Conscious but unresponsive?

[DwayneEMTP]

I have an autistic son named Dylan and one of my greatest fears is that he will need EMS without his mother or I around.

Assuming you came to him after a schoolbus rollover accident and are unable to reach his parents or teacher, how would you assess and care for him?

I don't know enough to know what is important to include here, so I'll do my best. (Maybe it doesn't matter so much in this situation?)

He has a 6cm lac at his right temple, no deformation to the skull, also a swollen and deformed right wrist. Slight swelling and bruising to right lower abdomen. His airway is patent. I would be highlighting my ignorance if I attempted rr/hr/bp/pupils. Maybe you can make assumptions as to normals for this high stress situation?

He is 9 years old and almost completely without the ability to communicate to strangers. (He has some ASL (American Sign Language) but much of it is specific to him and his communication with his family and teachers)

He has an unusually high threshold for pain. (For example, almost no reaction to getting his fingers slammed in a car door in the past)

His motor functions are pretty standard except that he is somewhat clumsy when excited or moving fast.

To most any question you ask he will answer "My name is Dylan"

Ex: Where do you live, what is your name, how old are you?

If you ask if something hurts he will answer "yes" to all, unless he thinks that answer makes you unhappy, in which case he will begin to answer "no" to all.

He has no concept of the passage of time, or any measurable concept of abstract thought. (No when, why, how long, did you, are you, can you)

In this situation he will almost certainly be either completely calm and nearly unreachable mentally or have somewhat manic behavior where he will notice almost everything to distraction. (Lets go with manic) (He will pull out IVs, fight Oxygen, etc)

He hates to be touched except by his mother or myself and will certainly panic and fight against a c-collar and backboard.

As his father I expect to hate any answer that doesn't involve one of our lady medics wrapping him in her arms and smothering him with kindness until I get there...(Medik8, can I put you on call for my boy?) but I'm curious to see how this would work. Perhaps it will help me better prepare him....just in case.

To many of you this is probably not a big deal...been here...done this...but it seems like a horror to me, having no real world experience...

Thanks to those of you that respond...and apologies in advance if this should have been presented in a different manner.

Dwayne

[Punisher]

I hate to be blunt but chances are that if he resisted needed care, he would be treated in a manner similar to how we handle combative head injury patients- restraint to allow a proper level of care to be delivered.

Granted that's always a last resort in my book, but that tends to be necessary (unfortunately) with a lot of autistic kids (including two autistic children I took care of following a bus crash; one of whom became openly violent towards anyone who got close). The very situation you described is one of my worst nightmares as an EMT because of the sheer unpredictability involved.

[DwayneEMTP]

That's pretty much what I assumed....but I thought maybe there was a magic wand..(drugs?) that could be used.

Would you be able to do much of an assessment? Or just swoop and scoop? (don't remember where I heard that)

Any idea from the docs or others in the know what assessment would look like at the hospital?

Thanks for being blunt....having a handicapped child is challenging, not knowing what their world is like when your not there is terrifying....I'd rather know.

[Punisher]

That's pretty much what I assumed....but I thought maybe there was a magic wand..(drugs?) that could be used.

Would you be able to do much of an assessment? Or just swoop and scoop? (don't remember where I heard that)

Any idea from the docs or others in the know what assessment would look like at the hospital?

Thanks for being blunt....having a handicapped child is challenging, not knowing what their world is like when your not there is terrifying....I'd rather know.

Granted, I'm an EMT-I so I can't give medications to sedate or otherwise calm a panicking person, but even if I could I would be hesitant to do so unless I felt that the patient's life was endangered by their combativeness (example: their airway is impaired, but they are too responsive to intubate, etc) because to give such medications would further complicate the assessment both in the field and in the hospital.

In hospital, I am certain that the assessment would involve a head CT ("cat" scan; to rule out damage to his brain or bleeding within the skull) and either a CT of his abdomen or an ultrasound exam of his belly or both (to rule out intra-abdominal injuries).

[nsmedic393]

First off, in my neck of the woods, a rollover bus accident counts as one hell of an MCI. Asuming the bus was full we would have somewheres around fifty people to assess. If we were in my area, (only have one ambulance at night, two during the day) we would start following our MCI protocols. I would take incident command and my partner would start triaging patients.

Until more help arrives no-one would get treatment until everyone is traiged. We use the S.T.A.R.T triage system, uses colors green, yellow, red and black. Your son would recieve a red tag because of his innability to follow simple commands. He checks out on the other criteria, has a radial pulse and respiration under 30/min.

While triaging i would hope that someone would say something about your son being autistic. If we found out before extrication, we might be able to find a medic to treat you son alone, if not we would extricate him from the vehicle according to priority of tag colour and the triage medic.

If I recieved him in the treatment area and knew of his condition or recieved him directly into the ambulance for transport I would definatly consider sedating him. .5mg/kg of midazolam. Circumstances dependant if he is freaking out its not going to do me, him or the other patients any good if we have to take trhee medics to hold him down.

There are alot of "ifs" here. Mainly will we be able to find out from his classmates his medical condition.

Will we have enough manpower to treat him with special considerations.

What level providor will be caring for him.

Will we have a treatment area on scene or be extricating people straight to ambulances for transport.

Hope this helps

[AZCEP]

Many times an autistic patient will react to the approach of the care giver. If you act like something is bothering you, then the patient will act bothered by it as well.

I also have an autistic daughter, and one of the greatest challenges is convincing her that things will be alright, eventually. Autistic disorders tend to be rooted in routine. Mealtimes, medications, baths, waking up usually occur at, or near, the same times. When an event throws the routine off, the patient often will have a difficult time coping with the change.

Keep everything calm, try to build some degree of trust, maybe use a blanket wrap to help restrain, if needed. Good luck getting vascular access, consider nasal versed/ativan as a last resort. Unless they are critically injured, most of our treatment will only agitate them further, and make the situation worse.

[SSG G-man]

Not having an autistic family member and never having dealt with the situation before, I am not sure of the best avenue of approach. This may or may not help, but what about some kind of Medic alert type bracelet of necklace? If the pt is not responding normal and I see a bracelet I am going to check that, if I see that pt is autistic, it may alter my actions and reactions. Just a thought!

[medik8]

As his father I expect to hate any answer that doesn't involve one of our lady medics wrapping him in her arms and smothering him with kindness until I get there...(Medik8, can I put you on call for my boy?) Dwayne

Dwayne...first off...thank you for your kind comment about me. Yes..I'd love to take care of your little one...it would be an honor. However, chances are that I won't...considering our locations. lol...

But for the record, if I was, yes...I would do everything I could to ease his apprehension and protect him until he could be with you. However, keep in mind that before this, or at least along with this...comes whatever medically would be necessary for your son. That would be my first and foremost concern. Sometimes, the compassion accompanying medical care doesn't seem so compassionate at the time, especially depending on the situation. These types of situations are difficult. Most likely, I would recognize his condition after a short time with him, as I have taken care of autistic children and special needs children before. I have had 6-7 years of Peds only experience in the past, so I've seen a lot.

This is a scary situation...and unfortunately you can't really prepare him as you could any other child, to not be scared, or to cooperate should this happen. First off...start with alerting your local EMS, (or the ones along his bus route) about him, and about his condition. Discuss his needs. It's important that they know. I have had parents of two different special needs kids approach me with all their info, should I ever have a call for them. I have also met these children. It doesn't mean that I'll always remember should something arise that's not at their home, but I may recognize later should it happen in this town. Also, any bracelet or necklace alerting to his condition, with your name and phone number, would be helpful. I'll do what I need to do under an implied consent blanket and my med control, however, it would be helpful if the parents could be reached before things like sedation, etc, are done. Would be very important to know his history, allergies to meds, etc...the usual stuff.

God forbid this ever happens to him, but it's good that you are concerned and looking into this. I hate to tell you this, and I'm sorry to have to, but I have to be honest here. Chances are, should this happen, he will be scared and it may not be a pleasant experience...but in the end, I'm sure he will be ok. You can give yourself some piece of mind to help identify his disabilities, and to promote awareness about them. I would start there...

If there's anything else I can help you with, please ask or PM me.

xoxo. :wink: 8

[medic001918]

That's pretty much what I assumed....but I thought maybe there was a magic wand..(drugs?) that could be used.

Where I work we have the option of using chemical sedation, but unfortunately your son would not meet the criteria for me to consider sedation for him. The scenario you presented gives paints a picture where we could not rule out a head injury or Multi-system trauma. In the field we can't say for sure that the way he is acting (aggressively) is not the result of a head injury. Unfortunately, physical restraint would be the option most commonly used. With that being said, we could always try to contact medical control and get an order to sedate him if we could obtain his history. If the docs are like the ones in my area, they probably aren't going to approve that order though.

Now as for the treatment of him, he would be treated like any other patient. With regard to his mental status and his inability to communicate in a manner in which we can understand (by no fault of his own) I would treat this patient like a young child and base my assessment on what I can see and feel during a thorough exam. I would attempt to talk to him and explain to him what I'm doing in hopes that he might be able to understand at least part of what I'm saying and realize that I'm there to help him and not hurt him.

One other thought would be the possibility of a medical alert chain/bracelet to let providers know that he is autistic? That could prove beneficial to us to help understand his actions and how we need to act in order to care for him most appropriately.

Shane

NREMT-P

[Jeep_911]

not to try to sell a treatment on line here or anything but the first thing I have to say is take a look at this site:www.gordonpomarescentre.com next....

I have worked with dozens to not say hundreds of autistic kids and not one kid presented the same. Some autistic kids will do everything you say, without knowing why and therefor could be managed. Others as in your case are more difficult. I can only say what I would do at my level of care which isn't actually much. How old is that child? (I apologize if you already mentioned it and I missed it). Depending on the size of that individual it is a possibility that I would do much for my safety as some children are aggressive.

Answer: These kids for the most part do not know that you are there and do not understand what is going on around them so if the kid doesn't get freaked out by the lights and equipment, a gentle touch and slow "loving" approach is the only way I would have to treat the kid. Restraining an autistic would do nothing but injure them more and cause some serious issues in the future...or...like I said take a look at that site I sent you and basically cure you're child's autism. Sorry Im this blunt with my last statement but no one CAN argue it until they have taken a look and tried that program. Amen 8)