Seizure with 27 YR old and Consent

[livewiremaxx]

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

 

[thatJeffguy]

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.

 

[rescue99]

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

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.

 

[fast65]

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?

 

[mar7967]

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.

 

[Aidey]

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.

 

[Sassafras]

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.

 

[rescue99]

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.

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.

 

[Aidey]

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.

 

[8jimi8]

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.

 

[Fox800]

Should not have got a refusal on this pt.

 

[livewiremaxx]

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.

 

[tramachick]

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.

 

[Fox800]

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.

 

[reaper]

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.

 

[Sassafras]

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).

 

[looker]

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.

 

[Aidey]

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?

 

[8jimi8]

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.

 

[Aidey]

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.