on the floor of a drama classroom (yes, I know), GCS 15 CAOx4, demonstrated gross controllable neuro/motor function. I tried 5mg of Versed based on her "sometimes it works", and it didn't "it's like hot lava in my nose!" She'd only had it happen a few times before and she was under standing orders from her neurologist to be evaluated during and after each event per mother, had a few psych meds proscribed. Ended up with her gently restrained by her own request before we even loaded her up to keep her from putting her hands through my cabinets, even took her BFF as a third-rider to keep her calm and entertained (he was 18, so legit). I listened to her, did what she wanted, and took care of her within the EMS system to the best of our capability, and she was fine.

 

[Aidey]

You practiced health care related law, I'm surprised you haven't figured out a way to avoid being transported and not have a section 12 invoked.

 

[Dada Simba Detuned]

So you are again judging me...

What do you know about how many years I have worked more than 40 hours a week and paid into the social security system. Do you know how many hours a week I work right now WITH my PNES? I'm sorry that you feel that I am not entitled to live and work with a medical condition that is currently beyond my control, but that is really your problem not mine. Try not to take it out and me and others like me when you are doing your job!

I think that a lot of your problem is that your (legitimate?) medical concern is also used by a massive, massive portion of our patient base as an excuse to literally sit around and collect welfare/disability in excess of our partner's paychecks, verbally and physically abuse us, clog emergency rooms with diagnosed non-emergent conditions and try and get free highs from high-dose controlled substances. Is it flawed that EMS providers apply human prejudices to their patients? Yes, but it is unavoidable.

You really get SSDI for what are essentially severe panic attacks with associated partial loss of muscle control? Retirement just got easy.

 

[RocketMedic]

You could compose your reply in Word and copy/paste it in...

If you're aspirating or suffering from acute complications, you're going to end up getting Real Medicine. Psychotherapy and other fields are great for fixing long-term mental-health problems, less so for preventing acute physiological death. If you present to us as a complete unknown, we're going to treat you based on the most-likely and most-common causes of symptoms until we have more information.

Also, "trauma" makes us think of things far worse than pats on the back. You're not suffering from trauma. You're suffering from psychological reactions to past insults that may have included trauma. When you use the word 'trauma', you put thoughts of traumatic brain injuries, bleeds, etc into our minds.

Us- "Hey, he's seizing...or at least moving oddly. What do you think, partner?"
You- "I experienced a TRAUMA! and I'm having a PNES incident!"
Us- ??? Like a fall? Help me out here, what's going on?"
You- "A TRAUMA!"
Us- "Well, we have an unknown here."

That's what you're dealing with when you come across people who don't know what PNES is, or are not provided with the information to pick that out. As horrible as it sounds, emergency medicine is not built to screen zebras and gazelles from the herds of cloven animals. When I see ALOC + a report of a seizure or seizure-like activity, it's a seizure until otherwise proven.

 

[Dada Simba Detuned]

It's a liability problem

there is currently no definitive way to rule out epilepsy in PNES patients, so during any given PNES episode I could be having an epileptic episode. When I try to refuse transport I am told that I do not have that option, so I comply. No health care provider who I have asked is willing to give me anything to facilitate the process of denying emergency care... mostly due to liability concerns... because I MIGHT be having a hypoglycemic or epileptic seizure and that don't want to be liable if something bad happens when I refuse treatment.

You practiced health care related law, I'm surprised you haven't figured out a way to avoid being transported and not have a section 12 invoked.

 

[RocketMedic]

Type it in word, then copy and paste.

And a cardiac rule-out isn't somebody who needs to be seen over PNES? Explain? Are they that severe as to warrant back-seating somebody with a potential acute coronary syndrome?

In 3-15 hours, he's stabilized.
In 3-15 hours, that "hmm, I feel a little odd in my stomach and my chest hurt a bit a while ago" turns into a full-blown cardiac arrest. I watched it happen to my father-in-law- no tryponin, no ECG changes until the Fatal Death Spiral of NSR-Stach-Vtach-VF-asystole. I won't be leaving anyone in triage with even a hint of cardiac complaint to give emotional trauma a bed.

Psychological disorders = a bad day requiring mental health care.
Cardiac disorders = death/real disability.

 

[Aidey]

Um, yeah. You still have the option to refuse. Even if it is an epileptic event you can refuse. People do it all the time.

 

[Dada Simba Detuned]

agreed...

If I'm aspirating, I want you to treat me like any other patient who is aspirating.

And the nomenclature point is a good one... mental health and PTSD health professionals and survivors use the word quite differently than first responders (I've worn all of those hats at some point).

When I use the word "trauma reaction" I mean a state similar to shock that is precipitated by current stimuli (internal and external) that trigger physiological reactions that are likely due unresolved emotions about past "trauma." Does that make sense?

You could compose your reply in Word and copy/paste it in...

If you're aspirating or suffering from acute complications, you're going to end up getting Real Medicine. Psychotherapy and other fields are great for fixing long-term mental-health problems, less so for preventing acute physiological death. If you present to us as a complete unknown, we're going to treat you based on the most-likely and most-common causes of symptoms until we have more information.

Also, "trauma" makes us think of things far worse than pats on the back. You're not suffering from trauma. You're suffering from psychological reactions to past insults that may have included trauma. When you use the word 'trauma', you put thoughts of traumatic brain injuries, bleeds, etc into our minds.

Us- "Hey, he's seizing...or at least moving oddly. What do you think, partner?"
You- "I experienced a TRAUMA! and I'm having a PNES incident!"
Us- ??? Like a fall? Help me out here, what's going on?"
You- "A TRAUMA!"
Us- "Well, we have an unknown here."

That's what you're dealing with when you come across people who don't know what PNES is, or are not provided with the information to pick that out. As horrible as it sounds, emergency medicine is not built to screen zebras and gazelles from the herds of cloven animals. When I see ALOC + a report of a seizure or seizure-like activity, it's a seizure until otherwise proven.

 

[RocketMedic]

there is currently no definitive way to rule out epilepsy in PNES patients, so during any given PNES episode I could be having an epileptic episode. When I try to refuse transport I am told that I do not have that option, so I comply. No health care provider who I have asked is willing to give me anything to facilitate the process of denying emergency care... mostly due to liability concerns... because I MIGHT be having a hypoglycemic or epileptic seizure and that don't want to be liable if something bad happens when I refuse treatment.

If I read this right, you're asking for medications and an AMA? That's a lot of liability on us.
If you're alert and oriented to your condition and your situation and you're not dying, I have no problem letting you go about your twitchy business.
"Do you want to go to the hospital? No? Bystander, it's ok, he doesn't want to go." Problem solved. If you want random injections of calcium and then to be released...well, I'm not doing that. You either ride the train or you don't, and asking a paramedic with 2.5 years of votech to start using his drug box in a way that will make him unemployed in a hurry is not going to get you too far with off-label drug uses.


Also, IV rehydration due to norovirus isn't exactly an emergency for most folks. Asking for unique, personalized care and then using the EMS system for urgent-care or sick-call matters isn't exactly the way to make your local paramedics think "wow, this guy has a totally legitimate medical complaint."

 

[Dada Simba Detuned]

Um... not in MA

If I try to refuse, they will physically force me to go... possibly precipitating an even more severe PNES... which leads to involuntary hospitalization and commitment with benzos and haldol... been there, done that... until you try to refuse care/transport under my circumstances in my city and state please don't tell me what my options are.

Um, yeah. You still have the option to refuse. Even if it is an epileptic event you can refuse. People do it all the time.

 

[RocketMedic]

If I'm aspirating, I want you to treat me like any other patient who is aspirating.

And the nomenclature point is a good one... mental health and PTSD health professionals and survivors use the word quite differently than first responders (I've worn all of those hats at some point).

When I use the word "trauma reaction" I mean a state similar to shock that is precipitated by current stimuli (internal and external) that trigger physiological reactions that are likely due unresolved emotions about past "trauma." Does that make sense?

When I think trauma, I think of something damaged or disrupted physically, ie "that humvee transmission was just propelled through your torso" or "hmm, that looks a lot like a concussion" or "hmm, that seems like a tear of something." Not 'unresolved emotions about past trauma.'

To be honest, if I found you in an urban setting with you babbling on about trauma and PNES, I'd probably be looking for a fall or something as an MoI. "Psych problem" covers your complaint far more accurately in the emergency medical lexicon.

 

[Aidey]

You, someone with a legal education, are telling me it is perfectly legal to be physically forced to go to the hospital where you are not a threat to yourself or others and are legally competent to make decisions? I find that extraordinarily had to believe.

 

[Dada Simba Detuned]

I personally do not have a Dx of fibro

But some of the medical literature shows a correlation. It's not clear whether the fibro is considered to be "psychogenic pain" for those patients or not.

I DO have chronic pain, but I'm almost fifty and have had a bad colles fractures with subsequent complications and surgery, hip and knee surgery after a bad car accident, and multiple sports injuries and injuries sustained while riding as an urban bike commuter. So most of it is not of unknown etiology!

Simba, I'm curious if you have also been diagnosed with fibromyalgia. Anecdotally, I often see PNES along with fibromyalgia and was curious if there was any details on connection/causation between the two.

 

[RocketMedic]

If I try to refuse, they will physically force me to go... possibly precipitating an even more severe PNES... which leads to involuntary hospitalization and commitment with benzos and haldol... been there, done that... until you try to refuse care/transport under my circumstances in my city and state please don't tell me what my options are.

Um...you literally must be doing something wrong. AMAs are fairly legal across the nation.

 

[the_negro_puppy]

there is currently no definitive way to rule out epilepsy in PNES patients, so during any given PNES episode I could be having an epileptic episode. When I try to refuse transport I am told that I do not have that option, so I comply. No health care provider who I have asked is willing to give me anything to facilitate the process of denying emergency care... mostly due to liability concerns... because I MIGHT be having a hypoglycemic or epileptic seizure and that don't want to be liable if something bad happens when I refuse treatment.

long term EEG?

May I ask how many times have you been to hospital in the last 12 months with your condition?

Why did you need an ambulance ride for vomiting / norovirus? why didn't you get a ride to the ED if you needed IV hydration?

I view PNES in a similar fashion to people who self-harm by 'cutting' or other means. Many people do this to deal with 'trauma' and for other reasons.

If it is a psychological condition in which you, yourself are experiencing harm (banging head on concrete) and attending hospital frequently, perhaps you would be safer as an inpatient in a psychiatric facility?

I often see some people with chronic health problems (including psychological) identify so much with their condition that it becomes their life. When they are not at their doctor or the hospital every second day for their condition, they are spending time "raising awareness" or telling everyone online on the street about their condition, possibly trying to invoke pity and attention.

 

[Dada Simba Detuned]

You're welcome to come hang out with me in Boston and come along in the truck...

... the next time I have a PNES! I don't like it (at all) and neither do most of my health care providers... but such is the state of our current health and legal systems (part of why I retired from the practice of law). :glare:

You, someone with a legal education, are telling me it is perfectly legal to be physically forced to go to the hospital where you are not a threat to yourself or others and are legally competent to make decisions? I find that extraordinarily had to believe.

 

[Wheel]

You, someone with a legal education, are telling me it is perfectly legal to be physically forced to go to the hospital where you are not a threat to yourself or others and are legally competent to make decisions? I find that extraordinarily had to believe.

I agree. If you are A&Ox4 and can coherently explain your history and reason for seizure, you are free to sign the refusal. I think there may be something else going on in the situations if she is being physically forced to go to the hospital.

 

[RocketMedic]

I strongly, strongly doubt Boston EMS is in the habit of involuntary detention, kidnapping, assault and battery.

 

[systemet]

there is currently no definitive way to rule out epilepsy in PNES patients, so during any given PNES episode I could be having an epileptic episode.

The links / articles you posted earlier seem to suggest that you could dstinguish the two by the absence of epileptiform activity on an EEG during an observed episode.

Granted, each new episode could represent a potential new-onset epilepsy, but if you're conscious and making purposeful movements during these episodes, then it's certainly not a tonic-clonic or 'grand mal' seizure. It might resemble a "psychomotor" or complex-partial seizure, psychosis, or a drug-induced state.

When I try to refuse transport I am told that I do not have that option, so I comply. No health care provider who I have asked is willing to give me anything to facilitate the process of denying emergency care... mostly due to liability concerns... because I MIGHT be having a hypoglycemic or epileptic seizure and that don't want to be liable if something bad happens when I refuse treatment.

A hypoglycemic episode should be fairly easy to determine. You measure a blood glucose level. Granted, there could be some concern that you've seized due to a low glucose level and now the glucose has come up, but if you can explain your history it might be helpful.

I would also be reluctant to sign a refusal of care form on you, if you're having a PNES episode, because I don't want to be responsible if something happens to you later.

That being said, if you can tell me in a calm and lucid manner that what I'm seeing is your previously diagnosed chronic health condition, that it's similar to previous episodes, and that you have someone responsible who can monitor your condition, and you have the means to call me back if you need further help, then I'd be willing to sign you off.

You state earlier that you have a legal background. If you refuse my treatment, which you're entitled to, then I have to demonstrate that you're incompetent. And then I have to call a police officer, convince them that this is the case, and that they should arrest you and accompany me to the hospital. If you're lucid and alert throughout all of this and can demonstrate your competence, I can't kidnap you.

The problem, I assume, is that these episodes impede your ability to communicate and demonstrate that you're competent? This must be very frustrating.