AIR CARE & MOBILE CARE

Autism & EMS

Factoids and Incidence:

Also called: Autistic spectrum disorder (ASD), Pervasive developmental disorder (PDD).

Autism is a neurologically based developmental disability.  It is described as spectrum disorder where levels of autism can range from severe to mild. It also may be associated with other disorders such as seizures.  

The diagnosis of autism has increased to 1 in 150 children and is more common males than females. Diagnosis is typically around the age of three.  There is no cure but therapies have proven to increase areas of need.

Autism affects the area of the brain which controls the ability to communicate, socialize, comprehend and make appropriate decisions. 

Autism Screening 

Typical Behaviors

Communication:

• Non verbal or limited speech, reverse pronouns
• Difficulty expressing needs, 
• Inappropriate laughing, echolia
• May appear deaf and cover ears (hyperacousis)
• Difficulty understanding facial expressions
• Appear to be unaware when other people talk to them

Socialization
• Avoid eye contact, 
• Prefer to be alone, difficulty interacting with others,
• Avoids touch or seeks out touch (sensory integration) difficulty expressing needs, attachment/ fascination to objects,
• Self-stimulating behaviors such as spinning objects, rocking, esp. pressure sensation,
•Lack concept of time,
•Interrupted sleep patterns,
•Rigid with routines, restrictive behaviors

Comprehension
• Lacks ability to make decisions, lack of fear or real danger,
• Lack their sense of their body in their surroundings.
• Have unusual reactions to the way things smell, taste, look, feel, or sound.
• Find it hard to make sense of the world around them.

A typical individual has no problem walking down the street with a friend, having a conversation, hearing the sounds of the neighborhood in the background, smelling the blooming spring flowers, and maybe chewing gum, all at the same time.  For an autistic individual, who has a dysfunctional sensory system, this typical experience may be completely overwhelming. The individual may be completely oblivious to the sounds of the neighborhood such as an ambulance screaming by, or may be totally overpowered by the smell of blooming flowers. The sun shining through the trees may be such an intense experience, it may inhibit the individual from being able to concentrate on walking down the sidewalk.  Thus this inability to mesh the senses appropriately may profoundly impact someone's ability to "act" and communicate in a "normal" fashion.

Treatments

Treatments include. OT, PT, Speech Therapies, Music/Auditory Processing Therapies, Craniosacral Therapy Sensory Integration, Behavioral Analysis Program such as ABA, Sunrise, Floor time, Miller Method. Medicine, diets and alternative therapies are also options.  Early Intervention is key to any success in therapies.

Insurance rarely covers the cost of therapies. Federal funded program provide some assistance but waiting list can be long.

Family stressors are manifested. Support systems are essential. Families are encouraged to utilize the Autism Society and related support groups for information. CAN & Autism Speaks are also legislative/research/resource organization.

 Children if not mainstreamed attend Autism specific schools or are home schooled.  Adults are geared toward rehabilitation centers for job placements.

Autistic Savants have extraordinary rare talents such as memorization, music & art.

Research holds a strong genetic component plus immune response development during gestation. Vaccines debates still continue.

	EMS Situations During an EMS situation remember: • Assure your safety- if the patient is violent, allow police to intervene.  Low tone (hypotonic) individuals may not be able to support airway- avoid positional asphyxiation- turn pt on side. • Remain calm- quick movements can agitate, individual may run • Talk calm, quietly and smooth • Determine level of understanding and communicating • Look for medical alert tags on clothes, shoe strings, tattoos, GPS devices
• Identify a primary caregiver for suggestions.  • Speak in short direct phrases – where do you hurt? Difficulty processing questions- expect a delay in responses. Explain what you are doing. May not look like they are paying attention. • Avoid slang phrases- phrases are taken literally. • Use plain facial expressions.  • The Wong-Baker Faces Pain Rating Scale will NOT be an accurate measurement for pain. • Use pictures, sign language, simple phrases to communicate. • Refrain from pointing or waving. • Failure to respond to questions, delayed responses, may not indicate obvious painful situation. May show an unusual pain response that could include laughter & singing.  • Turn off sirens/lights- may over-stimulate. May stare at badges, lights, fixate on an object. • Remain alert for outburst or impulsive actions. • Asthma, heart conditions and seizures are common associated conditions. • What works for one individual with autism may not work for another. • Echolia and self stimulating behaviors are a comfort measures. Try to stop them may cause agitation. • Medications may include antipsychotic and calming medications.

Sample EMS Dispatch

•  Is there a history of seizures? 
• Are there sensory issues? Which ones (touch, sound, lights, etc). 
• Does the patient have a favorite topic or favorite object?  These can be used to make the patient more comfortable during assessment/treatment. 
• How does the patient communicate- picture system, sign language, verbal, speech issues, comprehension.
• Remind responding EMT’s that the person may have a high threshold for pain.
• May be very resistant to physical exam, and will need extra time to process information. The patient assessment should be done slowly and deliberately if at all possible. EMT’s should seek out family members or other persons familiar with the patient. 
• Avoid sensory overload.

Important: An increase in stimming behavior means the person’s level of stress is increasing, and a “fight or flight” response is possible.

Case Studies

Case Study # 1

911 Dispatcher receives a call- a 4 year old boy with autism has fallen and cut his arm. As EMS arrive, police are on the scene and tells you he is bleeding pretty good from a cut on his arm, he won’t let anyone touch it and the person with him is his babysitter who started yesterday. She is holding him and he is upset- crying. The caregiver states he fell while running and hit his arm on a rock. She has contacted his mother who will meet you at a hospital.  After you see that the scene is safe (BSI), you ask the care giver how he communicates.  She says he has limited verbal skills but seems to understand what she says. She tells you he can get pretty agitated with new things or change in his routines. You ask her what he likes to play with.  She tells you he likes spinning objects. You limit the caregivers surrounding the child . You tell him you want to help him. You complete an initial survey by visual means. The only issue is a slow bleeding laceration to his forearm that will require stitches and you question a possible deformity. He remains agitated and withdrawn when you approach but is calm with the caregiver. He will not maintain eye contact with you. You give the caregiver gloves to place a sterile 4x4 on the wound and ask her to hold direct pressure. You tell the child you are putting a board under his arm and a bandage over it. She carries the child into the ambulance. You place the child on the stretcher, lights are dim, the area is kept quiet. He begins to verbalize in an echolia and appears content. Caregiver sits near the child restrained. You notify the emergency room of the injury and the diagnosis of autism.  

Discussion: 

Your primary concern is your safety. Rely on caregivers to assist. You have implied consent from a care giver- ask for the mother’s phone number and call them. Decreasing additional stimuli will reduce possible outburst. If it is an issue his well being comes first and ignore the agitated behavior. Do your procedures slow as not to startle.

Case Study # 2

A mother walks into your station and says her 9 year old son is having an asthma attack. She has forgotten his inhaler. He has autism. You escort them to your truck, the child begins to cry and you notice he has limited verbal skills. You hear audible wheezes without a stethoscope.  You tell the mother he needs a breathing treatment and to be transported to the ER. She agrees. Your partner begins to get information from the mother especially what she does to help him with an asthma exacerbation. The child will not walk up the step of the truck to get the treatment. He said he is scared ands begins stimming. You turn on soft lighting. You ask the mother how does he communicate and what she uses to play or redirect him. She states he likes dinosaurs and likes to draw. She distracts him and goes into the truck and he follows. She sits next to him. You prepare the HHN treatment and hand it to the mother to give to the child. He cooperates. You show him your stethoscope and let him play with it while he is getting his treatment. He allows you to listen to his lungs. You tell him you are going to the hospital in the ambulance. You secure him and his mother. You notify the receiving ER of the child’s condition and his Autism diagnosis. Limiting contact and conversation allows for a quiet environment. Instead of asking him questions you limit your re-assessment to visual assessment.

Discussion:  

After you get consent its important to get the caregivers clues how to relate to the child. Notify the ER ahead of time provides continuity of care- request a quiet room.

Case Study # 3

Police request medic assistance with an “out of control autistic child” at a school. On arrival the school nurse reports the child was found down in the hallway- they thought he was sleeping. Teachers have said today he had several episodes of “blank stares”. He walked to the nurse’s office agitated, crying, and disoriented. “He normally is quiet and cooperative, he’s been like this for a few minutes”. You realize you are unable to communicate with him or that he can comprehend. You think trauma or seizure. Does he have a head injury or is he postitical? ABC’s are cleared.  No obvious trauma is noted. Despite his demeanor- you lay him down,  collar/backboard using short simple sentences and direction. He is suddenly becomes quiet and sleepy. You ask him if he hurts anywhere and he doesn’t respond- he just looks around the room. Then gives a delayed response “no”. You recheck ABC and are cleared. Your neuro exam is within normal limits and he is cooperative but sleepy. Vitals are stable. To do a blood sugar level, you tell him you are going to pinch his finger and a little bit of blood will come out. School has contacted his parents and they will meet you at the hospital. You notify the hospital of his condition and Autism diagnosis.  

Discussion: 

After you realize the scene is safe and you get a rapid assessment story- advise the police and other this maybe more of a medical issue than behavioral. Continue your assessment as situation continues to change.  Remember delayed responses are expected. Remember to always tell the patient what you are doing even though other may think he doesn’t understand.

Case Study # 4

Fire department is called to a house after a home alarm sounded for a fire. When you arrive, you find a man unconscious on the ground. Medics are caring for him as you approach the house to search for more occupants. You notice on the door window a sticker that demotes an occupant with Autism resides there. The fire is out but you search for a possible victim. You remember autistic people can hide in stressful situations. You find a 7 year old child in a closet, rocking with stimming and echolia. You pick up the child and remove him. You advise medics of a possible autistic child.  

Discussion:  

Always look for signs on entrance doors and cars for possible medical conditions of occupants. Do not interrupt the stimming. The autistic needs stimming to calm themselves down.

Follow this link to take the test!


Thank you,
Air Care & Mobile Care

THANK YOU FOR YOUR CONTINUED SUPPORT!