hi it's john again and we're covering chapter 23 behavioral health emergencies so part of the national education standard competencies is the recognition of behaviors that pose a risk to you as the emt your patient or others we're going to talk about the basic principles of mental health the mental health system more specifically we're going to talk about the assessment and management of acute psychosis uh suicidal or risk at risk patients and agitated delirium so unfortunately it's becoming more and more prevalent in our careers that we have to deal with behavioral health emergencies some of the uh crisises that we deal with are are acute mental a medical situation mental illness uh mind altering substances which is really on the rise stress and that stress could be amongst ourselves and other causes at some point most people are going to experience an emotional crisis okay that doesn't mean that you're going to develop a mental illness but having an emotional crisis is not the same thing as mental illness we're not going to jump to conclusions and say just because this person is having an emotional crisis they have mental illness it says the most common misconception is that if you're feeling better depressed that you must be sick no it's it's an absolute falsehood that you would be sick now it's okay to be depressed every one of us goes through depression at some point you know you think about uh maybe when you were younger your parents got divorced or maybe you yourself went through a divorce death of a relative or friend i know some of you are young enough that you may not haven't encountered that death yet but again it is perfectly fine to be feeling bad or being depressed some people believe that all individuals with mental health disorders are dangerous violent or unmanageable that's not true again another misconception small percentage is going to fall into that category uh but again as emts we might be exposed to a higher proportion of violent patients and really the the key to to dealing with violent patients is you're going to be your ability to communicate and you have to be able to recognize the signs that might indicate that you have impending violence so over time people are going to learn to adapt to stress i think right now in america and across the globe people are feeling lots of stress because of covid and the masks and the mandates and the testing and i really think that even this morning i saw on the news how younger children are becoming more and more violent because of the stresses that are put on them due to covid sometimes stress is great so great that the normal ways of coping don't work so the stress becomes overwhelming and your reaction or their reactions to stress that are acute and those that develop over time can create a crisis yes you will have stress in your job a behavioral crisis includes patients who exhibit agitated violent or uncooperative behavior or who are a danger to themselves or others these are the patients that we are going to encounter in ems because this is what we're called for again if an abnormal disturbing pattern behavior lasts from a month or more it's a matter of concern [Music] and a behavior mental health emergency arises the patient may show agitation violence become a threat to themselves or others not only are you are we worried about our patients we have to be worried about each other our family uh these are things that not only for your job but it's for your home life and your and your yourself mental disorders are common yeah okay and that's a big thing a psychiatric disorder is an illness with psychological or behavioral symptoms that may result in impaired functioning so your inability to function properly and anxiety disorders are among the most common you will hear this time and time and time again a lot of people will say they have anxiety disorders a huge huge it's just i think it's really becoming recognized it's not that it wasn't there before it's just being recognized anxiety disorders include generalized anxiety disorder panic disorder social and other phobias uh ptsd huge not only for the military but for us as first responders and obsessive compulsive disorders so if you think about those things these are uh the anxiety disorders and people will tell you hey i have an anxiety disorder okay what does that mean the us mental health system provides many levels of assistance there's counselors for any type of conflict and the most serious are handled by psychologists and severe psychological conditions require a psychiatrist or psychiatrist excuse me i said that wrong psychiatrist uh depending on the level of assistance you need is going to dictate who you're going to see um the most excuse me most psychological disorders can be handled throughout patient visits that's you know not the really severe things and some are going to require hospitalization and again we can't help them outpatient they have to be seen inpatient so there might be some underlying causes to these behavioral disorders social and situational stress covenant i'm just gonna throw it out there that's that is creating a lot of mental health disorders right now diseases such as schizophrenia yeah that's still around physical illnesses such as diabetic emergencies chemical problems with alcohol or drugs yeah huge and then biological disturbances even such as electrolyte imbalances uh might have an underlying cause to their mental health disorder as an emt you're not responsible for diagnosing the underlying cause but we just treat our patient the doctor is going to diagnose what that underlying cause is [Music] organic disorder so we have organic brain syndrome temporary permanent dysfunction of the brain caused by a disturbance we can't diagnose that the the doctor is going to diagnose that we can although help with some of the underlying organic disorders such as sudden illness a traumatic brain seizure disorders drug and alcohol abuse overdose withdrawal but sometimes like diseases of the brain we're not going to be able to help with but there are things that you can do as an emt that will help with the with these behavioral disorders so some of the things that we can think about would be hypoglycemia you know if your blood sugar gets low how does your patient act be bizarrely sometimes they act violent sometimes they uh act um like they're drunk hypoxia causes the same thing impaired cerebral blood flow so like a stroke and then hyperthermia or hypothermia can also uh create an altered mental state in your patients so there are again things that you can treat things that you can almost diagnose if you will and there's others that you really can't help with so physiologic disorders that impair the body and when the body seems to be normal so like they appear to be normal but it's their schizophrenia they have anxiety conditions or even depression you know the worst thing you could tell somebody ah i have a severe depression well just buck up it's gonna be a good day today uh just you just need to get over it that is ridiculous that's not how we treat depression so again when you're having a behavioral crisis or you're dealing with a patient who has a behavioral crisis you see how this uh person has put themselves at a 45 degree angle again if they were to kick out or lunge we're kind of at their side we're not directly in front of them that's why we're kind of off to that side it's the way to protect yourself because we're not sure how our patient's going to respond scene safety is huge it's huge it's one of those things that i always always have a problem with because people always say bsi scene safe bsi scene safe for everything okay maybe it's safe when the when you get there and when you you know in your head say bsi scene safe but does the scene stay safe the entire time you're in contact with your patient if you're not thinking about scene safety throughout your contact you're going to get hurt so again is it dangerous to you or your partner do you need law enforcement backup should you stage until pd gets there absolutely that that's their job our job is patient care our job is not not to get into physical conflicts with our patients does the behavior seem typical or normal are there legal issues was it a crime scene is there consent a refusal wow some of these patients refuse to go to the hospital but yet you know that they have a behavioral disorder now we might actually need to have police officers involved again request additional resources when you request additional resources that's not always paramedic that's not always the fire department to help you lift and move somebody that could be the police officers to help you with this scene the mechanism of injury or the nature of illness yep so again any medications or substances that they took could contribute to what they're what they're doing or how they're acting uh again maybe it's a treatment for a medical condition so maybe there's a reaction to those medications or whatever your general impression when you have a behavioral patient start from the doorway or from a distance as you walk up to your patient don't get right up to them you can assess from a distance if that person is having a behavioral episode perform your rapid physical exam observe the patient closely using abpu look for alertness establish a rapport with the patient you know sometimes when you're doing your patient assessment uh that person might for whatever reason not have a rapport with you but they might have a rapport with your partner hey that's great let your partner take it then don't force the issue don't force them to deal with you let them pick who they want to deal with you know maybe you have a female partner and they feel more comfortable talking to a female or vice versa maybe they won't feel more comfortable talking to a male don't force the issue and again most medical trauma situations will include a behavioral component uh trauma are they going to be under stress absolutely airway and breathing we always make sure they have a patent and adequate airway and breathing again watch how fast their breathing may be use pulse oximeter if available and then provide oxygen if appropriate circulation we're going to assess for shock we're going to check the pulse for rate quality and rhythm we're going to look for signs of shock you know the pale cool clammy skin capillary refill of less than two seconds again your patient might be completely normal and they have schizophrenia or there might be a condition causing this behavioral disorder transport unless the patient is unstable prepare to spend time with them again this is not something we're going to rush this is not something we're going to throw them in the ambulance and drive like heck to the hospital this is going to take time we always like to talk about medical uh conditions you know the 15 minutes for our assessment this might be longer than that it's okay because we need to spend time with these patients investigate the chief complaint get that sample history it's going to tell you a lot is their central nervous system functioning properly are hallucinations or other drugs or alcohol involved you know don't feed into them yeah i see your pink elephants because they might just be asking that to see how you respond to them are there significant life changes symptoms illnesses you know you might have a geriatric patient who just lost his wife after being married for 50 or 60 years that's a significant change in their lifestyle is there a history of behavioral health do they you know that's part of their pertinent past pertinent history when you get your sample history it might tell you a lot what's going on you might elicit information that would be helpful to the hospital staff in geriatric patients consider alzheimer's or dementia i'm going through dementia with my mother-in-law she has really a poor short-term memory but her long-term memory is great actually but it's the short-term memory you know did she take her medicine did she eat today those are all questions that your dementia or your alzheimer patient might not know the answer to or they'll tell you they did and they didn't use reflective listening in other words they tell you something and then you kind of repeat it let them talk don't fill their mouth with your words let their words fill your head questions to ask these are some really good questions does a patient's behavior seem appropriate do they understand you are they hostile or friendly happy or depressed the patient's vocabulary and expressions are those appropriate do they seem aggressive or dangerous to you or others there's a lot of questioning here that you need to think about when you're dealing with a behavioral patient physical exam after unconscious begin your physical exam a conscious patient may not respond to your questions you can ask but they might just remain silent we're not going to force them again you can tell a lot about their emotional state by looking at your patient their facial expressions their pulse rate how about if that person is constantly uh squeezing their hands into balls to make fists and then relax and then make a fist again holy smokes be careful be careful that's that scene safety they might have a blank gaze uh that again might be an indication of a medical condition like hypoglycemia or something hypoxia transport have pd or firefighters accompany you if possible that's just for your safety um you have to think of which facility you're going to go to most hospitals will be able to handle that behavioral situation uh but they might end up transferring them to another facility don't put them in a helicopter oh my gosh they gotta go my ground uh you think about somebody who's go loses a control in a helicopter that's just uh that's crazy make your patient comfortable you know maybe a warm blanket uh maybe we you know dim the lights a little bit maybe then we turn the lights up for them you know whatever the condition is uh turn down the volume of our radio in the back uh there's a lot of things that we can do to make them comfortable turn the heat up turn the air conditioning on here's that thing i talked about earlier with scene safety the scene is a as a living breathing thing it's from when you get there to when you drop your patient off at the hospital you have to be concerned about scene safety the entire time you're transporting this patient or when you're within contact of that patient you know if you don't think something's right trust your instincts again document every five minutes you know if especially if you're restraining the patient respirations pulse motor sensory in all extremities interventions most of your interventions are just going to be talking to the patient or listening to the patient i mean that's that's really it there's not a lot of medical quote-unquote treatments that we may do it might just be more supportive care again if you think uh pharmacologic restraint is necessary you need to have paramedics there as quickly as possible there's medications that paramedics can give that would uh actually help that patient to relax or to to actually chemically restrain them communication documentation oh my goodness yeah this is going to be huge in a behavioral patient you need to document very completely and thoroughly because they may say you did something or said something to them um and when you didn't we don't know how they're going to respond and especially if they're violent we need to have good reports if you use restraints you got to say what type you used and why you use it you have to document why you use that that restraint psychosis is a state of delusion which the person is out of touch with reality now that might be caused by drugs that they took could be stress i mean they just physically just the stress has been too much and it's boom they just can't control it anymore delusional disorders or schizophrenia are the ones that really come to mind and then schizophrenia is a complex disorder it really is how do they treat it oh my gosh i have no idea but again that is not anything that we are going to diagnose uh it says typical onset occurs in adulthood uh i have dealt with schizophrenic pediatric patients that is that's scary and that's sad when you think about it but there's other things that might contribute to this it might be a brain damage it might be genetics social or psychological influences who knows what brings us on and again it's not our responsibility to diagnose that it's our job to do patient care symptoms that you might encounter with somebody who has schizophrenia delusions or hallucinations a lack of interest in pleasure erratic speech and again not sure why it's being caused but these are the symptoms that we are going to see guidelines here we go when you're dealing with a psychotic patient clearly identify yourself because we do wear uniforms sometimes people uh identify us as law enforcement and then maybe they have an issue with that be calm direct maintain an emotional distance don't get too involved with that patient because now you're going to take that emotional baggage home with you make sure make sure the scene is safe don't argue with them you know you're not going to win it does you no good to argue with them explain what you would like to do you know when you want to check a blood sugar or take a blood pressure explain everything you're gonna do because again in their delusional state they might think that you're attacking them involve people who they trust friends or family you know might that might be a great way you know to transport your patient have a friend with them or have a family member with them in the back of the ambulance that'll help them stay calm delirium or excited delirium is where they because of whatever function problem they have they have this uh disorientation illusions excuse me hallucinations or delusions uh restless irregular physical activity now what i'm not again we're not diagnosing what causes the problem but these are the things that we're going to notice we're going to see hyperactive behavior vivid hallucinations the cops are chasing me hypertension tachycardia diaphoresis dilated pupils man there are just excited delirium one of my last ems calls involved a guy running around his neighborhood in a city completely naked it was in january in indiana and he was completely naked running around saying he was being chased and they wanted to kill him and again it's because of what he took be calm and supportive approach them slowly don't get up in their face you know that personal bubble that personal space thing limit your physical contact and never leave them unattended because you never know what's going to happen and i know you wouldn't be careful when you're interviewing this person because we're not really sure at what level they're functioning at determine their ability to communicate sometimes they're they're just everything is going so fast in their mind that they're actually thinking faster than they can speak or they're speaking faster than they can think see how they're dressed or like in my case they were undressed think about personal hygiene maybe this person has been using some type of narcotic or whatever some type of drug and they haven't bathed in a week maybe they haven't slept in a week if they've taken an overdose take all medications or drugs with you to the hospital uh that's going to help in diagnosing what they may have taken or how much and again lights and sirens are only going to make that excited delirium even more so calming that's what we need to do we need to get a calm environment call als if if you really can't get that person to calm down again because paramedics might have the ability to use some type of chemical restraint some type of medication that will calm them down and again if you leave them in this excited delirium state it could cause sudden death so we want to be very careful every hospital provider should create and follow a patient care protocol every everybody's going to have that bible that protocol book that tells you what you can and can't do and again it's going to vary from you know service to service state to state whatever but you want to make sure that your restraints actually are safe for your patient and everybody else involved in that call personnel must be properly trained how to use restraints and if you restrain a person without authority you can expose yourself to assault battery false imprisonment violation of civil rights all kinds of crazy stuff so you just can't restrain everybody for no reason [Music] you might need to use those and it's not going to happen every day but it might be something that you have to use to protect yourselves or to protect them from hurting themselves so you have to be careful you have to document why you did it involve law enforcement early uh really with these these bad cases because again uh their restraint methods aren't going to be necessarily what we use uh but you i don't know if you know this but in the police academy a lot of law enforcement officers are taught how to verbally de-escalate situations you can take a class uh we in in law enforcement we called it verbal judo and it's a way to de-escalate de-escalate and talk to your patient without using physical force process of restraining them so we've got to do it really quickly if you're going to do it quickly you don't kind of okay let's talk about this and this is what we're going to do hey this is what we're going to do we got to do it now go really there should be five people one for each arm and leg and one person to control their head if you can do that you can control anybody there should be a team leader and you gotta have this plan of action and we need to do it quickly and very do do it now you take one leg you take one leg you take one arm one tire i'll take the head and here we go one two three go boom and you have to be quick it has to be dynamic and decisive you can't hesitate because that's when you get hurt you want to use a minimum force necessary you're not going to use too much force the level of force is really going to depend on a lot of things number one their theirs their size their gender their strength wow maybe what they're on because some of these medications and drugs that they take in excess might have kind of like that super human strength so you really have to take that into consideration how much force you're going to use don't use too little because you're going to get hurt talk to the person throughout the process you know they they need to know what you're doing and why you're doing it treat them with dignity and respect don't be swearing at them don't call them names uh i've seen that that's not helping the situation at all it's making the situation worse and if possible use the same gender uh that person should attend to the the patient you know if it's a female have another female attendant taking care of that person and maybe the male steps back or vice versa proper uh barrier protection sometimes with behavioral patients they're going to spit at you so you want to make sure that we're going to be protected avoid direct eye contact because they take that as is threatening don't be in their personal space back off give them space to breathe and have control we're kind of giving them when we take away someone's control that's what's going to be the worst thing if we can give them some type of control back in their life that might help so we get away from them a little bit let them breathe let them speak never leave them unrestrained that's uh or excuse me a restrained person unattended because they could be hurt there's four point restraints both arms both legs are preferred you always put one arm down to their side restrained to the cot and one arm above their head that way they can't come off the cot and headbutt you you want to monitor vomiting airway obstruction you know the abcs has been really what you want to do if you have somebody restrained because again we don't want them to to fight those restraints and create another medical condition so with violent patients again it's a really small percentage and again if it's not safe for you get law enforcement involved history so are they overly hostile overly aggressive violent how are they sitting or standing uh that's going to tell you a lot about how this person did they take the fighter stance where they drop one leg back like they're gonna punch you uh we had a a diabetic in our service area that every time his blood sugar got low we had to have law enforcement go with us and we had to have three or four squad cars go because this guy was so violent when his blood sugar dropped but after we got his blood sugar back up the first thing that guy would say is i'm sorry did i hurt anybody he knew um too bad he couldn't control his blood sugar very well the scene do they have anything in their hand oh my gosh get the heck out of there uh you know your your life your your medication bag your trauma bag your o2 tank none of that is worth your life leave it drop it get out of there what kind of speech are they using are they swearing are they super loud are they talking about um flying monkeys you know that's the kind of stuff that we really like look at we go what the heck is going on here looking at your your patient is going to tell you a lot are they clenching their fists are they glaring at you are they breathing real deep and heavy staring at you that kind of stuff yeah they can't sit still are they up pacing back and forth oh my gosh that's that's a sign and your hair should be sit standing up in the back your necks thinking oh my god i gotta get police here is fiercely protecting their personal space they don't want you near them i respect that other factors poor impulse control uh a history of truancy fighting or uncontrollable temper history of substance abuse huge uh depression depression can cause violence and any type of functional disorder that we've talked about with suicides again in ems we're called to suicides all the time and we think about depression being the single most significant factor that contributes to suicide and typically if someone has not recognized that depression it's a common misconception that people who threaten suicide never committed they say oh they're just crying out for help and and they'll never really commit suicide yeah it happens all the time and again suicide is the only thing that they think of and that's the only way out of their situation we really need to intervene not just our patients because i've seen it in my lifetime where my law enforcement brothers and sisters have committed suicide because of depression and no one recognized it and that's the only thing that they could think or that's the only way they thought to get out of it out of this depression so some signs to think about tearfulness sadness despair okay we can see that they're avoiding eye contact they're speaking slowly they projecting a sense of vacancy like nobody's home unable to talk about the future they talk about suicide maybe they have plans related to their death so they're making plans this is this table 23-3 there's a lot of risk factors you know you look at some of these people older than 40 particularly if single widow divorced alcoholic or depressed men who are older than 55 have an especially high risk and are often successful if they make an attempt wow recent loss of a spouse yeah or other family member financial setbacks loss of a job they got arrested for drunk driving they get you know whatever um drug and alcohol abuse maybe it's it's a child of an abusive patient there's a lot of different things to look at here on this list you know think about maybe your partner a loved one a family friend a friend of yours uh are they going through any of these things so it might be time for you to talk to that person consider additional risk are there any unsafe objects nearby oh my gosh in a house you never know where weapons are i always tell this story there was the chief of police in madison wisconsin uh there was a report of shots fired at the chief's apartment all the officers run to this to his house to make sure he's okay he greets the officers at the door he said okay it's okay it's okay yeah i had a hidden gun in my oven and when i forgot it was there when i turned the other oven on and the heat cooked off the round in the oven holy smokes he hit a gun in his stove well how do you know where people hide guns or knives in a house their house you never know is it safe or unsafe is there evidence of self-destructive behavior is there an imminent threat to the patient or others those are things that we really need to think about when we talk about suicide underlying medical conditions maybe that's why they're at risk for suicide maybe they have cancer cultural or religious beliefs that promote suicide is there been recent trauma again the suicidal patient might be homicidal because just because they want to harm themselves doesn't mean they'll take somebody with them when they go so you need to have law enforcement there with with you ptsd oh it's huge you know we have all a lot of veterans a lot of first responders that are uh experiencing ptsd uh and again if it might be from injury but it might be from a traumatic event like war it might be you seeing your first dead infant that's ptsd sexual or physical assault child abuse serious injuries and again as a first responder i've had students drop out of emt and paramedic classes because they saw a infant or a young child who was sexually assaulted and killed that was their first exposure to death they were done they were out of this job and they were going to go do something else you have to really consider these events that might cause ptsd natural disasters war loss of a level and stressful life situations all this is ptsd it could be something not just one event but it could be a multiple multiple events that are going to create this ptsd about seven to eight percent of the population will experience ptsd at some point and again military personnel with combat experience have a high incidence we do not take care of our veterans when they come back they're forgotten symptoms of ptsd include the feelings of helplessness anxiety fear anger uh i really wish my son who has a a degree in psychology was here to do this lecture for you because he is way smarter than i am with this uh and he can this was going to be one of the fields he wants to work in his ptsd so people with ptsd frequently avoid reminders of the trauma loud noises or smells interactions with people so you know here's the thing if you're a combat veteran around 4th of july some of those things will trigger your memories i have friends that are so dead set against fireworks on the 4th of july that they have to go somewhere else they have to do something and to avoid those loud noises uh again it's that constant nervous system arousal that they're suffering from they can relive that traumatic event through their nightmares or flashbacks and they you know they they wake up in the middle of night screaming and they're sweating combat veterans are prone to early heart disease early type 2 diabetes loss of brain gray matter and they have a higher incidence of traumatic brain injuries and we don't take care of them caring for the combat veteran you have to it's a different level of understanding and and you may not be able to understand it be careful how you phrase your questions use a calm firm voice which military they're kind of used to but be in charge respect their personal space limit the number of people and you can ask it's okay do they have any suicidal thoughts or they have any intention of hurting themselves ensure that there's nothing the patient can access such as a weapon oh my gosh a pen can be a weapon you have to be very careful with these patients and that physical strengths might simply escalate the problem and make it worse again we're not going to restrain them just because we can medical legal considerations okay legal problems are reduced when the patient's consent to care but again we're they're not always going to consent to your care you must decide whether that patient needs immediate medical care whether the police department takes them whether you take them and again it's going to be every situation is going to be different we need consent if we can implied consent is assuming a patient who is not mentally competent to grant consent so that they might have such a bad psychotic event that they can't give you consent so we're going to go under implied consent as consent matters are not always clear cut so yeah this is kind of that gray area uh with behavioral health do they really consent or not uh does their consent mean something does their non-consent height you know it's just a it's a it's a crappy call if you're not sure request pd because again legally they have other ways to handle your patient legally limited legal authority emts don't have a really limited legal authority to require a patient to undergo care and competent adults really have the right to refuse we are kind of there to judge whether they're competent or not in psychiatric cases a court of law would probably consider actions in providing life saving care to be appropriate a patient who has a anyway an impaired con uh impaired cognitive ability may not be considered competent again maybe there's a medical condition that's creating this condition and again we can give them oxygen we can transport and and maybe that's the only thing we can do just for caution so a behavioral crisis is most accurately defined as i'll let you read all those i'll give you time that gives me time to drink my iced tea okay what'd you come up with good it's b any reaction to events that interferes with their ability or has become acceptable to his or her family whatever that's not a mental disorder on the top see is this could be normal behavior as they go through depression and the bottom might be normal so any reaction to events that interferes with activities of daily living or has become unacceptable to the patient the family or the community depression and schizophrenia are examples of functional disorders altered mental status behavioral emergencies or or organic brain syndromes yep it's that a depression schizophrenia ocd those are examples of functional disorders when assessing a patient with a behavioral crisis your primary concern must be allowing the patient to express himself or herself to you in his or her own her own words setting your personal feelings aside providing needed care gathering the patient's belonging take them to the hospital whether the patient will cause harm to you or your partner your primary concern when dealing with a patient with a behavioral crisis i hope you did this one right d scene safety your safety of yourself your partner and your patient in that order obviously you're going to do those other things you know when you're dealing with this but your primary concern general guidelines to follow when caring for a patient with a behavioral crisis include all the following except so be honest reassuring sounds good rapid transport to the hospital transport to the patient let's think about that having a definitive plan of action avoiding arguing with the patient there are some really good things that we should be doing but which one would you do which one would you not do good rapid transport this is the one where we might spend a lot more time with our patient be listening to them before we decide to transport reflective listening an assessment technique used when caring for patients with an emotional crisis involves asking the patient to repeat his or her statements simply listening to the patient without speaking asking the patient to repeat everything that you say repeating in question form what the patient tells you so what is reflective listening yeah it's d you know when they tell you something just kind of repeat it back to them in a question form which of the following patients is at highest risk for suicide 24 year old woman who began treatment for depression 29 year old man recently promoted with a large pay increase 33 year old man who regularly consumes alcohol and purchased a gun yikes 45 year old woman who recently found out her cancer is in full remission which one is at highest risk for suicide yep the guy with the gun drinks a lot again that that chronic alcohol use maybe his alcoholism is because of another reason when caring for a patient with an emotional crisis who is calm and not in need of immediate care your best course of action is to advise the patient that he or she cannot refuse treatment leave the patient with a trusted friend or family member attempt to obtain consent from the patient transport or lastly apply soft restraints in case they become violent so they're calm and not in need of immediate emergency care how would you handle that patient yes really try to get consent tell them it's in their best interest to be seen by a physician um you know and sometimes using the physician on the phone to tell them hey i really think you should come in and you're like oh okay i've done that before i've had here talk to the doctor they want you to come in and they kept refusing me excuse me but as soon as they talk to the doctor they hand me my phone back and they say well the doctor wants me to come in i better go even though i've been saying that for the last hour when caring uh sorry skip this one excuse me when physically restraining a violent patient you should talk to the patient as he or she is being restrained check circulation all extremities only if the patient is prone remove the restraints that the patient appears to be calming down and use additional force if the restrained patient begins to yell at the providers i hope you made that right choice yeah we're going to continually talk to them throughout the process we need to tell them what's going on and why and we never um restrained somebody in the prone position on their belly no upon arrival at the residence of a young male with an apparent emotional crisis a police officer tells you the man is acting bizarrely you find him sitting on the couch he's conscious but confused he takes medications but cannot remember why he is pale and diaphoretic and you notice that he has tremors in his hands you should first rule out hypoglycemia suicidal thoughts severe depression or schizophrenia yeah we need to make sure he's not hypoglycemic his blood sugar is so low maybe that's why he's has this different behavior we're not going to be able to diagnose schizophrenia or suicidal thoughts and we're going to rule out that hypoglycemia first lastly which of the following signs is least indicative of a patient's potential for violence he appears tense and edgy he's six foot five and weighs 230 pounds he's loud in shouting obscenities he's facing you and clenched with clenched fists which is least indicative of their potential for violence i hope you picked b just because he's big doesn't mean that he there's a potential for violence the others are obvious signs of the potential for violence just because i'm 6'3 270 pounds that doesn't mean that i'm prone for violence okay that was chapter 23.