The Q Word Podcast

"Neurodivergent Trauma, Part 2"

Lisa  
This is part two of our neurodivergent episode with educator Brittany Smith, which focuses on a toolkit that she frequently references in part one. This will likely make more sense if you've listened to Part 1. So, if you haven't stopped now, go back, listen to it, and come back later. We know that most ERs are on a tight budget and don't have the money for extras that shouldn't be extras in the first place. And now, with the additional strain that COVID has placed on hospitals, putting together this toolkit for your department might prove an additional challenge. So here are some ideas. Approach the volunteers at your hospital for donations. Do you have a medical foundation that gives grants? Is there community or state grants that you can apply for? What about projects through community service organizations like Civitan or Kiwanis, or Junior League or Rotary Club? Could this toolkit be an Eagle Scout project? Look around in your communities to see if there are other organizations that may be able to step in and help you assemble this toolkit. We also want to mention that the weighted blanket and the weighted lap blankets that Brittany mentioned in this episode are not like the commercial ones that we sleep under at night. For multiple patients uses, these weighted blankets can be disinfected. Patients, Nyssa's dog, Gus, has made cameo appearances in previous episodes with barking and ear flapping. In this episode, he let something else fly. We know that ER nurses have excellent assessment skills, so you are likely to be able to pick it out. And since Nyssa was talking when it happened, even my wizard editing skills couldn't do anything about it. So, we apologize for Gus's noisy appearance, but we hope that you appreciate all the excellent information that can be found in this episode about dealing with your neurodivergent population. And without further ado, here we go with part two.

Welcome to The Q Word, a podcast about the tips, trends, and taboos of emergency nursing, where we pull the hospital curtain back on issues that emergency nurses and their patients often think about, but seldom talk about. Hello, Nyssa, Welcome back to the second half of this special population episode.

Nyssa  
So, we're covering autism, ADHD, ODD, and some other psychiatric diagnoses that are a little rarer, like pediatric schizophrenia and pediatric bipolar. And we have with us Britanny Smith, who is a special-needs teacher and is an expert on teaching children with these diagnoses. And if you haven't checked out the first half of this two-part series, you probably want to stop now and check it out. So, we're going to go into the toolkit that Britanny has created and is willing to share with all our listeners. It is a beautiful, beautiful toolkit. Some of them are actual items, and some of them are ideas and tricks that you can use. In her case, in teaching these students; in our case, as nurses or emergency providers, it would be in treating these patients if they were to come into your ambulance or into your ER, your trauma bay, or your resuscitation room.

Lisa  
And we will, of course, post a link to this document in the show notes, go to our website, so you can check it out, along with some other information.

Nyssa  
And she's made it super easy. There are links to YouTube videos; the YouTube videos are awesome because they actually take you through a two-or three-minute experience as if you were an autistic person, like going to a coffee shop and having a cup of coffee as if you were an autistic person or walking down the street as if you were a person with autism.

Lisa  
I found that very fascinating and helpful for being more empathetic. 

Nyssa  
And there's also a link to an Amazon Wishlist where if you have a beautiful budget in your ED and you just want to click and buy all these things and make your toolkit, it's all right there. 

Lisa  
And for those of us that are visually stimulated, there are a lot of pictures. 

Nyssa  
Yes.

 

Lisa  
This also makes it a great tool, as we discussed in episode one, for just about any pediatric patient. So, whether your patient has special needs or not, this is a good toolkit that you can use for any patient, maybe even anybody under trauma, because who doesn't like looking at pictures? And doesn't it make it easier when you don't have to talk and can point? So, let's go ahead and dive into this. I'm fascinated by it. And I love this document.

Nyssa  
Yeah, Britanny, we've said a lot of stuff. But you're the expert, and you created this toolkit. Tell us a little bit about it. Tell us a lot about it. 

Britanny  
Well, first, this toolkit, the document itself, is worded like a social fact story. So "social facts" are what you use with a person with autism to help communicate something. Usually, it can be teaching a skill, it can be teaching a coping skill, it can even be, you know, "Hi, my name is _____ and I'm here to help you." I have found that something that you always remember when you go to the doctor. They give you a chart of how much pain you're in. I never look at the numbers, I always look at the faces. So that's how a person with autism is. That's all they would notice: "What do the faces look like?" The biggest thing I want to encourage you to do is please check out the videos of what it is like to be a person with autism. And as close as you can get to empathizing, it will give you a beneficial point of view because a lot of the agitation and frustration that you'd see in pediatric patients, especially, could simply be because you don't understand what they're trying to tell you. I mean, how frustrating is it for an adult when you're like, "You're not listening to me." We talked in the previous episode about your neurons and you’re wiring in your brain and having autism, they have triple the amount. And so, there's so much happening at one time that sometimes they can't communicate verbally at all. And so, you must use cards, and you must use charts of where you are hurt. What can I do to help you? So, this chart is set up in a way that if you were a person with autism, you would love it. It has pictures, simple questions, and simple things for you to do to kind of help pediatric patients.

Nyssa  
The other thing that I took away from the video that you were mentioning is the intense amount of stimulation that's coming in when you are a person with autism: the lights, the noises, the inability to separate one noise from another noise. And so, when I think about our emergency room, there is so much stimulation and so much input. There are weird noises, there is loud beeping, there are all kinds of weird smells. There are all kinds of things around that you've never seen before, like machines and beds that look different than your bed at home.

Lisa  
There are bright lights, there are people you don't know, and you get the same questions. I mean, I've been in the ER and it's mystifying. So yeah, it's very easy. A lot of sharp objects, a lot of people taking your clothes off.

Nyssa  
That's right, everyone's touching you, maybe multiple people coming in and out of the room, wanting to touch you so. So, what I thought maybe we could do is because your toolkit is not only designed for people with autism, or children with autism, but also for the other diagnoses that we talked about. So, what I'd like to do is kind of describe to you what we would do in an emergency room when we have a new patient come in. And then if you would tell us what some of the interventions in your toolkit would be best to use to help make those children feel more comfortable or maybe help it be a less traumatic experience for them. And again, I'd like to point out that you've made a couple of times that this is good for any pediatric patient, not just pediatric patients with these specific diagnoses. In fact, it could be adults with autism, or it could be just adults who are anxious about being in a hospital. So, one of the first things that we mentioned was that we would bring them into the room. The room is going to have bright lights. And we are going to ask them, in most cases, to take their clothes off and put on a gown. So, children with autism, children with ADHD, children with other psychiatric diagnoses, what can we do to make that more comfortable for them? Or how can we approach that?

Britanny  
I would have a schedule of what it was going to be like in that room right then. So first, you can have a picture of somebody wearing clothes and then a body. And you could say, "I need you to take your clothes off your body, then I need you to lay down." And just the visuals can be very, very soothing. It's almost like you're telling a story: first, this is what's going to happen, then this is what's going to happen next. It's almost like you're asking for permission. And that's a sacred thing right now for a lot of people: this is their body and I need you to do this so that you can be safe, but that's what this looks like. Because a lot of times we forget that, especially at a young age, you're a visual learner, and you're a visual learner often until you're in high school. So is the power of a great visual. And so, on my list here, I have visual cards for body parts. And I have cards that you can use that just kind of talk about the different parts of your body. And you could just put those together and say, you know, point to the cars, you know, I need you to take your clothes and put them here and then lay down.

Lisa  
Okay, it almost sounds as if you're saying we should build something like a children's picture book for nurses. That's kind of like a "Choose Your Own Adventure." Here's our million-dollar idea: Here are people that write that, yeah, right. Like here, the first few pages would be the same; everybody must take their clothes off, and they must get on the bed. But then this student does this: this patient might need to get an ID or might need to get to this. So, you flip to those pages, or this person, and say, "Here's the body part pages or something like that." I could easily flip around and be like, "Here, can you do this?" So, there we go. There's a million-dollar idea. We heard it first on The Q Word Podcast.

Britanny  
That's right.

Nyssa  
So, the next thing that we're going to do, or one of the next things that we're going to do, is get some vital signs. So, what that might include is taking your temperature, so sometimes we can do it with a thermometer in the mouth, sometimes we will go in the armpit. Sometimes the ear probes are even across the forehead. So, what could we do with your student population that would change that? Would they go for something under the armpit? Or would they?

Britanny  
I say the least invasive, always go for the least invasive unless they are uncooperative. And whenever there's the Uncooperating, you can always offer a visual, you can even show them a picture of the forehead and say, you know, I'm going to put it here. And then a lot of times, it's like magic. Many times, you know, even in class, we would have a diabetic. Unfortunately, autism and diabetes that's like a living nightmare. We just have a social story that said, you're going to check your blood, you're going to put your finger here and you know, now I have these cool arm things. So, you know, the visual of the cue cards is always super, super, super helpful. And that's on the wish list.

Lisa  
What holds up your phone with an image doing the same thing?

Britanny  
Yeah, it really will. Yes.

Nyssa  
As demonstrated on mom.

 

Britanny  
Yeah.  

Nyssa  
I'm going to put it in mom's ear. See, it didn't work.

Britanny  
Any visual demonstration? Yes. As a result, So scavenger hunt. If you don't have a card, use your phone, or visually show it to somebody else. And then try it. 

Nyssa  
Got it. 

Britanny  
And that's any kid.

Nyssa  
Yes, that's true. So, Britanny has created this beautiful toolkit, but she also has what she's calling the scavenger hunt. That is, if you don't have a budget for this tool kit, she also has ideas for what you can just scavenge around in your ad that you might already have there. And so that's what she's referring to when she's referring to a scavenger hunt. That's what we're talking about. Okay, so one of the next things we would do is blood pressure, and we're going to, you know, but the blood pressure cuff on the arm. It's going to squeeze tight, really tightly, really tightly.

Britanny  
Tightly.

 

Nyssa  
Tightly. Thank you. So, some of the things I'll say to two little kids are, "I'm going to, like, see how big your muscles are. "Or I'm going to give your arm a hug. I will say that to preschool-age kids sometimes to get them to kind of cooperate or whatever. What would you say? What do you think about your student population?

Britanny  
If you're a person with autism, you love it. Deep pressure is a huge comfort. What you can always do though, is other if you don't have like the visual for it, you can just squeeze their hand to model how tight it's going to be. And then say this is going to just be on your arm like this. So, something like that, like the modeling of it.

Lisa  
I'll be honest, they'll absolutely love it.

Nyssa  
Oh, that's interesting.

 

Britanny  
Yeah.

Lisa  
Just keep an eye on them.

Nyssa  
keep an eye on them.

Lisa  
Then they just keep it. Yeah, exactly. Just keep it on a cycle. It's just like a little hug. 

Britanny  
That is right.

 

Nyssa

What about the stickers? If we're going to do continuous EKG monitoring, we have to put stickers on them and then wires so they can deal with that.

Lisa  
When they go on, the cold that cold little ones are cold.

Britanny  
I'd like to pick a Yeah, I would say they would pick that off in a heartbeat. I would have a social story about this. This is what's going to happen. You can't, you know, then I'll have the big "X" that says don't do this, this, and this. And one of the things in my toolkit is that you should. It's really cool to create a nursing book of Have you ever done it and thought to yourself, "You know, this is the picture, this is how it's supposed to look. “And so that means you're not touching it, you're leaving it there. But once you put it on and put them on, I would say a weighted blanket would be a great second great tool to put across it. So that then kind of negates, maybe not balances out, the achy, sticky feeling of something on their chest.

Nyssa  
Out of sight, out of mind, to me.

Lisa  
In terms of the visual images that you're talking about, is there a preference for cartoony images over photographic ones?

Britanny  
Um, Autism Speaks is a great resource for getting these images that are probably most appropriate. You want them to be real. But if you go on the link, that is the wish list. They're mostly known as ASD, like visual communication. So don't just act like a stick figure. Usually, they're kind of binarized. I mean, there's not a lot to them. The less you're putting into the visual the better. You don't want it to be overpowering.

Lisa  
So, like key instructions for assembling the mouse? Absolutely.

Britanny  
That's right.

Lisa  
which I have. 

 

Nyssa  
Here's the big one. So, what if we have to start an IV and draw blood? Or what if we must start an IV and draw blood and then they're going to get stitches? Or they're going to have to have some other sort of painful procedure? But starting an IV is very, very common. Drawing blood then from that IV is very, very common. So, not just with your autistic children.  
There are other diagnoses as well. No kid likes this. Obviously, it's going to involve being still, it's going to involve a needle, it's going to involve seeing blood, it's going to involve a tourniquet, which is tight. If they move too much, it's going to mean that the IV doesn't go in, and we're going to have to do it all over again. So, it's a procedure that takes several minutes from start to finish. What thoughts do you have on that? A lot of times with kids, we use a lot of distraction to distract you while we're doing that.

Britanny  
That is exactly what I would say. For someone with autism, the vibration would be a cool thing to do. At the same time, I would say it's in the top five list of favorite things, which would be vibration. So, a lot of the fidgets in this box would have a vibration. They can be small things; they can be large things. The biggest thing would be a weighted blanket and some type of thing in their hand, whether it's a vibrating tool or something like if you don't have anything, give them a pen, give them something to hold on to. If it's handmade, move it and rip it out or go to pinch you because you're hurting them. So, they're going to hurt you, too.

Lisa  
Okay.

Nyssa  
What about your ODD kid starting an IV to draw blood?

Britanny  
Choices always give a choice to the oppositional child. So, say, you know, I'm going to do this, but while I'm doing it, you have a choice of what you can look at or hold on to while it's happening. Okay, and the power of choice is like, "Now I'm in control." 99% of the time, it'll take away some of the angsty feelings that are there.

Nyssa  
One of the things that I like to say to kids when I'm starting an IV is that they can scream and yell as loud as they want. But I just need you to be still. And one of the reasons why it works well, oftentimes, is because kids are never told that they're allowed to be as loud as they want, especially inside. As a result, when I say you can yell and scream as much as you want, older kids will tell you that you can even curse.   And moms are usually like, "No, you can't." But now is the time for an F-bomb and no one will yell at you. As long as you're still.

Britanny  
That's perfect. And I always tell people that I had a kid who cursed 250 times a day on average. 

Nyssa  
It was awesome. I loved it. 

Britanny  
I gave him one every ten minutes. I gave him a cussing list and he read it out. And then, after a while, he didn't want to cuss anymore because why? I used to take the power away from it, and that's a powerful tool. When you have to do something that's painful, or you have to do this procedure, I'm going to do this, but let me give you some power, or remove the power and let you, you know, cuss, scream,  yell, but it is, you know, it's going to happen. So, laying out those guidelines, but also offering the power of choice, and sometimes even negating some of the negative things like screaming, cursing, yelling. Very powerful.

Nyssa  
Okay, so can you go over some of the do's and don'ts of what to do when we're caring for—we talked about it in the first half of the episode, but in the second half, we're in the treatment room with your students. What would be some of the don'ts?

Britanny  
I know, this is probably a difficult one to work around. But we're repeating questions. I would say, repeating a question that they don't know the answer to, or that you're not understanding their response to, can cause a stir and an intense stemming episode. I would say if they're not understanding your question, I would say this about a second time you ask it, you just need to go to a different question, or totally ask it in a different way. Even as a parent, I get into an awful habit of repeating the same thing. And I'm like, "You obviously, what am I doing? You obviously don't understand." Or maybe I'm not understanding you. Moving too quickly, I would say, is another big thing I know. Sometimes it's an emergency situation. And if you do have to move quickly, coming from the arms of the game, from your sides forward, rather than from the chest, there's something about the visual-spatial parts of that that makes a difference as well.

Nyssa  
And you mentioned also intense eye contact. It's really an autism spectrum thing, that it's almost like a rude thing.

Britanny  
It is. I mean, that's the closest thing I could use to describe it. But if you watch the videos that are linked at the bottom of the document, you kind of get an idea of how intense eye contact is as a nonverbal form of communication. Well, you're asking someone who is already struggling to pick up the normal form of communication to pick up your nonverbal cues, and it can create a lot of frustration. It can also kind of cause their anxiety to increase. So, I usually look at the sides of the eyes, the tip of the nose, and the forehead.

Lisa  
Okay, so you're still looking them in the face, which is respect. You are locking eyes.

Britanny  
You're just not locking eyes, because they're like, "Are you trying to say something to me?" Because I'm genuinely not getting what you're putting out.

Lisa  
But well, there are other cultures that respond very adversely to the American impulse to look you in the eye and to smile a lot. I've heard about that. You know, you can go into other countries, and we Americans, like blindly smile, and immediately walk by and people like to show me their teeth. What is that all about? because in other cultures it's a bit aggressive or unfamiliar. So, you know, if that is a cultural thing already, I can imagine how confusing it would be for a child whose sensory perception is already overloaded.

Britanny  
Yes, absolutely.

Nyssa  
And I think the other two points that you make are probably true for every child. But if they come in with a comfort object of some kind that they brought in from home, make sure that they get to keep that as much as possible, if possible. And then I noticed that you say in your toolkit to try to get kind of instead of standing over them to Yeah, like, and that's true of any kind. We should always try to get down to eye level with them. So, you don't feel like you're in a hurry.

Lisa  
Like lording, right, right.

Nyssa  
Try to get down to their level.

Britanny  
Absolutely. And then just remember, when you're down at that level, especially with a person with autism, or even, you know, some of your lower functioning friends, they might consider your close proximity and eye contact, like we were saying, to be aggressive. So, they might lash out unintentionally, just like what are you doing, like a shove or a pinch. Occasionally, we'll get a bite. And then another doesn’t is that I would be really careful about handing them something that could be put in their mouth and choked on. So, you know, if you're going somewhere, holding this or that will make you feel better. Always be careful about the oral fixation that you can often see.

Nyssa  
As a result, the distraction and fidget items that you encourage them to have in their hands should be too large for them to put in their mouths. Maybe they can put it in their mouth, but it's not going to be something that they can choke on.

Britanny  
And some of the things are small, I would say just know your patient just like I know the student, and it is harder because it's on a quicker basis. But if you if they're not talking to you, or you notice, like they're biting their mouth a lot or they're biting their skin, I would definitely not give them anything that could be put in their mouth. You can usually pick up your oral fixation kids who Really quick their shirt will be soaked for their second on their shirt.

Lisa  
Okay, interesting. 

Britanny  
Yeah.

Lisa  
That's a good hint to see. Mm-hmm. So, we've talked about physical bruising, bruising, and other things. But if they've got an oral fixation, you just pointed out that. Is there anything else that you might, see?

Britanny  
They have bite marks on their bodies. I mean, it's hard to see somebody with bite marks. Your first instinct is that they have hurt you or that you are being abused. Bite marks on their bodies could be like that. I had a girl who used to suck her skin and have all these purple bruises all over her body. I mean, it looked like she was just being a piece of meat. I mean, genuinely being abused. And it was her. It was her bruises. And it was something we really, really worked on by the end. We got her to stop doing that, which was awesome. But initially, yeah, initially, I mean, she was head to toe purple, with thick bruises and bruising.

Lisa  
Wow, that's amazing.

Britanny  
So yeah, if you get a patient that's covered in them, call a social service worker. But I would also keep a close eye on how often they might put something in their mouth. And that might be an indicator that it's then that they're doing it.

Lisa  
That's good to know.

Nyssa  
You mentioned in the last episode that often children with some of the diagnoses that we have talked about will have some sort of special interest. As you mentioned, Titanic, I had a friend who was especially interested in maps. Anything map-related. He loved it. So, would that be something that we could focus on and talk about and encourage them to do, and that would be soothing to them? We could bring that up.

Britanny  
Absolutely. The power of a good conversation can go a long way, especially if you're a high-functioning person with autism or one of the other disabilities we've discussed. Bring up special interests. I would say it's a special need flag, the special interest. So, you can start that conversation by saying, "Hey, I really like this." Do you like that? Or do you have something that you're interested in? Sadly, for your nonverbal friends, it's hard to kind of pick out their special interests without some type of visual cueing. So that's why on my list, there's a book that talks about different things that they might be interested in. So maybe they could look at it while you're doing stuff.

Nyssa  
So maybe music or something on TV, and you could tune into possibly.

Britanny  
Absolutely. Never underestimate the power of good technology. I would say music is another one.

Lisa  
And to drown out the sounds, as you said earlier, noise-cancelling headphones could be helpful. I could see how they would pop a couple of headphones on them and their favorite band.

Britanny  
Or white noise. 

Lisa  
White noise.

Britanny  
There's also white noise, and if you've heard of it, that's a hertz. It's a certain number of hertz. And that's basically like a vibration. And a sector that involves almost that vibration is really, really soothing. And you can buy an app. Easy. Put 99 cents away, spend that baby, and you're set.

Lisa  
Good to go. 

Nyssa  
Wow, that would be good in the ER, where it would be very difficult to manage the noise. Yeah, but those noise-cancelling headphones may be just the thing. 

Britanny  
Yeah.

Nyssa  
And you could wipe them down in between patients. 

Britanny  
Yes, we had to wipe them down now. I mean, I still use my stuff. But the first day of school, we spent a good hour talking about cleaning them with our sanitation wipes that smell like tequila.

Lisa  
Rona, is that why? Are there any closing thoughts? Any final thoughts or advice you'd give to nurses in the ER that we didn't cover? Or encouragement? What parting words would you like to give to our listeners about how to best deal with special populations, not only for the patients but also for the nurses themselves?

Britanny  
The two things: first is that you are probably doing a lot of things right. You just don't know if you're doing it right. And so, I often commend the hard work that you do to cover all the bases that you have to cover while also triaging and stabilizing patients. And that's amazing. And the second thing is that we are never too old to learn something new. And we're never, honestly, better for it. Every time we learn something new, we should always challenge ourselves to stay educated and try new things. And if it doesn't work, don't give up on that thing. But be willing to give new things a shot. We can get really stuck in our ways sometimes, especially when day in and day out, you know, repetitive things.

Lisa  
And in this industry, specifically with our nurses, it's this. This is the difference between life and death. And this is the difference between making a patient have a better experience surviving trauma when they have to go into the ER. And I know that all the nurses I've spoken with and met through this podcast are primarily concerned with the well-being and care of their patients. And this episode, these two episodes, I hope will provide them with more information on how to do that even more effectively for a very special population that is very, very difficult to manage. We really, really appreciate your coming. 

Nyssa  
Just a few comments. Britanny, I thank you for what you're doing. And with all this information that you've put together and that you're willing to share with our listeners, I have learned so many things that I can't wait to implement into my practice. And I love what you have at the end of your toolkit where it says that they are different but not less. Right.

Lisa  
I love it. I love it. That's perfect. Thank you so much, Britanny. We really appreciate your spending your time with us today.

Britanny  
Thank you.

Lisa  
Great. All right, well, I'll talk to you soon. Thanks, listeners, for listening. And we will have a new episode for you shortly. Bye.                                                                      

Britanny  
Bye.

                                                                                                 

Lisa  
The anal probe is no longer used, right? I'm not being rude here. But I remember being a little girl and my mother always took my temperature using an anal thermometer, and I remember, even as a little kid, thinking that was torture, and yeah, my friends like when my mom puts it in my mouth.

Nyssa  
It's rectal first. Once you're past, I don't know how old enough to hold it in your mouth. That's for babies, and our responses will be.

Lisa  
I still remember this.

Nyssa  
Okay. Wow. Oh, man!

Lisa  
Parents were using the rectal thermometer way, way late, like.

Nyssa  
Hashtag Me too.

Lisa  
I must have been like.

Nyssa  
Hey, you need to talk to your mom.

Lisa  
What was that? Okay, sorry. Sorry, say back on topic.

Keywords

toolkit, patient, autism, ER, special interest, children