The PITT

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TooMuchResearch said:
You realize it's conversion disorder i.e. a mental health issue i.e. they're not intentionally doing it even if they can stop it? You treat anxiety attacks with medicine?
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Yes, I understand PNES as a condition. Additionally, I’m aware that individuals with PNES may also have epileptic seizures. No, I don’t usually treat anxiety attacks with medication in the ED. I admit/transfer to inpatient psychiatry on an emergency hold if gravely disabled, or I discharge with an outpatient referral. I don’t typically treat anxiety with medication as that is not an emergent condition nor do I have the expertise to appropriately manage. Plus I believe cognitive behavioral therapy or other methods may be preferable to medication management. Maybe not in some cases. The point is, I don’t know and know what I don’t know. Either way, I know what may be potentially harmful to patients, leads to abuse of the ED, and decline to participate. I also think it’s important to define the ED for what we are experts in and what we think it is meant to be used for treating. Many patients that present have a component of anxiety. Simple reassurance should suffice and most are grateful. Anxiety attacks in my opinion are not what the ED was created for to treat.
 
Not all PNES is conversion disorder. Some (most?) patients are very much consciously aware of the behavior and it is goal directed.
 
I was told by experienced people both EMS and in residency that "people that fake seizures have real seizures", so, in the acute moment, 1mg Ativan isn't going to break the bank, if no information is available right that second.

I mean, I rode along on a shift with the sheriff's dept about 17 years ago. One guy got "jailitis", and had a "seizure", and I told the deputy to apply painful stimulus, and he did, and guy kept "seizing". I lifted his arm, and it avoided his face. I said right there, "See, didn't pee his pants, and look at this - he's volitional" (and quickly told the deputy what that meant). Just like turning off a light switch, guy stops, and becomes model prisoner, on his way to the graybar hotel.
 
comp1 said:
Not all PNES is conversion disorder. Some (most?) patients are very much consciously aware of the behavior and it is goal directed.
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I’d say true PNES is exceptionally rare, at least in my patient population. I can’t remember the last time I had a patient with a non-epileptic episode that wasn’t clearly demonstrating secondary gain from their episode which is typically familial or relationship sympathy. These patients seem to ALWAYS have an aggressively overbearing family member or spouse that refuses to accept that these are not true seizures. I typically advise the nursing staff to not allow any family members back with the non-epileptic episode patients, or kick them out if they become disruptive. Significantly reduces the rate of work disruption from the family member screaming for me to come in the room every time the patient has an “episode”. Usually the patient magically stops having their “nonstop seizure” when they no longer have their intended audience present.

My more controversial opinion, however, is regarding the teaching that “30% of patients with PNES have true epilepsy”. I think that claim is mostly BS. I’ve yet to see a patient with non-epileptic episodes have a documented positive EEG during prior hospitalizations or noted to have had one on outpatient EEGs. Literally not a single one of the hundreds I’ve seen in my career, and I always chart dive on these patients. I know it happens, and I’m not claiming none of them have true epilepsy as my patient population is probably skewed, but it’s certainly not 30%.

More commonly these patients get put on anticonvulsants by an ER doc or a neurologist after one of their “episodes” “just in case”. Then everyone that sees them afterward just keeps documenting “epilepsy” on their history with their script for Keppra as confirmation of the diagnosis, and so anticonvulsant keeps getting refilled and diagnosis keeps getting documented on their chart. Then someone does a retrospective chart review study using ICD coding and finds that “30% of PNES patients also have true epilepsy” and the myth gets propagated more.
 
Predators would solve this problem .

Imagine if there were some dinosaur like creature that you had to be on the lookout for as you went about your day. Say the actual probability of you encountering one is small, but real. You can't fake a bull$hit seizure if there's a possibility a velociraptor would take this instance to strike and make a meal out of you, right?
 
One of our docs intubated one the other day after I clearly told him her history. Of course the neurocritical care doc that I know well said "why did he intubate her?" What did he do? Admitted to ICU, extubated, discharged her the next day.
 
southerndoc said:
One of our docs intubated one the other day after I clearly told him her history. Of course the neurocritical care doc that I know well said "why did he intubate her?" What did he do? Admitted to ICU, extubated, discharged her the next day.
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Standard of care.
 
RustedFox said:
Predators would solve this problem .

Imagine if there were some dinosaur like creature that you had to be on the lookout for as you went about your day. Say the actual probability of you encountering one is small, but real. You can't fake a bull$hit seizure if there's a possibility a velociraptor would take this instance to strike and make a meal out of you, right?
Click to expand...

Nope

Velociraptor would see a convulsing person and think "that thing has a deadly disease. I don't want it."
 
southerndoc said:
One of our docs intubated one the other day after I clearly told him her history. Of course the neurocritical care doc that I know well said "why did he intubate her?" What did he do? Admitted to ICU, extubated, discharged her the next day.
Click to expand...
You treat what you see. If they can fake it to the point of being tubed, then, it happens. You're all cool and the science guy (general "you", not you specific) until you're not. Better safe than sorry.

I heard from a coworker 30+ years ago of the same thing. That was not PNES, but, "unresponsive".
 
Apollyon said:
You treat what you see. If they can fake it to the point of being tubed, then, it happens. You're all cool and the science guy (general "you", not you specific) until you're not. Better safe than sorry.

I heard from a coworker 30+ years ago of the same thing. That was not PNES, but, "unresponsive".
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Had one of the new, fresh-out-of-residency docs tube one of our fakers about a year or so ago.

I laughed hard.
 
southerndoc said:
One of our docs intubated one the other day after I clearly told him her history. Of course the neurocritical care doc that I know well said "why did he intubate her?" What did he do? Admitted to ICU, extubated, discharged her the next day.
Click to expand...
Maybe it was punitive. Wouldn't be the first time I saw that.

Also, as a totally random aside.... I had an epiphany the other day. As most of you are aware, I'm escaping the pit to do pain Med. I still moonlight a few shifts in the month to keep the lights on during fellowship.

I'm in the dept about a month ago and some utterly terrible human was doing something likely worthy of summary execution in other countries. The charge RN mutters something about wishing they would just die already. I looked up, and realized that I haven't legitimately wished that someone would drop dead in months now. It was a really weird realization that 1: that frequent thought was no longer present and 2: that I had gotten used to that thought as a normal thing.

The ER is truly filled with the bottom 10% of humanity. Being able to leave that environment for prolonged periods of time does wonders for one's mental health and general perception of humanity as a whole.
 
Apollyon said:
You treat what you see. If they can fake it to the point of being tubed, then, it happens. You're all cool and the science guy (general "you", not you specific) until you're not. Better safe than sorry.

I heard from a coworker 30+ years ago of the same thing. That was not PNES, but, "unresponsive".
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I'm not in the habit of intubating people with unlabored respirations and non-concerning workups, even if they seem mostly unconscious.

If something is off, well okay. But I just can't recall the last time I had to intubate someone who didn't have true "needs a vent" level of illness.
 
southerndoc said:
One of our docs intubated one the other day after I clearly told him her history. Of course the neurocritical care doc that I know well said "why did he intubate her?" What did he do? Admitted to ICU, extubated, discharged her the next day.
Click to expand...
If I get called to a room three times for these fake seizures I tube them. If they want to play games they can learn an expensive lesson.
 
xaelia said:
It's not for EM doctors; it's for the non-medical family of EM doctors so they can SEE.
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I had multiple hospital board members last week ask about it. One had watched it and was telling others they needed to see it. They asked me if I thought they should watch it

IMG_0435.jpeg


Granted I’ve only seen 1.5 episodes but seems like a good idea…
 
xaelia said:
It's not for EM doctors; it's for the non-medical family of EM doctors so they can SEE.
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It might have been some kind of mass casualty episode or something though. The first thing I saw is "hour thirteen" and thought "this place is way to big to work that long why is everyone covered in blood"
 
TooMuchResearch said:
It might have been some kind of mass casualty episode or something though. The first thing I saw is "hour thirteen" and thought "this place is way to big to work that long why is everyone covered in blood"
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Shift change MCI so day/night shift and backup people come in. They actually did this extremely well in my opinion going over disaster management, sourcing supplies, triaging priority, team lead roles, etc.

They nailed the nocturnist vibes. You see the ED nocturnist in episode 1 post-nights. He’s grizzled, borderline suicidal ex-military and has that “looking through you” stare. He comes back again in that episode for his shift and the day attending has genuine “thank god you came in early, you are my savior” reaction. He also carries and uses Rich Levitan’s CricKnife which was a nice touch.

It really is the most medically accurate show that I’ve seen and does a great job of conveying some of the central themes that are relevant in emergency medicine today.

There are no miracles where the doctor starts crying and thumping on the chest and the patient comes back from the dead. One episode they bring in a 60% TBSA burn patient and they make a point of correcting the intern who was counting first-degree burns as part of the TBSA. After they stabilize and “save” the guy, you meet his young pregnant wife who is so thankful and sweet. They then end the mini-plot by informing the intern that even though he’s stabilized his mortality is essentially 100% and he will die from burn wound sepsis or other complications. And then they move on to the next patient.

Obviously for the sake of TV it compresses the acuity of 2-3 lifetimes Emergency Medicine into 15 episodes.
 
xaelia said:
It's not for EM doctors; it's for the non-medical family of EM doctors so they can SEE.
Click to expand...
Totally agree with this sentiment.
There was the mass casualty and someone got black tagged. They moved on to the next person.
My wife looks at me and says "why aren't they trying to save the guy?"
Have to explain the realities of saving what you can and forgetting the rest.
 
Pudortu said:
Totally agree with this sentiment.
There was the mass casualty and someone got black tagged. They moved on to the next person.
My wife looks at me and says "why aren't they trying to save the guy?"
Have to explain the realities of saving what you can and forgetting the rest.
Click to expand...
This makes for a compelling read for an event occurring just a year before I arrived:
 
At first I thought it was somewhat realistic. Then i saw a recurrent pattern of day 1 PGY-1’s and even medical students doing chest tubes, intubations and other procedures borderline unsupervised. All the while having perfect mastery of the new EMR and order system etc, not having any real time to chart on shift, etc. then realized it’s a fictional TV show…
 
Zebra Hunter said:
I’d say true PNES is exceptionally rare, at least in my patient population. I can’t remember the last time I had a patient with a non-epileptic episode that wasn’t clearly demonstrating secondary gain from their episode which is typically familial or relationship sympathy. These patients seem to ALWAYS have an aggressively overbearing family member or spouse that refuses to accept that these are not true seizures. I typically advise the nursing staff to not allow any family members back with the non-epileptic episode patients, or kick them out if they become disruptive. Significantly reduces the rate of work disruption from the family member screaming for me to come in the room every time the patient has an “episode”. Usually the patient magically stops having their “nonstop seizure” when they no longer have their intended audience present.

My more controversial opinion, however, is regarding the teaching that “30% of patients with PNES have true epilepsy”. I think that claim is mostly BS. I’ve yet to see a patient with non-epileptic episodes have a documented positive EEG during prior hospitalizations or noted to have had one on outpatient EEGs. Literally not a single one of the hundreds I’ve seen in my career, and I always chart dive on these patients. I know it happens, and I’m not claiming none of them have true epilepsy as my patient population is probably skewed, but it’s certainly not 30%.

More commonly these patients get put on anticonvulsants by an ER doc or a neurologist after one of their “episodes” “just in case”. Then everyone that sees them afterward just keeps documenting “epilepsy” on their history with their script for Keppra as confirmation of the diagnosis, and so anticonvulsant keeps getting refilled and diagnosis keeps getting documented on their chart. Then someone does a retrospective chart review study using ICD coding and finds that “30% of PNES patients also have true epilepsy” and the myth gets propagated more.
Click to expand...
Oh I see plenty of people with extensive history of negative EEGs and highly skeptical ED and neuro notes, yet very clearly dont have control over their pseudo-seizures. Less for secondary gain and more that their brain cant handle any stressor and any fight with mom or bad grade or unexpected rent hike causes them to seize. Their seizures come at inconvenient times for them.

Just gotta hang out with more people who have that multi-focal psych history. They have all of the supratentorial pathologies.

I also see plenty who just want to milk the gullible family members belief for all its worth. But I'd put the "its conversion disorder" narrowly > than the "secondary gain".

Your last comment is 100% on point though.
 
DocEspana said:
Oh I see plenty of people with extensive history of negative EEGs and highly skeptical ED and neuro notes, yet very clearly dont have control over their pseudo-seizures. Less for secondary gain and more that their brain cant handle any stressor and any fight with mom or bad grade or unexpected rent hike causes them to seize.
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This is why people misdiagnosing malingerers as “pseudoseizures” is a pet peeve of mine.

Are PNES “real” seizures? No.

Is the person faking them? Also no.

Unlike the malingerers, they actually deserve compassion.
 
Siggy said:
This is why people misdiagnosing malingerers as “pseudoseizures” is a pet peeve of mine.

Are PNES “real” seizures? No.

Is the person faking them? Also no.

Unlike the malingerers, they actually deserve compassion.
Click to expand...

Yeah but i can walk out of the room of both of them with equal haste

EDIT: forgot to mention my old system actually had a PNES clinic. It was prevalent enough to merit its own clinic, along with stone clinic and afib clinic, etc. The documentation from those visits was....interesting
 
AlmostAnMD said:
Yeah but i can walk out of the room of both of them with equal haste

EDIT: forgot to mention my old system actually had a PNES clinic. It was prevalent enough to merit its own clinic, along with stone clinic and afib clinic, etc. The documentation from those visits was....interesting
Click to expand...

Honestly don't know why actual epileptic seizures are an emergency either.

Like, if you have epilepsy and have one seizure, why are you coming to the ED?

Why are the nurses panicking everytime anyone has one seizure? By the time I get to the room, it has resolved.

Unless it's status I really don't care.
 
WhatJobDoIPick said:
Honestly don't know why actual epileptic seizures are an emergency either.

Like, if you have epilepsy and have one seizure, why are you coming to the ED?

Why are the nurses panicking everytime anyone has one seizure? By the time I get to the room, it has resolved.

Unless it's status I really don't care.
Click to expand...
That's really rather minimalist. Seizures appear scary. What if it's first seizure? Higher likelihood of a brain tumor. What if it's due to low levels of (or ran out of) meds? Any epileptic seizure has a chance to become status. And, a percentage of status die.

There used to be a guy here on SDN that preached (essentially) about doing nothing for many complaints. That's a very fine line to walk.
 
WhatJobDoIPick said:
Honestly don't know why actual epileptic seizures are an emergency either.

Like, if you have epilepsy and have one seizure, why are you coming to the ED?

Why are the nurses panicking everytime anyone has one seizure? By the time I get to the room, it has resolved.

Unless it's status I really don't care.
Click to expand...

Except for the small issue that people die of seizures every year. Other than that...most people come to the ER becuase they people they are with people don't know what to do.
 
Last edited:
Most seizures seize, and then they are fine. Yes, they seem scary to the general public. Most people don’t die from seizures though. Especially not the non-epileptic kind.
 
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