Eli Josefson is a 15-year-old male who was brought to the ER by EMS after being found unresponsive on the floor of his bedroom by his parents at 10:30 pm. The last time he had been seen was at 7 pm when the family ate dinner together; he was acting normally at that time.
Dilated but reactive pupils, flushed sweaty skin, dry mucus membranes, and hyperreflexia in all four extremities with occasional jerks of an arm or leg. He is unconscious with a positive gag reflex and withdraws to pain but does not respond to verbal stimuli.
An IV was started and he received a bolus of normal saline. He was intubated for airway protection.
An ingestion was suspected with unknown substances, so he was given activated charcoal and polyethylene glycol after an orogastric tube was placed.
While awaiting further diagnostic testing, you consult the critical care team to admit Eli to the intensive care unit. The resident arrives to collect additional information from Eli’s parents.
Eli is the youngest of five children and his parents describe him as “very difficult to live with.” He has been in counseling through their church for disruptive behavior at school, poor grades and increasing absenteeism as well as sneaking out of the house. He ran away a year ago and took a bus to Atlanta but the police found him later that day and returned him home to his parents. His primary care physician has prescribed fluoxetine and recommended cognitive-behavioral counseling as well as psychiatric care, but since free pastoral counseling is available through their church, Eli has been getting counseling via that route instead. The parents refused psychiatric referral due to concerns about Eli potentially “being locked up and drugged.”
At home, Eli gets along with his siblings just fine. He argues with his parent frequently about their requirement that he attend church and the school associated with the church. After these fights, he is notably less talkative, eats less and isolates himself. Once, during an argument, he stated the family would be better off without him.