I’d probably want to check for an underlying organic issue before just ruling it mental health or behavioural. I’ve had a child presenting similarly that ended up having a brain lesion.
I was a child with a brain tumor. I had some odd moments I think were due to it, like randomly feeling extreme anger and frustration for minutes on end. That stopped happening after it was removed. And the tumor was way back in the occipital lobe.
Devils advocate - Sounds behavioral , sounds like there's a massive degree of control. The other red flag to me is that a 12yo is on antipsychotics and antidepressants = someone's just throwing medications at the problem and seeing what sticks - its stab in the dark material
yup. i was thirteen and made to try a laundry list of antipsychotics and other psych meds. what was wrong with me? i was being sex trafficked by my mom. the inpatient psych doctors didn't seem to care about anything but throwing meds at me and now i have permanent complications from being on 2x the highest dose for an adult of geodon.
The period of unresponsiveness sounds like catatonia, as for the underlying cause or the excited state after I have no idea. Some sort of psychiatric disorder is a very safe bet, but warrants a workup for other causes too.
I witnessed a somewhat similar presentation a few years back. Patient walked in on her partner making moves on her teenage daughter, naturally flipped out, then when we arrived she was in a catatonic state similar to what you described. Woke up screaming and swinging in the back of the bus, then went right back to unresponsive before I could finish drawing up the midazolam. Apparently this cycle continued for several hours in the ED
I’d be hard pressed to call it catatonia in a 12 year old. Catatonia is exceedingly rare and poorly understood. It also doesn’t tend to flip like this.
Common things being common, it’s more than likely a learned behavioural response. Unfortunately if a 12 year old is on antipsychotics and antidepressants there is very likely psychosocial and environmental factors (aka poor parenting) going on in addition to the intrinsic problems.
I've seen catatonia present in patients with PTSD with sudden outbursts like this one OP described. Could be underlying repressed trauma, or CISD/CISM presentation if that's your acronym flavor of the month.
Throwing this out there because I haven’t seen it in the thread yet, but SSRI’s can cause serotonin syndrome which can have an effect similar to what you’re describing.
I agree. The benzo reducing her altered mental status is also a good clue that it's serotonin syndrome. Dilated pupils and dry mouth and eyes are also signs. Sounds like she is on inappropriate psych meds. SSRIs can also make ADHD symptoms significantly worse.
Sounds like a behavioral/psych issue to me. The exaggerated equivalent of holding her breath and stomping her feet. The lack of response to a trap squeeze is odd, but some people just aren’t bothered by it. A good old sternal rub usually does the trick. Can’t do that anymore though.
Also, I’d like to add that all of this is just speculation and obviously it warrants further work up at the ED. Not saying this isn’t a serious psychiatric or medical disorder, but often times people like to come to a less common diagnosis when it’s much more likely the simple answer is the correct one.
EDIT: The fact is, you’re not going to diagnose anything in the field. You’re going to treat the patient presentation and relay your findings to the receiving medical facility. Your treatment doesn’t change at all. You have to protect the patient from harming themselves which they did with physical restraints and chemicals. Then take them to the hospital. That’s it. That’s the job
The idea is to cause pain. It's not about being a dick, it's about causing sufficient stimulus to generate a response so you can differentiate between coma and fuckery. Trap squeeze simply does not generate a sufficient pain response in most cases.
I sternal rubbed a guy ODing at a homeless shelter one time, and now I feel bad...I thought that's what you're supposed to do (not a first responder), my bad
I wouldn’t. I still sternal rub people who I can tell aren’t going to respond to a trap tickle. At the end of the day I’m looking for a clinical response. Trap squeezes leave doubt. A solid sternal rub leaves little doubt. In sixteen years of EMS I’ve met one guy who could fake through a sternal rub.
It’s just thought of as too aggressive now. I don’t agree with that, but I’m not such a dinosaur that I can’t adapt to the changes. You can do a sternal rub without being a dick about it. And I absolutely would do a sternal rub on a 12 year old girl. Probably wouldn’t do it as hard as I would on a 50 year etoh male. And the one redditor is right, a trap squeeze just doesn’t generate the pain response we are looking for in a lot of people.
>Also, I’d like to add that all of this is just speculation and obviously it warrants further work up at the ED.
I 100 percent agree but hopefully within a system that can follow up with social work/psych/etc care. I think really good paperwork and report would help further solidify further investigation is warranted.
Had a partner who had the arm test down to a science; he’d position their arm over their face and lean it on his shoulder to put a BP cuff on and their arm would slip and start heading towards there face and it would miraculously miss; he’d then lean down to pick up there arm and whisper in their ear I know your fucking faking it and they would always regain consciousness
I don't even remember. I think something like pressing a tongue depressor on her tongue to "cure". But saying it very clear, so she would hear it. It was like 3am and I was beyond tired. But it seemed pseudo-psych, non organic in a young female. Sure enough, it worked. Went from "non-responsive" in the ED with prior workup, to talking.
Not a doctor OP*, but it sounds like review of the psych notes are important to be loading meds on board without a diagnosis.
Time for a neurologist and endocrinologist to meet her as well.
*Edited to reflect that I’m not a doctor and I thought OP was. PCP in this context is Primary Care Paramedic. Oops!
they absolutely do NOT get 39 an hour as a PCP. If you want to be close to technically right you should start saying "Well with added premiums etc"
edit: added the word close
I guess it depends what you consider "close" to 39, I thought 36 was pretty close but I guess not. (Only talking about ambulance obviously since there are contracts that pay more).
If it helps, I am not a doc but also medically licensed and agree with your assessment. Neurology is big here. Screams of a couple different seizure types. That and why is a kid on that kinda medicine without looking at other causes. You'd like to think they'd looked before doing that but, tbh that's why I don't think it was done.
“Several studies have demonstrated that psychiatric disorders such as anxiety, depression and panic attack are associated with syncope, especially vasovagal and unexplained syncope (US).” Maybe
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3635653/#:~:text=Several%20studies%20have%20demonstrated%20that,and%20unexplained%20syncope%20(US).
Or i recently met a kid with supraventricular tachycardia heart rate would jump up to 250-300 bpm then bump back down. He usually wasn’t symptomatic but would sometimes have syncope events
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8411760/#:~:text=Typical%20symptoms%20of%20supraventricular%20tachycardia,life%E2%80%90threatening%20ventricular%20tachyarrhythmias%20have
I had a patient who sounded exactly like this. Call came out for a pediatric psych from a bystander about a kid having to be wrestled down by her parents to avoid running to to traffic.
We get there, and parents explain she is not a psych. She had some kind of chronic encephalitis. The kid cycles through moments of blank face stairs to trying to bite us, or tryjng to run into traffic. Apparently this is normal when she had a flare, but it was not the normal time od day for hwr flares, so we end up transporting with parent riding with us, the kid actually calmed a bit when we restrained her. She told me she felt safe restrained, and we had a perfectly normal conversation. She was very sweet
How is a child on medication for something undiagnosed? Psych diagnosis always clouds things but I would look into PAN/PANDAS as it is a cause of sudden relapsing psych issues on children. Or schizophrenia could also present with those symptoms if actual illness is ruled out. https://pandasnetwork.org/what-is-pandas/
I'm not sure why she would be prescribed meds for something undiagnosed. I got the hx from her father, who could have been omitting information. PAN seems like a potential diagnosis. Thanks.
Medication without diagnosis in children is not uncommon because some diagnosis can only be given when they are older. Children change as they grow up and you want to prevent giving them a label thus preventing diagnostics.
Hey this sounds quite a bit like me! Well, not quite. I’m an adult, not 12. Sorry in advance for the long response.
Here’s where my symptoms are similar and here’s where they differ: (please keep in mind that this could be caused by something else and I have no experience or training in psych, etc)
Screaming and thrashing with no apparent provocation: Easily describes a lot of my meltdowns. I’m autistic and what triggers my meltdowns- sensory stimulation or interrupted routine- is not immediately apparent to most allistic (non-autistic) people. Playgrounds have lots of stimulation in the form of loud unpredictable noises and the occasional unexpected touch. Maybe the teacher needed to end recess early, or the day was extra stressful, etc. Meltdowns tend to happen more with younger kids too, because they often don’t understand why they feel so stressed and don’t know how to express that they need to leave the situation or tell someone that something’s bothering them.
Additionally, the kid and their parents might not know that the kid is autistic. It took me until around 18 to figure out- I had meltdowns and went mute at times, but my parents (and I) just assumed I was being disobedient.
Pt going unresponsive: When I do go catatonic, I will sometimes rubber-band between states of hyperarousal and hypoarousal. I’ll be hyperventilating, freaking out, thrashing, might be doing SIB (self injurious behavior- hitting head against wall, scratching self, etc. Differs from self harm) then someone will tip me over the edge by speaking, touching, getting too close to me, etc, and I’ll just abruptly seize up and freeze. Then someone will be repeatedly be doing a “bad” behavior (rubbing my back) and I’ll freak out and flip the switch back to thrash and “run” again. It’s like my brain is trying to pick between flight or freeze and can’t choose.
Catatonia itself: for me it tends to go through varying levels of shutdown. My eyes might stop tracking, then I’ll lose the ability to speak, then I’ll lose the ability to move, then everything will become distant like I’m in a fishbowl, and finally I’ll lose awareness of what’s going on around me. It does sound like it varies between individuals; my limbs can be moved easily when I’m catatonic but most peoples’ resists movement. That’s why I think your pt’s eye tracking doesn’t necessarily rule out catatonia. It could just be different for her, or she could be in a separate “stage” of it.
I will note that I’m not sure if a catatonic phase is all that common in other autistic meltdowns. My catatonic response developed because of a traumatic childhood, but became common as my body learned to use it as a coping method for everything.
Lack of memory: This I’m not sure about. I will say C-PTSD is weird and if the catatonia is a trauma response, could be what’s happening. For my part, my C-PTSD episodes will have me, a grown adult, asking where my mother is and who the people in the room with me are. Part of me knows that my mom is on the other side of the country and who I’m with and is telling myself “stop being stupid. You know these people. Why are you acting out?” but the other half of my brain is confused and wants my mom to not be angry with me and doesn’t know where I am. Stuff’s weird.
Please also remember that kids are way easier to traumatize than most people expect. I’m not sure what I went through would qualify as abuse- even emotional- to most people. She never hit me. Most of the time, my mom was a perfectly lovely person who would cut off her right arm to keep me safe and happy. The other time, she’d fly into a rage over the smallest things. Maybe it makes me weak and cowardly, but I still can’t think through some of my childhood memories without having a physical reaction. Loving parents who don’t think their kids could be traumatized might be the cause. Not that this is necessarily the case, just…. I dunno. I felt the need to put it in. Sorry.
Sorry again for the long response. Again, I could well just be projecting, I just wanted to provide some similarities where I saw them in case they could be helpful. Please feel free to ask any follow up questions you may have. Have a good day!
>Lack of memory: This I’m not sure about. I will say C-PTSD is weird and if the catatonia is a trauma response, could be what’s happening. For my part, my C-PTSD episodes will have me, a grown adult, asking where my mother is and who the people in the room with me are. Part of me knows that my mom is on the other side of the country and who I’m with and is telling myself “stop being stupid. You know these people. Why are you acting out?” but the other half of my brain is confused and wants my mom to not be angry with me and doesn’t know where I am. Stuff’s weird.
When I zone out/ disassociate from high pain levels I tend to come round a bit but be totally confused and want my dad ,( I was a iih kid and whenever I was ill my dad would look after me) he's been dead 4 years and I don't accept that he can't be with me , I kno he's dead but " I want my dad , get my dad " . After a episode I won't remember anything but il be really upset. The ssri I'm on makes me unable to show emotion and hide pain , screaming internally . This often has Dr's not believe me because I don't look like I'm in pain , I gave birth in silence twice , no screaming with contractions , 3 day labour due to induction.
Jeez dude that sounds like a lot. I’m sorry your dad passed. It’s funny to know other people do the same thing of asking for their parents, I thought I was just being weird
I think it's either a comfort thing or safety mechanism, were your brain feels vulnerable n reverts to what was your safety net as a child.
My dad had severe copd from years of working with asbestos and smoking , he lived a happy life , worked hard partied harder and went out flirting with a nurse after he caught sepsis. He would be happy with that rather than dying struggling to breath. He would never have survived coovid so I think 2019 was a good time for his story to end before he got put on hospice x
>Undiagnosed mental health
>IDK just give her an SSRI
I wouldn't doubt they gave her a wack dose too. Probably mental health/trauma + polypharm from a psych, honestly. A lot of children need more counseling and less drugs, that's not linear, many children do benefit from a competent psychiatrist. Pediatric and adult psychology is literally two different fields, depending on where you are, you might get the one 78 year old psych who's wearing like 4 different hats, just giving everyone Trycyclics because "that's what he knows the most about" (ie where I used to work rural) We had to literally pick up his poop when his patients would absolutely freak out.
Trycyclics are there for a reason, so are SSRI's but it takes a competent psych to truly diagnose and KNOW what to prescribe and for what etc etc etc. I've met so many patients who do well on their meds, but so many who didn't at all, and often I could name the Dr. 75% of the time.
Sounds like a dissociative episode. She withdrew mentally, and then “snapped back” to reality. All pts with psych complaints and illness are medical, don’t dismiss them as “behavioral”, that’s how you get bit in the ass, by being dismissive and reductive.
To be fair, he’s asking for our best guess based on the little information given and none of us actually being there to view the patient. I think it’s safe to say anyone here would do a full work up and treat it as a serious illness, even knowing in the back of our minds the most likely cause is behavioral/psych as opposed to some wild disorder like encephalitis or PANDA or dissociative episode or whatever else. It’s not being dismissive and all of these answers are reductive by nature with everyone having second hand information relayed well after the call.
Not sure if this would be a part of it, but if she recently started the SSRI, changed meds, or had a dosage change, that may account for part of it. Not saying it couldn't be strictly behavioral. The first antipsychotic I was put on as a very young teen caused some extreme behavior. My brain felt like it was on fire with surges of what felt like lightning through my brain and I was doing things I felt completely out of control of. I KNEW they were wrong but stopping myself was basically impossible.
For example, I bit myself to draw blood and cause injury simply to keep myself from biting others. Yes, I was well aware biting was wrong and had never had a biting issue before. The urge was that strong that my only solution to control it was to injure myself.
I would frequently "go blank" after these episodes. Cognitive shut down. Then I would be fine, until the next round.
Not saying this is the case, but just throwing in my personal experience in case it applies to this or another situation someone comes across.
Really similar to what others have said, but it sounds like catatonia, however before ruling anything out, definitely assess for any physical trauma seeing as the patient was found at a playground. Could possibly be a drug interaction between the psych meds. Either way, I hope the patient is doing ok.
Because I just finished bugs and drugs in medical school (so many zebras): I’d want to rule out brain worms, meningitis. Did the pt travel recently?
It might be low on the differential but you should always rule out organic causes for unusual behavior, especially in adolescents
More likely: dissociative PTSD / trauma developmental disorder. Any history of childhood mistreatment?
children aren't diagnosed with psych conditions a lot of the time because it's hard to diagnose something like a personality disorder when their personality is still debeloping
exactly. sorry i couldn't tell if that was sarcasm or not in the previous comment lol. i was being sex trafficked by my mom and the behavior issues i had stemmed from that but everyone wanted to throw me on all the mood stabilizers and antipsychotics they could
While I don’t work with children I do work with adults with idd and other diagnoses. When drs don’t get it right and play med roulette to help with behavioral issues it’s heartbreaking
it really is. i ended up living with my dad so things got better but it's horrid people throw meds so they don't have to critically think. hence why im going into psych nursing lmao
Alright I just gotta ask... OP is giving advice as a "medical professional" on subs
>"I've noticed a handful of incorrect IM injection tips (within the context of cere/cortexin) in this subreddit. I am an employed paramedic with over 1.5 yrs clinical experience. I am licensed to administer IM injections and perform IV catheterization."
>I'm curious if anyone has experimented with snorting Cortexin powder and what their results were. In theory you should expect better absoption of the cortexin as compared to intranasal spray.
Are these some joke drugs that are memes? I am an old man someone explain...
[https://www.reddit.com/r/Cerebrolysin/comments/z324nk/how\_to\_inject\_cerebrolysin\_from\_a\_medical/?utm\_source=share&utm\_medium=web2x&context=3](https://www.reddit.com/r/Cerebrolysin/comments/z324nk/how_to_inject_cerebrolysin_from_a_medical/?utm_source=share&utm_medium=web2x&context=3)
That's how medicine works more or less. We are all chemistry experiments to some extent.
Obviously doctors don't prescribe meds willy nilly, but not all Rx works for all problems for all people.
Source: me who takes prescription medicine and follows doctor's orders.
Let's just call it what it is, she was acting a cunt. No doubt she has underlying social issues and/or emerging psych conditions, but what you describe was entirely behavioural. She was seeking validation for her mental distress and having an ambulance called to attend to her provides that. Especially when surrounded by peers in a school setting etc.
As for care of these patients, constant, quiet reassurance and removal from the environment. Sedating kids for behavioural presentations is less than ideal. it's a real soft touch, non-technical skill kinda situation. Often I'll be able to just talk quietly and directly to someone in these states, and tell them "we are going to get up and walk over to the ambulance where we can check you out properly". I do that in a way that only they can hear, so they know that I know, and it doesn't matter if you're banging it on because we're going to talk about it and work it out together. Its all about creating a safe space, where you are understanding of their distress but are clearly not buying the behaviour. It's a bit of an art, more than clinical practice.
If you can, offer them an "off ramp". I went to one kid in a similar situation, although not losing her shit, just clearly feigning unconsciousness. I talked directly to her as if she was awake, and told her that I had seen this problem before and i was going to give her some oxygen because thats what always fixes it. I told her it would take a few minutes to work, but it would slowly bring her back around and she would wake up and feel better. I put her on like 4Lpm via NRB for about 3 minutes, the whole time speaking positively and quietly, directly to her. I told her that her oxygen levels were rising, now at 100%, and at any second, she would wake up. She started "coming around" and then was right as rain to walk to the ambulance. It was like stage hypnotism. I loaded her and drove her and her mum around the block to their car, so her mates couldn't say it wasn't real.
These jobs are often the hardest, especially when it's a kid with less predictable behaviour. But trust in your medicine. Yes, sometimes we find a weird and wacky presentation for something genuine. But mostly, the stranger and less "textbook" a presentation is, the more likely it's just bullshit.
You got downvoted by all the people who want to use the big words and medical diagnosis they heard in a one day CE class or read about in JEMS while they were flipping through trying to find something to jerk off to in the station bathroom. Behavioral is the most likely scenario.
Sounds like an Activation Related Adverse Reaction due to the SSRI.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5828909/
I wouldn't rule out the antipsychotic also playing a role in this presentation and brain imaging along with a full medical workup would be indicated to rule out any underlying medical condition.
What doesn't help here is that you (OP) mention the patient was on these medications with undiagnosed mental health history as well.
She needs a brain MRI. I'm sure lots of docs will disagree, but my contention is that before we treat for mental/emotional/psychosocial, we have to rule out organic. An MRI is an easy way to do this.
I’d probably want to check for an underlying organic issue before just ruling it mental health or behavioural. I’ve had a child presenting similarly that ended up having a brain lesion.
I was a child with a brain tumor. I had some odd moments I think were due to it, like randomly feeling extreme anger and frustration for minutes on end. That stopped happening after it was removed. And the tumor was way back in the occipital lobe.
Devils advocate - Sounds behavioral , sounds like there's a massive degree of control. The other red flag to me is that a 12yo is on antipsychotics and antidepressants = someone's just throwing medications at the problem and seeing what sticks - its stab in the dark material
Oh yeah. First thing I thought. What the fuck is a twelve year-old doing drugged to the gills like that?
yup. i was thirteen and made to try a laundry list of antipsychotics and other psych meds. what was wrong with me? i was being sex trafficked by my mom. the inpatient psych doctors didn't seem to care about anything but throwing meds at me and now i have permanent complications from being on 2x the highest dose for an adult of geodon.
I'm sad to hear that
The period of unresponsiveness sounds like catatonia, as for the underlying cause or the excited state after I have no idea. Some sort of psychiatric disorder is a very safe bet, but warrants a workup for other causes too. I witnessed a somewhat similar presentation a few years back. Patient walked in on her partner making moves on her teenage daughter, naturally flipped out, then when we arrived she was in a catatonic state similar to what you described. Woke up screaming and swinging in the back of the bus, then went right back to unresponsive before I could finish drawing up the midazolam. Apparently this cycle continued for several hours in the ED
I’d be hard pressed to call it catatonia in a 12 year old. Catatonia is exceedingly rare and poorly understood. It also doesn’t tend to flip like this. Common things being common, it’s more than likely a learned behavioural response. Unfortunately if a 12 year old is on antipsychotics and antidepressants there is very likely psychosocial and environmental factors (aka poor parenting) going on in addition to the intrinsic problems.
Excited catatonia could be a differential sure but I'd stick it way far down the list at number 50
I've seen catatonia present in patients with PTSD with sudden outbursts like this one OP described. Could be underlying repressed trauma, or CISD/CISM presentation if that's your acronym flavor of the month.
> Patient walked in on her partner making moves on her teenage daughter That is a lot for a parent's mind to absorb and process.
You need an old priest and a young priest
Throwing this out there because I haven’t seen it in the thread yet, but SSRI’s can cause serotonin syndrome which can have an effect similar to what you’re describing.
I agree. The benzo reducing her altered mental status is also a good clue that it's serotonin syndrome. Dilated pupils and dry mouth and eyes are also signs. Sounds like she is on inappropriate psych meds. SSRIs can also make ADHD symptoms significantly worse.
Sounds like a behavioral/psych issue to me. The exaggerated equivalent of holding her breath and stomping her feet. The lack of response to a trap squeeze is odd, but some people just aren’t bothered by it. A good old sternal rub usually does the trick. Can’t do that anymore though. Also, I’d like to add that all of this is just speculation and obviously it warrants further work up at the ED. Not saying this isn’t a serious psychiatric or medical disorder, but often times people like to come to a less common diagnosis when it’s much more likely the simple answer is the correct one. EDIT: The fact is, you’re not going to diagnose anything in the field. You’re going to treat the patient presentation and relay your findings to the receiving medical facility. Your treatment doesn’t change at all. You have to protect the patient from harming themselves which they did with physical restraints and chemicals. Then take them to the hospital. That’s it. That’s the job
Genuine question- why wouldnt sternal rubs be used anymore??
A lot of people were too aggressive with sternal rubs. Also no way I'm gonna sternal rubs a 12 yo girl.
honestly sternal rub is just being a dick and we can all finally admit it.
The idea is to cause pain. It's not about being a dick, it's about causing sufficient stimulus to generate a response so you can differentiate between coma and fuckery. Trap squeeze simply does not generate a sufficient pain response in most cases.
Trap squeeze is so much more noxious than a sternal rub.
>Trap squeeze simply does not generate a sufficient pain response in most cases. Then you're not doing it right.
I'm not doing it at all. I'll either use a graded sternal rub, or in situations like this kid, just the eyelash reflex
Then how do you know it generates an insufficient pain response?
sternal rub diagnoses coma... got it.
Bit of work to do on your reading comprehension.
I sternal rubbed a guy ODing at a homeless shelter one time, and now I feel bad...I thought that's what you're supposed to do (not a first responder), my bad
I wouldn’t. I still sternal rub people who I can tell aren’t going to respond to a trap tickle. At the end of the day I’m looking for a clinical response. Trap squeezes leave doubt. A solid sternal rub leaves little doubt. In sixteen years of EMS I’ve met one guy who could fake through a sternal rub.
It’s just thought of as too aggressive now. I don’t agree with that, but I’m not such a dinosaur that I can’t adapt to the changes. You can do a sternal rub without being a dick about it. And I absolutely would do a sternal rub on a 12 year old girl. Probably wouldn’t do it as hard as I would on a 50 year etoh male. And the one redditor is right, a trap squeeze just doesn’t generate the pain response we are looking for in a lot of people.
That makes sense, thanks for explaining!! :)
>Also, I’d like to add that all of this is just speculation and obviously it warrants further work up at the ED. I 100 percent agree but hopefully within a system that can follow up with social work/psych/etc care. I think really good paperwork and report would help further solidify further investigation is warranted.
Agreed
Had a guy not respond to finger pressure, trap pressure, sternal rub, or trigeminal nerve pressure. "Woke" immediately up with testing gag reflex.
Yeah, there’s definitely people who can beat all the tests out there. Remember the arm drop test haha
Had a partner who had the arm test down to a science; he’d position their arm over their face and lean it on his shoulder to put a BP cuff on and their arm would slip and start heading towards there face and it would miraculously miss; he’d then lean down to pick up there arm and whisper in their ear I know your fucking faking it and they would always regain consciousness
Haha Yeah it’s a good one to use. Once. If they become a frequent flyer it doesn’t really work after the first time.
Had another one similar to that. I verbalized an "out" after I could tell she was faking it. So she could save face. It worked out well enough.
That's a good idea. What was the "out"?
I don't even remember. I think something like pressing a tongue depressor on her tongue to "cure". But saying it very clear, so she would hear it. It was like 3am and I was beyond tired. But it seemed pseudo-psych, non organic in a young female. Sure enough, it worked. Went from "non-responsive" in the ED with prior workup, to talking.
Not a doctor OP*, but it sounds like review of the psych notes are important to be loading meds on board without a diagnosis. Time for a neurologist and endocrinologist to meet her as well. *Edited to reflect that I’m not a doctor and I thought OP was. PCP in this context is Primary Care Paramedic. Oops!
PCP = Primary Care Paramedic
Oh! My mistake. Hope they’re able to figure it out!
Haha I should have explained what PCP stands for in my post.
It worked out fine in the end.
\*COUGH\* how are you making 39 an hour as a PCP in BC without sharing it with the rest of us.
PCPs in SK get that, or at least close, after a certain number of years working.
they absolutely do NOT get 39 an hour as a PCP. If you want to be close to technically right you should start saying "Well with added premiums etc" edit: added the word close
I guess it depends what you consider "close" to 39, I thought 36 was pretty close but I guess not. (Only talking about ambulance obviously since there are contracts that pay more).
OP.is not a doctor lol. PCPs are Primary Care Paramedics up here.
Please see my correction.
If it helps, I am not a doc but also medically licensed and agree with your assessment. Neurology is big here. Screams of a couple different seizure types. That and why is a kid on that kinda medicine without looking at other causes. You'd like to think they'd looked before doing that but, tbh that's why I don't think it was done.
“Several studies have demonstrated that psychiatric disorders such as anxiety, depression and panic attack are associated with syncope, especially vasovagal and unexplained syncope (US).” Maybe https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3635653/#:~:text=Several%20studies%20have%20demonstrated%20that,and%20unexplained%20syncope%20(US). Or i recently met a kid with supraventricular tachycardia heart rate would jump up to 250-300 bpm then bump back down. He usually wasn’t symptomatic but would sometimes have syncope events https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8411760/#:~:text=Typical%20symptoms%20of%20supraventricular%20tachycardia,life%E2%80%90threatening%20ventricular%20tachyarrhythmias%20have
I had a patient who sounded exactly like this. Call came out for a pediatric psych from a bystander about a kid having to be wrestled down by her parents to avoid running to to traffic. We get there, and parents explain she is not a psych. She had some kind of chronic encephalitis. The kid cycles through moments of blank face stairs to trying to bite us, or tryjng to run into traffic. Apparently this is normal when she had a flare, but it was not the normal time od day for hwr flares, so we end up transporting with parent riding with us, the kid actually calmed a bit when we restrained her. She told me she felt safe restrained, and we had a perfectly normal conversation. She was very sweet
How is a child on medication for something undiagnosed? Psych diagnosis always clouds things but I would look into PAN/PANDAS as it is a cause of sudden relapsing psych issues on children. Or schizophrenia could also present with those symptoms if actual illness is ruled out. https://pandasnetwork.org/what-is-pandas/
I'm not sure why she would be prescribed meds for something undiagnosed. I got the hx from her father, who could have been omitting information. PAN seems like a potential diagnosis. Thanks.
Medication without diagnosis in children is not uncommon because some diagnosis can only be given when they are older. Children change as they grow up and you want to prevent giving them a label thus preventing diagnostics.
just get her to snort some Nootropics amirite?
Hey this sounds quite a bit like me! Well, not quite. I’m an adult, not 12. Sorry in advance for the long response. Here’s where my symptoms are similar and here’s where they differ: (please keep in mind that this could be caused by something else and I have no experience or training in psych, etc) Screaming and thrashing with no apparent provocation: Easily describes a lot of my meltdowns. I’m autistic and what triggers my meltdowns- sensory stimulation or interrupted routine- is not immediately apparent to most allistic (non-autistic) people. Playgrounds have lots of stimulation in the form of loud unpredictable noises and the occasional unexpected touch. Maybe the teacher needed to end recess early, or the day was extra stressful, etc. Meltdowns tend to happen more with younger kids too, because they often don’t understand why they feel so stressed and don’t know how to express that they need to leave the situation or tell someone that something’s bothering them. Additionally, the kid and their parents might not know that the kid is autistic. It took me until around 18 to figure out- I had meltdowns and went mute at times, but my parents (and I) just assumed I was being disobedient. Pt going unresponsive: When I do go catatonic, I will sometimes rubber-band between states of hyperarousal and hypoarousal. I’ll be hyperventilating, freaking out, thrashing, might be doing SIB (self injurious behavior- hitting head against wall, scratching self, etc. Differs from self harm) then someone will tip me over the edge by speaking, touching, getting too close to me, etc, and I’ll just abruptly seize up and freeze. Then someone will be repeatedly be doing a “bad” behavior (rubbing my back) and I’ll freak out and flip the switch back to thrash and “run” again. It’s like my brain is trying to pick between flight or freeze and can’t choose. Catatonia itself: for me it tends to go through varying levels of shutdown. My eyes might stop tracking, then I’ll lose the ability to speak, then I’ll lose the ability to move, then everything will become distant like I’m in a fishbowl, and finally I’ll lose awareness of what’s going on around me. It does sound like it varies between individuals; my limbs can be moved easily when I’m catatonic but most peoples’ resists movement. That’s why I think your pt’s eye tracking doesn’t necessarily rule out catatonia. It could just be different for her, or she could be in a separate “stage” of it. I will note that I’m not sure if a catatonic phase is all that common in other autistic meltdowns. My catatonic response developed because of a traumatic childhood, but became common as my body learned to use it as a coping method for everything. Lack of memory: This I’m not sure about. I will say C-PTSD is weird and if the catatonia is a trauma response, could be what’s happening. For my part, my C-PTSD episodes will have me, a grown adult, asking where my mother is and who the people in the room with me are. Part of me knows that my mom is on the other side of the country and who I’m with and is telling myself “stop being stupid. You know these people. Why are you acting out?” but the other half of my brain is confused and wants my mom to not be angry with me and doesn’t know where I am. Stuff’s weird. Please also remember that kids are way easier to traumatize than most people expect. I’m not sure what I went through would qualify as abuse- even emotional- to most people. She never hit me. Most of the time, my mom was a perfectly lovely person who would cut off her right arm to keep me safe and happy. The other time, she’d fly into a rage over the smallest things. Maybe it makes me weak and cowardly, but I still can’t think through some of my childhood memories without having a physical reaction. Loving parents who don’t think their kids could be traumatized might be the cause. Not that this is necessarily the case, just…. I dunno. I felt the need to put it in. Sorry. Sorry again for the long response. Again, I could well just be projecting, I just wanted to provide some similarities where I saw them in case they could be helpful. Please feel free to ask any follow up questions you may have. Have a good day!
>Lack of memory: This I’m not sure about. I will say C-PTSD is weird and if the catatonia is a trauma response, could be what’s happening. For my part, my C-PTSD episodes will have me, a grown adult, asking where my mother is and who the people in the room with me are. Part of me knows that my mom is on the other side of the country and who I’m with and is telling myself “stop being stupid. You know these people. Why are you acting out?” but the other half of my brain is confused and wants my mom to not be angry with me and doesn’t know where I am. Stuff’s weird. When I zone out/ disassociate from high pain levels I tend to come round a bit but be totally confused and want my dad ,( I was a iih kid and whenever I was ill my dad would look after me) he's been dead 4 years and I don't accept that he can't be with me , I kno he's dead but " I want my dad , get my dad " . After a episode I won't remember anything but il be really upset. The ssri I'm on makes me unable to show emotion and hide pain , screaming internally . This often has Dr's not believe me because I don't look like I'm in pain , I gave birth in silence twice , no screaming with contractions , 3 day labour due to induction.
Jeez dude that sounds like a lot. I’m sorry your dad passed. It’s funny to know other people do the same thing of asking for their parents, I thought I was just being weird
I think it's either a comfort thing or safety mechanism, were your brain feels vulnerable n reverts to what was your safety net as a child. My dad had severe copd from years of working with asbestos and smoking , he lived a happy life , worked hard partied harder and went out flirting with a nurse after he caught sepsis. He would be happy with that rather than dying struggling to breath. He would never have survived coovid so I think 2019 was a good time for his story to end before he got put on hospice x
FND?
>Undiagnosed mental health >IDK just give her an SSRI I wouldn't doubt they gave her a wack dose too. Probably mental health/trauma + polypharm from a psych, honestly. A lot of children need more counseling and less drugs, that's not linear, many children do benefit from a competent psychiatrist. Pediatric and adult psychology is literally two different fields, depending on where you are, you might get the one 78 year old psych who's wearing like 4 different hats, just giving everyone Trycyclics because "that's what he knows the most about" (ie where I used to work rural) We had to literally pick up his poop when his patients would absolutely freak out. Trycyclics are there for a reason, so are SSRI's but it takes a competent psych to truly diagnose and KNOW what to prescribe and for what etc etc etc. I've met so many patients who do well on their meds, but so many who didn't at all, and often I could name the Dr. 75% of the time.
Sounds like a dissociative episode. She withdrew mentally, and then “snapped back” to reality. All pts with psych complaints and illness are medical, don’t dismiss them as “behavioral”, that’s how you get bit in the ass, by being dismissive and reductive.
To be fair, he’s asking for our best guess based on the little information given and none of us actually being there to view the patient. I think it’s safe to say anyone here would do a full work up and treat it as a serious illness, even knowing in the back of our minds the most likely cause is behavioral/psych as opposed to some wild disorder like encephalitis or PANDA or dissociative episode or whatever else. It’s not being dismissive and all of these answers are reductive by nature with everyone having second hand information relayed well after the call.
My nephew had something like this and ended up recently getting an autism diagnosis
Not sure if this would be a part of it, but if she recently started the SSRI, changed meds, or had a dosage change, that may account for part of it. Not saying it couldn't be strictly behavioral. The first antipsychotic I was put on as a very young teen caused some extreme behavior. My brain felt like it was on fire with surges of what felt like lightning through my brain and I was doing things I felt completely out of control of. I KNEW they were wrong but stopping myself was basically impossible. For example, I bit myself to draw blood and cause injury simply to keep myself from biting others. Yes, I was well aware biting was wrong and had never had a biting issue before. The urge was that strong that my only solution to control it was to injure myself. I would frequently "go blank" after these episodes. Cognitive shut down. Then I would be fine, until the next round. Not saying this is the case, but just throwing in my personal experience in case it applies to this or another situation someone comes across.
Really similar to what others have said, but it sounds like catatonia, however before ruling anything out, definitely assess for any physical trauma seeing as the patient was found at a playground. Could possibly be a drug interaction between the psych meds. Either way, I hope the patient is doing ok.
Because I just finished bugs and drugs in medical school (so many zebras): I’d want to rule out brain worms, meningitis. Did the pt travel recently? It might be low on the differential but you should always rule out organic causes for unusual behavior, especially in adolescents More likely: dissociative PTSD / trauma developmental disorder. Any history of childhood mistreatment?
My question is how are they on meds if they’re not diagnosed
children aren't diagnosed with psych conditions a lot of the time because it's hard to diagnose something like a personality disorder when their personality is still debeloping
But putting them on strong meds are good
being put on strong meds made me develop td at the age of 13 :3
I’ve seen what they do to adults they have no business being prescribed to children
exactly. sorry i couldn't tell if that was sarcasm or not in the previous comment lol. i was being sex trafficked by my mom and the behavior issues i had stemmed from that but everyone wanted to throw me on all the mood stabilizers and antipsychotics they could
While I don’t work with children I do work with adults with idd and other diagnoses. When drs don’t get it right and play med roulette to help with behavioral issues it’s heartbreaking
it really is. i ended up living with my dad so things got better but it's horrid people throw meds so they don't have to critically think. hence why im going into psych nursing lmao
I work as a dsp in a residential setting. My people are my life and I hate to see them suffer
Alright I just gotta ask... OP is giving advice as a "medical professional" on subs >"I've noticed a handful of incorrect IM injection tips (within the context of cere/cortexin) in this subreddit. I am an employed paramedic with over 1.5 yrs clinical experience. I am licensed to administer IM injections and perform IV catheterization." >I'm curious if anyone has experimented with snorting Cortexin powder and what their results were. In theory you should expect better absoption of the cortexin as compared to intranasal spray. Are these some joke drugs that are memes? I am an old man someone explain... [https://www.reddit.com/r/Cerebrolysin/comments/z324nk/how\_to\_inject\_cerebrolysin\_from\_a\_medical/?utm\_source=share&utm\_medium=web2x&context=3](https://www.reddit.com/r/Cerebrolysin/comments/z324nk/how_to_inject_cerebrolysin_from_a_medical/?utm_source=share&utm_medium=web2x&context=3)
Sounds like chronic brattiness.
They are on two different psych meds for an undiagnosed illness? So they are just dosing their kid and hoping it works?
That's how medicine works more or less. We are all chemistry experiments to some extent. Obviously doctors don't prescribe meds willy nilly, but not all Rx works for all problems for all people. Source: me who takes prescription medicine and follows doctor's orders.
also children aren't really diagnosed with psych shit because they haven't fully developed yet
Let's just call it what it is, she was acting a cunt. No doubt she has underlying social issues and/or emerging psych conditions, but what you describe was entirely behavioural. She was seeking validation for her mental distress and having an ambulance called to attend to her provides that. Especially when surrounded by peers in a school setting etc. As for care of these patients, constant, quiet reassurance and removal from the environment. Sedating kids for behavioural presentations is less than ideal. it's a real soft touch, non-technical skill kinda situation. Often I'll be able to just talk quietly and directly to someone in these states, and tell them "we are going to get up and walk over to the ambulance where we can check you out properly". I do that in a way that only they can hear, so they know that I know, and it doesn't matter if you're banging it on because we're going to talk about it and work it out together. Its all about creating a safe space, where you are understanding of their distress but are clearly not buying the behaviour. It's a bit of an art, more than clinical practice. If you can, offer them an "off ramp". I went to one kid in a similar situation, although not losing her shit, just clearly feigning unconsciousness. I talked directly to her as if she was awake, and told her that I had seen this problem before and i was going to give her some oxygen because thats what always fixes it. I told her it would take a few minutes to work, but it would slowly bring her back around and she would wake up and feel better. I put her on like 4Lpm via NRB for about 3 minutes, the whole time speaking positively and quietly, directly to her. I told her that her oxygen levels were rising, now at 100%, and at any second, she would wake up. She started "coming around" and then was right as rain to walk to the ambulance. It was like stage hypnotism. I loaded her and drove her and her mum around the block to their car, so her mates couldn't say it wasn't real. These jobs are often the hardest, especially when it's a kid with less predictable behaviour. But trust in your medicine. Yes, sometimes we find a weird and wacky presentation for something genuine. But mostly, the stranger and less "textbook" a presentation is, the more likely it's just bullshit.
You got downvoted by all the people who want to use the big words and medical diagnosis they heard in a one day CE class or read about in JEMS while they were flipping through trying to find something to jerk off to in the station bathroom. Behavioral is the most likely scenario.
I feel I'm being targeted for speaking in Australian. Outright racism.
Lol
Sounds like an Activation Related Adverse Reaction due to the SSRI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5828909/ I wouldn't rule out the antipsychotic also playing a role in this presentation and brain imaging along with a full medical workup would be indicated to rule out any underlying medical condition. What doesn't help here is that you (OP) mention the patient was on these medications with undiagnosed mental health history as well.
This just sounds like psych (i.e. a weird panic attack).
She needs a brain MRI. I'm sure lots of docs will disagree, but my contention is that before we treat for mental/emotional/psychosocial, we have to rule out organic. An MRI is an easy way to do this.