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How to handle a seizure

© Copyright 1994 by Jay Wiseman (oldrope@aol.com),
author of "SM 101: A Realistic Introduction."

Reposted with the author's permission.

You can several other informative articles by Mr. Wiseman at his site: JayWiseman.com. He is also the author of SM 101: A Realistic Introduction, an excellent book for those interested in BDSM. It is published by Greenery Press.

As many of you already know, a seizure took place during a recent SM scene. Fortunately, everybody got through that one "more or less" OK. I offered to write something about seizure management and post it if anyone was interested. I got several distinctly affirmative posts in response, so here it is. The purpose of this article is to present the basics of the causes and management of seizures. The intended audience is primarily the (kinky) lay public. This is one of a series of seriously-researched "term papers" that I've either written or plan to write on health/medical matters related to SM play. I've already written one called "Melanoma Dangers of SM Play" that I will post in a week or so. (Don't whip funny looking moles! Doing so can spread cancer cells!) My next one will probably be on breath control play. I'd be interested in your suggestions for additional "term papers." Just so it gets said, I worked on an ambulance for eight years, attended medical school for three years, passed the internship-qualifying exam, and have taught various med emergency classes for over fourteen years -- ranging from very basic first aid to advanced wilderness emergency care to collision rescue/extrication procedures to advanced cardiac life support (ACLS). I've also personally treated a few hundred seizure patients, both adults and infants. While I consulted with a med student, an internist (recently board-certified; way to go, Charlie!) and a neurologist while preparing this article, any mistakes or controversial assertions herein are my responsibility, not theirs. I welcome correction, :-) clarifications, suggestions, and *appropriate* commentary. (You all know how the net can be. Sigh.) I'm retaining the copyright, but it's fine with me if you want to repost or print this elsewhere -- provided you don't charge a fee. This means "non-profit" SM clubs such as Threshold and Eulenspeigel can reprint this (unedited, please) in their newsletters if they wish (please send a complete copy of the publication it appears in to me at P.O. Box 1261, Berkeley, CA 94701 if you do) but commercial publications and BBS's need to clear re-printing this with me first.

Anyway, on to the subject: A seizure is a disorder of central nervous system function that leads to sensory and/or motor disturbances, often including unconsciousness and generalized convulsions. While many seizures occur without warning, patients with chronic seizure disorders sometimes sense that one is coming. This is commonly known, in a medical and not new-age sense, :-) as an "aura." There are many different types of seizures, and they can manifest in ways ranging from the very subtle to the all-too-obvious. Seizures are _usually_ not directly life-threatening, but can be and have been fatal (as I was recently and sadly reminded by just such a death in our Bay Area SM community). This article will deal primarily with a very common and dramatic type of seizure often called the grand mal seizure. It is also sometimes known as the complex seizure or the major motor seizure. One important thing to remember about any type of seizure is that it is a symptom, not a disease process in itself. Actually, it's more correctly called a "sign," because it is something that can be observed or otherwise sensed. Wounds, rashes, and heart murmurs are other types of signs. Heck, cardiac arrest is, strictly speaking, a sign. Complaints of pain, nausea, dizziness, and so forth are "proper" symptoms. [Insert graphic of Jay being *very* medically p.c. here.] Another important thing to remember is that most, but not all, seizures are "self-limiting conditions." This means that, as with a first-degree burn or common cold, in _most_ cases the patient will probably recover on their own and with little need for large amounts of external intervention. Furthermore, a seizure is a highly non-specific symptom, er, I mean sign. :-) Seizures, particularly grand mal seizures, have _many_ different underlying causes, or a combination of causes, so the exact diagnosis of what created them can be very challenging, even for an experienced clinician. Epilepsy is a common cause. A _few_ additional causes include brain tumor, cerebral infections, stroke, metabolic abnormalities, poisonings, emotional stress, drug overdoses, and trauma to the brain. [Here appears a digression regarding seizures in infants; might as well handle that subject "all in one swoop."] Infants cannot regulate their body temperature as well as adults can, therefore seizures in infants who are running a fever are very common, especially if they've been wrapped in too many blankets by well-meaning caregivers. These are called febrile seizures ("FEB" as in February, "rile" as in to get someone riled up). Febrile seizures can be prevented and/or reduced in frequency by making sure that a feverish infant is given adequate, but not excessive, anti-fever medication such as Tylenol for infants, making sure the child stays adequately hydrated, and, obviously, not over-doing the wrap-them-warmly bit. If the infant does seize, turn them on their side and, as best you can, hold them in a slightly head-down position. After the seizure has passed, make sure they are still breathing and have a pulse. (You learn how to do this in some, but not all, CPR classes. If you're responsible for taking care of a kid, be sure your annual CPR class includes infant and child CPR. Some do. Some don't.) Also make sure they didn't sustain a secondary injury. Remove all blankets and clothing from the infant, and wait for them to regain consciousness. If they're not breathing or are pulseless, or don't wake up within a few minutes (ten?), or have a second seizure, you have a genuine emergency on your hands. Begin giving necessary emergency care and call the paramedics. If the infant appears to recover, cool them in the kitchen sink using _slightly cool_ water. Don't use ice water. It's not particularly better and, quite understandably, it's harder to keep the kid in ice water. Furthermore, ice water may cause the blood vessels to shrink in diameter, *decreasing* the rate at which heat is removed from the infant when compared to the heat transfer rate associated with slightly cool water. There's also a higher risk of sending the kid into hypothermia.

Stick with slightly cool tap water. (Also, *don't* use rubbing alcohol to cool an infant. Inhaling its vapors can be highly toxic to someone that small.) There's a small but not negligible chance that the infant may have a second seizure while you are cooling them, so be alert for that. Stay with them, hold them in your arms, and keep the water level shallow. (Also clear the area around the kitchen sink before you start cooling them.) If you have a spray attachment, you might use that instead. Continue cooling them for about ten minutes (stop if they start to shiver), then give them clear fluids -- ordinary water would be great -- if they're alert enough to hold the bottle themselves. If they're overdue for some anti-fever medication, give them some. Take their temperature if you can. If you use a rectal thermometer, be ready to remove it instantly if another seizure starts. (Again, a second seizure means that it's paramedic time.) Hydration, anti-fever meds, and avoiding overly-vigorous usage of blankets and so forth will prevent most seizures in feverish tots. However, if a seizure _does_ occur, then take them to a hospital, *always*. One person drives, and the other watches over the kid (who still may seize on you). No speeding or other automotive heroics, please. Those are not necessary. A feverish infant who has had *one* seizure that they've apparently recovered from needs to be cooled, probably re-hydrated, and possibly given more anti-fever meds. They don't need to be raced to the hospital (if they do, call an ambulance; that's one of the main things they're for), but they *definitely* need to be evaluated at a hospital (lab tests will probably be needed) as soon as reasonably possible --meaning within a single-digit number of hours, preferably a _small_ single-digit number of hours. Major Caution: While "simple" fevers are by far the most common cause of seizures in infants, they are definitely not the _only_ cause. Candidly, you can't be sure that ye kidlet's seizure was not due to meningitis. It will take an experienced physician and probably some lab tests to rule that disease out, and meningitis can become life-threatening within hours. Don't dawdle in getting said kidlet over to white-coat-land. OK, now that you're all Junior Pediatricians (tm), back to our main topic:

Seizures are also not uncommon in "ordinary" unconscious patients, and are frequently seen in people who have gone unconscious due to suffocation, choking, fainting, or any other condition which caused short-term inadequate cerebral perfusion. (Long-term inadequate cerebral perfusion, of course, causes brain death.) In my experience, seizures are the second most common SM-related medical (i.e., non-trauma or non-injury) emergency. "Simple" fainting (ha!) is the first. The most common cause of serious SM-related trauma emergency seems to be a fall, typically because a submissive has been put in an unstable position while bound and/or blindfolded, because a whipping post or other large bondage device breaks, or because an overhead eyebolt pulls loose. SM-related seizure precautions would include the following: (1) If you have a seizure disorder, tell your partner about it early on. Also, if you go to a play party, mention it to the host -- along with basic info on what to do, and not do, if you have a seizure. (2) A Medic-Alert bracelet, anklet, or necklace, _in addition to_ a card in your wallet, is a good idea. (3) Think twice before putting a submissive into any sort of bondage that would require their cooperation to get them out of (or, as a bottom, letting yourself be put in such a position). Faintings, seizures, and so forth are not all that rare in the SM world. If you couldn't move an unconscious bottom *in a controlled manner* out of a certain positon and/or place and onto a "stable location" (lying flat on the floor, or on a bed, table, etc.,) don't put them in that position! In a typical grand mal seizure, the patient will suddenly become unconscious and slump in their seat or fall to the floor. They frequently sustain "secondary injuries" if they fall, some of which can be much more damaging than the seizure itself. This fall is sometimes accompanied by a brief, very-eerie-sounding, outcry or shriek. The patient usually will be limp for a few seconds, then go into a generalized, sustained muscle spasm. This is called the tonic (ordinary pronunciation) phase of the seizure. During the tonic phase, all the major muscle groups of the body contract -- making this somewhat like a whole-body isometric exercise. When muscle groups are in opposition, the stronger group will win the "tug of war." Thus, the upper arms will flex (biceps being stronger than triceps), the forearms will flex, the head will arch back, the back itself will arch, the legs will straighten, the toes will point, and, of course, the jaw will clench. In some cases, the patient may arch into a bow-like shape with only his feet and the back of his head in contact with the ground. Muscle strains, and tendon or ligament sprains, are not uncommon following a seizure. While it's rare, sometimes the muscle contractions are even strong enough to break the bones they're attached to. The patient usually cannot breathe effectively during the tonic phase, and they are consuming oxygen at an enormous rate. They therefore often become pale and/or cyanotic [SIGH-ann-otic] (blue, to various degrees) during this phase. Fortunately, the tonic phase *usually* does not last long enough to become highly life-threatening -- i.e., it lasts seconds rather than minutes. Major Caution: Keep a close eye on the patient's breathing pattern. If it's very shallow, and if the patient stays very pale or cyanotic for more than thirty seconds or so, start mouth-to-mouth breathing. If you're not sure whether or not you should give it, then give it. (The medical term for providing artificial respiration, by whatever means, is ventilation.) Ventilating a patient through their clenched teeth is not optimal, but I can tell you from experience that it can be done -- and done adequately. Also, mouth-to-nose breathing can be a literally life-saving optional approach in these cases. Most seizure patients who die from the incident die because their oxygen levels got too low. Don't let this happen.

The tonic phase is followed by the clonic (rhymes with tonic) phase, consisting of whole-body rhythmic convulsions and often accompanied by urinary and/or fecal incontinence and frothing at the mouth. (In my experience, the clonic phase seems to last longer, sometimes much longer, than the tonic phase, but I'm not sure enough about that to present it as a "hard" fact.) The patient *usually* breathes adequately during the clonic period which, again, *usually* doesn't last long enough to become life-threatening. As before, watch their breathing. It can range from almost non-existent to hyperventilation. Also, keep an eye on their color. If they're turning blue, something is *very* wrong. If the patient is african-american, check their nailbeds, the insides of their lips, and -- if possible --their tongues for changes in color.) A classic epileptic seizure is characterized by the medical mnemonic poem: The aura, the cry, the fall, and the fit. The tonus, the clonus, the pee, and the shit. After the clonic phase has run its course, the patient will usually become very limp. They will probably still be unconscious, and it will take them several minutes to regain consciousness -- sometimes even longer.

Fortunately, they are usually able to breathe adequately during this period. When they regain consciousness they are often sleepy and confused. This is called the postictal period (post-ICK-tal) and it can last for a period of hours to days. OK, so what do you do? The first thing you should do is understand that seizures _usually_ look worse than they actually are. These are among the most dramatic of medical emergencies, and can be very scary. (Emergency folks often keep a sharper eye on the patient who is getting more and more quiet and still than on the patient who is wildly thrashing about. I'm sure you can understand why.) Please understand that, while it does sometimes happen, it's rare for a patient to die as a direct result of having a seizure. If you happen to be present when the seizure starts, your first priority is usually to ease them onto the ground, the bed, or some other open horizontal surface. This can be difficult to accomplish with any degree of grace or dignity if they're limp or convulsing, and/or if they're too heavy for you to move easily, but do the best you can. Your main priority is to keep their head from smacking into anything, including the floor, while they're on their way down. If they're wearing glasses, remove them as quickly/gently as you can. Remove or loosen bondage, clothing, and/or jewelry as best you can *if* it's causing a problem. For example, given that arms tend to flex up onto the chest and that legs tend to extend and point, it could be far more urgent to free the arms than the legs, especially if the ankles were tied together. Indeed, hypothetically the legs needn't be loosened at all in such cases (not that I'm advocating keeping them restrained, you understand) -- unless they were also drawn back in some sort of "hog-tie" position. In such a case, particularly if they were attached to the wrists, freeing them so they could extend would be urgent. The force generated by large thigh muscles during a seizure could rip both of the hog-tied submissive's shoulders from their sockets! If the patient suffers a seizure while tied in a supine "spread-eagle" position, loosen all four points as soon as possible. In the case of a standing patient, it might be better to free the feet first, then the wrists. Keep in mind that releasing a patient from any form of standing bondage while they are convulsing or unconscious can be hazardous to all concerned. Get as much assistance as you can without delaying any urgently needed intervention. Major caution: Pay particular attention to anything around the patient's neck, and to anything that might restrict their breathing by restricting free movement of their chest and/or abdomen. (As a responsible SM person, you of course always have at least one pair of paramedic scissors very handy.) You don't necessarily have to frantically start cutting as your first approach to getting things loosened, but do whatever it takes to accomplish that fairly quickly. As mentioned above, keep a sharp eye on their breathing and skin color. *Oxygen deprivation* is what kills these people. If they start to look low on oxygen, ventilate! Don't wait until you're sure that they're getting seriously low. When in doubt, ventilate! When in doubt as to whether or not you're in doubt, ventilate! It is exactly that important. If you or someone else can move furniture, etc., away from them, do so. If that's not possible, try to get some type of padding between the patient and anything that might harm them if they were to strike it during their convulsions. (Your own body might qualify as such padding. Don't do this automatically, but remember that it might be a good option.) Once you have them on the ground, turn them on their side as best you can. While vomiting is rare in seizure cases (thank God), they often "foam at the mouth" and may aspirate saliva, blood, or other fluids into their lungs. An actively seizing patient does not usually have a problem with their tongue blocking their airway ("swallowing the tongue" is largely a myth), but their tongue can block their airway to a life-threatening degree if they enter the "limp" phase while lying on their back. My rule is to turn them to that a corner of their mouth is almost touching the ground. This usually puts them slightly more than "half over" with the top of their windpipe going "downhill." I've never had a patient aspirate once I got them into this position. By the way, don't ever put a pillow under an unconscious person's head if they're lying on their back. Doing so can make airway-blockage-by-tongue fatally severe. If you *must* put it somewhere, put it under their shoulder blades. This will help their head roll back, and that can help keep their airway open. Actually, unconscious patients are best turned on their sides, particularly if you have no reason to believe that their cervical spine might be injured. If you find an unconscious person on their side and breathing, leave them in that position. It almost couldn't be better.

After the seizure subsides, the patient will slowly come back to consciousness. During this time, they may be embarrassed and apologetic. Do what you can to reasssure them. One tip: Don't volunteer _too_ much reassurance unless they seem to need that. On the other hand, don't make the mistake of assuming that the patient who doesn't appear to need reassurance actually doesn't need reassurance. Most of them can use at least a little. Should you have someone immediately call 911? [Warning! Small controversy approaching!] In my opinion, not necessarily. I'm not sure that someone having *one* seizure is sufficient grounds, in all cases and in all situations, to start the police cars, fire trucks, and ambulances racing to your location. (Some people could legitimately disagree with me on this point.) My approach in most cases would be to do what I could to help the patient get through that seizure and see if and how well they recover. (Note: This assumes that the seizure has no obvious underlying condition which itself needs treatment. If I knew or suspected that a seizure was occurring secondary to something like a head injury or drug overdose I would definitely call 911.) [Brief digression into legal aspects of seizure management.] I feel that I must say, "on the record," that calling the paramedics would definitely be the safest way to handle almost any seizure situation. If someone has a seizure and you do not call 911, you are exposing that patient to at least a small degree of unnecessary risk. While I feel that a rational argument can be made _in some cases_ for not calling, understand that not doing so, for whatever reason, is always somewhat risky. Speaking strictly in terms of the medical aspects, and setting aside such factors as cost, privacy, and so forth, it's almost impossible to go wrong with calling the paramedics. Additionally, if a seizure were to occur in an "on the record" location, such as at work, I absolutely would call 911 and have the patient go in by ambulance.

If they were an employee that I supervised, I would insist. Exceptions would be permitted only if a physician were consulted at that time and approved them, preferably in writing, in that particular case. Scenario: Employee has seizure at work. Gets sent home by supervisor. While driving home employee has a second seizure and causes a multi-casualty wreck. Guess who is going to (quite rightly, by the way) get sued, and sued, and sued? [OK, now to leave the legal world and return to the real world.] A patient _with_ a history of seizure disorders who seems to have recovered from the seizure, and without secondary injury that itself requires medical treatment, can probably be adequately managed by having a knowledgeable and responsible friend stay with them for at least six hours. These patients often need a change or adjustment in their medication, so the physician who manages their seizure disorder should be consulted. While monitoring the patient, pay particular attention to any signs or symptoms that may signal a head injury (bleeding into the brain) such as nausea, dizzyness, headache, and a gradually decreasing level of consciousness. A patient _without_ a history of seizure disorders, but who seems to have recovered from the seizure without secondary injury, needs to go to the hospital at once, but not necessarily by ambulance. They could go by private car with one person driving and the other keeping them company in the back seat. (Don't say it! This is serious stuff, damnit!) They should not drive themselves, and they should avoid going in by public transit if possible, particularly by themselves. (Some people would feel that this patient needs to go in by ambulance. I can't outright say that they're wrong. Cases like these are something of a judgment call.) MAJOR CAUTION # 1: If the patient may have suffered any sort of blow to their head (like during the fall), or has any _new_ neurological problems such as numbness, weakness, paralysis, blindness, difficulty speaking, and so forth, call an ambulance. If you're not sure whether or not they hit their head when they fell (nobody witnessed the seizure), call an ambulance. These people could be bleeding into their skull, and they need immediate medical evaluation. MAJOR CAUTION # 2: If *two or more* seizures occur within minutes of each other, particularly if the patient doesn't wake up in between them, call the paramedics at once! The human body was *not* designed to withstand the various stresses of multiple seizures, and this patient's life is at immediate risk. This patient needs medication that paramedics carry, and they need to be taken to the hospital *by ambulance*, very arguably with the red lights and siren going. This condition is called status epilepticus and it's a killer. What do you do about clamped jaws and/or tongue biting? [Warning! Large controversy approaching!] When the patient first goes limp, their tongue may protrude between their teeth. (If you're reading this while sitting at your computer, try letting your head and neck go limp for a second and you may see what I mean.) If their tongue is still there when the tonic phase hits, they will bite it and, for reasons associated with the pathophysiology of the seizure, may bite it *much* harder than they would if they were conscious. Exactly what to do about this is a matter of spirited and legitimate "Learned Debate" (tm). "The party line" is to do nothing. This is especially true for ordinary citizens. This is also the most common "formal" training for medical folks. The reality, however, is frequently different. Medical supply companies sell various types of "bite sticks," usually made of firm, but not hard, plastic-like materials. Such sticks are also often improvised by wrapping gauze and/or tape around two or three tongue depressors. The usage of such bite sticks during a seizure by medical folks, ranging from first responders to physicians, is very common. There is even a small, threaded, cone-shaped device used for opening clenched jaws called an "oral screw." (Don't start!) This is one of several areas in medical training that can cause the new student considerable head-scratching. In class, you're told "never do this" and yet when you get out in practice you see lots of people doing -- to the patient's apparent benefit, let me add -- exactly what you were specifically told to never do. Sigh. Let me share a bit of personal experience: My first serious girlfriend was an epileptic. My involvement with this neat lady occurred far before I had any interest in medicine, by the way --the mid 60's. I wasn't any sort of "medical type" during the time I was seeing her. Her seizures could only be controlled by taking ever-larger doses of medication. After about three weeks, her dosage would reach toxic levels and she had to quit taking it for a week. During this week, she would have seizures -- a *lot* of seizures. Thus, while still a teenager, I ended up "midwiving" her through many such episodes. Most of these happened at her place, with just the two of us present. She taught me that, when she seized, I should push open her jaw and put something soft (such as the corner of a once-or-twice-folded washcloth, or my wallet) between her teeth, then turn her on her side. She told me not to call an ambulance, because the seizure would pass before they would arrive. At that time, I had absolutely no reason to doubt her, so that's exactly what I did --dozens of times. It even got kind of routine after a while. She got through these episodes "more or less" OK (due in large part, I suspect, to her youth and strong constitution). Years later, long after our relationship ended, I still had her teeth marks on my wallet as a very unusual type of relationship memento. I had never been taught to "never do that" and, in fact had been taught *to* "do that." So I did -- many, many times. And I never hurt her jaw, teeth, or anything else by doing so. My consistent experience, both in what I've seen and in what I've done, is that seizure patients _do_ benefit from having something soft (or, at least, something not real hard; *please*, no spoons, pencils, knife blades, etc. we don't want tooth fragments flying about) put between their teeth, and that this can almost always be accomplished without damaging the patient. Placing something soft frequently reduces degree of damage to their tongue (and sometimes to the inside of their cheeks) from biting -- and saliva, blood, and other fluids and drain from their mouth much more readily. Among other things, such drainage helps prevent and/or minimize aspirating such fluids into the patient's lungs. Most importantly, these patients seem to breath more effectively -- a sometimes all-important concern. I therefore usually recommend that such a soft object be so placed, and do it myself if I'm at a seizure scene. It's usually the third thing I do after I've gotten them onto the ground and over onto their side. The technique is simple. Grab your soft material (a wallet is a time-honored device) with one hand and move up near their head. Place the heel of your free hand on the point of their jaw and apply _gradually_ increasing pressure (no sudden hard shoves, please) until their teeth begin to separate. Insert the material as soon as you get enough room, and release the pressure. You'll get a better airway if you insert the material on only one side of their mouth instead of crossing the midline with it. Also, make sure that what you use is large enough that they can't swallow or asprirate it, yet small enough (and placed so that) it doesn't interfere with the patient's breathing. BIG EXCEPTION: The above assumes that that patient is breathing adequately. If that is not so, proceed to ventilate them -- and doing so is distinctly difficult if you have to try to fit your mouth around a wallet. ;-) By advocating placing a soft object between the jaws of a seizure patient, I imagine that I have horrified a fair segment of my audience. This advice, after all, does not follow "the party line." Also, and to be fair, I'm sure there are many people out there who have horror stories about fractured/dislocated jaws, broken teeth, and even worse complicatons due to clueless, ham-handed rescuers who attempted to jam something into a seizure patient's mouth. Furthermore, I'm sure that these stories are all true. (I've seen a few such cases myself. They usually involved an attempt to use a very hard object such as a spoon or knife blade.) I can only respectfully report my own experience. I have personally done this a few hundred times, on patients of many different types, without even one single incident of hurting a patient by doing so. Quite the contrary. They seemed to benefit from the procedure, and patients managed without it didn't seem to do as well. A hopefully useful additional comment is that, while I definitely believe that seizure patients do better with a bite stick in place, I can't say that I ever saw a survivable patient lost because the procedure was not performed. Placing a formal or improvised bite stick is a nice touch, but it's not a matter that usually affects the outcome of the case to a major degree one way or another. Don't give this matter all that much importance, particularly if you're a "civilian." When the paramedics arrive, they will want a history of what happened, including how many seizures the patient had and what medications, if any, the patient is taking. The patient may be given oxygen, and a complete examination done with emphasis on the neurological examination and checking for secondary injuries. If the patient does not appear to be medically stable, an I.V. may be started "just in case" and the patient may be given Valium, Dilantin, Ativan, or some combination of those. Which drugs to give, and why, is another subject of "Learned Debate" (tm).

In summary, seizures generally look more threatening than they really are. Treatment priorities include

  • getting the patient to a stable position,
  • not restricting their movement or breathing,
  • turning them on their side to facilitate airway drainage,
  • providing breathing assistance if necessary.
Patients generally benefit from the placement of a bite stick, but only if this can be accomplished without further trauma. More than one seizure within a few minutes is a severe medical emergency requiring immediate, formal medical intervention. After the seizure passes, check for secondary injuries and provide necessary comfort, monitoring, and reassurance. Immediate, but not emergent, medical consultation is mandatory. [This concludes the section of the "term paper" addressed to the lay public. The following subsection is addressed to medical folks.]

Medical folks may appreciate a trick I invented to help seizure patients. Such patients often benefit by suctioning them, giving them straight-flow oxygen or, particularly if the convulsions last more than a minute or so, giving them positive pressure ventilaton by using an ambu bag or demand valve. However, it's difficult to suction through clenched teeth, and all but impossible to fit an oxygen mask to a mouth that has a bite stick protruding from it. (Nasal cannula oxygen can and should, of course, usually be given.) Ordinary oral airways hold the lips and teeth apart, but they also trigger the gag reflex. Given that seizure patients often are not so "deep" that they've lost their gag reflex, ramming in an oral airway and making it stay there can be torture for them. Intubation can be even worse. (Either can also trigger an excess of vagal outflow that will do the patient's heartbeat no good at all.) Ready for a humane, effective alternative? Try this: Grab a standard oral airway, preferably one of the white Berman types with the perforated "I beam" running down the midline. A size five is about right. Cut it off about two inches from the flared end that goes between the patient's teeth. This is tough material, so use a sturdy cutting tool. Finish by rounding off the corners and file down all shrarp or rough spots until they're very smooth. I call this an "abbreviated airway," and it's now ready for use. When you get a seizure patient, use the heel or your palm and/or a standard, wedge-shaped bite stick to slightly open the patient's jaws. As soon as you get enough clearance, place the abbreviated airway squarely between the patient's front teeth and release your pressure. This kind of airway will hold the patients jaws apart, prevent tongue and cheek biting, not trigger their gag reflex, and allow easy access to their mouth for suctioning, a straight-flow oxygen mask, or positive pressure ventilation. In hundreds of uses, I have never seen this device cause any injury whatsoever to a patient's jaw, teeth, or elsewhere. My brothers and sisters, this thing works like a goddamn charm. (If you start marketing it, I want royalties.) ;-) I carried one of these on my belt pack for years, along with a standard blue bite stick and a number five Berman airway. (I found that a number five Berman OPA would work nicely in virtually any size adult, by the way.) The abbreviated airway is very easy to clean after each use, and is almost indestructible. I have used it successfully on patients with natural teeth, patients with dentures in place, and patients with no teeth. The procedure is the same. I've never had even a slight problem with potential swallowing or aspiration of the airway. It's basically too large to go down their throat, and can be easily removed when the seizure passes and the patient begins to regain consciousness. There are only three significant cautions: (1) This device will not keep the patient's tongue out of their postier pharnyx. You'll have to rely on properly positioning their head to accomplish that. (2) This device is intended for use *only* on a patient who is being very closely and personally watched. Don't leave a patient alone, even for a moment, if one is in place. (3) This airway management device is not intended for use on deeply comatose patients. Those patients need intubation and other advanced airway management procedures. Still, the abbreviated airway does its designated job far better than any other device I have ever seen. Properly used, it can and does make a major contribution to the management of a seizure emergency. It's contribution to facilitating positive pressure ventilation of a status epilepticus can and has been life-saving.

References: "American Red Cross Community First Aid textbook" "First Responder" "Emergency Care in the Streets" "The Merck Manual" "Problem Oriented Medical Diagnosis" "Principles of Internal Medicine" Persons with seizure disorders, and those close to them, may wish to contact the American Epilepsy Foundantion and to check out alt.support.epilepsy.

Greenery Press: Reading for the Sexually Adventurous

Copyright issues footnote: I wrote this article with the hope that it would be widely read and distributed, and without any particular expectation of financial compensation in return for writing it. Therefore, I consent to the following uses of this essay:

  1. It's fine with me if you read it.
  2. It's fine with me if you send it, in unaltered form and including this copyright issues footnote, in private e-mail to appropriate others.
  3. It's fine with me if you post it, as mentioned in point # 2, to newsgroups and closed mailing lists.
  4. If you put it up on a private, no-fee-to-access, website, please put it up as mentioned in point # 2 and include a link to the Greenery Press website (http://www.greenerypress.com/) and to JayWiseman.com (http://jaywiseman.com/).
  5. I do require that you get my specific prior permission before putting this article up on a pay-to-access website, putting it in a book or periodical offered for sale, or otherwise charge for any sort of access to it.

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