Chapter 23: Behavioral Health Emergencies

Introduction

• EMTs will care for patients experiencing behavioral health emergencies.
• Causes include acute medical conditions, mental illness, mind-altering substances, stress, etc.
• Covers drug overdoses, violent behavior, mental illness, suicide, PTSD, and managing potentially violent patients.

Myth and Reality

• Emotional crises are common but not always indicative of mental illness.
• Sadness can be a normal reaction to life events (e.g., divorce, death).
• Behavioral health disorders do not automatically mean the person is dangerous.

Defining a Behavioral Crisis

• Behavioral crisis: situations where behavior is agitated, violent, or a danger to self/others.
• Can result from stress, substance use, medical conditions, etc.
• Behavioral health emergencies are more severe than typical crises.

Magnitude of Mental Health Disorders

• Mental disorders affect millions in the US.
• Anxiety disorders are common.
• Treatment varies from counseling to medication or hospitalization.

Pathophysiology

• EMTs are not responsible for diagnosis but should understand organic vs. functional disorders.
  • Organic Disorders: Involve physical dysfunction of the brain (e.g., TBI, dementia).
  • Functional Disorders: No physical cause (e.g., schizophrenia, depression).

Safe Approach to a Behavioral Crisis

• Safety first; assess scene danger, require law enforcement if necessary.
• Communication is key.
• Establish trust and rapport.

Patient Assessment

Scene Size-Up

• Ensure safety, determine potential danger, and appropriate precautions.
• Identify legal issues.

Primary Assessment

• Assess from a distance; observe patient's appearance and behavior.
• Establish rapport, involve family, assess medical conditions.

History Taking

• Investigate chief complaint; consider CNS function, substance influence, mental health factors.
• Obtain past medical history and medication adherence.

Secondary Assessment

• For unconscious patients, perform a physical exam.
• Check for signs of drug abuse or self-mutilation.
• Use reflective listening to understand patient’s state of mind.

Reassessment

• Continuous reassessment, especially if restraints are used.
• Document all observations and interventions thoroughly.

Specific Conditions

Acute Psychosis

• State of delusion; causes include substances, stress, schizophrenia.
• Not easily managed by reasoning.
• Guidelines: ensure safety, communicate clearly, do not argue or challenge delusions.

Delirium

• Impairment in cognitive function; can be agitated.
• Approach safely, respect personal space, assess cognitive function.

Excited Delirium

• Hyperactive, irrational behavior with potential for violence.
• May result from substances or withdrawal.
• Chemical restraint may be necessary.

Restraints

• Use only when necessary for safety.
• Follow protocols for restraint types and applications.
• Constantly monitor restrained patients.
• Avoid positions leading to asphyxia.

The Potentially Violent Patient

• Assess for risk factors: history, posture, environment, vocal/physical activity.
• Use verbal de-escalation techniques.

Suicide

• Major risk factor is depression.
• Warning signs: despair, lack of future planning, specific plans for death.
• Immediate intervention needed.

Post-Traumatic Stress Disorder (PTSD)

• Triggered by traumatic events.
• Common in veterans; may include flashbacks and heightened arousal.
• Requires sensitive approach, understanding military background.

Medico-Legal Considerations

• Legal challenges arise in behavioral emergencies; consent is crucial.
• Implied consent applies in life-threatening emergencies.
• Know local protocols for involuntary holds.

Documentation

• Thorough documentation is essential, especially for medico-legal reasons.
• Provide detailed reports on observations, interactions, and interventions.