8(d) Seizure: ambulance and hospital
Advice as to when or whether to call an ambulance varies, doctors vary in their advice. Act in accordance with your own feelings, especially if you do not have clear directions from a doctor.
There is harm in allowing a seizure to run on by being brave; there is no harm in seeking help. If it seems to you, in the first minute or so, that this seizure may not resolve quickly, call for help. Here is where the cordless or mobile phone becomes invaluable. You can watch over the patient, watch the clock, call the ambulance, call the baby-sitter, the aunt, whoever else is needed to jump in for support.
If the person is out of seizure, sitting, conscious, coherent, when the ambulance team arrive, that's cause for celebration, not apology. If the person has not surfaced or returned to coherence when the ambulance team arrives, be glad you called them when you did.
Here is an important distinction: a 'self-resolving' seizure, one from which the person recovers without assistance, is much less worrisome than a non-self-resolving seizure, where a person remains in status epilepticus.
If the seizure resolves itself, with or without the help of an ambulance team, you still need, during office hours, to report it to the doctor, for review of what needs to be done, and just to track progress. A fax machine is handy for that, or a written note dropped to the doctor's office. Written notes are always better than trying to leave an oral message. Always try to set out the facts, describe the situation, don't be selective of information, leave the selection of what is significant and the actual diagnosis to the doctor. Rather than say "John had a focal seizure this morning" say "John appeared to have a seizure at 8.15am, lasting for three minutes, and resolving itself. What happened was this:..." By all means then ask the questions which may focus on issues of concern but ask open questions - i.e. "does this relate to change in dex/Dilantin dose?" rather than "it seems he needs more/less dex/Dilantin". |
If an ambulance crew arrives, be ready to tell them:
• when the seizure began (if you haven't a clue as to precise time, relate it to the time of your 000 call, which will have been logged, e.g. "a couple of minutes before I called")
• whether the person has been conscious/unconscious, when last ate/drank, whether coughed up anything during the seizure
• this is a person diagnosed on [approx date] with [a this type of tumour], last medical event was...
• these are the current medications
• any drug allergies
• whether you have been with the person throughout, whether you know if the person hit anything, suffered any injury during the seizure.
THEN you can surrender patient care to the ambulance team, and while they work, you can get yourself organised to go with them if they are taking the patient to the hospital.
Take everything handy for your own comfort (including fruit and water) as well as what you need to show and tell the triage nurse at the hospital. You, not the ambulance team, need to provide the history to the hospital.
Have the scans and medication chart, and also when last doses taken, readily to hand, sort out with the ambulance team how long the seizure lasted. You may be going into the hands of an emergency team at a hospital who have never seen this patient before and you are the one who can help them deal with the whole case properly.
They will not know best how to keep medications in therapeutic range unless you tell them exactly what established doses are, and when last doses taken. Help them help you. You want the triage nurse to smile and say to you: "Wow, you give great history!"
They will appreciate facts; separate your opinions from facts in giving the history. And be aware that you will be seeing a range of people one after the other, double that if you arrive near a shift change. Don't gush "oh it was awful", ask "do you want history from me?" Proffer notes on history and medications. Know that communications between doctor and nurse teams may be far from perfect, especially if things are under pressure in Emergency; offer briefing to both doctors and nurses. Don't guess whether you are talking to doctor or nurse, introduce yourself, ask who they are, name and job status. Your appearance of competence and understanding of issues may be rewarded.
Plan ahead how you are going to brief, before you get to the hospital. Do this with love, know that calm and perspective help most now, catch your breath, count to 100. Close your eyes for a moment (while sitting :)).
In the same period, while the ambulance team is working, make the other calls:- to alert neighbours (shape the neighbourhood gossip: "We are going to be OK, it's just a seizure." "She says it's JUST a seizure, wow!"), family, baby-sitters, employers, etc. Expect to be tied up for some time. Keep in touch with the ambos while you are doing this stuff. Tell them: "I am getting organised to come with you. How long do you expect to be? Do you need anything from me now?" Don't vanish, don't get under their feet.
You are also the person who knows the best way out of your house with a patient on a stretcher or trolley. Ask: "Are you right for getting out of here? There is a lane at the back" — or whatever, you can show one of them exit options, there will be one of the team who will be wanting to figure all that out while the other works on the patient.
If an ambulance team arrives at a person still in status epilepticus, in seizure, they will need first to stabilise the person and stop that. The ambos will probably be travelling with intravenous Valium and will administer that, which will calm and sedate the person. One consequence of this and also of other hospital administered intravenous drugs for the same purpose, see next paragraph, is that the patient will now be affected by the drugs, and there will be a degree of iatrogenic (treatment caused) muddle and sleepiness, which you should not attribute to the tumour or seizure damage until those medications work their way out of the system.
The hospital as well as ambulance team will need to use intravenous drugs because a person in this situation will not be given oral medication for some time, until clear of seizure prospect — that is, until normal swallowing mechanisms are assured and there is reduced prospect of regurgitation. The ambulance team, as noted above, will probably be using Valium, a general purpose benzodiazepine drug. Hospitals will use, from the same drug family:
• clonazepam, which is long tasting, stabilising, but can cause a lot of confusion and needs weaning off;
• midazolam, very swift acting, very short half-life, to knock over a seizure quickly. If a person is having problems with repeated seizures, this may be kept readily on hand and the test may be that if the patient resolves the seizure before the couple of minutes to fetch the 'midaz' then good, no need for the midaz.
There will also be use of intravenous forms of general use anti-seizure medication, especially Dilantin (see next section), and this may be used as the first line intravenous injection in hospital UNLESS the patient has been taking Dilantin already and it seems to be failing. Taking intravenous Dilantin can raise serum levels quickly. If you are the person there in the hospital watching the patient, have an eye out for Dilantin overdose symptoms. If the seizure has come about while the patient is taking Dilantin and the hospital is using clonazepam and or midazolam, make sure they also keep the Dilantin level up, don't let them forget to rebalance the antiseizure medications as they reduce the clonazepam dose.
If you have taken the hospital a list of tablet medications that the patient is taking, keep track of that medication timetable yourself. If the hospital staff are focused on the seizure, you may be the one to say: "She's now four hours overdue for dex, can you do intravenous dex now?" Look at the medication chart; if the dex is there, good, if it's not there, thrust the chart gently at the nurse or doctor as you make this comment, talking quietly but seriously, if possible over the top of your reading glasses. When they exclaim "are you a doctor?" you know you may be winning...
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