# Seizure with 27 YR old and Consent



## livewiremaxx (Aug 9, 2010)

Came across this call the other day.  Had a 27 yr old male who was having his second seizure in 2 weeks.  The first came after a skating accident into a pole, and has a history of seizures.  Is on Dilantin, pulse 104 bp was 150 / 90.  Myself and another EMT were on scene first before our medics.  The Pt. was in his postictal state after a 3 min seizure.  Not combative, but wanting to get up, get into his bag, confused and dazed. 

Medics arrived o/s per our policy - asked him the date, place and nuero questions.  He said it was 2009, but had the other questions correct.  Still dazed though.  He was asked if he wanted to go to the hospital and he said yes, He had his parents there as well (he lived with) the option to go POV or by ambulance.  He just wanted to go in and the parents said they have had problems getting him to go in after he has had seizures in the past and gets un treated.  The medics though gave the choice to the Pt. if he wanted to have the parents take him in or go in with us.  Dazed he chose to go in with the parent and car.  The Medics we were working with left it as that and departed.  

So my question is, what would you do or would this be appropriate.  The EMT I was with agreed with my assumption in saying that he was not in a mental state to make such decision for consent or release and should have deffered to family members who wantged us to take him in.  He had been getting seizures more frequently recently and should have seen a doctor about it. In  our department and much any other the medics on scene make the decision.  Would you have done the same choice?

Just throwing this out there as a discussion.  have a great day everyone


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## thatJeffguy (Aug 9, 2010)

Good question...

If you think someone needs to be treated, but the family states that they'll be taking them to a M.D. in their POV, how do you proceed?  

I'd probably obtain a refusal and note on the refusal "Pt. states they are proceeding to XYZ hospital immediately and will seek medical attention there." and have them sign/initial that area.


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## rescue99 (Aug 9, 2010)

livewiremaxx said:


> Came across this call the other day.  Had a 27 yr old male who was having his second seizure in 2 weeks.  The first came after a skating accident into a pole, and has a history of seizures.  Is on Dilantin, pulse 104 bp was 150 / 90.  Myself and another EMT were on scene first before our medics.  The Pt. was in his postictal state after a 3 min seizure.  Not combative, but wanting to get up, get into his bag, confused and dazed.
> 
> Medics arrived o/s per our policy - asked him the date, place and nuero questions.  He said it was 2009, but had the other questions correct.  Still dazed though.  He was asked if he wanted to go to the hospital and he said yes, He had his parents there as well (he lived with) the option to go POV or by ambulance.  He just wanted to go in and the parents said they have had problems getting him to go in after he has had seizures in the past and gets un treated.  The medics though gave the choice to the Pt. if he wanted to have the parents take him in or go in with us.  Dazed he chose to go in with the parent and car.  The Medics we were working with left it as that and departed.
> 
> ...



The crew is dead wrong....this patient is not capable of making a sound medical decision at this point and it's irresponsible to suggest he go POV.


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## fast65 (Aug 9, 2010)

rescue99 said:


> The crew is dead wrong....this patient is not capable of making a sound medical decision at this point and it's irresponsible to suggest he go POV.



Agreed, from what you've told us, the patient did not seem to be in a mental state where he was competent enough to make that decision. Not to mention how panicked do you think his parents would be if he had another seizure while they were transporting him to the hospital?


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## mar7967 (Aug 9, 2010)

As with others on this forum, I hesitate to comment on questions like this without hearing both sides...

Assuming all of the facts are above, I would not have let this patient go POV. I don't think he is in any state to know what is best for him. The parents said that they have had issues getting him to go in before, and at this point, he is willing to go, so get him in the ambulance and get him to the hospital.


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## Aidey (Aug 9, 2010)

Ok, I'm going to get up on my soapbox for a moment. 

The ER is not a good place to treat chronic conditions aside from a few exceptions such as a sudden change in condition, or a significant acute change from baseline.

In the case of a seizure patient that would be things like a patient who normally has a seizure every 4 months had 3 in a day, or someone who has only ever had simple partial seizures has a generalized seizure. 

A gradual increase in seizures over weeks is something that is best addressed by the patients normal doctor, the one who knows the patient, their history and is familiar with their condition. 

If a person who has been diagnosed with seizures, has a seizure, and is being treated by his primary care doctor for those seizures there isn't a lot the ER can do besides test the patient's medication level and monitor them for a couple of hours. There isn't much "after seizure" treatment that can be done. The ER can do further assessment, like MRIs or CT scans, but they are still going to refer the patient back to their normal doctor. I frankly don't blame seizure patients for not wanting to go. 

I can't say I would have done the same as the medics did, but I also have let parents/spouses take post-seizure patients POV. It is all situational.


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## Sassafras (Aug 9, 2010)

Aidey, my thoughts are, he still needs to go to the ER for a lab draw to see if his medication is even at a therapeudic level or not.  Did he miss a dose and simply forgot and is this why he is seizing?  Does he need his medication adjusted?  If so an ER can find this information out with a simple blood draw and a lot of times the labs will be back much quicker than if done in a doctor's office.  There's a reason he is seizing in spite of being under treatment w/ a physician and an ER may be able to find that, and will be able to find it if it is an accute cause.


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## rescue99 (Aug 9, 2010)

Aidey said:


> Ok, I'm going to get up on my soapbox for a moment.
> 
> The ER is not a good place to treat chronic conditions aside from a few exceptions such as a sudden change in condition, or a significant acute change from baseline.
> 
> ...



Yes, I think letting him go home without the benefit of a med level or evaluation is just fine....if one does not mind dying in his sleep from a seizure. 
The risk of that happening is quite real even without it being a woulda-coulda-shoulda situation. He needs an evaluation. 

 Sorry, I don't agree that this man is clear headed enough to sign off and as we all know, acute changes usually means something's up. Yer right though, it can be situational. This just isn't one of those cases IMO.


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## Aidey (Aug 10, 2010)

Again, I didn't say I would have let this guy go POV. My soapbox statement is directed more towards people who think every patient with seizures needs to go to the ER after every seizure. Treatment doesn't eliminate all seizures in all patients. Some people with continue to have seizures no matter what their primary doc or neurologist does. So the fact he had a seizure doesn't necessarily mean something is going on beyond his underlying condition.

Please don't fearmonger. Someone could be seen by the best neurologist in the world and die in their sleep from a seizure that same night. For most people their seizures can't be predicted, and dying from a seizure is always a possibility some people have.


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## 8jimi8 (Aug 10, 2010)

Aidey said:


> Again, I didn't say I would have let this guy go POV. My soapbox statement is directed more towards people who think every patient with seizures needs to go to the ER after every seizure. Treatment doesn't eliminate all seizures in all patients. Some people with continue to have seizures no matter what their primary doc or neurologist does. So the fact he had a seizure doesn't necessarily mean something is going on beyond his underlying condition.
> 
> Please don't fearmonger. Someone could be seen by the best neurologist in the world and die in their sleep from a seizure that same night. For most people their seizures can't be predicted, and dying from a seizure is always a possibility some people have.



And he may not go straight home.  He may go from Ed to the epilepsy monitoring unit.


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## Fox800 (Aug 10, 2010)

Should not have got a refusal on this pt.


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## livewiremaxx (Aug 10, 2010)

Thanks everyone for their replies.  It gave me a lot of thigns to think about and a way to approach the head medic on the call in regards to asking why he made the decision he did.


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## tramachick (Aug 11, 2010)

Well I think it more depends on how the parents felt about taking him. He defiantly needed to go to the hospital, but I wouldn’t want to put the parents in a situation where they felt uncomfortable. I would find out how they felt about it and use that to help make a decision.


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## Fox800 (Aug 11, 2010)

tramachick said:


> Well I think it more depends on how the parents felt about taking him. He defiantly needed to go to the hospital, but I wouldn’t want to put the parents in a situation where they felt uncomfortable. I would find out how they felt about it and use that to help make a decision.



While their input is certainly valid, they don't get to decide the outcome of this situation. The patient is an adult, therefore you are bound to transport him under implied consent.


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## reaper (Aug 11, 2010)

Fox800 said:


> While their input is certainly valid, they don't get to decide the outcome of this situation. The patient is an adult, therefore you are bound to transport him under implied consent.



Was waiting to see who would catch this. If the pt is not able to make a decision on his own, you make it for him. While you can take into consideration what the parents would like. They have no legal say in it.


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## Sassafras (Aug 11, 2010)

I agree about the fearmongering but the thing that tipped me that labs need drawn on this patient is that his seizures are increasing (albeit slowly, but still something has changed).


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## looker (Aug 11, 2010)

Having family member with epilepsy it sounds like medic made the right call. Usually once they recover from seizure they are okay. What his mom said is normal as they do not remember having a seizure and will not want to go to the hospital. Instead of ER pt needs to see his personal doc ASAP to check medication level. Basically he needs to get blood test and maybe medication adjustment.

edit:Not emt or medic. Owner of ambulance company and have personal experience/knowledge with this illness.


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## Aidey (Aug 11, 2010)

Sassafras said:


> I agree about the fearmongering but the thing that tipped me that labs need drawn on this patient is that his seizures are increasing (albeit slowly, but still something has changed).



I do agree with you. The question is does a slow increase in seizures warrant an ER visit or a GP visit?


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## 8jimi8 (Aug 12, 2010)

Aidey said:


> I do agree with you. The question is does a slow increase in seizures warrant an ER visit or a GP visit?



If you don't know why the seizures are increasing, it deserves a few nights in the EMU.


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## Aidey (Aug 12, 2010)

So all testing should be done in hospital? Even if it is as simple as a med level check? In some cases would it not be appropriate to run tests like med level checks out of the hospital, and then if the tests come back within therapeutic limits to then discuss admission to an EMU? 

A patient who normally has 1 seizure a month has 3. I find it hard to believe that admission to the hospital is is the most appropriate move without other things having been done first.


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## 8jimi8 (Aug 12, 2010)

Aidey said:


> So all testing should be done in hospital? Even if it is as simple as a med level check? In some cases would it not be appropriate to run tests like med level checks out of the hospital, and then if the tests come back within therapeutic limits to then discuss admission to an EMU?
> 
> A patient who normally has 1 seizure a month has 3. I find it hard to believe that admission to the hospital is is the most appropriate move without other things having been done first.




It is already determined that the patient needs to go to the hospital.  The resultant lab levels will determine the need for admission or not. 

i'm not saying everyone needs to go to the EMU.  Sorry i know i stated it that way.


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## Aidey (Aug 12, 2010)

Ok, that does make more sense.

I still will maintain though that not all seizure patients who experience a slow increase in seizures need an ER. It does absolutely depend on the patient and their specific circumstances, but I don't believe in the blanket idea that all people who have a seizure need to go to the ER.


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## 8jimi8 (Aug 12, 2010)

Aidey said:


> Ok, that does make more sense.
> 
> I still will maintain though that not all seizure patients who experience a slow increase in seizures need an ER. It does absolutely depend on the patient and their specific circumstances, but I don't believe in the blanket idea that all people who have a seizure need to go to the ER.



So what circumstances would you not transport a seizure?  Please keep in mind, I don't consider myself the authority on this board, that's why i make small points and ask questions.


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## reaper (Aug 12, 2010)

8jimi8 said:


> So what circumstances would you not transport a seizure?  Please keep in mind, I don't consider myself the authority on this board, that's why i make small points and ask questions.



You will find a lot of epileptic pt's will refuse to be transported. They know their condition better then you do. They have lived with it, most for their entire lives. If they know that it was a break through seizure, they do not want to go to the ER. The ER will do nothing for them. They will tell their neurologist and go from there.

Now, I treat them like a diabetic. They will not be allowed to refuse, unless fully alert and oriented. Plus, there must be someone with them, to keep an eye on them.

I think that is the point that is trying to be made. The ER will not do a lot for an Epilieptic. They may check levels, but will not adjust medication. That will be left to the Pt's Dr to decide.

This is a decision that must be made very carefully. You have to take a lot into consideration. But, always remember. If the Pt is alert and able to make their own decisions, you cannot force them to go. It is still their choice. We can advise them and give them options. It is still their choice to make.


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## Aidey (Aug 12, 2010)

It is situational, and I tend to approach it the same way as I approach  hypoglycemic patients. I have kind of a mental check list that applies  to either one (or really any other chronic condition that can have acute  flare ups, like asthma). 

 First off, does the patient have a history, and who called? What  preceded the situation? Trauma? Stress? Flashing lights? What is the  patient's normal baseline (one seizure a month, one a year, none since  starting medication). What type of medication is the patient taking? How  fast is the situation resolving? What do the patient's vital signs look  like? Were there any secondary injuries sustained (bitten tongue, fall  trauma).

 I look at the patient over all, does the patient look like they have the  ability to take care of themselves? Do they have their medications and  are they taking them? Do have a primary doctor to call? 

 This is a patient we left at home, which kind of illustrates how my thought process works. 

 18 year old female, at college living in the dorms (family is in the  area). She has a witnessed seizure in her dorm room while sitting on her  bed. Her roommate called 911, and described a generalized seizure (I  don't remember the exact details of length or progression). Pt was  nearly totally alert and oriented when we arrived, and within a few  minutes had GCS of 15. 

 She had been diagnosed with epilepsy as a kid, documentation was on file  with the dorm Resident Manager. She told us she had seizures around  once a month, and they were generally triggered by stress or illness. It  had been a few weeks since her last seizure, and it was the beginning  of midterms that week. I can't remember her meds or vitals, but I there  wasn't anything crazy (like a pulse of 160 or something). She had been  sitting on her bed and hadn't suffered any injuries. 

 The patient didn't want to go, and hadn't gone to the ER for seizures in  some time. She volunteered to call her parents and her doctor in the  morning. Her roommate knew she had seizures, but had never seen one  before and fully admitted to panicking when she saw it and called 911  automatically. 

 So essentially, the pt experienced a seizure that was normal for her  without any complications and she didn't want to be transported. 

 Now, had there been concerns about any of the above issues, I likely  wouldn't have agreed with the no transport. Even the fact that the pt  was local played part, because a college student who isn't local may not  have had a GP in the area that they could go see, meaning they may not  have been able to get prompt follow up.*

 There are a ton of variables...Say this was the patients second seizure  in a week, but she had already scheduled an appointment with her doctor,  and it was the next day. I would be comfortable with her refusing  seeing as she is being proactive about addressing the issue. 

 When it comes down to it, it really depends on the patient, what is normal for them, and what they want to do. 

I guess my core point is that in some patients seizures are normal, that is their baseline. So part of your assessment should be determining if what they experienced is a deviation from their baseline or not. 



  * If patients without GPs continue to refuse transport I will usually  take the time to track down the names/phone numbers of the student  clinic, or the local walk in clinics, or low income clinics or whatever  it is that suits them.


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## Aidey (Aug 12, 2010)

reaper said:


> You will find a lot of epileptic pt's will refuse to be transported. They know their condition better then you do. They have lived with it, most for their entire lives. If they know that it was a break through seizure, they do not want to go to the ER. The ER will do nothing for them. They will tell their neurologist and go from there.
> 
> Now, I treat them like a diabetic. They will not be allowed to refuse, unless fully alert and oriented. Plus, there must be someone with them, to keep an eye on them.
> 
> ...



Figures someone would say what I wanted to while I was spending 2 hours making sure my reply made sense, lol.

I find it interesting you approach them the same way as diabetics; I'm comforted when I'm not the only one who thinks about something a certain way.


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## 8jimi8 (Aug 12, 2010)

Thanks you two.  I feel comfortable with those thought processes.


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## Hellsbells (Aug 12, 2010)

My only concern with this pt would be that he had the skating injury with a pole a couple weeks back. Was that a head injury? If so it could explain the recent increase in his seizure activity, did he have follow-up medical Tx for that injury? My decision for transport would rest on the answers to those qeustions.


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## MasterIntubator (Aug 12, 2010)

I don't think I saw this answer on here yet... ( and it was there... my bad for repeating it.. )

Med control.  Why put that liability on us?  If the person is not coherent, and we did not do *everything in our power as a typical provider would* ( court terms ), that can damage you. ( and you better bet they will hold those professional standards high, and will use professional references with our textbooks... and if you deviate, at least have an acceptable reason why )

Things like make an extra effort to contact family. 
Get med control and advise them... 1 - its a recorded line.  2 - If he gives you an order, you ( at least we can ) can summons law enforcement for an emergency detainment order.  Sure, the pt won't be happy.... not my problem.  But if the pt is bad enough to raise a flag in my head and could potentialy injure or harm themselves or someone else... you bet I am gonna cover myself very well.  Been thru it... court sucks.... depositions suck...  the documentation saved my gluteous. 

Most of my court cases came from drunks/stressed folks who don't remember signing a refusal/or agreeing to treatment and call foul play.  Your documentation will play the biggest role in your life on the outcome. ( and that includes documented witnessess, like law enforcement... so that they too can get sucked in the legal vortex that should be on our side. )

And I do agree with the one post... where there are 2 sides to the story.  And its best to get them all, accurately.  Some of my cases were mere misunderstandings and uneducated complaints because of someone thinking it should have turned out one way without all the facts.  ( one side gets that all the time. )

consensus facit legem

Peace


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## FLEMTP (Aug 12, 2010)

The way I look at it, is that the patient had a significant seizure (3 minutes) and has a history of recent trauma, and is still "dazed and confused"

If the patient is not completely alert, and orientated to person place time and event, then they get transported. 

I know that if I were in the patient's shoes, I would hope that someone would transport me to the ER via EMS. 

You have no way of knowing if the seizures are of the same etiology as his previous seizures, (especially given the recent trauma) or if he is compliant with medications, and the patient is really not in any condition to give you an accurate history.


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