Tuesday, March 13, 2012

Rancho Los Amigos

This is another of those entries where there's a chance you might learn something about PM&R. But don't worry, you won't learn much.

Physiatrists (i.e. specialists in PM&R) can sometimes work with traumatic brain injury (TBI). During my rotations in TBI, being a mother as well, it was hard not to make comparisons between brain injured patients and small children.

We use a scale called Rancho Los Amigos to describe the stages of recovery of cognitive functioning following a severe brain injury. Conversation from six years ago, on my first day of residency:

Attending: "What is this patient's Rancho Los Amigos level?"

Me: [laughs]

Attending: "What's so funny?"

Me: "Oh, you were serious?"

So yes, that's actually what it's called. It's not, like, some restaurant that serves Mexican style food and flavors. At least, it's not just a Mexican restaurant.

Anyway, there are 8 Rancho levels and each one corresponds to the age of a child:

Rancho I: No Response
--appears to be in a deep sleep, completely unresponsive to stimuli

That would be, like, I don't know, when you're an embryo. OK, this comparison isn't perfect. Just stay with me.

Rancho II: Generalized Response (vegetative state)
--reacts inconsistently and non-purposefully to stimuli in a non-specific manner
--responses may be physiological changes, gross body movements, and/or vocalization

Fetus maybe? I promise, it gets better.

Rancho III: Localized Response (minimally conscious state)
--reacts specifically, but inconsistently, to stimuli
--responses are directly related to the type of stimulus presented, as in turning head toward a sound or focusing on an object presented
--may also show a vague awareness of self and body by responding to discomfort

That is totally a newborn, right?

Rancho IV: Confused/Agitated
--heightened state of activity
--behavior is frequently bizarre and non-purposeful relative to his immediate environment
--may cry out or scream
--unable to cooperate
--verbalization is frequently incoherent and/or inappropriate
--unable to perform self-care (feeding, dressing) without maximum assistance

Hello, terrible 2's.

Rancho V: Confused, Inappropriate Non-Agitated
--able to respond to simple commands fairly consistently
--may show agitated behavior as a result of external stimuli
--has gross attention to the environment, but is highly distractible and lacks ability to focus attention to a specific task without frequent re-direction back to it
--can usually perform self-care activities, with assistance
--may wander off, either randomly or with vague intentions

I'd say this pretty well describes a 3 or 4 year old.

Rancho VI: Confused, Appropriate
--goal-directed behavior, but is dependent on external input for direction
--response to discomfort is appropriate and he is able to tolerate unpleasant stimuli when need is explained
--follows simple directions consistently and shows carry-over for tasks
--no longer wanders and is inconsistently oriented to time and place

I'd say this would be a 5 or 6 year old.

Rancho VII: Automatic, Appropriate
--goes through daily routine automatically
--decreased judgment and problem-solving and lacks realistic planning for his future
--carry-over for new learning
--requires at least minimal supervision for learning and for safety purposes
--independent in self-care activities and supervised in home and community skills for safety
--initiates tasks such as social or recreational activities
--judgment remains impaired, such that he is unable to drive a car

OK, I don't have any kids this age, but this probably describes a 7-10 year old.

Rancho VIII: Purposeful, Appropriate
--alert and oriented, is able to recall and integrate past and recent events, and is aware of, and responsive to, his culture
--needs no supervision once activities are learned
--independent in home and community skills, including driving
--somewhat impaired abstract reasoning, tolerance for stress, and judgment

Does this sound like a teenager? I think so.

And now you know a little bit more about traumatic brain injury. And why I sometimes treat my TBI patients like they're my babies.


  1. If I ever open a Mexican restaurant, I know what I'm going to name it.

  2. You know Rancho Los Amigos is a National Rehab Center hospital in Southern California, right? Since 1888...

  3. Dr. Fizzy, do TBI patients that recover go through the stages? For example, if a patient starts at Rancho III, and they get better, do they go from IV to V to VI to VII to VIII, or can they jump levels?

  4. I'm pleased to say this is immediately applicable in my life right now (not for myself, but for a TBI victim I know). Thanks, doctor!

  5. oh my god I am craving enchiladas right now. wait...that wasn't the point?

  6. Hahaha I've been studying for my boards and I keep thinking of the Rancho levels as different levels of intoxication, I like this though.