Understanding Behavioral Health Emergencies

Chapter 23. Behavioral Health Emergencies. Introduction. As an emergency medical technician, you'll care for patients experiencing behavioral health emergencies. A crisis may be the result of an acute medical condition, mental illness, mind-altering substances, stress, or other causes. This chapter discusses various types of behavioral health emergencies, including those involving drug overdoses, violent behavior. and different forms of mental illness. You will learn how to assess a person who exhibits signs and symptoms of a behavioral health emergency, and understand what kind of emergency care may be required in these situations. The chapter also covers legal concerns in dealing with behavioral health emergencies, the dangers of suicide, and difficulties related to post-traumatic stress disorder. Finally, you will learn how to identify and manage a potentially violent patient. including the use of patient restraints. Myth and reality. At some point, most people experience an emotional crisis, but only rarely does this crisis result in mental illness. Otherwise healthy people may sustain acute or temporary mental health disorders. Therefore, you should not jump to the conclusion that a patient is mentally ill when exhibiting behaviors discussed in this chapter. A common misconception about mental illness is that if you are feeling bad or depressed, you must be sick. That is simply not true. There are many perfectly justifiable reasons for feeling depressed, including divorce or the death of a relative or friend. For a teenager who just broke up with his girlfriend of 12 months, it is altogether normal to withdraw from ordinary activities, and to feel down for a while. This is a normal reaction to an acute crisis situation. However, When a person finds that the majority of his or her days are characterized by sadness, week after week, he or she may indeed have a behavioral health problem. Some people believe anyone with a behavioral health disorder is dangerous, violent, or otherwise unmanageable. This is also not true. Only a small percentage of behavioral health patients fall into these categories. However, as an emergency medical technician, You may be exposed to a higher proportion of violent patients because you are seeing people who are, by definition, considered to be having a behavioral crisis. Otherwise, you probably would not be seeing them. You have been called because family members or friends felt unable to manage the person on their own. The situation may be a result of drug or alcohol use or abuse or medication noncompliance, or the individual may have a long history of mental illness. and is reacting to a particularly stressful event. It is easy to assume the patient having a behavioral crisis does not understand the situation or the message you are trying to convey. However, especially during an acute crisis, many patients still have awareness and understanding. Communication is key. Never make disparaging or inappropriate statements. It is not only poor patient care, but inappropriate comments could escalate the situation. You may be able to calm the patient with reassurances and avoid restraints or other physical interactions that can be a danger to you or the patient. In some cases patients will de-escalate once a level of trust has been established. Although you cannot determine what has caused a person's crisis, you may be able to predict whether the person will become violent. The ability to predict violence is one of your more important assessment tools. Defining a Behavioral Crisis Behavior is what you can see if a person's response to the environment, his or her actions. Sometimes, it is obvious what is causing a person's response. A person is punched, and he or she runs away, bursts into tears, or hits back. Sometimes, it is less clear, such as when someone is depressed for complex emotional or biological reasons. Most of the time, people respond to the environment in reasonable ways. Over the years, People learn to adapt to a variety of situations in daily life, including stress. Stress is managed by the use of coping mechanisms. However, there are times when the stress is so great that the normal means of coping are not enough, or the person uses negative coping mechanisms such as withdrawal or numbing self-medication with drugs and alcohol. In some cases, the reaction is acute, but in other cases it develops over time. Both situations can create a crisis. The change in behavior may be considered inappropriate or not normal by the person who calls 911. A behavioral crisis describes the situation involving patients of all ages who exhibit agitated, violent, or uncooperative behavior or who are a danger to themselves or others. Emergency medical service is called when behavior has become unacceptable to the patient, family, or community. Emergency medical service can be called for an older adult who lives alone and started a kitchen fire when he or she left the burner on or for a person who is in danger from hoarding behavior. In these instances, a patient may have dementia or depression, behavior that may interfere with the activities of daily living. Chronic depression is a persistent feeling of sadness and despair. It may be a symptom of an underlying health disorder. There may not be a medical or traumatic emergency but simply a request for evaluation. A person who experiences a panic attack after having a heart attack is not necessarily mentally ill. Likewise, you would expect a person who is fired from a job to have some sort of reaction, often sadness and depression. These problems are short-term and isolated events. However, when a person reacts with a fit of rage, Attacking people and property, this behavior has gone beyond what society considers within the scope of a normal response to stressful stimulus. That person is likely undergoing a behavioral crisis. Depending on the nature of the response, an abnormal or disturbing pattern of behavior is regarded as a matter of concern from a mental health standpoint. When a behavioral health emergency arises, patients may show agitation or violence or become a threat to themselves or others. This is more serious than a typical behavioral crisis that causes inappropriate behavior. A behavioral health emergency often leads to severe impairments in the ability to perform activities of daily living, and may be accompanied by bizarre behavior. When there is an immediate threat to the person involved or when a patient's behavior threatens you, family, friends, or bystanders, the situation should be considered a behavioral health emergency. For example, A person might respond to the death of a spouse by attempting suicide. Other patients might respond to an upsetting event by exhibiting bizarre behavior. The magnitude of mental health disorders According to the National Institute of Mental Health, mental disorders are common throughout the United States, affecting tens of millions of people each year. A psychiatric disorder is an illness with psychological or behavioral symptoms that may result in impaired functioning. Anxiety disorders are among the most common mental health disorders and include generalized anxiety disorder, panic disorder, and social and other phobias. The mental health system in the United States provides many levels of assistance to people with psychological conditions. Common emotional issues such as marital conflict and parenting issues can often be resolved with the assistance of a professional counselor. More serious issues, such as clinical depression, are often handled by a psychologist who has specialized training dealing with more complex psychological conditions. For the treatment of the most severe conditions, such as schizophrenia or bipolar disorder, a psychiatrist may need to prescribe medication. Most behavioral health disorders can be treated in an outpatient environment, however, some people require hospitalization in specialized behavioral health units. Behavioral health disorders have many underlying causes. These include social and situational stress, such as divorce or death of a loved one, psychiatric diseases, such as schizophrenia, physical illnesses, such as diabetic emergencies, chemical problems, such as alcohol or drug use, or biologic disturbances, such as electrolyte imbalances. Sometimes these conditions can be compounded by non-compliance with prescribed medication regimens. Pathophysiology As an emergency medical technician You are not responsible for diagnosing the underlying cause of a behavioral crisis or emergency. However, you should understand the two basic categories of diagnosis that a physician will use, organic, physical, and functional, psychological. Organic. Organic brain syndrome is a temporary or permanent dysfunction of the brain caused by a disturbance in the physical or physiologic functioning of brain tissue. Causes of organic brain syndrome include sudden illness, traumatic brain injury, seizure disorders, drug and alcohol abuse, overdose, or withdrawal, and diseases of the brain, such as Alzheimer dementia or meningitis. Altered mental status can arise from a physiologic issue such as a hypoglycemia, hypoxia, impaired cerebral blood flow, and or hyperthermia or hypothermia. In the absence of a physiologic cause, altered mental status may be an indicator of a psychiatric disorder such as bipolar disorder. Functional. A functional disorder is a physiologic disorder that impairs bodily function when the body seems to be structurally normal. Something has gone wrong, but the root cause cannot be identified. Schizophrenia, anxiety conditions, and depression are good examples of functional disorders. The chemical or physical basis of these disorders does not alter the appearance of the patient. Safe approach to a behavioral crisis. All routine emergency medical technician skills. Patient approach, assessment, patient communication, obtaining the history, and providing care. are used in a behavioral crisis. However, other management techniques are also involved. Follow the general guidelines listed in Table 23-1 to ensure your safety at the scene of a behavioral health emergency. Patient Assessment. Scene Size Up. The first things for you to consider at the scene of a behavioral crisis or psychiatric emergency are your safety, and the patient's response to the environment. Is the situation potentially dangerous for you and your partner? Do you need immediate law enforcement backup? Should you stage until law enforcement personnel have secured the scene? Does the patient's behavior seem typical or normal for the circumstances? Are there legal issues involved? Crime scene? Consent? Refusal? Make sure to take appropriate standard precautions. Request any additional resources you may need. Law enforcement. Additional personnel, early. You can always send them away if they are not needed. Be vigilant and avoid tunnel vision. Determine the mechanism of injury and or nature of illness. Remember, certain injuries and medical conditions can cause altered behavior that can be confused with a behavioral health emergency. Note any medications or substances that may contribute to the complaint or that may be for treatment of a relevant medical condition. Primary assessment. Begin your assessment from the doorway or from a distance. How does the patient appear? Calm? Agitated? Awake or sleepy? How is the patient dressed? Is the patient out in the cold wearing only shorts? Is the patient's attire appropriate for the situation? Begin by introducing yourself, and let the patient know you are there to help. Allow the patient to tell you what happened or how he or she feels. Perform a rapid physical exam if the patient allows you. Look for trauma, especially head trauma. Remember, sometimes a traumatic brain injury can take several days to present with symptoms. Traumatic brain injury is discussed further in Chapter 29, Head and Spine Injuries. Closely observe the patient. Does the patient answer slowly with single-word answers or rapidly in long, rambling sentences? Do the patient's words make sense? or do they have no apparent sequence? Is the patient sitting slumped in a chair, hunched and shuffling around the room, or rigid and standing perfectly still? Is the patient alert and oriented? Use the awake and alert verbal stimuli pain unresponsive scale to check for alertness. To determine orientation, ask the patient, Who are you? Where are you? What time is it? What happened, and how can I help? Asking these questions will allow you to begin to establish a rapport with the patient. This rapport is critical to the success of your interaction. Engage family members or loved ones to encourage the patient's cooperation. If their presence does not worsen the patient's agitation, most medical or trauma situations will include a behavioral component. Anyone experiencing an emergency will generally have some level of fear or anxiety. A patient with difficulty breathing will be anxious the parent of a small child who fell out of a second story window will most likely be hysterical and feeling guilty an assault victim often experiences fear or anger it is important to treat the whole patient the behavioral component as well as the medical or traumatic issue if your patient is in physical distress assess the airway to make sure it is patent and adequate next evaluate the patient's breathing and obtain rate and effort. Use pulse oximetry if available. Provide the appropriate interventions based on your assessment findings. Some behavioral situations will involve a compromised airway or inadequate breathing if a patient has ingested prescription medications, drugs, or alcohol. Next, you'll need to assess the pulse rate, quality, and rhythm. Assessing a patient's circulation includes an evaluation for the presence of shock and bleeding. Assess the patient's perfusion by evaluating skin color, temperature, and capillary refill. Because skin paleness can be difficult to detect in patients with dark skin, instead check for pale mucous membranes inside the inner lower eyelid or slow capillary refill. Unless your patient is unstable from a medical problem or trauma, prepare to spend time with your patient. It may take time and patience to gain the patient's trust if he or she is fearful or unwilling to cooperate with you. History Taking When a medical patient is conscious, the next step in your assessment is to investigate the chief complaint, and then obtain a signs and symptoms, allergies, medications, pertinent past medical history, last oral intake. Events leading up to the illness or injury history. Obtain information about the patient and his or her medical history. Determine the reason for the patient's behavior. Your assessment should consider four major areas as possible contributors. Is the patient's central nervous system functioning properly? For example, the patient may be experiencing a diabetic emergency such as hypoglycemia. This situation could cause the patient to behave in an unusual or irrational manner. Are hallucinogens or other drugs or alcohol a factor? Does the patient see strange things? Is everything distorted? Do you smell alcohol on the patient's breath? Are there clues at the scene that suggest intoxication? Are significant life changes, symptoms, or illness, caused by mental rather than physical factors, involved? These might include the death of a loved one, severe depression, history of behavioral illness, threats of suicide, or some other major interruption of activities of daily living. If a patient has a history of behavioral health illness, has there been a recent change in medications? Often, treatment of functional behavioral health conditions is a trial and error process with medications and therapy. Doctors and therapists work with the patient and family to find the most effective course of treatment. with medication changes sometimes causing unexpected or undesirable outcomes. In some cases, the patient may refuse to take a medication. During the signs and symptoms, allergies, medications, pertinent past medical history, last oral intake, events leading up to the illness or injury history, you may be able to elicit information that would be helpful to the hospital staff. Ask specifically about previous episodes, treatments, hospitalizations. medications related to behavioral symptoms in geriatric patients consider Alzheimer disease and other causes of dementia as possible causes of abnormal behavior determining the patient's baseline mental status will be essential in guiding your treatment and transport decisions and will also be extremely helpful to hospital personnel family friends observers and caregivers may be of great help in answering these questions Together with your observations and interactions with the patient, they should provide enough data for you to assess the situation. This assessment has two primary goals, recognizing major threats to life, and reducing the stress of the situation as much as possible. Reflective listening is a technique frequently used by behavioral health professionals to gain insight into a patient's thinking. It involves repeating, in question form, what the patient has said. encouraging the patient to expand on his or her thoughts. Although it often requires more time to be effective than is available in an emergency medical service setting, it may be a helpful tool for you to use when other techniques are unsuccessful at gathering the patient's history. Secondary Assessment In an unconscious patient, begin with a physical exam to look for a reason for the unresponsiveness. Rule out trauma, especially to the head. Follow this rapid exam for hidden life threats with a detailed physical exam, and obtain a complete set of vital signs. Obtain vital signs only if you are able to do so without worsening your patient's emotional condition. Make every effort to assess blood pressure, pulse, respirations, skin, and pupils. Then gather what history you can from others. Consider whether prior events such as physical agitation, use of stimulants, alcohol withdrawal, or taser exposure may be contributing to the patient's condition. Many law enforcement agencies use taser devices to immobilize people who are behaving in a violent or aggressive manner. When physically examining a patient with a history of behavioral crises, check for track marks indicating drug abuse, and for signs of self-mutilation. Sometimes even a conscious patient in a behavioral health emergency will not respond to your questions. In those cases, You may be able to tell a lot about the patient's emotional state from facial expressions, pulse rate, and respirations. Tears, sweating, and blushing may be significant indicators of state of mind such as sadness, nervousness, or embarrassment. Also, make sure you look at the patient's eyes. A patient who has a blank gaze or rapidly moving eyes may be experiencing central nervous system dysfunction. A behavioral health emergency puts tremendous stress on a person's coping mechanisms. The person is actually incapable of responding reasonably to the demands of the environment. This state may be temporary, as in an acute illness such as drug-induced hallucinations, or more chronic, as in a complex, mental illness such as schizophrenia. The patient's perception of reality may be compromised or distorted. If you feel transport may put you at risk, ask law enforcement personnel to accompany you or call for advanced life support to provide chemical restraint. If uncertain about the value of advanced life support given the particular situation, seek medical direction. This provides you with additional assistance should the patient's behavior change rapidly. If a police officer restrains the patient with handcuffs, The officer must ride in the back of the ambulance to release the cuffs in the case of an emergency. Always follow local protocols regarding the use of physical restraints. There may be a specific facility to which patients with behavioral health emergencies are transported. Transport by ground rather than by air. If you feel transport may put you at risk, ask law enforcement personnel to accompany you or call for advanced life support to provide chemical restraint. If uncertain about the value of advanced life support given the particular situation, seek medical direction. Try to make the patient comfortable, but require that he or she ride on the stretcher with all straps secured. Stretchers with foam padding around the head allow the patient to position his or her head for adequate airway patency. Placing the stretcher in fowler or high fowler position helps prevent aspiration, and reduces physical exertion by relaxing the abdominal muscles. Reassessment. Never let your guard down. Most patients you treat and transport with emotional complaints pose no danger to you or others, but it is not always possible to determine this while on scene. Remember, many patients experiencing a behavioral crisis may act spontaneously. Be prepared to intervene quickly. If restraints are necessary, reassess and document the patient's respirations, as well as pulse, motor, and sensory functions in all restrained extremities, every five minutes. Restraint is discussed later in this chapter. In terms of interventions, as much as your heart may go out to an emotionally distressed patient, there often is little you will be able to do during the short time you will be treating the patient. Your job is to diffuse and control the situation and safely transport your patient to the hospital. The best treatment may be to be a good listener. Often these patients are happy if someone will listen to their problem. Intervene only as much as it takes to accomplish these tasks. Be caring and careful. Be aware of standard precautions. If the patient is spitting, place a surgical mask loosely over his or her mouth, and make sure you are wearing appropriate personal protective equipment including adequate eye protection, and a mask. Continually reassess the patient's ability to protect the airway, and breathe. In many areas, local protocol allows advanced life support providers to administer medications to calm a combative patient. This will often make the situation safer for you and your patient. If you encounter a situation where you think chemical, pharmacologic, restraint might be necessary, request advanced life support as early as possible. Give the receiving hospital advance warning when a patient experiencing a behavioral health emergency is coming in. Many hospitals require extra preparation to ensure the appropriate staff and rooms are available. Report whether restraints will be required when the patient arrives. Thoroughly and carefully document your actions. Think about what you are going to write before you write it, so that you can describe as clearly as possible what are often confusing scenes. Communicate to the hospital the things you observed at the scene that may help explain the patient's situation. These are important facts the hospital will not know unless you tell them. Include observed behaviors or items seen such as medications or weapons. Medications may have contributed to the crisis or may give you information about an otherwise undisclosed medical condition. Because behavioral health emergencies have few or no physical signs, you may have the only documentation clarifying the patient's distress. Because these emergencies are also fraught with legal dangers. Document everything that occurred on the call, particularly situations that required restraint. When restraints are required to protect you or the patient from harm, include why and what type of restraints were used. This information is essential if the case is reviewed for medico-legal reasons. Acute psychosis. Psychosis is a state of delusion in which the person is out of touch with reality. Affected people live in their own reality of ideas and feelings. To the person experiencing a psychotic episode, the line between reality and fantasy is blurred. That reality may make patients belligerent and angry toward others. Patients may become silent and withdrawn as they give all their attention to the voices and feelings within. Psychotic episodes occur for many reasons. The use of mind-altering substances is a common cause, and that experience may be limited to the duration of the substance within the body. Other causes include intense stress, delusional disorders, and, more commonly, schizophrenia. Some psychotic episodes last for brief periods, others last a lifetime. Schizophrenia schizophrenia is a complex disorder that is not easily defined or easily treated it affects how a person thinks feels and behaves the typical onset occurs during early adulthood between the ages of 16 and 30 years symptoms of the illness become more prominent over time some people in whom schizophrenia has been diagnosed display signs during early childhood their disease may be associated with brain damage or may have other causes Other influences thought to contribute to this disorder include genetics, and psychological and social influences. Patients with schizophrenia may experience symptoms including delusions, hallucinations, paranoia, a lack of interest in pleasure, and erratic speech. Dealing with the psychotic patient is difficult. The usual methods of reasoning with the patient are unlikely to be effective because the psychotic person has his or her own rules of logic that may be quite different from non-psychotic thinking. Follow these guidelines in dealing with a psychotic patient. Determine if the situation is a danger to yourself or others. Clearly identify yourself. I'm Gloria. I'm an emergency medical technician with the ambulance service, and this is my partner, Stan. We've come to see if we can help. Can you tell us what is happening? Be calm, direct, and straightforward. Your composure and confidence can do a great deal toward calming the patient. Maintain an emotional distance. Do not touch the patient, and do not patronize the patient or be overly reassuring. Do not argue. Do not challenge patients regarding the reality of their beliefs or the validity of their perceptions. Do not go along with their delusions simply to humor them, and do not make an issue of the delusions. Talk about real things. Explain what you would like to do. Let's walk downstairs to the ambulance. Involve people the patient trusts, such as family or friends, to gain the patient's cooperation. Delirium. Delirium is a condition of impairment in cognitive function that can present with disorientation, hallucinations, or delusions. Agitation is a behavior characterized by restless and irregular physical activity. Although patients experiencing delirium are generally not dangerous, if they exhibit agitated behavior they may strike out irrationally. One of the most important factors to consider in these cases is your personal safety. If you think you can safely approach the patient, become supportive and empathetic. Be an active listener by nodding, indicating understanding, and by limiting your interruptions of the patient's comments. It is extremely important to approach the patient slowly and purposefully and to respect the patient's personal space. Limit physical contact with the patient as much as possible. It is also imperative that you do not leave the patient unattended, unless the situation becomes unsafe for you or your partner. Use careful interviewing to assess the patient's cognitive functioning. Try to indirectly determine the patient's orientation, memory, concentration. judgment by asking simple questions such as when did you first begin to notice these feelings through interviewing try to determine what the patient is thinking are the patient's thoughts disorganized for example does the patient begin to answer your question and then drift off only to begin discussing a childhood friend is the patient experiencing delusions or hallucinations does the patient have any unusual worries or fears for example Does the patient express anxiety if you go too close to a pile of old newspapers? Pay particular attention to the patient's ability to communicate clearly and make notes on the patient's apparent mood. Is the patient anxious, depressed, elated, extremely happy or joyful, or agitated? Pay attention to the patient's appearance, dress, and personal hygiene. If the patient appears to be experiencing a drug overdose, take all medication bottles or illegal substances with you to the medical facility. The patient should be transported to a hospital with behavioral health facilities capable of handling the condition. Whenever possible, refrain from using lights and siren because these may aggravate the patient's condition. Excited delirium. A medical emergency sometimes encountered in an emergency medical service response is excited delirium. Excited delirium is also known as agitated delirium or exhaustive mania. The symptoms of excited delirium may include hyperactive irrational behavior with possible vivid hallucinations, which can create the potential for violent behavior. Common physical symptoms include hypertension, hyperthermia, tachycardia, diaphoresis, and dilated pupils. Because hallucinations are erroneous perceptions of reality, the patient may perceive you as a threat. Agitation is recognized as a biologic attempt to release nervous tension, and can produce sudden, unpredictable physical actions in your patient. If the patient's agitation continues, request advanced life support assistance so chemical restraint can be considered. Uncontrolled or poorly controlled patient agitation. and physical violence can place the patient at risk for sudden cardiopulmonary arrest. Physical agitation can lead to sudden death, thought to result from metabolic acidosis, though the cause of death is not clear. Physical control measures, including tasers, can contribute to sudden death in these patients. Also, this condition can be worsened by stimulant drugs, for example, cocaine, or alcohol withdrawal. Finally, Positional asphyxia occurs when a patient's physical position restricts chest wall movements or causes airway obstruction. It can also cause sudden death. This condition can occur unintentionally when a patient is being physically restrained. Restraint In situations when a patient engages in combative behavior, your safety and that of your partner must be your top priority. Therefore, it may be necessary for the patient to be physically restrained. Pre-hospital patient restraint reduces the possibility of patient injury and the potential for injury to emergency medical service providers and allows for safe and appropriate treatment of an uncooperative patient. The National Association of Emergency Medical Services Physicians recommends that every pre-hospital care transport provider create and follow a pre-hospital patient restraint protocol. Such protocols consider the appropriateness of restraint, the types of restraints, and care provided to the patient following restraint. Legislation regarding restraints ensures the safety of individuals who are an immediate threat to themselves or others. Your protocol must consider the laws of your state as they pertain to an individual's rights and processes for involuntarily restraining patients. There is wide variation in pre-hospital patient restraint protocols throughout the country. Protocols should include only the use of restraint devices that have been approved by the state health department or local emergency medical service agency. Restraint types can be soft, leather, or cloth. Soft restraints can include sheets, wide wristlets, and chest harnesses. Hard restraints can include plastic ties, handcuffs, or leather restraints. Emergency medical service protocols should avoid the use of hard restraints if possible. If heart restraints are approved, they will most likely be limited to the use of leather wrist restraints. The type of restraints used should not occlude circulation in the extremity, and should allow the emergency medical technician to quickly remove them if the patient vomits or respiratory distress develops. The method of restraint chosen should be the least restrictive method that will ensure the safety of the patient and providers. Risks associated with patient restraint Personnel must be properly trained in the use of restraints. Improperly applied restraints can result in severe and potentially life-threatening complications, such as positional asphyxia, aspiration, severe acidosis, and sudden cardiac death. If you restrain a person without authority in a non-emergency situation, you expose yourself to a possible lawsuit, and to personal danger. Legal actions against you can involve charges of assault, battery, false imprisonment. and violation of civil rights. You may use restraints only to protect yourself or others from bodily harm or to prevent the patient from injuring himself or herself. In either case, you may use reasonable force only as necessary to control the patient, something that courts may define differently. For this reason, follow local protocols and your company pre-hospital restraint policy, and consult medical control if needed. You should always involve law enforcement personnel if you are called to assist a patient in a severe behavioral health emergency, especially when restraining a competent individual against his or her will. Law enforcement may provide physical backup in managing the patient, and serve as the necessary witnesses. A patient who is restrained by law enforcement personnel is in their custody. Before you consider physical restraint, make a significant effort to use verbal de-escalation techniques to ease the situation and avoid the need for physical restraint. Also, consider asking the family to assist you in calming and reasoning with the patient. Verbal de-escalation is safest because it does not require any physical contact with the patient. Be honest and straightforward with the patient. and talk in a calm and friendly tone. The process of restraining a patient. Once the decision has been made to restrain a patient, you should carry it out as quickly as is safely possible. Make sure you have adequate help to safely restrain a patient. Ideally, five people should be present to carry out the restraint, each being responsible for one extremity and the head. There should also be a team leader who directs the restraining process. as well as a person to assist with applying the restraints. Before you begin, discuss the plan of action. As you prepare to restrain the patient, stay outside the patient's range of motion. Use the minimum force that is necessary to control a patient. Avoid acts of physical force that may cause injury to the patient. The level of force will vary, depending on the following factors. The degree of force that is necessary to keep the patient from injuring himself or herself. and others. A patient's sex, size, strength, and mental status, including the possibility of drug-induced states. Phencyclidine use may make the patient especially difficult to restrain. The type of abnormal behavior the patient is exhibiting. Other important considerations include. Somebody, preferably you or your partner, should talk to the patient throughout the process. Remember to treat the patient with dignity and respect at all times. Wear appropriate barrier protection during patient restraint activities. Never leave a restrained patient unattended. Physically uncooperative patients should be restrained in the supine position with one arm restrained up and one restrained down. The head can be elevated at a 30-degree angle, if possible, to help prevent airway compromise. Both legs and both arms should be restrained. Restraining the hips, thighs, and chest inhibits movement. Restraining the thighs just above the knees prevents kicking and is more effective than only restraining the ankles. Do not place anything over the patient's face, head, or neck. If the patient is spitting, a surgical mask may be placed loosely over the patient's mouth. Patients should never be transported while hobbled, hogtied, or restrained in a prone position with hands and feet behind the back, as positional asphyxia could occur. It is impossible to adequately monitor the patient in this position, and it may inhibit the breathing of an impaired or exhausted patient. Patients should never be transported while sandwiched between backboards or mattresses. Stretcher straps should be applied during transport as the standard procedure for all patients. Sheets can be used as additional stretcher straps if necessary. Stretcher straps and sheets should never restrict the patient's chest wall motion. Respiratory and circulatory problems have been known to occur in combative patients who are restrained. A physically restrained patient struggling against restraints can experience severe acidosis or fatal dysrhythmia. Monitor the patient for vomiting, airway obstruction, respiratory status, circulatory status, blood pressure, and changes in level of consciousness. Drug or alcohol intoxication may initially cause violent behavior that may lead to physical deterioration. Reassess airway and breathing continuously. You should make frequent checks of circulation on all restrained extremities, regardless of patient position. Chemical restraint administered by advanced life support personnel is an effective way to safely transport and treat the violent, combative, or agitated patient. Physical restraint should be reserved for situations where chemical restraint is unavailable or otherwise ineffective or contraindicated. Restraints applied in the field should not be removed until the patient is evaluated at the receiving facility. Release the restraints only if necessary to provide emergency patient care, and only if you have assistance. Be especially careful if a combative patient suddenly becomes calm and cooperative. This is not the time to relax but to be vigilant. The patient may suddenly become combative again and injure someone. Keep in mind that you may use reasonable force to defend yourself against an attack by an emotionally disturbed patient. It is extremely helpful to have, and document, witnesses in attendance, even during transport, to protect against false accusations. Emergency medical technicians have been accused of sexual misconduct and other physical abuse in such circumstances. Also document the reason for the restraint, the type of restraint used, and the technique that was used. Performing patient restraint. The steps in Scale Drill 23-1 show an example of the four-point restraint technique. 1. Bring down the patient into the supine position. 2. Acting at the same time. Secure the patient in the supine or left lateral position. 3. Secure the patient's extremities with wrist and ankle restraints. Step 1. 4. Use stretcher straps or sheets to secure the legs. Step 2. 5. Fasten the remaining straps, including chest and pelvis straps if available. Step 3. Do not use multiple knots. 6. Continue to verbally reassure and calm the patient. following chemical or physical restraints. 7. Regularly check circulation to the extremities. Step 4. Skill drill 23-1 restraining a patient. Step 1. Bring down the patient into the supine position. Acting at the same time, secure the patient in the supine or left lateral position with wrist and ankle restraints. Step 2. Use stretcher straps or sheets to secure the legs. Step 3. Fasten the remaining stretcher straps. Step 4. Continue to verbally reassure and calm the patient following chemical or physical restraints. Regularly check circulation to the extremities. A two-point restraint technique is an option if allowed per local protocols. This technique is performed in the same way as four-point restraint, except instead of restraining all four extremities to the stationary frame of the stretcher. One arm is placed upward toward the head, and the other is placed downward toward the waist. Once a patient has been restrained, reassess the airway and breathing. Document this information in your patient care report. The Potentially Violent Patient Violent patients account for only a small percentage of the patients experiencing a behavioral crisis. However, the potential for violence should always be a critical consideration for you. Use the following list of risk factors to assess the level of danger. History. Has the patient previously exhibited hostile, overly aggressive, or violent behavior? Ask people at the scene, or request this information from law enforcement personnel or family. Posture. How is the patient sitting or standing? Is the patient tense, rigid, or sitting on the edge of his or her seat? Such physical tension is often a warning signal of impending hostility. The Sane Is the patient holding or near potentially lethal objects such as a knife, gun, glass, poker, or bat, or near a window or glass door? Vocal Activity What type of speech is the patient using? Loud, obscene, erratic, and bizarre speech patterns usually indicate emotional distress. Someone using Quiet Ordered speech is not as likely to strike out as someone who is yelling and screaming. Physical activity. The motor activity of a person undergoing a psychiatric emergency may be the most telling factor of all. A patient who has tense muscles, clenched fists, or glaring eyes, is pacing or cannot sit still, or is fiercely protecting personal space requires careful watching. Agitation may predict a quick escalation to violence. Other factors to consider in assessing a patient's potential for violence include the following. Poor impulse control. A history of truancy, fighting, and uncontrollable temper. History of substance abuse. Depression, which accounts for 20% of violent attacks. Functional disorder. If the patient tells you voices are telling him or her to kill, believe it. Suicide. The single most significant factor that contributes to suicide is depression. Anytime you encounter an emotionally depressed patient, you must consider the possibility of suicide. The risk factors for suicide are listed in Table 23-3. It is a common misconception that people who threaten suicide never act on the threat. Suicide is a cry for help. Threatening suicide is an indication that someone is in a crisis that he or she cannot handle alone. Immediate intervention is necessary. Whether the patient has any of these risk factors, you must be alert to the following warning signs. Does the patient have an air of tearfulness, sadness, deep despair, or hopelessness that suggests depression? Does the patient avoid eye contact, speak slowly or haltingly? and project a sense of vacancy, as if he or she really is not there? Does the patient seem unable to talk about the future? Ask the patient whether he or she has any vacation plans. Suicidal people consider the future so uninteresting that they do not think about it. People who are seriously depressed consider the future so distant that they may not be able to think about it at all. Is there any suggestion of suicide? Even vague suggestions should not be taken lightly. even if presented as a joke. If you think that suicide is a possibility, do not hesitate to bring up the subject. You'll not give the patient ideas if you ask directly, are you considering suicide? Does the patient have any specific plans related to death? Has the patient recently prepared a will? Has the patient given away significant possessions or told close friends what he or she would like done with them? Arranged for a funeral service? These are critical warning signs. You should also consider the following additional risk factors for suicide. Are there any unsafe objects in the patient's hands or nearby? A sharp knife, glass, poisons, or a gun? Is the environment unsafe? An open window in a high-rise building? A patient standing on a bridge or precipice? Is there evidence of self-destructive behavior? Partially cut wrists, excessive alcohol or drug use? Is there an imminent threat? to the patient or others? Is there an underlying medical problem? Are there cultural, religious, or social beliefs promoting suicide? Has there been trauma? On the basis of your observations and conversations with the patient, you may need to determine if interventions such as restraints are needed. Remember, a suicidal patient may be homicidal as well. Do not jeopardize your life or the lives of your partners. If you have reason to believe that you are in danger, you must obtain police intervention. In the meantime, try not to frighten the patient or make him or her suspicious. Remember, the most important service you can provide for a suicidal patient is compassionate transportation to a medical facility where the patient can receive proper treatment. Post-traumatic stress disorder and returning combat veterans. Post-traumatic stress disorder can occur after exposure to, or injury from, a traumatic event. Such events may include sexual or physical assault, child abuse, a serious accident, a natural disaster, war, loss of a loved one, or stressful life changes. People may have experienced fear of danger, helplessness, or a severe reaction during the event. The reaction could be to trauma that occurred long ago or may be the result of multiple traumatic events over time. It is not necessarily the result of one isolated or recent event. It is estimated that 7% to 8% of the general population will experience signs of post-traumatic stress disorder at some point in their lives. For healthcare workers returning from a warfare environment, which could include disaster workers, threat of personal harm is considered a predictive factor in determining in whom post-traumatic stress disorder will develop. Military personnel who experienced combat have a high incidence of post-traumatic stress disorder. Post-traumatic stress disorder occurred in up to 20% of veterans of the Iraq and Afghanistan wars, 10% of Gulf War veterans, and 30% of Vietnam War veterans. Reminders of their experiences in the military such as news coverage or gatherings of veterans can also be triggers. Signs and symptoms of post-traumatic stress disorder. Symptoms of post-traumatic stress disorder include feelings of helplessness, anxiety, anger, and fear. People with post-traumatic stress disorder may avoid things that remind them of the trauma, including loud noises or smells, and sometimes avoid interactions with other people. This emotional and physical distancing from others can have a negative effect on one's quality of life. Memories of the trauma linger and continue to be disruptive. Symptoms of post-traumatic stress disorder may be made worse in the context of other mental health challenges. The sympathetic nervous system provides the fight or flight mechanism to help protect us in a perceived dangerous situation. It is not intended to last any longer than required to mitigate the threat. People with post-traumatic stress disorder suffer nervous system arousal that continues and is not easily suppressed. Heart rate increases to channel blood into the heart, lungs, and brain. Pupils dilate, and systolic blood pressure is increased. Senses are sharpened, and mental acuity is heightened. The victim may be hypervigilant or display an exaggerated startle response to perceived danger. People with post-traumatic stress disorder can relive the traumatic event through intrusive thoughts, nightmares, or even flashbacks. Flashbacks are uncontrollable events triggered by a sound, sight, or smell. The patient may experience the same visceral response as when he or she initially encountered the stress. These episodes can last seconds or hours, and can occur at any time, even years after the exposure. The person fears this inability to control a flashback and worries that it will present as irrational behavior. Recent traumatic events may also trigger old memories, and create a reflex reaction of preparing for the worst. A person who has experienced flashbacks may become preoccupied with the perception of danger. Hypervigilance and trouble sleeping are not unusual. Dissociative post-traumatic stress disorder occurs when the person attempts to escape from constant internal distress or a particularly disturbing event. His or her altered consciousness allows him or her to continue functioning under negative conditions. Some people may undergo an out-of-body experience. Others experience delusions. Other psychological conditions such as personality disorders and increased functional impairment can develop in those with the dissociative sub-traumatic stress disorder. type of post-traumatic stress disorder. Guilt, shame, paranoia, hostility, and depression are not uncommon for combat veterans. Alcohol and or drug use is a common way to suppress the sympathetic nervous system activity and slow down the body. This attempt at anesthesia can easily become addictive. Suicide is sometimes sought to end the pain. Veterans are much more likely to harm themselves or try to harm themselves They also sustain a host of physical conditions, some from injuries sustained in combat, and sometimes vague, unfocused pain not associated with any specific part of the body. This perception of physical pain may be a sign of their anguish. In particular, combat veterans may have heart disease at a younger age than expected, a higher incidence of type 2 diabetes, and a loss of brain gray matter. High cholesterol and hypertension are not uncommon and are often undiagnosed or misdiagnosed. Another consideration for the combat veteran is the higher incidence of traumatic brain injury sustained from trauma secondary to explosion of an improvised explosive device. In some cases, the traumatic brain injury may go undiagnosed due to similarities with the symptoms of post-traumatic stress disorder or because the patient downplays the symptoms. People with traumatic brain injury can sustain sensory dysfunction, confusion headaches, memory loss, and general disorientation. Memory loss can include retrograde and anterograde amnesia, before and after the event. Try to eliminate excess noise. Do not touch or do anything to the veteran without an explanation. Interestingly, diesel fumes often can be a trigger for combat veterans. Keep your diesel equipment far enough away. caring for the combat veteran. How do you recognize returning veterans? They often continue to adhere to their military identity with short haircuts and wearing military clothing with combat patches and often have tattoos. Their homes may have flags, memorials, commendations, and military photos. They may have a military appearance and use military vocabulary. They tend to show respect for authority but may be reluctant to talk to you about post-traumatic stress disorder. They may not be aware that they have it, or do not want to be considered mental. They might have trouble asking for help. Asking, how do you want me to help you? Or, what is it you need right now, is a good way to open the conversation. The returning combat veteran is a patient who will require a unique level of understanding, compassion, and specialized attention. These patients experience pain that is emotional as well as physical. You'll need to take time to establish the history of this patient and listen to his or her concerns. Approach this patient with sensitivity and respect. Be careful how you phrase your questions. Were you in combat is an appropriate question, but in some cases, veterans may be in denial or do not believe they were in combat. A better question might be, were you shot at or under fire? If you served in combat, you can create trust by letting the patient know. Ask questions about the patient service, branch, rank, etc. You may get enough information out of that conversation to eliminate the need to probe further with specific questions. Use a calm, firm voice, but be in charge. Respect a veteran's personal space. Limit the number of people involved or move to a private and quiet space. In some cases, supportive family or friends can be helpful. Ask about suicidal intentions. this might create an opportunity for the patient to reach out. Military veterans are trained to use weapons, and are also resourceful in improvising weapons. If you are concerned about suicide, ensure there is nothing the patient can access and use as a weapon. Physical restraint will not be effective with this population, and may only escalate the problem. Even seat belts on the stretcher can aggravate a patient. If it is necessary to calm the patient, Especially in the face of safety considerations, chemical restraints administered by advanced life support should be considered. Medico-legal considerations. The medical and legal aspects of emergency medical care become more complicated when the patient is experiencing a behavioral health emergency. Nevertheless, legal challenges are greatly reduced when an emotionally disturbed patient consents to care. Gaining the patient's confidence is, therefore, a critical task for you. Mental incapacity can take many forms, unconsciousness, as a result of hypoxia, alcohol, or drugs, temporary but severe stress, and depression. Once you have determined that a patient has impaired mental capacity, you must decide whether he or she requires immediate emergency medical care. A patient in a mentally unstable condition may resist your attempts to provide care. Nevertheless, you must not leave the patient alone. Doing so may result in harm to the patient and expose you to civil action for abandonment or negligence. In such a case, consult medical control. If medical control believes that an involuntary emergency petition is in order, then taking the patient into protective custody is appropriate, and you should request law enforcement personnel to help restrain the patient and transport under involuntary circumstances. Each state has different processes for involuntary emergency petitioning for a person in a behavioral health emergency situation. Be familiar with your state's protocols. For example, in some states two physician signatures are necessary on the petition to make it valid. It is therefore imperative to get the first physician to agree to the appropriateness of petitioning a patient prior to initiating protective custody in the field. Consent When a patient is not mentally competent to grant consent for emergency medical care, the law assumes that there is implied consent. For example, the consent of an unconscious patient is implied if life or health is at risk. The law refers to this as the emergency doctrine. Consent is implied because of the necessity for immediate emergency treatment. In a situation that is not immediately life-threatening. Emergency medical care or transportation may be delayed until the proper consent is obtained. In cases involving behavioral health emergencies, however, the matter is not always clear. Does a life-threatening emergency exist or not? If you are not sure, contact your supervisor if available or appropriate based on local protocols, or contact medical control. Only with the concurrence of medical control can the patient be taken into custody with an emergency petition. Once the emergency petition is in place, law enforcement personnel can be used to help achieve restraint and transport. Limited legal authority. As an emergency medical technician, you do not have legal authority to require a patient to undergo emergency medical care if the patient is competent and understands the risks and benefits of transport versus refusal. Patients have the right to refuse care. However, Most states have legal statutes regarding the emergency care of mentally ill and drug-impaired people. These statutory provisions may permit law enforcement personnel to place the person in protective custody so that emergency care can be given. You should be familiar with your local and state laws regarding these situations. A typical provision may state the following. Any police officer who has reasonable cause to believe that a person is mentally ill and dangerous to himself, herself. or others or gravely disabled may take such person into custody and take or cause such person to be taken to a general hospital for emergency examination the general rule of law is that a competent adult has the right to refuse treatment even if life-saving care is involved However, in psychiatric cases, a court of law would probably consider your actions in providing life-saving care to be appropriate, particularly if you have a reasonable belief that the patient would harm himself or herself, or others, without your intervention. If you decide a patient must be transported against his or her will, make sure you have the appropriate resources on scene to avoid unnecessary injury to the patient, you, or your partner. In addition, a patient who is impaired in any way. Whether by mental illness, medical condition, or intoxication, may not be considered competent to refuse treatment or transportation. These situations are among the most perilous you will encounter from a legal standpoint. When in doubt, consult with your supervisor or medical control. Always maintain a high index of suspicion regarding your patient's condition. Assume the worst and hope for the best. Err on the side of treatment and transport. Carefully document the patient's statements and behavior to support your actions.

Chapter 23. Behavioral Health Emergencies. Introduction. As an emergency medical technician, you'll care for patients experiencing behavioral health emergencies.

A crisis may be the result of an acute medical condition, mental illness, mind-altering substances, stress, or other causes. This chapter discusses various types of behavioral health emergencies, including those involving drug overdoses, violent behavior. and different forms of mental illness.

You will learn how to assess a person who exhibits signs and symptoms of a behavioral health emergency, and understand what kind of emergency care may be required in these situations. The chapter also covers legal concerns in dealing with behavioral health emergencies, the dangers of suicide, and difficulties related to post-traumatic stress disorder. Finally, you will learn how to identify and manage a potentially violent patient.

including the use of patient restraints. Myth and reality. At some point, most people experience an emotional crisis, but only rarely does this crisis result in mental illness. Otherwise healthy people may sustain acute or temporary mental health disorders.

Therefore, you should not jump to the conclusion that a patient is mentally ill when exhibiting behaviors discussed in this chapter. A common misconception about mental illness is that if you are feeling bad or depressed, you must be sick. That is simply not true. There are many perfectly justifiable reasons for feeling depressed, including divorce or the death of a relative or friend. For a teenager who just broke up with his girlfriend of 12 months, it is altogether normal to withdraw from ordinary activities, and to feel down for a while.

This is a normal reaction to an acute crisis situation. However, When a person finds that the majority of his or her days are characterized by sadness, week after week, he or she may indeed have a behavioral health problem. Some people believe anyone with a behavioral health disorder is dangerous, violent, or otherwise unmanageable.

This is also not true. Only a small percentage of behavioral health patients fall into these categories. However, as an emergency medical technician, You may be exposed to a higher proportion of violent patients because you are seeing people who are, by definition, considered to be having a behavioral crisis. Otherwise, you probably would not be seeing them. You have been called because family members or friends felt unable to manage the person on their own.

The situation may be a result of drug or alcohol use or abuse or medication noncompliance, or the individual may have a long history of mental illness. and is reacting to a particularly stressful event. It is easy to assume the patient having a behavioral crisis does not understand the situation or the message you are trying to convey. However, especially during an acute crisis, many patients still have awareness and understanding.

Communication is key. Never make disparaging or inappropriate statements. It is not only poor patient care, but inappropriate comments could escalate the situation. You may be able to calm the patient with reassurances and avoid restraints or other physical interactions that can be a danger to you or the patient.

In some cases patients will de-escalate once a level of trust has been established. Although you cannot determine what has caused a person's crisis, you may be able to predict whether the person will become violent. The ability to predict violence is one of your more important assessment tools. Defining a Behavioral Crisis Behavior is what you can see if a person's response to the environment, his or her actions. Sometimes, it is obvious what is causing a person's response.

A person is punched, and he or she runs away, bursts into tears, or hits back. Sometimes, it is less clear, such as when someone is depressed for complex emotional or biological reasons. Most of the time, people respond to the environment in reasonable ways. Over the years, People learn to adapt to a variety of situations in daily life, including stress.

Stress is managed by the use of coping mechanisms. However, there are times when the stress is so great that the normal means of coping are not enough, or the person uses negative coping mechanisms such as withdrawal or numbing self-medication with drugs and alcohol. In some cases, the reaction is acute, but in other cases it develops over time.

Both situations can create a crisis. The change in behavior may be considered inappropriate or not normal by the person who calls 911. A behavioral crisis describes the situation involving patients of all ages who exhibit agitated, violent, or uncooperative behavior or who are a danger to themselves or others. Emergency medical service is called when behavior has become unacceptable to the patient, family, or community.

Emergency medical service can be called for an older adult who lives alone and started a kitchen fire when he or she left the burner on or for a person who is in danger from hoarding behavior. In these instances, a patient may have dementia or depression, behavior that may interfere with the activities of daily living. Chronic depression is a persistent feeling of sadness and despair. It may be a symptom of an underlying health disorder. There may not be a medical or traumatic emergency but simply a request for evaluation.

A person who experiences a panic attack after having a heart attack is not necessarily mentally ill. Likewise, you would expect a person who is fired from a job to have some sort of reaction, often sadness and depression. These problems are short-term and isolated events. However, when a person reacts with a fit of rage, Attacking people and property, this behavior has gone beyond what society considers within the scope of a normal response to stressful stimulus. That person is likely undergoing a behavioral crisis.

Depending on the nature of the response, an abnormal or disturbing pattern of behavior is regarded as a matter of concern from a mental health standpoint. When a behavioral health emergency arises, patients may show agitation or violence or become a threat to themselves or others. This is more serious than a typical behavioral crisis that causes inappropriate behavior. A behavioral health emergency often leads to severe impairments in the ability to perform activities of daily living, and may be accompanied by bizarre behavior. When there is an immediate threat to the person involved or when a patient's behavior threatens you, family, friends, or bystanders, the situation should be considered a behavioral health emergency.

For example, A person might respond to the death of a spouse by attempting suicide. Other patients might respond to an upsetting event by exhibiting bizarre behavior. The magnitude of mental health disorders According to the National Institute of Mental Health, mental disorders are common throughout the United States, affecting tens of millions of people each year.

A psychiatric disorder is an illness with psychological or behavioral symptoms that may result in impaired functioning. Anxiety disorders are among the most common mental health disorders and include generalized anxiety disorder, panic disorder, and social and other phobias. The mental health system in the United States provides many levels of assistance to people with psychological conditions.

Common emotional issues such as marital conflict and parenting issues can often be resolved with the assistance of a professional counselor. More serious issues, such as clinical depression, are often handled by a psychologist who has specialized training dealing with more complex psychological conditions. For the treatment of the most severe conditions, such as schizophrenia or bipolar disorder, a psychiatrist may need to prescribe medication. Most behavioral health disorders can be treated in an outpatient environment, however, some people require hospitalization in specialized behavioral health units. Behavioral health disorders have many underlying causes.

These include social and situational stress, such as divorce or death of a loved one, psychiatric diseases, such as schizophrenia, physical illnesses, such as diabetic emergencies, chemical problems, such as alcohol or drug use, or biologic disturbances, such as electrolyte imbalances. Sometimes these conditions can be compounded by non-compliance with prescribed medication regimens. Pathophysiology As an emergency medical technician You are not responsible for diagnosing the underlying cause of a behavioral crisis or emergency.

However, you should understand the two basic categories of diagnosis that a physician will use, organic, physical, and functional, psychological. Organic. Organic brain syndrome is a temporary or permanent dysfunction of the brain caused by a disturbance in the physical or physiologic functioning of brain tissue.

Causes of organic brain syndrome include sudden illness, traumatic brain injury, seizure disorders, drug and alcohol abuse, overdose, or withdrawal, and diseases of the brain, such as Alzheimer dementia or meningitis. Altered mental status can arise from a physiologic issue such as a hypoglycemia, hypoxia, impaired cerebral blood flow, and or hyperthermia or hypothermia. In the absence of a physiologic cause, altered mental status may be an indicator of a psychiatric disorder such as bipolar disorder. Functional. A functional disorder is a physiologic disorder that impairs bodily function when the body seems to be structurally normal.

Something has gone wrong, but the root cause cannot be identified. Schizophrenia, anxiety conditions, and depression are good examples of functional disorders. The chemical or physical basis of these disorders does not alter the appearance of the patient.

Safe approach to a behavioral crisis. All routine emergency medical technician skills. Patient approach, assessment, patient communication, obtaining the history, and providing care. are used in a behavioral crisis. However, other management techniques are also involved.

Follow the general guidelines listed in Table 23-1 to ensure your safety at the scene of a behavioral health emergency. Patient Assessment. Scene Size Up.

The first things for you to consider at the scene of a behavioral crisis or psychiatric emergency are your safety, and the patient's response to the environment. Is the situation potentially dangerous for you and your partner? Do you need immediate law enforcement backup? Should you stage until law enforcement personnel have secured the scene?

Does the patient's behavior seem typical or normal for the circumstances? Are there legal issues involved? Crime scene? Consent? Refusal?

Make sure to take appropriate standard precautions. Request any additional resources you may need. Law enforcement. Additional personnel, early.

You can always send them away if they are not needed. Be vigilant and avoid tunnel vision. Determine the mechanism of injury and or nature of illness.

Remember, certain injuries and medical conditions can cause altered behavior that can be confused with a behavioral health emergency. Note any medications or substances that may contribute to the complaint or that may be for treatment of a relevant medical condition. Primary assessment.

Begin your assessment from the doorway or from a distance. How does the patient appear? Calm? Agitated?

Awake or sleepy? How is the patient dressed? Is the patient out in the cold wearing only shorts?

Is the patient's attire appropriate for the situation? Begin by introducing yourself, and let the patient know you are there to help. Allow the patient to tell you what happened or how he or she feels. Perform a rapid physical exam if the patient allows you.

Look for trauma, especially head trauma. Remember, sometimes a traumatic brain injury can take several days to present with symptoms. Traumatic brain injury is discussed further in Chapter 29, Head and Spine Injuries. Closely observe the patient.

Does the patient answer slowly with single-word answers or rapidly in long, rambling sentences? Do the patient's words make sense? or do they have no apparent sequence?

Is the patient sitting slumped in a chair, hunched and shuffling around the room, or rigid and standing perfectly still? Is the patient alert and oriented? Use the awake and alert verbal stimuli pain unresponsive scale to check for alertness. To determine orientation, ask the patient, Who are you? Where are you?

What time is it? What happened, and how can I help? Asking these questions will allow you to begin to establish a rapport with the patient. This rapport is critical to the success of your interaction. Engage family members or loved ones to encourage the patient's cooperation.

If their presence does not worsen the patient's agitation, most medical or trauma situations will include a behavioral component. Anyone experiencing an emergency will generally have some level of fear or anxiety. A patient with difficulty breathing will be anxious the parent of a small child who fell out of a second story window will most likely be hysterical and feeling guilty an assault victim often experiences fear or anger it is important to treat the whole patient the behavioral component as well as the medical or traumatic issue if your patient is in physical distress assess the airway to make sure it is patent and adequate next evaluate the patient's breathing and obtain rate and effort. Use pulse oximetry if available.

Provide the appropriate interventions based on your assessment findings. Some behavioral situations will involve a compromised airway or inadequate breathing if a patient has ingested prescription medications, drugs, or alcohol. Next, you'll need to assess the pulse rate, quality, and rhythm.

Assessing a patient's circulation includes an evaluation for the presence of shock and bleeding. Assess the patient's perfusion by evaluating skin color, temperature, and capillary refill. Because skin paleness can be difficult to detect in patients with dark skin, instead check for pale mucous membranes inside the inner lower eyelid or slow capillary refill.

Unless your patient is unstable from a medical problem or trauma, prepare to spend time with your patient. It may take time and patience to gain the patient's trust if he or she is fearful or unwilling to cooperate with you. History Taking When a medical patient is conscious, the next step in your assessment is to investigate the chief complaint, and then obtain a signs and symptoms, allergies, medications, pertinent past medical history, last oral intake. Events leading up to the illness or injury history.

Obtain information about the patient and his or her medical history. Determine the reason for the patient's behavior. Your assessment should consider four major areas as possible contributors.

Is the patient's central nervous system functioning properly? For example, the patient may be experiencing a diabetic emergency such as hypoglycemia. This situation could cause the patient to behave in an unusual or irrational manner.

Are hallucinogens or other drugs or alcohol a factor? Does the patient see strange things? Is everything distorted? Do you smell alcohol on the patient's breath? Are there clues at the scene that suggest intoxication?

Are significant life changes, symptoms, or illness, caused by mental rather than physical factors, involved? These might include the death of a loved one, severe depression, history of behavioral illness, threats of suicide, or some other major interruption of activities of daily living. If a patient has a history of behavioral health illness, has there been a recent change in medications?

Often, treatment of functional behavioral health conditions is a trial and error process with medications and therapy. Doctors and therapists work with the patient and family to find the most effective course of treatment. with medication changes sometimes causing unexpected or undesirable outcomes.

In some cases, the patient may refuse to take a medication. During the signs and symptoms, allergies, medications, pertinent past medical history, last oral intake, events leading up to the illness or injury history, you may be able to elicit information that would be helpful to the hospital staff. Ask specifically about previous episodes, treatments, hospitalizations.

medications related to behavioral symptoms in geriatric patients consider Alzheimer disease and other causes of dementia as possible causes of abnormal behavior determining the patient's baseline mental status will be essential in guiding your treatment and transport decisions and will also be extremely helpful to hospital personnel family friends observers and caregivers may be of great help in answering these questions Together with your observations and interactions with the patient, they should provide enough data for you to assess the situation. This assessment has two primary goals, recognizing major threats to life, and reducing the stress of the situation as much as possible. Reflective listening is a technique frequently used by behavioral health professionals to gain insight into a patient's thinking. It involves repeating, in question form, what the patient has said.

encouraging the patient to expand on his or her thoughts. Although it often requires more time to be effective than is available in an emergency medical service setting, it may be a helpful tool for you to use when other techniques are unsuccessful at gathering the patient's history. Secondary Assessment In an unconscious patient, begin with a physical exam to look for a reason for the unresponsiveness. Rule out trauma, especially to the head.

Follow this rapid exam for hidden life threats with a detailed physical exam, and obtain a complete set of vital signs. Obtain vital signs only if you are able to do so without worsening your patient's emotional condition. Make every effort to assess blood pressure, pulse, respirations, skin, and pupils. Then gather what history you can from others.

Consider whether prior events such as physical agitation, use of stimulants, alcohol withdrawal, or taser exposure may be contributing to the patient's condition. Many law enforcement agencies use taser devices to immobilize people who are behaving in a violent or aggressive manner. When physically examining a patient with a history of behavioral crises, check for track marks indicating drug abuse, and for signs of self-mutilation.

Sometimes even a conscious patient in a behavioral health emergency will not respond to your questions. In those cases, You may be able to tell a lot about the patient's emotional state from facial expressions, pulse rate, and respirations. Tears, sweating, and blushing may be significant indicators of state of mind such as sadness, nervousness, or embarrassment.

Also, make sure you look at the patient's eyes. A patient who has a blank gaze or rapidly moving eyes may be experiencing central nervous system dysfunction. A behavioral health emergency puts tremendous stress on a person's coping mechanisms. The person is actually incapable of responding reasonably to the demands of the environment. This state may be temporary, as in an acute illness such as drug-induced hallucinations, or more chronic, as in a complex, mental illness such as schizophrenia.

The patient's perception of reality may be compromised or distorted. If you feel transport may put you at risk, ask law enforcement personnel to accompany you or call for advanced life support to provide chemical restraint. If uncertain about the value of advanced life support given the particular situation, seek medical direction.

This provides you with additional assistance should the patient's behavior change rapidly. If a police officer restrains the patient with handcuffs, The officer must ride in the back of the ambulance to release the cuffs in the case of an emergency. Always follow local protocols regarding the use of physical restraints. There may be a specific facility to which patients with behavioral health emergencies are transported. Transport by ground rather than by air.

If you feel transport may put you at risk, ask law enforcement personnel to accompany you or call for advanced life support to provide chemical restraint. If uncertain about the value of advanced life support given the particular situation, seek medical direction. Try to make the patient comfortable, but require that he or she ride on the stretcher with all straps secured. Stretchers with foam padding around the head allow the patient to position his or her head for adequate airway patency.

Placing the stretcher in fowler or high fowler position helps prevent aspiration, and reduces physical exertion by relaxing the abdominal muscles. Reassessment. Never let your guard down.

Most patients you treat and transport with emotional complaints pose no danger to you or others, but it is not always possible to determine this while on scene. Remember, many patients experiencing a behavioral crisis may act spontaneously. Be prepared to intervene quickly.

If restraints are necessary, reassess and document the patient's respirations, as well as pulse, motor, and sensory functions in all restrained extremities, every five minutes. Restraint is discussed later in this chapter. In terms of interventions, as much as your heart may go out to an emotionally distressed patient, there often is little you will be able to do during the short time you will be treating the patient.

Your job is to diffuse and control the situation and safely transport your patient to the hospital. The best treatment may be to be a good listener. Often these patients are happy if someone will listen to their problem.

Intervene only as much as it takes to accomplish these tasks. Be caring and careful. Be aware of standard precautions. If the patient is spitting, place a surgical mask loosely over his or her mouth, and make sure you are wearing appropriate personal protective equipment including adequate eye protection, and a mask.

Continually reassess the patient's ability to protect the airway, and breathe. In many areas, local protocol allows advanced life support providers to administer medications to calm a combative patient. This will often make the situation safer for you and your patient.

If you encounter a situation where you think chemical, pharmacologic, restraint might be necessary, request advanced life support as early as possible. Give the receiving hospital advance warning when a patient experiencing a behavioral health emergency is coming in. Many hospitals require extra preparation to ensure the appropriate staff and rooms are available. Report whether restraints will be required when the patient arrives.

Thoroughly and carefully document your actions. Think about what you are going to write before you write it, so that you can describe as clearly as possible what are often confusing scenes. Communicate to the hospital the things you observed at the scene that may help explain the patient's situation.

These are important facts the hospital will not know unless you tell them. Include observed behaviors or items seen such as medications or weapons. Medications may have contributed to the crisis or may give you information about an otherwise undisclosed medical condition. Because behavioral health emergencies have few or no physical signs, you may have the only documentation clarifying the patient's distress.

Because these emergencies are also fraught with legal dangers. Document everything that occurred on the call, particularly situations that required restraint. When restraints are required to protect you or the patient from harm, include why and what type of restraints were used. This information is essential if the case is reviewed for medico-legal reasons.

Acute psychosis. Psychosis is a state of delusion in which the person is out of touch with reality. Affected people live in their own reality of ideas and feelings. To the person experiencing a psychotic episode, the line between reality and fantasy is blurred.

That reality may make patients belligerent and angry toward others. Patients may become silent and withdrawn as they give all their attention to the voices and feelings within. Psychotic episodes occur for many reasons. The use of mind-altering substances is a common cause, and that experience may be limited to the duration of the substance within the body.

Other causes include intense stress, delusional disorders, and, more commonly, schizophrenia. Some psychotic episodes last for brief periods, others last a lifetime. Schizophrenia schizophrenia is a complex disorder that is not easily defined or easily treated it affects how a person thinks feels and behaves the typical onset occurs during early adulthood between the ages of 16 and 30 years symptoms of the illness become more prominent over time some people in whom schizophrenia has been diagnosed display signs during early childhood their disease may be associated with brain damage or may have other causes Other influences thought to contribute to this disorder include genetics, and psychological and social influences. Patients with schizophrenia may experience symptoms including delusions, hallucinations, paranoia, a lack of interest in pleasure, and erratic speech. Dealing with the psychotic patient is difficult.

The usual methods of reasoning with the patient are unlikely to be effective because the psychotic person has his or her own rules of logic that may be quite different from non-psychotic thinking. Follow these guidelines in dealing with a psychotic patient. Determine if the situation is a danger to yourself or others. Clearly identify yourself. I'm Gloria.

I'm an emergency medical technician with the ambulance service, and this is my partner, Stan. We've come to see if we can help. Can you tell us what is happening? Be calm, direct, and straightforward. Your composure and confidence can do a great deal toward calming the patient.

Maintain an emotional distance. Do not touch the patient, and do not patronize the patient or be overly reassuring. Do not argue.

Do not challenge patients regarding the reality of their beliefs or the validity of their perceptions. Do not go along with their delusions simply to humor them, and do not make an issue of the delusions. Talk about real things. Explain what you would like to do. Let's walk downstairs to the ambulance.

Involve people the patient trusts, such as family or friends, to gain the patient's cooperation. Delirium. Delirium is a condition of impairment in cognitive function that can present with disorientation, hallucinations, or delusions. Agitation is a behavior characterized by restless and irregular physical activity. Although patients experiencing delirium are generally not dangerous, if they exhibit agitated behavior they may strike out irrationally.

One of the most important factors to consider in these cases is your personal safety. If you think you can safely approach the patient, become supportive and empathetic. Be an active listener by nodding, indicating understanding, and by limiting your interruptions of the patient's comments. It is extremely important to approach the patient slowly and purposefully and to respect the patient's personal space. Limit physical contact with the patient as much as possible.

It is also imperative that you do not leave the patient unattended, unless the situation becomes unsafe for you or your partner. Use careful interviewing to assess the patient's cognitive functioning. Try to indirectly determine the patient's orientation, memory, concentration. judgment by asking simple questions such as when did you first begin to notice these feelings through interviewing try to determine what the patient is thinking are the patient's thoughts disorganized for example does the patient begin to answer your question and then drift off only to begin discussing a childhood friend is the patient experiencing delusions or hallucinations does the patient have any unusual worries or fears for example Does the patient express anxiety if you go too close to a pile of old newspapers? Pay particular attention to the patient's ability to communicate clearly and make notes on the patient's apparent mood.

Is the patient anxious, depressed, elated, extremely happy or joyful, or agitated? Pay attention to the patient's appearance, dress, and personal hygiene. If the patient appears to be experiencing a drug overdose, take all medication bottles or illegal substances with you to the medical facility. The patient should be transported to a hospital with behavioral health facilities capable of handling the condition.

Whenever possible, refrain from using lights and siren because these may aggravate the patient's condition. Excited delirium. A medical emergency sometimes encountered in an emergency medical service response is excited delirium.

Excited delirium is also known as agitated delirium or exhaustive mania. The symptoms of excited delirium may include hyperactive irrational behavior with possible vivid hallucinations, which can create the potential for violent behavior. Common physical symptoms include hypertension, hyperthermia, tachycardia, diaphoresis, and dilated pupils. Because hallucinations are erroneous perceptions of reality, the patient may perceive you as a threat.

Agitation is recognized as a biologic attempt to release nervous tension, and can produce sudden, unpredictable physical actions in your patient. If the patient's agitation continues, request advanced life support assistance so chemical restraint can be considered. Uncontrolled or poorly controlled patient agitation.

and physical violence can place the patient at risk for sudden cardiopulmonary arrest. Physical agitation can lead to sudden death, thought to result from metabolic acidosis, though the cause of death is not clear. Physical control measures, including tasers, can contribute to sudden death in these patients. Also, this condition can be worsened by stimulant drugs, for example, cocaine, or alcohol withdrawal. Finally, Positional asphyxia occurs when a patient's physical position restricts chest wall movements or causes airway obstruction.

It can also cause sudden death. This condition can occur unintentionally when a patient is being physically restrained. Restraint In situations when a patient engages in combative behavior, your safety and that of your partner must be your top priority. Therefore, it may be necessary for the patient to be physically restrained. Pre-hospital patient restraint reduces the possibility of patient injury and the potential for injury to emergency medical service providers and allows for safe and appropriate treatment of an uncooperative patient.

The National Association of Emergency Medical Services Physicians recommends that every pre-hospital care transport provider create and follow a pre-hospital patient restraint protocol. Such protocols consider the appropriateness of restraint, the types of restraints, and care provided to the patient following restraint. Legislation regarding restraints ensures the safety of individuals who are an immediate threat to themselves or others. Your protocol must consider the laws of your state as they pertain to an individual's rights and processes for involuntarily restraining patients.

There is wide variation in pre-hospital patient restraint protocols throughout the country. Protocols should include only the use of restraint devices that have been approved by the state health department or local emergency medical service agency. Restraint types can be soft, leather, or cloth. Soft restraints can include sheets, wide wristlets, and chest harnesses. Hard restraints can include plastic ties, handcuffs, or leather restraints.

Emergency medical service protocols should avoid the use of hard restraints if possible. If heart restraints are approved, they will most likely be limited to the use of leather wrist restraints. The type of restraints used should not occlude circulation in the extremity, and should allow the emergency medical technician to quickly remove them if the patient vomits or respiratory distress develops.

The method of restraint chosen should be the least restrictive method that will ensure the safety of the patient and providers. Risks associated with patient restraint Personnel must be properly trained in the use of restraints. Improperly applied restraints can result in severe and potentially life-threatening complications, such as positional asphyxia, aspiration, severe acidosis, and sudden cardiac death. If you restrain a person without authority in a non-emergency situation, you expose yourself to a possible lawsuit, and to personal danger. Legal actions against you can involve charges of assault, battery, false imprisonment.

and violation of civil rights. You may use restraints only to protect yourself or others from bodily harm or to prevent the patient from injuring himself or herself. In either case, you may use reasonable force only as necessary to control the patient, something that courts may define differently. For this reason, follow local protocols and your company pre-hospital restraint policy, and consult medical control if needed.

You should always involve law enforcement personnel if you are called to assist a patient in a severe behavioral health emergency, especially when restraining a competent individual against his or her will. Law enforcement may provide physical backup in managing the patient, and serve as the necessary witnesses. A patient who is restrained by law enforcement personnel is in their custody. Before you consider physical restraint, make a significant effort to use verbal de-escalation techniques to ease the situation and avoid the need for physical restraint. Also, consider asking the family to assist you in calming and reasoning with the patient.

Verbal de-escalation is safest because it does not require any physical contact with the patient. Be honest and straightforward with the patient. and talk in a calm and friendly tone. The process of restraining a patient. Once the decision has been made to restrain a patient, you should carry it out as quickly as is safely possible.

Make sure you have adequate help to safely restrain a patient. Ideally, five people should be present to carry out the restraint, each being responsible for one extremity and the head. There should also be a team leader who directs the restraining process. as well as a person to assist with applying the restraints.

Before you begin, discuss the plan of action. As you prepare to restrain the patient, stay outside the patient's range of motion. Use the minimum force that is necessary to control a patient. Avoid acts of physical force that may cause injury to the patient.

The level of force will vary, depending on the following factors. The degree of force that is necessary to keep the patient from injuring himself or herself. and others.

A patient's sex, size, strength, and mental status, including the possibility of drug-induced states. Phencyclidine use may make the patient especially difficult to restrain. The type of abnormal behavior the patient is exhibiting.

Other important considerations include. Somebody, preferably you or your partner, should talk to the patient throughout the process. Remember to treat the patient with dignity and respect at all times. Wear appropriate barrier protection during patient restraint activities.

Never leave a restrained patient unattended. Physically uncooperative patients should be restrained in the supine position with one arm restrained up and one restrained down. The head can be elevated at a 30-degree angle, if possible, to help prevent airway compromise.

Both legs and both arms should be restrained. Restraining the hips, thighs, and chest inhibits movement. Restraining the thighs just above the knees prevents kicking and is more effective than only restraining the ankles.

Do not place anything over the patient's face, head, or neck. If the patient is spitting, a surgical mask may be placed loosely over the patient's mouth. Patients should never be transported while hobbled, hogtied, or restrained in a prone position with hands and feet behind the back, as positional asphyxia could occur. It is impossible to adequately monitor the patient in this position, and it may inhibit the breathing of an impaired or exhausted patient. Patients should never be transported while sandwiched between backboards or mattresses.

Stretcher straps should be applied during transport as the standard procedure for all patients. Sheets can be used as additional stretcher straps if necessary. Stretcher straps and sheets should never restrict the patient's chest wall motion. Respiratory and circulatory problems have been known to occur in combative patients who are restrained.

A physically restrained patient struggling against restraints can experience severe acidosis or fatal dysrhythmia. Monitor the patient for vomiting, airway obstruction, respiratory status, circulatory status, blood pressure, and changes in level of consciousness. Drug or alcohol intoxication may initially cause violent behavior that may lead to physical deterioration.

Reassess airway and breathing continuously. You should make frequent checks of circulation on all restrained extremities, regardless of patient position. Chemical restraint administered by advanced life support personnel is an effective way to safely transport and treat the violent, combative, or agitated patient. Physical restraint should be reserved for situations where chemical restraint is unavailable or otherwise ineffective or contraindicated. Restraints applied in the field should not be removed until the patient is evaluated at the receiving facility.

Release the restraints only if necessary to provide emergency patient care, and only if you have assistance. Be especially careful if a combative patient suddenly becomes calm and cooperative. This is not the time to relax but to be vigilant. The patient may suddenly become combative again and injure someone.

Keep in mind that you may use reasonable force to defend yourself against an attack by an emotionally disturbed patient. It is extremely helpful to have, and document, witnesses in attendance, even during transport, to protect against false accusations. Emergency medical technicians have been accused of sexual misconduct and other physical abuse in such circumstances. Also document the reason for the restraint, the type of restraint used, and the technique that was used. Performing patient restraint.

The steps in Scale Drill 23-1 show an example of the four-point restraint technique. 1. Bring down the patient into the supine position. 2. Acting at the same time. Secure the patient in the supine or left lateral position. 3. Secure the patient's extremities with wrist and ankle restraints.

Step 1. 4. Use stretcher straps or sheets to secure the legs. Step 2. 5. Fasten the remaining straps, including chest and pelvis straps if available. Step 3. Do not use multiple knots. 6. Continue to verbally reassure and calm the patient. following chemical or physical restraints.

7. Regularly check circulation to the extremities. Step 4. Skill drill 23-1 restraining a patient. Step 1. Bring down the patient into the supine position. Acting at the same time, secure the patient in the supine or left lateral position with wrist and ankle restraints.

Step 2. Use stretcher straps or sheets to secure the legs. Step 3. Fasten the remaining stretcher straps. Step 4. Continue to verbally reassure and calm the patient following chemical or physical restraints. Regularly check circulation to the extremities.

A two-point restraint technique is an option if allowed per local protocols. This technique is performed in the same way as four-point restraint, except instead of restraining all four extremities to the stationary frame of the stretcher. One arm is placed upward toward the head, and the other is placed downward toward the waist.

Once a patient has been restrained, reassess the airway and breathing. Document this information in your patient care report. The Potentially Violent Patient Violent patients account for only a small percentage of the patients experiencing a behavioral crisis. However, the potential for violence should always be a critical consideration for you. Use the following list of risk factors to assess the level of danger.

History. Has the patient previously exhibited hostile, overly aggressive, or violent behavior? Ask people at the scene, or request this information from law enforcement personnel or family.

Posture. How is the patient sitting or standing? Is the patient tense, rigid, or sitting on the edge of his or her seat? Such physical tension is often a warning signal of impending hostility. The Sane Is the patient holding or near potentially lethal objects such as a knife, gun, glass, poker, or bat, or near a window or glass door?

Vocal Activity What type of speech is the patient using? Loud, obscene, erratic, and bizarre speech patterns usually indicate emotional distress. Someone using Quiet Ordered speech is not as likely to strike out as someone who is yelling and screaming. Physical activity. The motor activity of a person undergoing a psychiatric emergency may be the most telling factor of all.

A patient who has tense muscles, clenched fists, or glaring eyes, is pacing or cannot sit still, or is fiercely protecting personal space requires careful watching. Agitation may predict a quick escalation to violence. Other factors to consider in assessing a patient's potential for violence include the following. Poor impulse control. A history of truancy, fighting, and uncontrollable temper.

History of substance abuse. Depression, which accounts for 20% of violent attacks. Functional disorder.

If the patient tells you voices are telling him or her to kill, believe it. Suicide. The single most significant factor that contributes to suicide is depression.

Anytime you encounter an emotionally depressed patient, you must consider the possibility of suicide. The risk factors for suicide are listed in Table 23-3. It is a common misconception that people who threaten suicide never act on the threat.

Suicide is a cry for help. Threatening suicide is an indication that someone is in a crisis that he or she cannot handle alone. Immediate intervention is necessary.

Whether the patient has any of these risk factors, you must be alert to the following warning signs. Does the patient have an air of tearfulness, sadness, deep despair, or hopelessness that suggests depression? Does the patient avoid eye contact, speak slowly or haltingly?

and project a sense of vacancy, as if he or she really is not there? Does the patient seem unable to talk about the future? Ask the patient whether he or she has any vacation plans.

Suicidal people consider the future so uninteresting that they do not think about it. People who are seriously depressed consider the future so distant that they may not be able to think about it at all. Is there any suggestion of suicide?

Even vague suggestions should not be taken lightly. even if presented as a joke. If you think that suicide is a possibility, do not hesitate to bring up the subject. You'll not give the patient ideas if you ask directly, are you considering suicide?

Does the patient have any specific plans related to death? Has the patient recently prepared a will? Has the patient given away significant possessions or told close friends what he or she would like done with them? Arranged for a funeral service?

These are critical warning signs. You should also consider the following additional risk factors for suicide. Are there any unsafe objects in the patient's hands or nearby?

A sharp knife, glass, poisons, or a gun? Is the environment unsafe? An open window in a high-rise building? A patient standing on a bridge or precipice? Is there evidence of self-destructive behavior?

Partially cut wrists, excessive alcohol or drug use? Is there an imminent threat? to the patient or others? Is there an underlying medical problem?

Are there cultural, religious, or social beliefs promoting suicide? Has there been trauma? On the basis of your observations and conversations with the patient, you may need to determine if interventions such as restraints are needed.

Remember, a suicidal patient may be homicidal as well. Do not jeopardize your life or the lives of your partners. If you have reason to believe that you are in danger, you must obtain police intervention.

In the meantime, try not to frighten the patient or make him or her suspicious. Remember, the most important service you can provide for a suicidal patient is compassionate transportation to a medical facility where the patient can receive proper treatment. Post-traumatic stress disorder and returning combat veterans. Post-traumatic stress disorder can occur after exposure to, or injury from, a traumatic event. Such events may include sexual or physical assault, child abuse, a serious accident, a natural disaster, war, loss of a loved one, or stressful life changes.

People may have experienced fear of danger, helplessness, or a severe reaction during the event. The reaction could be to trauma that occurred long ago or may be the result of multiple traumatic events over time. It is not necessarily the result of one isolated or recent event. It is estimated that 7% to 8% of the general population will experience signs of post-traumatic stress disorder at some point in their lives.

For healthcare workers returning from a warfare environment, which could include disaster workers, threat of personal harm is considered a predictive factor in determining in whom post-traumatic stress disorder will develop. Military personnel who experienced combat have a high incidence of post-traumatic stress disorder. Post-traumatic stress disorder occurred in up to 20% of veterans of the Iraq and Afghanistan wars, 10% of Gulf War veterans, and 30% of Vietnam War veterans.

Reminders of their experiences in the military such as news coverage or gatherings of veterans can also be triggers. Signs and symptoms of post-traumatic stress disorder. Symptoms of post-traumatic stress disorder include feelings of helplessness, anxiety, anger, and fear.

People with post-traumatic stress disorder may avoid things that remind them of the trauma, including loud noises or smells, and sometimes avoid interactions with other people. This emotional and physical distancing from others can have a negative effect on one's quality of life. Memories of the trauma linger and continue to be disruptive. Symptoms of post-traumatic stress disorder may be made worse in the context of other mental health challenges.

The sympathetic nervous system provides the fight or flight mechanism to help protect us in a perceived dangerous situation. It is not intended to last any longer than required to mitigate the threat. People with post-traumatic stress disorder suffer nervous system arousal that continues and is not easily suppressed. Heart rate increases to channel blood into the heart, lungs, and brain. Pupils dilate, and systolic blood pressure is increased.

Senses are sharpened, and mental acuity is heightened. The victim may be hypervigilant or display an exaggerated startle response to perceived danger. People with post-traumatic stress disorder can relive the traumatic event through intrusive thoughts, nightmares, or even flashbacks. Flashbacks are uncontrollable events triggered by a sound, sight, or smell. The patient may experience the same visceral response as when he or she initially encountered the stress.

These episodes can last seconds or hours, and can occur at any time, even years after the exposure. The person fears this inability to control a flashback and worries that it will present as irrational behavior. Recent traumatic events may also trigger old memories, and create a reflex reaction of preparing for the worst.

A person who has experienced flashbacks may become preoccupied with the perception of danger. Hypervigilance and trouble sleeping are not unusual. Dissociative post-traumatic stress disorder occurs when the person attempts to escape from constant internal distress or a particularly disturbing event.

His or her altered consciousness allows him or her to continue functioning under negative conditions. Some people may undergo an out-of-body experience. Others experience delusions. Other psychological conditions such as personality disorders and increased functional impairment can develop in those with the dissociative sub-traumatic stress disorder. type of post-traumatic stress disorder.

Guilt, shame, paranoia, hostility, and depression are not uncommon for combat veterans. Alcohol and or drug use is a common way to suppress the sympathetic nervous system activity and slow down the body. This attempt at anesthesia can easily become addictive. Suicide is sometimes sought to end the pain. Veterans are much more likely to harm themselves or try to harm themselves They also sustain a host of physical conditions, some from injuries sustained in combat, and sometimes vague, unfocused pain not associated with any specific part of the body.

This perception of physical pain may be a sign of their anguish. In particular, combat veterans may have heart disease at a younger age than expected, a higher incidence of type 2 diabetes, and a loss of brain gray matter. High cholesterol and hypertension are not uncommon and are often undiagnosed or misdiagnosed.

Another consideration for the combat veteran is the higher incidence of traumatic brain injury sustained from trauma secondary to explosion of an improvised explosive device. In some cases, the traumatic brain injury may go undiagnosed due to similarities with the symptoms of post-traumatic stress disorder or because the patient downplays the symptoms. People with traumatic brain injury can sustain sensory dysfunction, confusion headaches, memory loss, and general disorientation. Memory loss can include retrograde and anterograde amnesia, before and after the event. Try to eliminate excess noise.

Do not touch or do anything to the veteran without an explanation. Interestingly, diesel fumes often can be a trigger for combat veterans. Keep your diesel equipment far enough away. caring for the combat veteran. How do you recognize returning veterans?

They often continue to adhere to their military identity with short haircuts and wearing military clothing with combat patches and often have tattoos. Their homes may have flags, memorials, commendations, and military photos. They may have a military appearance and use military vocabulary.

They tend to show respect for authority but may be reluctant to talk to you about post-traumatic stress disorder. They may not be aware that they have it, or do not want to be considered mental. They might have trouble asking for help. Asking, how do you want me to help you?

Or, what is it you need right now, is a good way to open the conversation. The returning combat veteran is a patient who will require a unique level of understanding, compassion, and specialized attention. These patients experience pain that is emotional as well as physical.

You'll need to take time to establish the history of this patient and listen to his or her concerns. Approach this patient with sensitivity and respect. Be careful how you phrase your questions. Were you in combat is an appropriate question, but in some cases, veterans may be in denial or do not believe they were in combat.

A better question might be, were you shot at or under fire? If you served in combat, you can create trust by letting the patient know. Ask questions about the patient service, branch, rank, etc. You may get enough information out of that conversation to eliminate the need to probe further with specific questions. Use a calm, firm voice, but be in charge.

Respect a veteran's personal space. Limit the number of people involved or move to a private and quiet space. In some cases, supportive family or friends can be helpful.

Ask about suicidal intentions. this might create an opportunity for the patient to reach out. Military veterans are trained to use weapons, and are also resourceful in improvising weapons. If you are concerned about suicide, ensure there is nothing the patient can access and use as a weapon.

Physical restraint will not be effective with this population, and may only escalate the problem. Even seat belts on the stretcher can aggravate a patient. If it is necessary to calm the patient, Especially in the face of safety considerations, chemical restraints administered by advanced life support should be considered.

Medico-legal considerations. The medical and legal aspects of emergency medical care become more complicated when the patient is experiencing a behavioral health emergency. Nevertheless, legal challenges are greatly reduced when an emotionally disturbed patient consents to care. Gaining the patient's confidence is, therefore, a critical task for you. Mental incapacity can take many forms, unconsciousness, as a result of hypoxia, alcohol, or drugs, temporary but severe stress, and depression.

Once you have determined that a patient has impaired mental capacity, you must decide whether he or she requires immediate emergency medical care. A patient in a mentally unstable condition may resist your attempts to provide care. Nevertheless, you must not leave the patient alone. Doing so may result in harm to the patient and expose you to civil action for abandonment or negligence.

In such a case, consult medical control. If medical control believes that an involuntary emergency petition is in order, then taking the patient into protective custody is appropriate, and you should request law enforcement personnel to help restrain the patient and transport under involuntary circumstances. Each state has different processes for involuntary emergency petitioning for a person in a behavioral health emergency situation. Be familiar with your state's protocols.

For example, in some states two physician signatures are necessary on the petition to make it valid. It is therefore imperative to get the first physician to agree to the appropriateness of petitioning a patient prior to initiating protective custody in the field. Consent When a patient is not mentally competent to grant consent for emergency medical care, the law assumes that there is implied consent. For example, the consent of an unconscious patient is implied if life or health is at risk.

The law refers to this as the emergency doctrine. Consent is implied because of the necessity for immediate emergency treatment. In a situation that is not immediately life-threatening. Emergency medical care or transportation may be delayed until the proper consent is obtained. In cases involving behavioral health emergencies, however, the matter is not always clear.

Does a life-threatening emergency exist or not? If you are not sure, contact your supervisor if available or appropriate based on local protocols, or contact medical control. Only with the concurrence of medical control can the patient be taken into custody with an emergency petition. Once the emergency petition is in place, law enforcement personnel can be used to help achieve restraint and transport.

Limited legal authority. As an emergency medical technician, you do not have legal authority to require a patient to undergo emergency medical care if the patient is competent and understands the risks and benefits of transport versus refusal. Patients have the right to refuse care. However, Most states have legal statutes regarding the emergency care of mentally ill and drug-impaired people. These statutory provisions may permit law enforcement personnel to place the person in protective custody so that emergency care can be given.

You should be familiar with your local and state laws regarding these situations. A typical provision may state the following. Any police officer who has reasonable cause to believe that a person is mentally ill and dangerous to himself, herself.

or others or gravely disabled may take such person into custody and take or cause such person to be taken to a general hospital for emergency examination the general rule of law is that a competent adult has the right to refuse treatment even if life-saving care is involved However, in psychiatric cases, a court of law would probably consider your actions in providing life-saving care to be appropriate, particularly if you have a reasonable belief that the patient would harm himself or herself, or others, without your intervention. If you decide a patient must be transported against his or her will, make sure you have the appropriate resources on scene to avoid unnecessary injury to the patient, you, or your partner. In addition, a patient who is impaired in any way.

Whether by mental illness, medical condition, or intoxication, may not be considered competent to refuse treatment or transportation. These situations are among the most perilous you will encounter from a legal standpoint. When in doubt, consult with your supervisor or medical control. Always maintain a high index of suspicion regarding your patient's condition. Assume the worst and hope for the best.

Err on the side of treatment and transport. Carefully document the patient's statements and behavior to support your actions.

Transcript for:Understanding Behavioral Health Emergencies

Transcript for:
Understanding Behavioral Health Emergencies