Seizure with 27 YR old and Consent

[8jimi8]

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.

 

[Aidey]

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.

 

[8jimi8]

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.

 

[reaper]

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.

 

[Aidey]

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.

 

[Aidey]

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.

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.

 

[8jimi8]

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

 

[Hellsbells]

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.

 

[MasterIntubator]

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

 

[FLEMTP]

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.