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First Aidby DirkAdvice on problems of particular relevance to SMersTable of Contents:
FaintingA faint, or syncope, is loss of consciousness caused by reduction in the supply of fresh oxygenated blood to the brain. The symptoms are unconsciousness, pallor and a slow pulse. Provided normal supply is restored, recovery is usually rapid and complete, though there is some evidence to suggest that regular incidence of oxygen restriction leading to fainting can result in cumulative brain damage. (For a more detailed discussion of these issues, see the discussion on Breath Control risks in the Breath Control briefing.) Fainting is different to the more dangerous condition of shock, which is the result of a serious loss of blood to all parts of the body, and is characterized by a rapid pulse, sweating and clammy skin. Fainting may be a reaction to pain, fear or fright, emotional upset, exhaustion or lack of food. It may also happen after long periods of physical inactivity, especially in warm conditions and/or where the body is in an upright position, where blood can tend to pool in the lower part of the body. When the person faints, the body falls into a vertical position, making it easier for the circulation to restore the blood flow to the brain. In an SM context, fainting could be brought on by the physical or emotional intensity of the scene, and some people are particularly prone when sensory deprivation such as blindfolds are used. Standing bondage for long periods of time creates the perfect conditions for a faint due to blood pooling, especially where the bottom is kept immobile, and tops should be aware of the risk. Fainting can also be brought about by the restriction of breathing or oxygen supply with hoods, gags, collars and so on (see breath control ). If you are playing in such a way that fainting is a risk, minimize it: do not play when too drunk, drugged, tired, hungry or thirsty; keep a good supply of fresh air in the playroom; avoid remaining immobile in an upright position for long periods. Avoid bondage that relies for safety and security on the bottom keeping a standing position: especially avoid anything that will put undue pressure on the neck if the bottom collapses. Make sure that if the bottom falls, it is onto something soft: the biggest danger with fainting is cracking your head when you fall. Just before fainting someone will most likely go pale and report dizziness, nausea, ringing in the ears or 'feeling faint'. At this point you may be able to avert a faint by removing bonds, gags and breathing obstructions, and getting the person to sit in a chair taking deep breaths with their head between their knees. Stay calm, quiet and reassuring and remember they may feel disoriented or panic-stricken. If someone does lose consciousness, instantly remove all bonds and obstructions, lay them down on their backs and raise and support the legs, and ensure a good supply of fresh air. Consciousness should be quickly regained, though the person will be disoriented for a few minutes and will probably require comfort and reassurance. Keep them quiet and resting for half an hour or so. If the person doesn't regain consciousness quickly, seek emergency help. Check breathing and pulse and be prepared to resuscitate if you know how. Place in the recovery position, lying on the side with head tilted well back and supported by a hand, and uppermost leg bent to prop the body up. Medical help should also be sought if the person remains listless and irrational, or if they drift in and out of consciousness, especially if drugs have been used. Sources: Johans 1988, St John Ambulance, 1992.
Seizure Managementby Jay WisemanA seizure is a disorder of central nervous system function that leads to sensory and/or motor disturbances, often including unconsciousness and generalized convulsions. In my experience, they are the second most common SM-related medical (i.e. non-trauma or non-injury) emergency after fainting. 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. Here I 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
What are Seizures?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; complaints of pain, nausea, dizziness, and so forth are 'proper' symptoms). 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 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. 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)
General PrecautionsSM-related seizure precautions would include the following:
What happens during a Seizure?A classic epileptic seizure is characterized by the medical mnemonic poem: The aura, the cry, While many seizures occur without warning, patients with chronic seizure disorders sometimes sense that one is coming. This is commonly known, in the medical sense, as an aura. Then, in the 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. 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, patients may arch into a bow-like shape with only their feet and the back of their heads 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 (blue, to various degrees) during this phase. Fortunately, the tonic phase usually lasts only seconds, which is not long enough to become highly life-threatening. The tonic phase is followed by the clonic 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. The patient usually breathes adequately during the clonic period which, again, usually doesn't last long enough to become life-threatening. 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 and it can last for a period of hours to days
Dealing with a SeizureThe 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. Please understand that, while it does sometimes happen, it's rare for a patient to die as a direct result of having a seizure. When the seizure starts, your first priority is usually to ease the patient 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. In particular try 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 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, You don't necessarily have to frantically start cutting with emergency scissors as your first approach to getting things loosened, but do whatever it takes to accomplish that fairly quickly. Next, keep a sharp eye on their breathing and skin color. If the breathing is very shallow, and if the patient stays very pale or cyanotic for more than thirty seconds or so, start ventilating the patient with mouth-to-mouth breathing. If you're not sure whether or not you should do this, then do it. Ventilating a patient through their clenched teeth is not optimal but it can be done, and 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. Continue to keep an eye on breathing during the clonic phase. If they're turning blue, something is very wrong. If the patient is black skinned, check their nail-beds, the insides of their lips, and, if possible, their tongues for changes in color. 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 thankfully rare in seizure cases the patient may 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 but this can happen to a life-threatening degree if they enter the 'limp' phase while lying on their back. My rule is to turn them so 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'. The question of whether or not you should place something in the patient's mouth to stop them biting their tongue is the subject of some controversy. The usual advice, especially for lay people, is not to do so, but I discuss the issues below. Never 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 reassure them. 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 for the emergency services? 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. 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. 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 an ambulance. It must be said, however, that calling the paramedics would definitely be the safest way to handle almost any seizure situation. If you do not, you are exposing that patient to at least a small degree of unnecessary risk
After the SeizureA 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, dizziness, 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. They should not drive themselves, and they should avoid going in by public transit (transport) 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). There are two main exceptions to this. Firstly, 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. Secondly, 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 siren going. This condition is called status epilepticus and it's a killer. 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 IV may be started 'just in case' and the patient may be given Valium, Dilantin, Ativan, or some combination of those
About clamped jaws and tongue bitingWhen the patient first goes limp, their tongue may protrude between their teeth. 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 debate. The usual advice 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'. My first serious girlfriend, from a time long before I had any interest in medicine, was an epileptic. 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. 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. 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) 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 can 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 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 aspirate it, yet small enough (and placed so that) it doesn't interfere with the patient's breathing. The above assumes that that patient is breathing adequately. If that is not so, proceed to ventilate them first 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. 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 complications due to clueless, ham-handed rescuers who attempted to jam something into a seizure patient's mouth. 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'.
References
Persons with seizure disorders, and those close to them, may wish to contact the American Epilepsy Foundation and to check out alt.support.epilepsy.
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