Handling a seizure victim who insists on driving
Three GPs discuss a problem presenting in general practice
Teresa, 45, is not registered with you, but you know her slightly from the leisure club. One Sunday you are in the supermarket and there is a commotion. Teresa is lying on the floor surrounded by staff and shoppers, and her three children are close by.
You ask what has happened and the supervisor, who is a registered first-aider, describes a tonic clonic-type seizure, which lasted several minutes. Teresa's teenage daughter tells you that this has never happened before and gives you the name of her GP who works at a neighbouring practice and is near retirement. The staff at the supermarket have called an ambulance. You help place her in the recovery position and when the ambulance appears, you leave the paramedics to continue.
The following week, you are surprised to see Teresa driving her children to the leisure club. By coincidence you bump into her GP at a meeting the same evening and ask about her. You say you were there at the supermarket when she had a convulsion and you were rather concerned to see her driving. He smiles rather patronisingly and says that Teresa had told him she had missed her breakfast and fainted and that everything was fine. She had apparently recovered fully by the time she had arrived at hospital and had discharged herself immediately.
Dr Alex Williams
'What should I do about my colleague's inaction should I let sleeping dogs lie?'
My first thought is that this will have to be handled with tact and diplomacy, but one of the main considerations must be the safety of her children and other members of society. It doesn't bear thinking of the consequences if Teresa had a fit while driving and crashed her car into children waiting at the bus stop for school.
In the first instance I would contact my more senior colleague and explain that I thought her history gave little doubt that Teresa had experienced a grand mal seizure and that guidance notes from the DVLA were unequivocal that she should not drive until she had been investigated, formally diagnosed, and, if epilepsy were confirmed, until she was fit-free.
The real dilemma would be if my advice fell on deaf ears, or Teresa continued to drive. I would then feel obliged to make contact with my defence organisation and discuss with them what actions I should take.
Presumably as she is not a patient of my practice I would not be breaching her confidentiality if I spoke to the police about her or rang the DVLA to inform them of this potentially dangerous situation.
What should I do about my senior colleague's inaction? Perhaps let sleeping dogs lie? Our responsibility, according to the GMC, is to raise concerns about under-performance of colleagues. Without wishing to be heavy-handed, a discussion with the clinical governance lead for the PCT or the local LMC secretary may be appropriate. They may wish to discuss with the other partners or manager in the practice if there are any other concerns they may have about performance. On a recent clinical governance visit we were encouraged to open a debate about how to raise concerns about colleagues.
We used 'vignettes' as a framework to open a discussion and produced a protocol on the series of steps that should be taken by any member of the primary health care team.
At a recent discussion of a similar scenario at a trainers' meeting, several of my colleagues said they would be less authoritarian and try to engage the patient in a dialogue or discussion, and then persuade them to take the appropriate moral decision. While I can understand this approach, I feel it is indefensible on moral grounds.
Dr Robin Fox
'If I blow the whistle on patient and GP my life is likely to alter significantly'
It appears Teresa should not be driving. She is potentially endangering herself, her children and society. I do not have a duty of care here as she is not my patient and I may not know all the facts. Her GP should be in the best position to sort this out.
There are three main issues here: that Teresa is continuing to drive; the behaviour of her GP; and my long-term personal or professional welfare as a potential whistleblower.
It is easiest to do nothing and to pretend I have done my bit by informing her GP. This is what most of us would be tempted to do. I actually would ring my medical defence organisation. If it agrees, in the first instance I would formally write to her GP detailing the events at the supermarket.
Should he not make efforts to address this problem I would write again outlining my concerns while acknowledging I may not have all the relevant information, and copying the letter to the clinical governance head of his PCT. If I were aware of another GP who had a better relationship with the GP concerned I would lobby them as my spokesperson. Eventually, if I was getting nowhere, I would speak to Teresa explaining to her why she should not be driving and, ultimately, if she continued to do so, I would inform the DVLA, as a local citizen rather than as her GP. Doing it anonymously is unlikely to serve any purpose.
My relationship with Teresa's GP appears poor. This may reflect personal differences or, more worryingly, be due to him having performance or conduct problems. If I am suspicious of the latter, the GMC has made it explicit that I have a duty to take this further.
As a first step I would gather as much information as possible and then raise my concerns with the clinical governance lead of his PCT.
Despite good intentions, whistleblowers often come out of these situations badly, and I will try my hardest to resolve this one without doing this or ducking the issue. If I blow the whistle on Teresa and especially her GP, it is likely that I will be talked about, resented, and, perhaps by some, admired, both in the medical as well as the wider local community. My life will be significantly altered by it.
I plan to develop agoraphobia in future.
Dr Rachel McKenzie
'I have an obligation not to simply ignore this even if she's not my patient'
This is a difficult situation and there are a number of different issues to address. The first thing I have to acknowledge is that I didn't actually witness the alleged convulsion and the description I have of a supposed tonic clonic seizure was given to me by a supermarket supervisor who has first-aid experience but no formal medical training.
Were there any other clues, such as urinary incontinence or tongue biting, or another, independent witness statement to confirm this episode was more than a simple faint?
How convinced am I that Teresa really had an epileptic-type seizure? If I am convinced then I have an obligation not to simply ignore this situation even though Teresa is not my patient. After all, one of my patients or family members could be killed in a road traffic accident if she has her second convulsion while driving.
The next thing I would do would be write to her GP, or a more sympathetic partner in the practice if there is one, and outline my involvement. In fact, there is an argument that I should have done this straight away after 'treating' her in the supermarket. I will outline the witness statement and any other evidence that this was more than a simple faint.
Receiving this in writing, they may then act on the information and discuss driving and DVLA notification. I would keep a copy of the letter for my own records.
If I see Teresa in the leisure club I will take the opportunity to ask how she is, and if the opportunity arises I will mention that I was present in the supermarket.
She may not know that she had a seizure as she may have no recollection of events and informing her might prompt her to go back and talk further with her own GP.
I am aware such a situation is difficult both for the GPs and Teresa herself, who probably relies heavily on her car. I may well become unpopular in both my leisure club and with local GPs, but I have to accept this.