Eye contact is important as a part of nonverbal communication and body language to demonstrate understanding, respect, and attention. Upon entering a room, make eye contact with your patient and address them directly as you would any other patient. It is important not to assume their communication abilities based on their diagnosis. Introduce yourself, explain your goals, and evaluate their response. If there is a caretaker available, you can ask the patient for permission to have the caretaker contribute to the history. You can also always ask, with the caretaker or family member at bedside, “How do you communicate?” They can tell you if the patient uses words, hand squeezes, gaze changes, blinking, sounds, or changes in expression. You also can ask about how the patient expresses pain, as this will be helpful in how you evaluate for tenderness.

Quiet environments can be crucial for patients with sensory or processing difficulties, namely those living with autism spectrum disorder. For these patients, the ED can be a very overstimulating place to be, especially when they are already experiencing new feelings due to getting sick. Evaluating them in a less stimulating space can be helpful in getting the best possible exam, improving outcomes, and reducing the need for de-escalation and sometimes, chemical sedation. The ED is constantly overloaded with patients, so this will require some teamwork to coordinate, including nursing staff, pod lead, and other clinicians.

United approaches to care for these patients are also needed, in that communicating with all staff interacting with this patient can improve their experience. The care team should be aware of how this patient communicates and expresses pain, what their needs are, what their abilities are, and their physical exam findings. This preserves patients’ dignity because everyone acknowledges the abilities of this patient and how they are being addressed. It also helps with prevention. Communication between providers and nursing regarding indwelling devices, bed sores, cleanliness, or signs of neglect is important, as the thoroughness of each examination may vary. This makes documentation and communication of the utmost importance for these patients for their health and safety.

This leads into the next part of the model—Assessment. This is important in most of our patients with disabilities, but especially those who cannot communicate their complaints verbally or with a device. Instead, we resort to vital-sign abnormalities, physical exam findings, or suspicion from their care partners. Their care partners typically know when something is abnormal, and more often than not their concerns are correct. In the scenarios where we are unable to find a care partner or family member, a head-to-toe physical assessment is important, starting with vitals. While vitals may be abnormal for some, they may be normal for that patient. The inverse is also true; what’s normal for most may be significantly abnormal for that patient and be the first red flag. One commonly used example is tachycardia. Oftentimes, it can be an indication of pain, infection, distress, anxiety, dehydration, or the first sign of sepsis. Remove all braces, prosthetics, and clothing, check the undersurfaces and intertriginous areas, look for bruising or fractures, evaluate all indwelling devices (tracheostomy sites, gastrostomy-jejunostomy tubes, foleys, peripherally-inserted central catheter lines and ports), and inspect nail beds, ears, and teeth. These are all important places to examine, as they can hide infections, or be signs of possible neglect. As mandated reporters, especially for vulnerable populations, this type of exam is necessary.