Jeff Clawson, M.D.

Jeff Clawson, M.D.

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By Jeff Clawson

Hi Brett:

An EMD asked me a couple of questions about Protocol 12: Convulsions/Seizures and thought it would be great to add your insights to my answers in the reply.

1.Why was the question “Is he epileptic or ever had a seizure before?” changed to “Is he an epileptic (diagnosed with a seizure disorder)?” I think that the way the question was changed will exclude patients who may have had one febrile seizure as an infant and, since then, no other occurrence. The question is now very specific and there are some patients not diagnosed with a disorder, but who do have seizures. Are we missing these patients with this question?

2.Can you explain why a 12-B-1 is a BRAVO? If breathing cannot be verified, shouldn’t the Determinant Descriptor be at a higher level? For example, a 12-C-4 is at a higher level and we know that patient is breathing on this one. I realize that a 12-C-4 is no seizure history (confirmed no seizure disorder), and that the unknown is lower because we don't know; the C-4 is a CHARLIE because we know that the patient doesn't have a seizure disorder and, therefore, is at a higher likelihood of cardiac arrest. Do you have words of wisdom regarding why unknown issues are BRAVO?

Thanks friend!

Kim Rigden-Briscall

Master ED-Q Instructor / EMD Instructor / BOA Reviewer

Hi Kim:

The Key Question you refer to [in the first question] was changed because of under triage. There were several Proposals For Change (PFCs) and other anecdotal evidence alerting us to the fact that patients who had experienced a recent seizure, but had not been diagnosed with a seizure disorder, were being included in this group when the intention was to include only diagnosed patients, who have been shown to be at lesser risk of hypoxic seizure (about 75 percent less risk, in fact).

The question differentiates patients with a “diagnosed” history, and this group should not include patients who have had a previous seizure or two and have not had more serious causes ruled out. Your point about excluding patients with a history of a febrile seizure is true; but these patients are intentionally not included in the “diagnosed with a seizure disorder” group because a history of a febrile seizure is likely not related to a current seizure, or does not lessen the odds of the current seizure being more serious than a common grand mal seizure.

Your second question involves statistical probability. When the caller is not with the patient and breathing cannot be verified, the probability of cardiac arrest is greater in the patients of cardiac age range; the probability that the problem is a standard, grand mal seizure is greater in the patient under cardiac age range. If the patient’s current status of breathing is not known, it is less likely that the patient's history of seizures is known. The “E” suffix is available if the history of seizures is known. Therefore, an agency may elect to send a different resource based on the suffix. In the absence of information other than the complaint of seizure, the BRAVO response “recommendation” is relatively standard in the MPDS as a method of sending someone to assess.

It is important to remember that an agency can send what it deems appropriate to any code, and the response may well be the same as the 12-C-4 code you point out. As a reference for acuity, consider the following London Ambulance Service data (v12.1.2):

As you can see, there is a decreased risk for both patients under cardiac age range and patients with a history of epilepsy. Unfortu-nately, because the 12-C-4 code was added in v12.2, we do not yet have the CAQ data to compare. My guess is that the results will be somewhere between the above BRAVO and DELTA levels (without “E” suffix), and likely closer to the BRAVO level because breathing has been verified.