Anxiety/Seizure?

Glucatron

Glucatron

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Dispatched in midafternoon to 40yof with anxiety at a sheriff's office. On arrival we find her to be very shaken though not in a panic. She is clammy. Says she doesn't remember getting to there. Staff inform us she was panicking and shaking and talking very fast and wouldn't listen to everyone. We take her into ambulance. BP: 125/74, HR: 112, RR: 20, SPO2: 96. Glucose: 102. I don't feel like I handled this call well at all. First, I tried to get her to relax by telling her that we are here to help and that we will do anything we can for her. This did help. Then I asked, I feel, the worst question I could have. I asked her what has been going on with her life. She went on and on about her stresses (pretty legitimate ones, too). I redirected her focus to medical history, SAMPLE, etc... She was not having any pain. She had eaten lunch but couldn't remember exactly what it was. She said she had a history of "anxiety" and "mental problems". I attempted to get her to elaborate. She began to panic again about how she has been to the hospital so many times and has to pay them back and can't. I attempted to redirect her again by asking what medications she was taking. This is where it became strange. After I ask her this, (she has been staring at the back doors of the ambulance the entire time) she won't respond. She stares absently forward. Nothing will make her aware of me. I talk louder, take her hand, snap fingers, trapezius pinch finally, no response. At this point I'm thinking, is she breathing? She is. Then she comes back. Looks at me as if nothing had happened. Claims she doesn't remember that happening. Before I can ask further questions or take additional vitals she does it again. I alert my medic and we switch. Honestly, I do not remember what he did from there. So, the call started out seeming to be anxiety, then I began suspecting a partial seizure or psyche issues. How would you have dealt with this patient?
 
Why was she in the sheriff's office in the first place?

"She said she had a history of "anxiety" and "mental problems"" This is probably an explanation for just about all her symptoms.

To me this unexplained altered mental status. Nothing really to do for it other than monitor and transport.
 
Agreed. I'd just transport.

Here's the big question... did your medic do anything "paramedical"?
 
I agree with Chase about an absence seizure; definitely a possibility.

Glucatron said:
I don't feel like I handled this call well at all. First, I tried to get her to relax by telling her that we are here to help and that we will do anything we can for her. This did help.
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What makes you think you didn't handle this well?

Then I asked, I feel, the worst question I could have. I asked her what has been going on with her life.
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I would beg to differ about this. Why do you do say that this was the worst question you could have asked? Collecting information is an important thing to do, and this is a very valid question considering the situation.
 
Absence seizure is a possibility (zebra) but I'd lean towards conversion disorder (horse). Nothing wrong with asking the patient what was going on. If she didn't want to tell you, she wouldn't. Don't mistake your discomfort with the situation with a mistake.
 
If you ask people what's been going on, you have to be ready with the skills to talk about it. The only way to get those skills is to ask people to talk to you.

For some tips on what and how to say things in these situations, look up "therapeutic communication."

I think high stress and anxiety could possibly trigger an absence seizure but the most likely ship she sailed on it the psych boat. I'm with Kyle on the conversion disorder.
 
Not that I'm discounting seizures or "Monday morning quarter back"...ing you (is that the expression?)... but..

I don't quite understand why you (the OP) seemed quite set on redirecting the pt to topics other than her psych issues. I understand that there is a time and place for opening up some cans of worms. The potential for violence being a good example of times when digging can go wrong and when its perhaps best left for another time in another more controlled environment.

From what was described...that doesn't seem like the case. I could be misreading this a bit, but a good chat and a vent seems like it might be just what she needed.

The presenting problem and its friends, the co-presenting symptoms in addition to the hx surrounding them all is exactly what we're interested in for most pts. Why not this one? Whats going on in her life seems like a perfectly reasonable question given the presentation. If anything I'd make it more targeted to get to the point quicker but in general, it seems perfectly reasonable.

It does, of course, depend on the pt and the situation, as I've said, but I don't know that immediately moving to the ambulance with this presentation and then avoiding psych issues is what I would have thought of doing. I once spent 90 mins assessing and counselling a 70YOF suffering a somewhat complex psychiatric episode in her bathroom. We consulted with the area mental health service and flagged her for a geriatric psych team assessment first thing in the morning. Most importantly, we agreed on a care plan with the family involving a building a consensus on courses of action for several different eventualities and advice/reassurance about how to mange the situation. In total it was a solid 2.5 hours of talking. Sure that isn't every psych pt, but I just thought I'd throw it out as an example of alternative methods of assessment and treatment.

A psych issue requires psych assessments and psych treatments. I don't know that you need to be afraid of asking how her life is going. Redirecting her and asking her lots of questions about her asthma (for eg), avoiding the issue at hand seems silly. I'd say don't be afraid to properly and compassionately assess a psych pt for psych issues. Would you avoid questioning a pt on their cardiovascular hx if they had CP?


usalsfyre said:
Absence seizure is a possibility (zebra) but I'd lean towards conversion disorder (horse). Nothing wrong with asking the patient what was going on. If she didn't want to tell you, she wouldn't. Don't mistake your discomfort with the situation with a mistake.
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I don't know that conversion disorder is a horse. My understanding of it is that its reasonably rare and that existence/classification is still controversial.


Complex partial seizures, absence seizures +/- psych issues, conversion disorder, various combinations of drugs....they're all options. However, I hope this doesn't sound nasty, and I wasn't there to see the extent or nature of this episode of absence, but I think the possibility that she was putting it on in order add validity or a sense of seriousness to whatever else was going on has to be considered. I'd be the last person to write this pt off for malingering or attaching the potentially damaging labels of attention seeker or my pet hate: 'pseudo seizure'. I know enough about the world of psych issues and of seizure disorders to know how much we don't know; that there are some zebras out there that are not fully understood by anyone, let alone us. I think, however, the idea that it may all be something else somewhat more cynical but perhaps also far more simple and more common has to at least be considered.
 
Thanks for all of the replies. It's nice to know that my question wasn't a bad call. Sorry, it took me so long to reply!
 
Standing Takedown. Board and Collar. NRB with high flow 02. Bright lights.


No, it seems to me like you did a fine job. You took your pt seriously and did the best assessment you could and when you felt the situation warranted a higher level of care you asked for it.
 
Anyone have a reference as to how anxiety will bring on a seizure? "Me neither."

Conversion disorder, or simply having absence seizures plus being anxious, would each fill the bill since her glucose was WNL and no drugs involved.........

Did ok. Even if you aren't specially trained in therapeutic communication, a couple tips. Asking people what's wrong is ok, just be ready to listen and nod and take notes. Since you are not intervening and certainly are not acquainted with their case, you cannot give advice about changing their lives or therapies, but listening without judgement rarely goes wrong.

Except two ways. One, you JUST CANNOT stay quiet. Two, the pt looks at you and asks for an opinion. Either way, just be honest, say you aren't a counselor or a doctor, but you can see why they would be very upset or something like that.
 
This screams psyc/anxiety at me. Conversion disorder is definitely high on the list. My other thought was a hypocarbia induced "syncopal". Did she have any carpal pedal spasms? What was her respiratory rate? Only issue with this thought is she maintained enough muscle tone to stay upright, something I wouldn't expect in this case.

With that said I see no reason why you should feel badly about how you handled this call. Everyone's already covered it pretty well so I wont repeat everything that's already been said.

I agree with what SeeNoMore said as well. While this call doesn't require anything "paramedical", as n7 puts it :rofl: , it's something that you hadn't seen and were not comfortable with. Asking for help is exactly what you should have done. Did you talk to your partner about the call afterwards? This is a great opportunity to learn something new. From what you described this call is well within your scope of practice as an EMT, in my opinion, but it's not something you can handle if you don't know how.

Take it as a learning experience, don't beat yourself up about it and apply what you learned from the call, your partner (hopefully), the replies on this board and apply it the next time you run into a similar situation!
 
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