Letâ€™s start with a question which we will circle back to later: Have you ever turned red out of embarrassment, stuttered a bit around the person you had a crush on, or felt your hands tremble when you got excited or nervous? Keep that in mind, and letâ€™s move on for now.
You respond with the fire department to a 30-year old female complaining of a seizure. Upon arrival you find the patient fully conscious, alert, verbal, lying on the kitchen floor, and flopping around like a fish. Inevitably, one of the responders is going to say the F word.
Weâ€™ve probably all heard it, thought it, or said it: â€œStop fakingâ€.
If you been in EMS or emergency medicine for any period of time youâ€™ve seen some pretty odd seizure presentations.
How many in EMS are content with rolling our eyes, labeling these patients as fakers, and dumping them off on the ER. We have a bit of a checkered history with the infamous â€˜hold their hand over their face and drop itâ€™ test and the â€˜pseudo-medication saline flushâ€™ test. But let me ask you this:Â What makes a patient â€œfakingâ€ a seizure any less of a patient?Â Chris Kaiser over atÂ Life Under the LightsÂ wrote a great article regarding EMS professionalism. If you havenâ€™t read it, you need to.
We should cut ourselves some slack though: EMS education is woefully inadequate. Weâ€™ve indoctrinated medics on a few presentations of seizures and send them out into the field. When they encounter a presentation which doesnâ€™t fit the cookie-cutter molds in EMS textbooks, we shouldnâ€™t be surprised when they resort to the logic ofÂ itâ€™s not what I was taught, so it must not be real.
But actually, we shouldnâ€™t cut ourselves slack because we need to fix these issues in our education. Additionally, we need to hammer home that Psychogenic Non-Epileptic Seizures, Conversion Disorder, and Malingering are real, legitimate, psychiatric problems.
The brain is an organ just like any other.
The brain can break just as every organ, tissue, system, and cell on the body can.
When you mix the awe of being consciousness with a organ encased in a vault of bone and then subject all of that to the harsh realities of our existence, itâ€™s no wonder we see some pretty strange things on the streets and in the emergency rooms.
Letâ€™s take a quick look atÂ psychogenic non-epileptic seizuresÂ (PNES), or what uses to be known as pseudo seizures (which is now considered a derogatory term). There is no lightening-storm of faulty electrical activity assaulting the brain. Instead, there is intense psychological stress and emotional trauma. It isnâ€™t easily observed in a lab or duplicated in a rat and it doesnâ€™t have a voltage-gated ion channel or biochemical pathway directly tied to it.Â None of that makes it any less real.
Perhaps it makes it more real. Patients and providers are both humans and humans break. We probably all carry emotional and psychological scars to some degree, except that ours hasnâ€™t overwhelmed us. Some of our patients were born into terrible environments and have survived terrible things. Imagine everything you own, have, and love was suddenly taken away from you and you were forced onto the same streets you presently work. Maybe your brain would break too under all the stress.
We barely know how the brain works but we do know it can react very strangely to intense stress and emotional trauma. In the case of PNES, this bizarre activity is thought to be a coping mechanism. Very few things in medicine are for certain, but in this case basicallyÂ 100%Â of patients with PNES will have an underlying psychiatric disorder. Of course we have to contend with malingerers stalking ERâ€™s and on occasion weâ€™ll run into a kid who doesnâ€™t want to go to school.
Remember the question we started with? If you experienced any of those things or something similar, then you had a physical manifestation of an emotion. That â€˜fake seizureâ€™ patient? Thatâ€™s a physical manifestation of an emotion too. Itâ€™s a normal response but sometimes it breaks and EMS and emergency medicine is in the business of providing excellent care to broken body parts and broken people. Letâ€™s strike this particular F word from our vocabulary.