real seizure versus fake seizure

[fiznat]

Long post here but it was a good call, so....

My partner (ALS) and I (BLS, in medic school) responded to an "active seizure" yesterday, I'd like to see what you guys would have done differently.

On arrival we found a 17 year old female supine in bed in full tonic-clonic generalised seizure activity. The patient was nonresponsive to voice and pain (good, deep sternal rub). We noted the patient was incontinent to urine, frothing at the mouth with eyes in a fixed conjugate gauze to the upward right. PEARRL, not constricted or abnormally dialated. Skin was warm, pink, dry. Family on scene states (through a language barrier/translation) that the patient was in this exact seizing state for a full 45 minutes prior to our arrival. They said that this has happened once before, a month ago, and they assumed this would resolve on its own like it did last time. They denied, however, that the patient had any dx of any kind of seizure disorder. The patient is on no meds, and has no allergies.

We placed the patient on 15lpm O2 via a NRB, established an IV (18#, right AC). Blood sugar off of the IV was 108. Per protocol we gave 1mg Ativan IVP with no effect. A 2nd mg of Ativan IVP got the patient to calm down completely. Stair chair'ed the patient to the stretcher, to the ambulance. Got the patient on the monitor: sinus tachy at 137bpm. BP 130/74, RR 24. The patient began to seize again, so we decided to transport right away. Priority 1 to a local children's hospital. Enroute the patient got another mg of Ativan per on-line medical control, which again caused the activity to cease. The patient remained unresponsive for the entire time she was in our care.

As we were transferring the patient over to the ED bed, she began to seize again. The ED staff gave her yet another mg of Ativan, which again caused the patient to calm down. The hospital did a search for the patient's history in their own records, which showed that she had been seen at this ED 5 times in the past 2 months for the same presentation. She had a neuro consult a few visits before with no dx. It was written in the history that the seizures were assumed to be "fake." Around this same time, the patient opened her eyes at the request of her mother. She was still not answering questions, but was obviously alert and lethargic. It isnt clear whether the lethargy is part of a postdictal state, or from the 4 mg of Ativan she got over the last half hour.

In a converstation with the ED doc after finishing our paperwork, the doctor said that this particular patient was "apparantly very, very good at faking seizures," however there were things in her presentation that led him to believe that she was in fact faking. He claims this was obvious to him before even reading the history. His points were:

1) Her seizure motion was not bliaterally equal. The patient was shaking both arms, but they were seemingly at random and not in sync with eachother at all. The doc stated that "real seizures" generally present with bilaterally equal, or close to bilaterally equal tonic-clonic motion. I have never heard of this before.

2) Her motion was too purposeful. While she never accomplished any sort of task with this motion, according to the doc it was obvious to him that the motion was not genuine seizure motion, but rather a calculated, conscious motion. I dont know how he was able to determine this. She certainly looked like a real seizure to me.

3) Her mother's story didnt add up. A 45 minute seizure doesnt "just resolve" like the mother stated it did last time, and patients who have these seizures dont end up with no dx and no meds - which was the mother's story.

So I guess we were fooled. ...But I dont see how we could have avoided it here-- the patient was incontinent to urine, and was COMPLETELY unresponsive to pain. It really blows my mind that the patient could have been conscious and have NO reaction to the sternal rub or IV, nevermind urinate on herself. On top of that, it seems incredible to me that the patient was able to maintain these "fake' symptons for us with 3mg on Ativan on board. Youd think by that time she'd be completely snowed.

Anyways, I'd like to hear what experiences you guys have had with seizures. What kind of criteria/tests do you like to use to differentiate between real and fake seizures, and do you think there was anything that my partner and I could have done differently on this call?

[PRPGfirerescuetech]

I would have treated this as a seizure too...dont beat yourself up on it.

[fiznat]

dont beat yourself up on it.

Oh, I'm not really upset that she fooled us-- haha I'm actually pretty impressed. I thought it would be an interesting topic to discuss though, and perhaps there are a few other things we could have done/seen that would have helped us understand what was really going on... Also I'd like to hear what people think about the ED doc's points-- cause some (especially the first one) seem kinda odd to me.

[Ridryder 911]

I have been reeled in by the best .........I have even tried to nominate some for an Oscar. I agree, sounds like they were good at presenting the s/s . It does take a lot of experience and understanding seizures to detect some of the fakers. Since there are so many seizure disorders I have been careful, trying to determine real ones from fake ones. Always err on the patent's behalf....

r/r 911

[windsong]

I'M CURIOUS AS TO WHAT WAS THE THE PSYCHOANALYSIS OF THE 17YR OLD?

(Without Prejudice)

Thats fine if you find this humorous your allowed, my concern is what became of her?

When you hear that it affects children thats my concern as it would be yours as the Individual (EMT/Medic)

So wining an oscar hmmm, so what if it was your kid, are you going to call their bluff?

It must be hard to deal with it but of course your not a psych major

[Scaramedic]

The etiology behind many patients who fake illness, not to be confused with Munchausen by Proxy.

[align=center:3812aee389]Munchausen Syndrome[/font:3812aee389][/align:3812aee389]

What is Munchausen syndrome?

Munchausen syndrome is a type of factitious disorder, or mental illness, in which a person repeatedly acts as if he or she has a physical or mental disorder when, in truth, they have caused the symptoms. People with factitious disorders act this way because of an inner need to be seen as ill or injured, not to achieve a concrete benefit, such as financial gain. They are even willing to undergo painful or risky tests and operations in order to get the sympathy and special attention given to people who are truly ill. Munchausen syndrome is a mental illness associated with severe emotional difficulties.

Munchausen syndrome—named for Baron von Munchausen, an 18th century German officer who was known for embellishing the stories of his life and experiences—is the most severe type of factitious disorder. Most symptoms in people with Munchausen syndrome are related to physical illness—symptoms such as chest pain, stomach problems, or fever—rather than those of a mental disorder.

Note: Although Munchausen syndrome most properly refers to a factitious disorder with primarily physical symptoms, the term is sometimes used to refer to factitious disorders in general. In this article, Munchausen syndrome refers to factitious disorder with physical symptoms.

What are the symptoms of Munchausen syndrome?

People with this syndrome deliberately produce or exaggerate symptoms in several ways. They might lie about or fake symptoms, hurt themselves to bring on symptoms, or alter diagnostic tests (such as contaminating a urine sample). Possible warning signs of Munchausen syndrome include the following:

Dramatic but inconsistent medical history

Unclear symptoms that are not controllable and that become more severe or change once treatment has begun

Predictable relapses following improvement in the condition

Extensive knowledge of hospitals and/or medical terminology, as well the textbook descriptions of illnesses

Presence of multiple surgical scars

Appearance of new or additional symptoms following negative test results

Presence of symptoms only when the patient is alone or not being observed

Willingness or eagerness to have medical tests, operations, or other procedures

History of seeking treatment at numerous hospitals, clinics, and doctors offices, possibly even in different cities

Reluctance by the patient to allow health care professionals to meet with or talk to family, friends, or prior health care providers

Problems with identity and self-esteem

What causes Munchausen syndrome?

The exact cause of Munchausen syndrome is not known, but researchers believe both biological and psychological factors play a role in the development of this syndrome. Some theories suggest that a history of abuse or neglect as a child, or a history of frequent illnesses requiring hospitalization might be factors associated with the development of this syndrome. Researchers also are studying the possible link with personality disorders, which are common in individuals with Munchausen syndrome.

How common is Munchausen syndrome?

There are no reliable statistics regarding the number of people in the United States who suffer from Munchausen syndrome, but it is considered to be rare. Obtaining accurate statistics is difficult because of dishonesty in representation. In addition, people with Munchausen syndrome tend to seek treatment at many different health care facilities, which causes misleading statistics.

While Munchausen syndrome can occur in children, it most often affects young adults.

How is Munchausen syndrome diagnosed?

Diagnosing Munchausen syndrome is very difficult because of the dishonesty that is involved. Doctors must rule out any possible physical and mental illnesses, and often use a variety of diagnostic tests and procedures before considering a diagnosis of Munchausen syndrome.

If the doctor finds no physical reason for the symptoms, he or she might refer the person to a psychiatrist or psychologist — mental health professionals who are specially trained to diagnose and treat mental illnesses. Psychiatrists and psychologists use a thorough a medical history and physical, laboratory imagery, and psychological assessment tools to evaluate a person for Munchausen syndrome. The doctor bases his or her diagnosis on the exclusion of actual physical or other mental illness, and his or her observation of the patient’s attitude and behavior.

Questions to be answered include:

Do the patient's reported symptoms make sense in the context of all test results and assessments?

Do we have collateral information from other sources that confirm the patient's information? (If the patient does not allow this, this is a helpful clue.)

Is the patient willing to take the risk for more procedures and tests than you would expect?

Are treatments working in a predictable way.

The doctor then determines if the patient’s symptoms point to Munchausen syndrome as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), which is the standard reference book for recognized mental illnesses in the United States.

How is Munchausen syndrome treated?

Although a person with Munchausen syndrome actively seeks treatment for the various disorders he or she invents, the person often is unwilling to admit to and seek treatment for the syndrome itself. This makes treating people with Munchausen syndrome very challenging, and the outlook for recovery poor.

When treatment is sought, the first goal is to modify the person’s behavior and reduce his or her misuse or overuse of medical resources. Once this goal is met, treatment aims to work out any underlying psychological issues that might be causing the person’s behavior or help them find solutions to housing or other social needs.

As with other factitious disorders, the primary treatment for Munchausen syndrome is psychotherapy (a type of counseling). Treatment likely will focus on changing the thinking and behavior of the individual (cognitive-behavioral therapy). Family therapy also might be helpful in teaching family members not to reward or reinforce the behavior of the person with the disorder, but often the person is estranged from his or her family.

There are no medicines to treat factitious disorders themselves. Medicine might be used, however, to treat any related disorder—such as depression, anxiety, or a personality disorder. The use of medicines must be carefully monitored in people with factitious disorders due to the risk that the drugs might never be picked up from the pharmacy or might be used in a harmful way.

What are the complications of Munchausen syndrome?

People with Munchausen syndrome are at risk for health problems (or even death) associated with hurting themselves or otherwise causing symptoms. In addition, they might suffer from reactions or health problems associated with multiple tests, procedures, and treatments; and are at high risk for substance abuse and suicide attempts.

What is the prognosis (outlook) for people with Munchausen syndrome?

Some people with Munchausen syndrome suffer one or two brief episodes of symptoms. In most cases, however, the disorder is a chronic, or long-term, condition that can be very difficult to treat. Further, many people with Munchausen syndrome deny they are faking symptoms and will not seek or follow treatment. Even with treatment, it is more realistic to work toward managing the disorder rather than to try curing it. Avoiding unnecessary, inappropriate admissions to the hospital, testing, or treatment is important.

Can Munchausen syndrome be prevented?

There is no known way to prevent this disorder. However, it might be helpful to begin treatment in people as soon as they begin to have symptoms.

© Copyright 1995-2005 The Cleveland Clinic Foundation. All rights reserved[/font:3812aee389]

Peace,

Marty

:joker:

[medic001918]

Just another point, her seizures weren't "obviously" fake if the ED staff felt the need to medicate her with another millgram of Ativan.

As far as the motor activity being equal vs non equal, I'm not sure I buy into that comment. People have isolated focal seizure frequently. There's no rule (that I know of) that says that all seizure activity has to be equal. Using the doc's theory, I'd be curious to have him explain a focal motor seizure.

Also a 45 minute seizue that really lasts the full 45 minutes would either leave the pt so hypoxic and/or exhausted that they would remain very lethargic.

All in all, it sounds like an interesting call.

Shane

NRMET-P

[medic53226]

It sounds in the initial call and actions that she was really seizing, but the seizure lasting 45 mins nonstop that would be a little troubling and having on before and lasting the same amount of time, and no meds that would rise some concern, but if I had any doubt I would just raised her hand above her head and drop it and if it hit in the face then, see passed and if not, and she continued to be unresponsive try a ammonia inhaler and it she can take that then either she is strong willed or you are probably dealing with seizure, but it seems that you guys/gals was right on target with your treatment.

[uglymedic]

I recently had a call for a 17 y/o female in seizure. F.D. on scene stated she was in full seizure on their arrival, lasted a few minutes, then subsided. On our arrival, patient was unresponsive to pain and appeared postictal. According to F.D. patient has a history of seizures. I still believe I have run on her before for the same.

Upon getting the patient in the ambulance: monitor, vitals, etc. She started to have a seizure which started in the head and neck and gradually worked itself down through her torso with not a lot of extreme movement in her arms and legs.

Gave her 5 mg valium, then 5 mg more which cause the seizures to cease. While calling in the radio report to the hospital, the patient had another seizure. I advised the ED that I was going to go with Versed. 5 mg of Versed later, the seizure stopped.

Out at ED, one of the "old dog" nurses recognized her for a previous c/c of seizure.

I learned later that they were under the impression that she was faking all of the seizures and they were trying to GOMER her.

I have had others that were accused of faking, then lab tests confirmed that they did have seizures. (I can't remember what the test was for. Myoglobin?)

I really think that some EDs are too quick to call a seizure fake just because either they don't see the seizure, or the patient's seizure doesn't fit into their mindset of what a seizure should look like.

Ya do the best wit' watcha got!

G

[strippel]

It's all about the drama.

My partner and I have been fooled, too. No big.

I first look for the incontinence. To be willing to fake that, you need to be good. I have seen fakers do that, though.

What gives it away is what is what you see when you are on scene. All family members, SOs, etc, will deny that there was stress prior to the seizure. But about 1/2 the time, the tension is so thick you can cut it with a knife. It's like walking into the set of a bad Mexican soap opera, or the Jerry Springer show.

The thing that makes me aware of fakers is that we have so many regulars with real seizures. Most are urban outdoorsman, domicile challenged. We have one who seizes, and drops to the ground. He has a huge head, so he is always injured, then flops around for a few minutes. He has a long, violent post-ictal state, which involves many members of the law enforcement community, and sometimes an extra ambulance or engine company to keep him and bystanders apart. He is very dangerous. Usually, when he becomes alert, he runs away. I have learned from watching during the seizure, and post-ictal phase. i know everyone is different, but it's still good learning.

If only they would take their prescriptions, and not sell them.