Driving riders with a brain injury: protective helmets, memory, agitation, and fatigue

Who these riders are

A traumatic brain injury is damage to the brain from an outside force, such as a fall, a crash, or a blow to the head, as NINDS defines it. CDC reports that falls cause nearly half of TBI hospitalizations and that older adults are more likely than any other age group to be hospitalized or die from one.

After a moderate or severe injury, the effects can last for years. CDC’s figures for people still living five years after a moderate or severe TBI show that 57 percent are moderately or severely disabled and 33 percent rely on others for help with everyday activities.

That is why so many of them need rides. The Model Systems Knowledge Translation Center (MSKTC), a federally funded center that publishes research-based factsheets, says people who return home from inpatient rehab usually cannot drive right away, and that finding transportation is critical for getting to outpatient therapy and medical visits. It also warns that in the first year after discharge, people with a TBI face 10 times the risk of an injury that puts them in the hospital, compared with people without one.

Riders who must wear a helmet

Ask at booking whether the rider wears a protective helmet, and why. When the brain swells after an injury, surgeons may remove a piece of the skull to relieve the pressure. This is a decompressive craniectomy. A 2022 case report in 3D Printing in Medicine explains that the procedure leaves that part of the head unprotected during recovery, that a hit to the area can cause severe brain injury, and that protective helmets are commonly prescribed for the recovery period. Conventional helmets fasten with a strap under the chin.

The driver’s rules are simple:

1. The helmet goes on before the rider moves. If the care plan says helmet on, there are no short transfers without it.
2. Check the fit and strap before the rider stands, the way the caregiver or facility showed you.
3. Guard the head at the door frame. Watch the rider’s head as they duck into the van, and keep your hand between the helmet and the frame.
4. Keep pressure off the open side. Do not let the rider rest that side of the head against a window or a headrest.
5. Do not ask the rider to bend down to pick something up. MedlinePlus brain surgery discharge instructions say bending over from the waist puts pressure on the head.

If the rider shows up without the helmet, call dispatch before you move them. A missing helmet is a reason to pause the trip, not to improvise.

Memory: say it, then write it

Expect some riders to forget the plan you explained at pickup. MSKTC explains that a brain injury disrupts the making of new memories, so recent events are harder to recall than old ones. Common problems it lists include forgetting appointments, losing track of time or the day, and asking the same thing again and again.

What works is the same thing MSKTC teaches survivors: outside reminders instead of relying on memory.

• Say the plan in short pieces. “We’re going to the clinic. I’ll take you home after.”
• Answer the same question calmly each time it comes up.
• Put it in writing. A card with the destination, the return plan, and the company’s phone number gives the rider something to check.
• Talk slower and repeat. MSKTC tells survivors to ask people to do exactly that.
• Do not count on the rider to remember to request the return trip. Confirm the return with the clinic or the caregiver, or use a will-call the clinic triggers.

Reminder calls and texts the day before help too, but send them to the caregiver as well as the rider.

Noise, light, and agitation

Irritability and anger are common after a brain injury. MSKTC cites research finding irritability in as many as three in four people with a TBI, and anger problems in up to half. These feelings can come on suddenly and build fast, and the person may not recognize them in time.

MSKTC lists the triggers caregivers should watch for. Most of them can be found in a van:

• Fatigue, too much stimulation, or heat.
• Noise and light. Both can bother a person more after a brain injury. MSKTC’s vision factsheet lists being bothered by light or glare among vision problems after a TBI, and says tinted sunglasses can help.
• Misreading other people. A brain injury can make someone think others are angry or mean harm when they are not.
• Pain and poor sleep.

So keep the radio off or low, close a sun-facing shade if the van has one, and use a calm, even voice. Do not argue, and do not take harsh words personally. MSKTC reminds caregivers that the injury makes anger harder to manage and that it is not the person’s fault. If a rider becomes aggressive, find a safe place to stop and call dispatch. For de-escalation and reporting, see our guide to difficult passengers.

Impulsive moves: belts, doors, and walking off

CDC lists “more impulsive than usual” among the effects of a brain injury. MSKTC explains that poor impulse control can lead a person to say or do something unsafe before thinking it through. Some survivors are also not fully aware of their limits and may refuse a walker or wheelchair they need. Restlessness, fidgeting, and pacing are common as well.

On the road, that can mean a rider who unbuckles, reaches for a door handle, or gets out at a red light. These habits help:

• Seat the rider where you can see them in the mirror.
• Check the belt at every stop and before pulling away. Our guide to passenger seat belts covers the rules.
• If the rider unbuckles while moving, stop somewhere safe and buckle them back in before moving again.
• At pickup and drop-off, keep the rider beside you until you hand them to the person meeting them. Book a hand-to-hand trip when the care plan calls for it.

Fatigue and seizures

Fatigue ranks among the most frequent complaints after a brain injury. MSKTC says as many as 70 percent of survivors report mental fatigue, the tiredness that builds from working harder to think. Physical fatigue tends to get worse in the evening. A rider who handled the morning trip well may be much harder to talk with on the late-afternoon return, so book the easier time when the schedule allows.

Seizures are the medical risk to know. MSKTC reports that roughly 1 in 10 people who were hospitalized for a TBI go on to have seizures. Most happen in the first days or weeks, but some start months or years later. Not every seizure looks like shaking. MSKTC lists staring and not responding, chewing or lip smacking, fumbling, sudden tiredness, trouble speaking, and new outbursts of anger or tears. After a seizure, the person may be drowsy, weak, or confused.

That list matters because a seizure can look like a behavior problem. If a rider suddenly stares and stops answering, or has an outburst that does not fit, treat it as a possible seizure first. The steps, and the signs that mean 911, are in our medical emergency guide.

Some riders also take blood thinners. CDC notes that these medicines can make a brain bleed more likely after a head injury. Report any fall or knock to the head during a trip to dispatch and the caregiver, whatever the rider says about how they feel.

Guardians, escorts, and who decides

Some adults with a serious brain injury have a guardian or a family member with legal authority over their health care. Under HIPAA, at 45 CFR 164.502(g), a person with that authority for an adult must be treated as the adult’s personal representative for the health information involved. In practice, treat that person as you would the rider for trip details and changes. Record who they are on the rider’s profile.

Escorts are a separate question. Under 49 CFR 37.5(e), the ADA rule for transportation providers, a company cannot refuse to carry a rider with a disability unless an attendant comes along. When an escort does ride, the payer’s rules and the care team decide it. See the escort and attendant entry for how escorts are booked and billed.

Refusals happen too. MSKTC lists refusing to do things, such as going to therapy, among the common behavior changes after a moderate or severe brain injury. Slow processing can also make a rider look uncooperative when they simply have not caught up. Do not force the rider into the van. Explain again, wait, and call dispatch to reach the caregiver.

Rehab trips after discharge

NINDS says people with a severe TBI often move from the hospital to a rehabilitation center, and MSKTC says rehab may then continue in an outpatient setting along with medical follow-ups. Outpatient programs mean repeating trips, often to the same building at the same time. Keep the same driver on those trips when you can. A familiar driver is one less new person for a rider with memory problems to learn.

Keeping a steady routine in HealthRide

For these riders, a familiar driver arriving at a familiar hour is half the job. In Ryder Go, lock a trip to a driver and it stays put when you plan the day. Drivers can send the office a message or a voice note from the driver app when a rider is having a hard day, so dispatch can warn the next driver before pickup.