Seizures result from abnormal, excessive neuronal activity in the brain and may be provoked (e.g., hypoglycemia, hypoxia, electrolyte imbalance, toxic exposure) or unprovoked (e.g., epilepsy). Seizure presentations vary widely, and not all seizure-like activity represents epileptic disease. Most generalized seizures are self-limiting and resolve within 1 to 2 minutes, followed by a post-ictal period. The role of paramedics is to identify seizure type, treat reversible causes, terminate active seizures when indicated, and determine the appropriate disposition. Under ALS-PCS v5.4, selected patients who have returned to baseline may be considered for treat and discharge, provided strict criteria are met.

By the end of this tip, paramedics will be able to recognize common seizure types and determine which patients meet ALS-PCS criteria for treatment and discharge versus mandatory transport.

You respond to a 27-year-old patient with a known history of epilepsy. Family report a generalized tonic-clonic seizure lasting approximately 90 seconds, consistent with the patient’s usual seizures. On arrival, the seizure has stopped. The patient is initially post-ictal but gradually becomes alert, oriented, and returns to their normal baseline. Vital signs and blood glucose are normal.
Does this person require ongoing care, or are they safe to discharge?

Common seizure types paramedics may encounter include:

1. Generalized Seizure
   1. Sudden LOC, tonic stiffening followed by rhythmic clonic movements
   2. Often followed by post-ictal phase
   3. May be epileptic or provoked by metabolic/toxic causes  
2. Focal (partial) Seizures
   1. Motor, sensory, or behavioural changes without full loss of consciousness
   2. Post-ictal confusion may be minimal or absent
3. Absence Seizures
   1. Brief staring spells, typically no post-ictal state
   2. More common in pediatric population
4. Status Epilepticus
   1. When any seizure lasts more than 5 minutes or when seizures occur very close together and the person does not recover consciousness between them
5. Physcogenic Nonepileptic Seizures (Functional Seizures)
   1. Prolonged or fluctuating episodes
   2. Eye tightening, crying, talking, or purposeful movement
   3. Rapid return to baseline

Important note: PNES are real medical events, not intentional or “faked”. Management focuses on patient reassurance, assessment for injury or medical illness, and disposition based on overall presentation.

Treat and discharge is an appropriate, evidence-based outcome for select seizure patients who fully recover and meet ALS-PCS criteria. Recall your IDEAL discharge planning framework:

I - Incldue the patient and family as full partners

• Engage the patient and caregivers early
• Confirm who will assist at home
• Encourage questions
• Avoid provider-only decision making

D - Discuss key areas

Specifically:

• Medications (changes, new prescriptions, stopped meds)
• Warning signs and symptoms
• Follow-up appointments
• Daily living needs
• Test results

E - Educate using teach-back 

• Use plain language
• Ask the patient to repeat instructions in their own words
• Clarify misunderstandings immediately
• Provide written instructions (if required)

A - Assess understanding and barriers

• Health literacy
• Transportation
• Financial constraints
• Home supports
• Cognitive limitations 

L - Listen to and honor patient preferences

• Cultural considerations
• Goals of care
• Capacity and autonomy
• Feasibility of the plan 

When a patient with known epilepsy returns to baseline after a typical seizure, consider how applying ALS-PCS criteria can safely support treat and discharge as the right clinical decision.

Talking about mistakes and failure isn’t something we do often enough. As humans, we naturally appreciate being recognized for what we do well, but let’s be honest, no one enjoys having their flaws or errors pointed out. The truth is simple: everyone makes mistakes. Yes, everyone.

This topic is not meant to intimidate, assign blame, or act as a scare tactic. Its purpose is to create clarity, encourage honest reflection, and support growth. The framework focuses on professionalism, ethical practice, documentation integrity, patient advocacy, and accountability because learning from mistakes is how we strengthen ourselves, our practice, and the trust placed in us.

Objective:
By the end of this tip, paramedics will have a clearer understanding of ethical and professional standards, gain insight into accountability and documentation practices, strengthen patient advocacy and escalation of care, and reflect on expectations that support positive and meaningful practice change.

Key Content:
Professionalism
Professionalism is reflected in how you act when things don’t go as planned. It includes honesty, respect, humility, and a willingness to acknowledge mistakes. Owning your actions especially during challenging calls demonstrates integrity and reinforces trust within your teams and with the public.

Ethical Practice
Ethical practice requires you to place patient safety and well-being at the center of every decision. When errors or near misses occur, ethics guide you to be transparent, reflective, and committed to improvement rather than avoidance or defensiveness.

Documentation Integrity
Accurate, timely, and truthful documentation is essential. Ambulance Call Reports (ACRs) tell the story of your clinical decision-making and are critical for continuity of care, quality improvement, and legal accountability. Documentation should always reflect what actually occurred and not what you wish had happened.

Patient Advocacy
Advocating for patients means speaking up when something doesn’t feel right, reassessing when conditions change, and escalating care when needed. Advocacy is not about questioning competence, it’s about ensuring patients receive the safest and most appropriate care possible.

Accountability
Accountability is not about punishment, it is about responsibility. Taking ownership of your actions, learning from mistakes, and making changes when needed. This strengthens both individual practice and the profession as a whole. Accountability helps maintain public trust and supports a culture of safety and learning.

Scenario:
A 78-year-old patient with a head injury and on blood thinners refuses transport after a fall. Pressured by family, short on time, and facing a busy system, the crew accepts a quick refusal with minimal risk explanation and limited documentation. Hours later, the patient deteriorates and dies from an intracranial bleed. The crew is later subpoenaed.

Patient refusals are not just about assessing orientation, quantifying vitals and obtaining signatures. High-risk patients require a clear capacity assessment, thorough explanation of risks in plain language, freedom from outside influence, and strong documentation. Rushed decisions and “checkbox refusals” can turn ethical shortcuts into legal consequences.

Remember, if you wouldn’t feel comfortable reading your ACR out loud in court, it’s not finished.

In paramedicine, ethical care isn’t just about getting it right, it’s about what you do when things go wrong. Failure can sting, especially in a profession shaped by legal accountability and public trust. But reflective practice asks you to look squarely at your decisions: the pressures you faced, the information you had, the biases you carried, and the systems around you. Owning mistakes doesn’t weaken professionalism, it strengthens it by turning accountability into learning, protecting patients, and safeguarding your future practice.

Challenge: Think of a recent call that didn’t sit right. What would you do differently next time, and what support or system change would help you do it?

When assessing a patient in shock or with altered mental status, do not just look at the Systolic Blood Pressure (SBP). The Mean Arterial Pressure (MAP) is often a more accurate reflection of organ perfusion, particularly for the brain, kidneys, and heart. Pulse pressure (PP) is a vital sign that often tells a more compelling story about your patient’s hemodynamic status than the systolic blood pressure alone. In the prehospital environment, it serves as a "window" into stroke volume and systemic vascular resistance.

Hypothermia is a dangerous drop in core body temperature below 35°C, affecting the whole body, including the brain and organs, and can be fatal if untreated. Symptoms progress from shivering and confusion to loss of coordination, unconsciousness, and death, often caused by prolonged exposure to cold, wet, or windy conditions. 

Frostbite is the freezing of skin and underlying tissues, usually in extremities like fingers, toes, nose, or ears. It causes localized numbness, pale or gray skin, and a hard or waxy feel, with severe cases leading to blisters or tissue death. While frostbite can cause permanent damage or amputation, it does not kill by itself.