hello and welcome to chapter 23 behavioral health emergencies of the emergency care and transportation of the sickening year 12th edition after you complete this chapter and the related coursework you will be able to recognize behaviors that pose a risk to the emt patient and others and the basic principles of the mental health system additionally you will have the knowledge and skills to successfully assess and manage patients suffering from a behavioral health emergency within the legal parameters of your scope of practice okay so let's get started emts often care for patients experiencing behavioral crisis emergencies the crisis may be the result of an acute medical situation a mental illness a mind-altering substance stress and other causes when we talk about the mithras versus reality at some point most people experience an emotional crisis so this does not mean though that everyone develops a mental illness otherwise healthy people may sustain acute or temporary mental health disorders do not jump to a conclusion that a patient is mentally ill the most common misconception about mental illness is that if you are feeling bad or depressed you must be sick there are many justifiable reasons for feeling depressed such as a divorce or a loss of a job perhaps death of a relative or friend this is a normal reaction to an acute crisis some people believe that all individuals with mental health disorders are dangerous violent or otherwise unmanageable only a small percentage of people with mental health problems fall into these categories emts may be exposed to a higher proportion of violent patients because they are seeing people who are in by definition considered to be having a behavioral crisis communication is the key in some cases patients will de-escalate when a level of trust is established so although you cannot determine what has caused a person's crisis you may be able to predict whether the person will become violent so let's talk about defining a behavioral crisis behavior is what you see of a person's response to the environment meaning his or her actions over time people learn to adapt to a situation in daily life including stress so sometimes stress is so great that the normal ways of coping are not enough or the person uses negative coping mechanisms such as withdrawing or drugs and alcohol reactions to stress that are acute and those that develop over time can create a crisis the change in behavior may be considered inappropriate or not normal by the person who calls 9-1-1 a behavioral crisis includes patients of all ages who exhibit agitated violent or uncooperative behavior or who are in a danger to themselves or others ems is called when a behavior has become unacceptable to the patient family or community usually if an abnormal or disturbing pattern of behavior lasts for a month or more it is a matter of concern for from a health mental health standpoint when a behavioral health emergency arises the patient may show agitation or violence or may become a threat to their self or others so let's talk about the magnitude of mental health disorders all right so according to the national institute of mental health mental health disorders are common throughout the united states affecting tens of millions of people each year a psychiatric disorder is an illness with a psychological or behavioral symptoms that may result in impaired functioning so anxiety disorders are among the most common mental health disorders you could have a generalized anxiety disorder or panic disorder social or other phobias post-traumatic stress disorder or some type of obsessive-compulsive disorder the us mental health system provides many levels of assistance to people with psychological conditions professional counselors are available for marital conflicts and parenting issues and the most serious issues such as clinical depression are often handled by psychologists some of the most severe psychological conditions such as schizophrenia and bipolar disorder require psychiatrists and that's because they need to prescribe medicine most psychological disorders can be handled through outpatient visits but some require hospitalization in a specialized behavioral health unit behavioral health disorders have many underlying causes you could have a social or situational stress such as a divorce or a death of a loved one you could have the disease such as schizophrenia physical illness such as a diabetic emergency a chemical problem such as alcohol or drug use or a biological disturbances such as some type of electrolyte imbalance sometimes these conditions are compounded by non-compliance with prescribed medications let's talk about the pathophysiology of what's happening as an emt um it's not you're not responsible for diagnosing the underlying cause of the behavioral crisis or emergency you should understand though two basic diagnosis a physician will use so the first is organic and that's a physical condition and then the section second is a functional and that's a psychological condition okay so let's talk about organic disorders an organic brain syndrome is a temporary or permanent dysfunction of the brain caused by a disturbance in the physical or psychological functioning of the brain tissue okay so causes can be sudden illness traumatic brain injury perhaps a seizure disorder drug and alcohol abuse overdose or withdrawal and these diseases of the brain such as alzheimer's disease and meningitis altered mental status can arise from hypoglycemia hypoxia impaired cerebral blood flow hyperthermia or hypothermia in the absence of a psychologic case or physiologic case ultimate mental status may be an indicator of a psychiatric disorder such as bipolar disorder so a functional disorder so physiological disorders that impair body function when the body seems to be structurally normal these include schizophrenia some anxiety conditions and depression so the safe approach to the behavioral crisis is all emts should up with patient approach assessment patient communication obtaining a history and providing care are used in a behavioral crisis so let's just go right into that patient assessment and of course the first thing is the scene size up and scene safety so the first things to consider are the scene safety and the patient's response to the environment and is the situation potentially dangerous for you and your partner do you need immediate law enforcement backup or should you stage until law enforcement personnel has secured the scene does the patient's behavior seem typical or normal for the circumstance and are there legal issues involved so is the the is it a crime scene or do you need to get consent or obtain a refusal so take appropriate standard precautions and request any additional resources you may need such as law enforcement or additional personnel early mechanism of injury and nature of illness so note any medications or substances that may contribute to the complaint or that may be a treatment for a relevant medical condition now we're into the primary assessment so of course the very first thing you're going to do when you look at the patient is you're going to form that general impression begin your assessment from the doorway or from a safe distance perform a rapid physical exam observe the patient closely and use avpu scale to check for alertness so alert verbal painful unresponsive establish a rapport with the patient most medical or trauma situations will include a behavioral component and then of course is the abcs and d and with the a and the b if your patient is in physical distress you need to assess the airway to make sure that it's patent and adequate evaluate the patient's breathing and obtain a rate and effort if pulse ox is available use that and provide the appropriate interventions based on your assessment findings then c so assess the pulse rate rhythm and quality evaluate the presence of shock and bleeding and assess the patient's perfusion and so we're going to do this by evaluating the skin color temp and cap refill and then the d of course i use unless the patient is unstable from a medical problem or trauma prepare to spend some time with that patient now after the abcs of that primary is going to be the history taken and so when we do the history taking with this medical patient we're going to do a sample history and we want to consider four major areas of possible contributors okay so is the patient's central nervous system functioning properly and are hallucinogens or other drugs or alcohol effector and are significant life changes symptoms or illness in this caused by mental rather than physical factors okay so and is there a history of this behavioral health illness you may be able to get the information that would be helpful um to the hospital staff okay so in geriatric patients consider alzheimer's disease and dementia as possible causes of abnormal behavior identify the patient's baseline mental status is very important with those patients use reflective listening to gain insight into the patient's thinking so the table on the slide lists some questions to ask when you're trying to evaluate the mental health issue okay so um and you could read those but does the patient appropriately answer the questions and is that behavior seeming appropriate there's a few more on the slide and then the secondary the secondary is that physical exam and in a con unconscious patient we want to begin with a physical exam to look for any reason for that unresponsiveness we want to rule out trauma especially the head and consider whether prior events such as a physical agitation use of stimulants alcohol withdrawal or taser exposure may be contributing to the patient's condition and we want to check for track marks indicated drug abuse or for some signs of self mutilation right a conscious patient may not respond to your questions okay you can tell a lot by a patient's emotional state from their facial expressions their heart rate respirations as well tears sweating and blushing may also be a significant indicator of states of mind so look at the patient's eyes a blank glaze or rapidly moving eyes may mean the patient is experiencing some type of central nervous system dysfunction next is that transport decision so when available have law enforcement personnel or firefighters accompany you to the back of the in the back of the ambulance during transport there may be a specific facility to which the patients with behavioral health emergencies are transported transport by ground rather than air okay and try and make the patient feel comfortable so when it comes to reassessments never let your guard down and if restraints are necessary we're going to reassess and document the patient's respiration pulse motor and sensory functions and all the restrained extremities we need to do this every five minutes and then intervention so diffuse and control the situation the best treatment may be to be a good listener intervene only as much as it takes to accomplish tasks and if you encounter a situation where you think a pharmalogical restraint might be necessary request advanced life support early communication documentation so we're going to get that receiving hospital advance warning when we have a patient experiencing a behavioral health emergency because we want to report whether restraints will be required when the patient arrives at the hospital and give them some time to get ready for that so we need to document thoroughly and carefully if restraints are used say what type is used and why they were used when it comes to acute psychosis so psychosis is a state of delusion in which the person is out of touch with reality and affected people live in their own reality of ideas and feelings and causes of psychotic episodes include altered mind-altering substances intense stress or delusional disorders and also schizophrenia so let let's talk about schizophrenia then okay schizophrenia is a complex disorder that is not easily defined or easily treated the typical onset occurs during early adulthood with symptoms becoming more prominent over time influences thought to contribute to the disorder include brain damage genetics physiologic or and social influences symptoms are delusions hallucinations a lack of interest and pleasure erratic speech and guidelines for dealing with this are you need to determine if the situation is safe or dangerous okay so clearly identify yourself be calm direct and straightforward and maintain an emotional distance do not argue explain what you're going to do involve people whom the patient trusts such as family members and friends to gain the patient's cooperation next we're going to talk about excited delirium okay so excited delirium you'll also hear it um called agitated delirium or exhaustive mania in delirium that's a condition of impairment in cognitive function that can present with disorientation hallucinations or delusions agitation is a behavior characterized by restlessness and irregular physical activity so some symptoms of excited delirium include hyperactive irrational behavior vivid hallucinations hypertension tachycardia diaphoresis dilated pupils if you think you can safely approach the patient be calm supportive and empathetic approach the patient slowly and purposefully and respect the patient's personal space limit physical contact as much as possible and do not leave the patient unattended use careful interviewing to assess the patient's functioning okay so cognitive functioning determine the patient's ability to communicate and observe the patient's appearance dress and personal hygiene if the patient appears to be experiencing an overdose take all medicine bottles or legal substances with you to that medical facility the patient should be transported to the hospital with behavioral health facility and refrain from using lights and sirens the patient is if their agitation continues you need to request advanced life support assistance so chemical restraints can be considered excited delirium can lead to sudden death and this is from cardiac arrest physical agitation thought to result from a metabolic acidosis physical control measures including tasers stimulant drugs or positional affixia okay so when we talk about um excited delirium and it just we just kind of progress into using restraints okay so pre-hospital patient restraints reduce the possibility of a patient injury and the potential for injury to emergency medical service providers it also 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 in these this patient uh restraint protocol should address the appropriateness of the restraint the types that we would use the care provided to the patients following a restraint your protocol must consider the laws of your state pre-hospital patient restraint protocols vary widely so protocols should include only the use of restraint devices that have been approved by the state's health department or local ems agency the method of restraint chosen should be the least restrictive method that will ensure the safety of the patient and the providers there are risks associated with patient restraints okay improper use of restraints can lead to life-threatening conditions including positional asphyxia aspiration severe acidosis and possibly cardiac arrest restraint of a person without authority in a non-emergency situation can result in legal aspects actions so you could it could be assault battery false imprisonment or violation of civil rights restraints are only to protect yourself and others from broadly harm or to prevent the patient from injuring him or herself you need to involve law enforcement personnel if you are called to assist a patient in a severe behavioral crisis or behavioral health emergency prior to using physical restraint use a verbal de-escalation techniques to diffuse the situation the process of restraining a patient so once the decision has been made to restrain the patient you should carry it out quickly ideally five people should be present to carry out this restraint you need to have one person on each extremity and one responsible for the head there should be a team leader who directs the process of a plan of action before you begin and use the minimum force necessary to control the patient the level of force will vary depending on the following factors so the degree of force that is necessary to keep the patient from injuring themselves or others also the patient's size strength sex and mental status including the possibility of drug induced states so the type of abnormal behavior the patient is exhibiting will also make the level of force dependent it's important that you and your partner talk to the patient throughout the process you need to treat the patient with dignity and respect at all times and if possible a provider of the same gender should tend the patient okay wear appropriate barrier protection during the restraint process avoid direct eye contact and respect the patient's personal space until necessary so never leave a restrained patient unattended and four point restraints meaning both arms and the legs are preferred for uncooperative patients respiratory and circulatory problems have been known to occur in combative patients who are restrained restraints applied in the field should not be removed until the patient is evaluated at a at the receiving hospital okay performing patient restraint so you you need to follow the skill drill in 23-1 to implement a four-point restraint a two-point restraint technique is an option if allowed per local protocol all right so the potentially violent patient violent patients account for only a small percentage of the patients undergoing a behavioral crisis you want to assess the level of danger based on the following risk factors so the history has a patient previously exhibit a hostile overly aggressive or violent behavior and the posture is the patient sitting or standing is the patient tense rigid or sitting on the edge of his or her seat also the scene is going to give you some clues so is the patient holding or near potentially lethal objects such as a knife gun glass poker or a bat or near a glass near window or a glass door and vocal activity so which kind of speech is the patient using is it loud or obscene erratic or bizarre um speech patterns usually indicate emotional distress and then physical activity so the motor activity of a person undergoing a psychiatric emergency may be most telling factor of all so a patient requiring careful watching is one who has tense muscles or clenched fists is pacing cannot sit still or it's fiercely protecting personal space poor muscle impulse or control okay a history of uh truancy or fighting or uncontrollable temper a history of substance abuse depression which accounts for 20 percent of violent acts and also a functional disorder so if the patient tells you um they hear voices and they're telling him or her to kill um believe it next we're going to talk about suicide so depression is the most significant factor that contributes to suicide it is a common um misconception that people who threaten suicide will never commit it threatening suicide is an indication that someone is in a crisis and that he or she cannot handle alone immediate intervention is necessary some of the warning signs are going to be feelings of sadness despair hopelessness and that suggests depression appearing detached or inability to talk about the future suggestions of suicide and specific plans for committing suicide or related to death so the table on this slide lists some of those risk factors for suicide consider the following additional risk factors for suicide so are there unsafe objects uh in the patient's hands or nearby is the environment unsafe is the is either evidence of self-destructive behavior or is there an immediate threat to the patient or others is there an underlying medical problem in our cultural religious and social beliefs promoting the suicide and has there been trauma a suicidal patient may be also homicidal so let's talk about post-traumatic stress disorders and returning combat veterans so ptsd can occur after exposure to or injury from a traumatic event examples could be sexual or physical assault child abuse or some type of serious accident maybe a natural disaster war a loss of a loved one or a stressful life event ptsd is not necessarily the result of one isolated or recent event an estimated seven to eight percent of the general population will experience signs of ptsd at some point in their lives military personnel who have experienced combat have a high incidence of ptsd signs and symptoms include helplessness anxiety anger or fear and frequently they avoid things that remind them of the trauma so they suffer constant nervous system arousal that is not easily suppressed heart rate increases pupils dilate in the systolic blood pressure increases incenses are sharpened and mental acuity is heightened often the traumatic event they relive this through thoughts nightmares or even flashbacks and ptsd occurs when the person attempts to find and escape from constant internal distress or a particularly disturbing event okay alcohol and drug use are common veterans have an increased risk of suicide and veterans may develop a variety of physical conditions related to injuries sustained during combat as well as from unfocused pain that is not associated with any specific body part combat veterans have a higher incident of tbi which is traumatic brain injury sustained from trauma and this is secondary to an explosion of an improm improvised explosive device or an iad so you want to eliminate excess noise refrain from touching or doing anything to that veteran without an explanation and keep the diesel equipment far away if you can caring for a combat vet so um the returning vet is a patient who will require a level of understanding compassion and specialized attention be careful how you phrase your questions use a calm form of worries but do not but be in charge and respect a veteran's personal space limit the number of people involved and move to a private and quiet space if possible and ask about suicidal intentions military personnel are trained to use weapons and are resourceful in improvising weapons so ensure there is nothing the patient can assess and use as a weapon physical restraint will not be effective with this population and may simply escalate the prof the problem okay so next we're going to talk about medical legal considerations so legal considerations the medical and legal aspect of emergency medical care become more complicated when the patient is undergoing a behavioral health emergency once you have determined the patient is impaired or has an 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 attempt to provide care but do not leave this patient alone you should request law enforcement personnel to handle the patient you do need consent though implied consent is assumed with the patient who is not mentally competent to grant consent so consent matters are not always clear cut in a behavioral health emergency if you're not sure request the assistance of law enforcement personnel or guide from medical control limited legal authority so the emt has limit limited legal authority to require or force a patient to undergo emergency medical care when no life-threatening emergency exists a competent adult has a right to refuse treatment even if life-saving care is involved in psychiatric cases a court of law would probably consider your actions in providing life-saving care as appropriate a patient who is in any way impaired may be may not be considered competent to refuse treatment and transport always maintain a high index of suspicion regarding the patient's condition assume the worst and hope for the best error on the side of treatment and transport carefully document the patient's statements and behaviors to support your actions okay so this concludes chapter 23 behavioral health emergencies and next we're going to go into the review to see what we've learned so a behavioral crisis is most accurately defined as what do we think it is is it acute is it a reaction to a stressful event it is any reaction of the events so any reaction to events that interferes with activities of daily living or has become unacceptable to the patient family or community depression and schizophrenia those are examples of what did we say are those functional or are those organic brain syndromes they are organic disorders a functional disorder that can't be linked to any type of change so it's a functional disorder okay when assessing a patient with a behavioral crisis your primary concern is i think it's probably we're worried about ourselves of course but we also want to know whether the patient will cause harm to you or your partner okay general guideline to follow when caring for a patient with a behavioral crisis include all of the following except so we want to be honest um we want to have a plan and we want to avoid arguing but rapidly transporting that is not always the case you're usually going to take some time reflective listening is an assessment technique used when caring for patients with an emotional crisis so what does that do i'm pretty sure it's repeating what the patient's going to tell you so repeating in a question form what the patient tells you which of the following patients is the highest risk for suicide so a woman who's successfully being treated 29 year old male who recently is promoted 33 who regularly consumes alcohol okay so right there the alcohol and the gun purchase of that 33 year old that should um that is the highest risk when caring for a patient with emotional crisis who is calm and not in need of immediate emergency care your best course of action is what do you think so we want to obtain consent from the patient to treat when physically restraining a violent patient what should the empty do and i'm pretty sure that you want you to continually talk to the patient throughout the process okay upon arrival of residents a young male with an apparent emotional crisis a police officer tells you that the man has been acting bizarrely you find him sitting on the couch he's conscious but confused he takes meds but cannot remember why his skin is pale and diaphoretic and he has noticeable tremors what should you do what should you rule out first i would say hypoglycemia right away right away he's altered pale cool which diaphragm the following signs is least indicative of a patient's potential for violence okay so i'm going to say right away it's uh is tall his height and weight has nothing to do with the violence okay so right yep the height and weight is the correct answer okay thank you for uh joining us tonight for chapter 23 and uh if you like this like this lecture go ahead and subscribe to the channel because we're going to complete the whole book all right thank you