1. Principles of Patient Assessment in EMS By: Bob Elling, MPA, EMT-P & Kirsten Elling, BS, EMT-P

2. Chapter 13 – Focused History & Physical Exam: Behavioral Emergencies © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

3. Objectives Describe the elements that lead up to a behavioral emergency. Describe the elements that lead up to a behavioral emergency. Describe the EMS provider’s role in controlling the setting in a behavioral emergency. Describe the EMS provider’s role in controlling the setting in a behavioral emergency. List eleven classifications of psychiatric disorders and provide an example of each. List eleven classifications of psychiatric disorders and provide an example of each. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

4. Objectives (continued) Provide examples of specific behaviors manifested by persons with emotional and psychiatric disorders. Provide examples of specific behaviors manifested by persons with emotional and psychiatric disorders. List a major misconception concerning behavioral emergencies. List a major misconception concerning behavioral emergencies. Describe examples of nonverbal communication. Describe examples of nonverbal communication. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

5. Describe specific risk factors the EMS provider should screen for during the focused history of a patient experiencing a behavioral emergency. Describe specific risk factors the EMS provider should screen for during the focused history of a patient experiencing a behavioral emergency. Describe the components of the mental status examination. Describe the components of the mental status examination. List the most common behavioral emergencies the EMS provider is called for. List the most common behavioral emergencies the EMS provider is called for. Objectives (continued) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

6. List medical conditions that mimic behavioral disorders. List medical conditions that mimic behavioral disorders. List the possible signs and symptoms of ineffective or failing coping mechanisms of stress that may be seen in EMS providers. List the possible signs and symptoms of ineffective or failing coping mechanisms of stress that may be seen in EMS providers. Objectives (continued) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

7. Introduction Every type of illness/injury will come with some type of emotional or psychological element. Every type of illness/injury will come with some type of emotional or psychological element. Behavioral emergencies occur when a person with/without a psychiatric hx becomes stressed & overwhelmed or feels they are “loosing control.” Behavioral emergencies occur when a person with/without a psychiatric hx becomes stressed & overwhelmed or feels they are “loosing control.” © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

8. Introduction (continued) A crisis occurs when a person’s perception of an acute distressing event results in an abnormal behavioral response. A crisis occurs when a person’s perception of an acute distressing event results in an abnormal behavioral response. Crisis is an internal response that can create reactions such as: Crisis is an internal response that can create reactions such as: Severe anxiety Severe anxiety Panic Panic Paranoia Paranoia Other psychotic events Other psychotic events © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

9. The EMS Provider’s Role You must be able to take an active role in controlling the situation without being threatening: You must be able to take an active role in controlling the situation without being threatening: Upon arrival make a clear, short and calm statement of who you are and why you are there. Upon arrival make a clear, short and calm statement of who you are and why you are there. Determine the problem and how many people are involved. Determine the problem and how many people are involved. Get a description of any unusual activities, risk factors, prior episodes. Get a description of any unusual activities, risk factors, prior episodes. Remember scene safety! Is this a crime scene? Remember scene safety! Is this a crime scene? © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

10. Common Psychiatric Disorder Classifications Mental Mental Emotional Emotional Behavioral Behavioral Effect an estimated 20% of the U.S. population Effect an estimated 20% of the U.S. population © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

11. Psychological Disorders Features: Features: Observe the patient’s body language and verbal responses for clues Observe the patient’s body language and verbal responses for clues Various disorders have distinctive characteristics Various disorders have distinctive characteristics © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

12. General Appearance: General Appearance: Neglect in personal hygiene, grooming Neglect in personal hygiene, grooming Inappropriate dress Inappropriate dress Excessive attention to details (obsessive- compulsive) Excessive attention to details (obsessive- compulsive) Unilateral neglect (brain lesion) Unilateral neglect (brain lesion) Psychological Disorders (continued) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

13. Psychological Disorders (continued) Intellectual Function: Intellectual Function: Assess memory, concentration, judgment and orientation Assess memory, concentration, judgment and orientation Psychiatric disorders may affect short, long and recall memory Psychiatric disorders may affect short, long and recall memory Assessment is done in the patient interview Assessment is done in the patient interview © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

14. Thought Content: Thought Content: Thought content and perceptions should be logical, consistent and connected with the current situation Thought content and perceptions should be logical, consistent and connected with the current situation Delusions – a false personal belief or idea is portrayed as true Delusions – a false personal belief or idea is portrayed as true Hallucination – a perception of something that is not present Hallucination – a perception of something that is not present Psychological Disorders (continued) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

15. Psychological Disorders (continued) Physical Complaints: Physical Complaints: Often vague – headache, muscle ache, weight loss, lack of energy Often vague – headache, muscle ache, weight loss, lack of energy Consider medical causes first Consider medical causes first Motor Activity: Motor Activity: Tense, restlessness, pacing, crying, fidgeting or slow moving Tense, restlessness, pacing, crying, fidgeting or slow moving Consider drug intoxication, pain, abnormal blood sugar or hypoxia first Consider drug intoxication, pain, abnormal blood sugar or hypoxia first © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

16. Psychological Disorders (continued) Speech & Language: Speech & Language: Consider word choice, quality, pace and articulation of speech and language Consider word choice, quality, pace and articulation of speech and language Consider other causes for alterations such as stroke, tumors or trauma. Consider other causes for alterations such as stroke, tumors or trauma. Body Language: Body Language: Body language is the expression of thoughts or emotions by means of posture or gestures Body language is the expression of thoughts or emotions by means of posture or gestures Stay alert to non-verbal cues for potential violence Stay alert to non-verbal cues for potential violence © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

17. Psychological Disorders (continued) Mood: Mood: Assess mood and affect through facial expressions, body language and responses to questions Assess mood and affect through facial expressions, body language and responses to questions Should be appropriate for the current situation and transitions according with topics in conversation Should be appropriate for the current situation and transitions according with topics in conversation © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

18. Assessment Scene Safety: Scene Safety: A major misconception “all mental patients are unstable and dangerous” A major misconception “all mental patients are unstable and dangerous” Many behavioral emergencies begin as medical calls. ALWAYS assess scene safety in every call. Many behavioral emergencies begin as medical calls. ALWAYS assess scene safety in every call. Respect a patient’s personal space. Respect a patient’s personal space. Limit the number of people and avoid overwhelming the patient. Limit the number of people and avoid overwhelming the patient. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

19. Assessment (continued) Focused History: Focused History: Obtaining a history may be difficult, these patients are often unreliable, poor historians or uncooperative Obtaining a history may be difficult, these patients are often unreliable, poor historians or uncooperative Family or caretakers may not be available or may distort the information Family or caretakers may not be available or may distort the information Assess predisposing risk factors such as depression or major life event Assess predisposing risk factors such as depression or major life event © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

20. Assessment (continued) O – Where, when and how did the event begin? O – Where, when and how did the event begin? P – What is the problem today? Did the patient intend on harming him/herself? P – What is the problem today? Did the patient intend on harming him/herself? Q – What type of crisis is the patient experiencing? Q – What type of crisis is the patient experiencing? R – Are there any concomitant medical factors? R – Are there any concomitant medical factors? S – Is this event similar to previous episodes? S – Is this event similar to previous episodes? T – How long has this been going on? T – How long has this been going on? © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

21. Assessment (continued) S – What type of crisis is the patient having? Any associated symptoms? S – What type of crisis is the patient having? Any associated symptoms? A – Are there any allergies to meds? A – Are there any allergies to meds? M – What meds and any recent changes to medication schedule? M – What meds and any recent changes to medication schedule? P – What is the patient’s behavioral history? Any substance abuse? P – What is the patient’s behavioral history? Any substance abuse? L – meds, meals, alcohol? L – meds, meals, alcohol? E – new stress, changes in social status? E – new stress, changes in social status? © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

22. Mental Status Exam Obtain baseline assessment and verify finding with family/caretaker, MD Obtain baseline assessment and verify finding with family/caretaker, MD Appearance – note physical position and posture, personal hygiene, appropriate dress, age and gender Appearance – note physical position and posture, personal hygiene, appropriate dress, age and gender Affect – what feelings is the patient exhibiting Affect – what feelings is the patient exhibiting © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

23. Mental Status Exam (continued) Behavior – what is the patient doing? Behavior – what is the patient doing? Cognitive function – assess level of consciousness, memory, mood and affect. Cognitive function – assess level of consciousness, memory, mood and affect. Speech – assess word choice, content, intonation, clarity and pace. Speech – assess word choice, content, intonation, clarity and pace. Thought process – assess if judgment is reasonable for the current situation. Thought process – assess if judgment is reasonable for the current situation. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

24. Behavioral Emergencies Depression is a common reaction to major life stress: Depression is a common reaction to major life stress: Feelings of sadness, discouragement, and hopelessness Feelings of sadness, discouragement, and hopelessness Reduced activity levels, inability to function, and sleep disturbances Reduced activity levels, inability to function, and sleep disturbances Severe depression is a risk factor for suicide Severe depression is a risk factor for suicide May present as symptoms of disease (organic illness, cardiac or respiratory conditions) May present as symptoms of disease (organic illness, cardiac or respiratory conditions) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

25. Mental Illness There are many pathologies for behavioral and psychiatric disorders: There are many pathologies for behavioral and psychiatric disorders: Genetic Genetic Chemical imbalance Chemical imbalance Organic illness Organic illness © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

26. Substance Abuse Dependence, abuse and intoxication. Dependence, abuse and intoxication. True addiction is both psychological and physical. True addiction is both psychological and physical. Alcoholism is particularly insidious among the elderly. Alcoholism is particularly insidious among the elderly. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

27. Suicide Attempts Occur when a patient has a true desire to die. Occur when a patient has a true desire to die. Gestures are pleas for help. Gestures are pleas for help. Whether “attempt” or “gesture” do not discount the patient’s emotional state in any way. Whether “attempt” or “gesture” do not discount the patient’s emotional state in any way. Be direct and ask: Be direct and ask: “Where you trying to kill yourself?” “Where you trying to kill yourself?” “Do you want to die?” “Do you want to die?” Clearly report and document your findings. Clearly report and document your findings. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

28. Attention/Pleas for Help Some behavior calls are related to a patient’s cry for attention: Some behavior calls are related to a patient’s cry for attention: Suicide gesture Suicide gesture Hypochondriac Hypochondriac Lonely person calling repeatedly for no apparent medical reason Lonely person calling repeatedly for no apparent medical reason Safest approach is to assume something is seriously wrong until proven otherwise. Safest approach is to assume something is seriously wrong until proven otherwise. Often people who want help are unaware of available resources and they call 9-1-1. Often people who want help are unaware of available resources and they call 9-1-1. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

29. Assisting a Transportation Mental health evaluation order. Mental health evaluation order. The police should have an order and be on the scene The police should have an order and be on the scene Inmates feigning illness. Inmates feigning illness. Complete a thorough assessment Complete a thorough assessment © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

30. Patients who are a danger to themselves or another. Patients who are a danger to themselves or another. Major concern is safety for EMS providers and the patient Major concern is safety for EMS providers and the patient Do not use excessive force and be aware of the dangers of restraint Do not use excessive force and be aware of the dangers of restraint Never restrain a patient in a prone position! Never restrain a patient in a prone position! Review the NAEMSP policy on patient restraint Review the NAEMSP policy on patient restraint Assisting a Transportation © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

31. Medical Conditions that Mimic Behavioral Disorders Stroke, tumors, or trauma can affect speech. Stroke, tumors, or trauma can affect speech. Medications, severe infections, hypoxia, hypo or hyperglycemia can cause altered mental status, depression or psychosis. Medications, severe infections, hypoxia, hypo or hyperglycemia can cause altered mental status, depression or psychosis. Psychotropic meds can have powerful side effects and severe interactions with other medications. Psychotropic meds can have powerful side effects and severe interactions with other medications. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

32. Stress and the EMS Provider Emergency responders are routinely subjected to both positive and negative stress. Emergency responders are routinely subjected to both positive and negative stress. Stress disorders may be acute or develop into chronic conditions if not recognized and managed. Stress disorders may be acute or develop into chronic conditions if not recognized and managed. Be watchful and recognize signs/symptoms of stress in yourself and coworkers. Be watchful and recognize signs/symptoms of stress in yourself and coworkers. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

33. Stress and EMS Providers (continued) Signs and symptoms of ineffective or failing coping mechanisms include: Signs and symptoms of ineffective or failing coping mechanisms include: Increased absenteeism Increased absenteeism Withdrawal Withdrawal Depression Depression Hyperactivity Hyperactivity Irritability Irritability Increased smoking or alcohol use Increased smoking or alcohol use Sleep disturbances Sleep disturbances Headaches Headaches Poor concentration and decision making Poor concentration and decision making © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

34. Conclusion Response to crisis varies by person. Response to crisis varies by person. Inability to cope or failing mechanisms can cause impaired functionality. Inability to cope or failing mechanisms can cause impaired functionality. Some become withdrawn/depressed, others overactive/violent. Some become withdrawn/depressed, others overactive/violent. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

35. Conclusion (continued) Many factors can alter a patient’s behavior (regardless of any mental health history). Many factors can alter a patient’s behavior (regardless of any mental health history). Personal safety comes first! Take an active role in controlling the situation and supporting the patient’s emotional and physical needs. Personal safety comes first! Take an active role in controlling the situation and supporting the patient’s emotional and physical needs. Whenever possible obtain a complete history! Whenever possible obtain a complete history! © 2003 Delmar Learning, a Division of Thomson Learning, Inc.