Let's Go to the Tape

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Mark Glencourse at 999Medic has an interesting post, Real or Fake about patients seizing or pretending to seize.

I had two calls recently involving seizures of curious origin. One, which deserves its own blog post at a later time (after the complaints are resolved), involved a young churchgoer who was “with the spirit.” The other was a school child who was arching her back and shaking her arms and rolling her eyes quite violently and quite at random.

Every Jerk and Twitch

Were they faking? I have learned in my reports to be as nonjudgmental as possible, simply writing a lengthy narrative notating each jerk and twitch as I saw it. I will say I saw no immediate medical need to give either patient Ativan.*

Still, these were difficult calls. Both performances were in front of large gatherings of concerned onlookers, including a nurse at both scenes as well as top authority figures, a pastor at one and a principal at the other. Each call required an extended extrication, one from the front row of the church balcony, the other out of a school auditorium. None of the onlookers were well experienced in or even aware of the art form of psuedoseizing. On both calls my partner had to leave me for a longer than comfortable period, one to get a stair chair, the other to move the ambulance to the back side of the building. I was left with “seizing” patients, large audiences and nothing to do. Yawning, doing my daily stretches or practicing tap dancing would hardly have been appropriate.

Demons! Be Gone!

If you are in the back of an ambulance with someone faking a seizure, it is one thing to say “Knock it off!” It is a bit more delicate to do so in front of an uncomprehending crowd. In the case of the church seizure, I considered and rejected, placing my hand on his forehead and commanding “Demons! Demons Be Gone!” The problem here was he was not in fact communing with a demon, but, according to the onlookers, with a higher spirit. I did attempt to talk to them (patient and spirit), placing my hands on the patient’s temples and asking if the two of them could find it in their hearts in the interests of safety as long as I wasn’t interrupting anything important, if they could adjourn so we could help him stand, and walk up to the corridor where our stretcher, a clean sheet upon it, lay awaiting his rest. To no avail.

The Tape

These episodes did remind me later, as I wrote my extended narratives chronicling every jerk, shimmy and coco-bop that a few years ago I had written a post suggesting that we be allowed to videotape our patients as they seized for later broadcast, not on You Tube, but for the patient’s ED doctor and consulting neurologist.

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“Let’s go to the tape…”

I feel more strongly today than I did back in 2006 when I posted New Frontier that if we can use digital cameras to capture pictures of crashed cars to show the trauma team, we can use video cameras to record our patient’s busted moves.

***

On a cautionary note, several years ago I attended an excellent presentation on seizures called a “Whole Lotta Shaking Going On” by noted EMS lecturer Bob Page that revealed to me that seizures are far more complex and varied than I had realized and that I had, in fact, on an occasion or two, mistaken a real seizure for an act. Here are my notes from that lecture;

Seizure Notes

* While neither patient got Ativan because I felt neither patient was seizing, in retrospect, a couple milligrams of Ativan for each would have made my life much easier and been more pleasing to the audiences (in addition to placating their howls) than simply allowing the patients to continue to perform.

In both cases, I should add, their “seizures” ended once they had been removed from their audiences.

7 Comments

  • Suzi Bernert says:

    Yeah – I got in trouble on that type of run for writing “appearance and severity of symptoms was dependent on size and composition of audience”. Don’t ya love ’em?

  • Laura says:

    Awhile ago, as a newly released EMT, I had a patient that was psuedo-seizing, and didn’t recognize it at the time. Turns out she had back spasms and wanted to get seen quickly.

    We hightailed it to the hospital, and about 1 mile out, got into a rollover accident that involved another government vehicle and two other cars. Thankfully there were no fatalities, but several were injured.

    I’m more likely to recognize “fake” symptoms now. I wish we didn’t need that talent.

  • Robert says:

    I thankfully work in an area where we get fairly few actors. The most “severe” I’ve written in a report was “Pt then complained of chest pain when advised that there was no medical outcome to his chief complaint”. Translation: He worked at dept store, unloading trucks. 10 minutes before the end of his shift, a large truck arrived, and policy was that he’d have to unload it before he could go home. However, in preparation for leaving, he’d just ingested a recreational substance, and was now annoyed that his buzz was going to be wasted moving boxes, not on his couch. He recalled that he had bumped his head 3 hours earlier on a loading dock and had reported such. Despite the lack of any pain, visible marking or deformity, he was now reporting dizziness and “near syncope”. Age 25. Vitals all normal, A/O x 3. Slightly skeptical, we asked what he wanted us to do… he moaned about not being able to get off shift… “Well, not sure what we can do about that, but the thing is, we’re not seeing anything we can really help you with, other than suggest you see your doctor”. He then discovered “severe chest pain”, right over his heart, which “felt like someone pushing the heel of their fist down on it”. Hmmm, yeah, okay…

  • Anon says:

    A few years back, I was a first aider at a large public event. I was called to young woman who was described as “fitting”. When I reached her, I recognised her immediately. I’m been an observer on an ambulance a few weeks earlier that had been sent to her for fitting. The crew treated her as protocol, but later told me she’d been faking, was a notorious faker and there was little they could do except make detailed notes.

    As I was attending the woman, I twice noticed her “peeking” and got fed up with what was quite clearly an attention-seeking act for the large crowd that had gathered around us. Under the guise of moving the crowd back, I quietly asked a teenager to give me a minute or so, then loudly say, “Jeez, is that car on fire or what?”

    I turned my attention back to the patient and as I did my “volunteer” obliged with my request—actually doing it far louder and with far more effect than I expected.

    My patient immediately sat bolt upright and said “Where?”

    She then remembered her act and laid down again, but the crowd were on to her and jeered. She got up, pushed her way through the crowd and ran off, followed by more jeers and laughter.

    Okay, it wasn’t protocol but it worked. (And no, I don’t make a habit of doing it.)

    I do wonder if she learned her lesson or if she’s still pulling her crowd pleasing routine.

  • 313 says:

    I deal with a number of both genuine and pseudo-seizures on a regular basis. My policy is to just treat the patient. If they are playing the game well enough I play along too. Regardless of its pathogenesis, if the tremors are enough to warrant treatment, I render treatment. If it seems like pseudo-seizures I’ll call med-con and let them know before I push a benzo.

  • medicscribe says:

    Excellent comments, thank you all.

    Suzi, I have thought of writing the same many times.

    Laura, we all get burned, more when we start than later, but it still happenes.

    Robert- Great story. We have a business in our town that gives people three days of if they fall at work, so we are constantly going there to pick up people laying sprawled on the floor who claim not to remember how they fell. On the way to the hospital they are always discussing their plns for the next three days.

    Anon- Great line, I wll have to try that.

    Thanks again for the comments,

    Peter C

  • Sarah says:

    I think it is sad you assume mu there are many kinds of seizures, have you seen them all? I started having seiruzes as a young child, my first eeg was normal the meds worked for a couple years then the seizures started again med change, eeg and mri ordered, both normal, I have had 65 mri,and eegs and all cameback positive on my 70 birthdayi had a surprise trip to Sweeden from my family and f riends. I had one on my third day there, the doctor immediately told me I hada seizure and he was going to run an eeg and mri I told him all the others came back normal even the sleep studies which I had seizures but none showed up on eeg. And he informed me that most seizures don’t show up on eegs because it happens so deep in the brain. I’m no doctor but why would anyone urinate themselves I have even deficated bad ride for thoze ems I dont understand why your not more trusting of the patient? I would love to never have one again to come back and see the fear I caused my grandchildren. What im trying to say is yes some of use have epilepsy, or pnes shouldnt we all get the same treatment and respect? And if they are making it up shouldn’t you as medical professionals, not demean and call them out,b et them help period! First do no harm is your motto right? And think if someone were treating yor family like that my mother god bless her soul got treated that way and I thank her everyday for fighting against the nay sayers. Everyone of us is different just like a seizur. Rant over go amongst your day

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