Psychiatric Emergencies

Psychiatric Emergencies
Chapter 22 Psychiatric Emergencies Chapter 22: Psychiatric Emergencies

Introduction EMTs often care for patients experiencing a behavioral crisis or psychiatric emergency. Crisis may be the result of: Acute medical situation Mental illness Mind-altering substances Stress Many other causes Lecture Outline I. Introduction A. EMTs often care for patients experiencing a behavioral crisis or psychiatric emergency. 1. The crisis may be the result of: a. Acute medical situation b. Mental illness c. Mind-altering substances d. Stress e. Many other causes

Myth and Reality (1 of 4) At some point, most people experience an emotional crisis. This does not mean that everyone develops mental illness. Do not jump to conclusions concerning: Yourself Your patient Lecture Outline II. Myth and Reality A. At some point, most people experience an emotional crisis. 1. This does not mean that everyone develops mental illness. 2. Otherwise healthy people may sustain acute or temporary mental health disorders. 3. Do not jump to the conclusion that a patient is mentally ill when he or she exhibits behaviors discussed in this chapter.

Myth and Reality (2 of 4) The most common misconception is that if you are feeling bad or depressed, you must be “sick.” There are many justifiable reasons for feeling depressed: Divorce Loss of a job Death of a relative or friend Lecture Outline B. The most common misconception about mental illness is that if you are feeling bad or depressed, you must be “sick.” 1. Common causes of depression: a. Divorce b. Loss of a job c. Death of a relative or friend

Myth and Reality (3 of 4) Another myth is that all individuals with mental health disorders are dangerous, violent, or unmanageable. Only a small percentage fall into these categories. EMTs may be exposed to a higher proportion of violent patients. Lecture Outline C. Many people believe that all individuals with mental health disorders are dangerous, violent, or otherwise unmanageable. 1. Only a small percentage of people with mental health problems fall into these categories. 2. As an EMT, 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.

Myth and Reality (4 of 4) Many people believe that all individuals with mental health disorders are dangerous, violent, or unmanageable. (cont’d) Communication is key. Patients may de-escalate when a level of trust is established. You may be able to predict violence. Lecture Outline 3. Communication is key. Maintaining a calm and reassuring tone can often help de-escalate the situation. 4. Although you cannot determine what has caused a person’s crisis, you may be able to predict whether the person will become violent.

Defining a Behavioral Crisis (1 of 3)
Behavior is what you can see of a person’s response to the environment: his or her actions. Most of the time, people respond to the environment in reasonable ways. Over time, people learn to adapt to stress. Sometimes the stress is so great that the normal ways of coping do not work and a crisis occurs. Lecture Outline III. Defining a Behavioral Crisis A. Behavior is what you can see of a person’s response to the environment: his or her actions. 1. Over time, people develop various coping mechanisms for dealing with stressful situations in a healthy manner. 2. Sometimes stress becomes overwhelming and the normal ways of coping are not enough or the person uses negative coping mechanisms (eg, withdrawal, drugs and alcohol). 3. Reactions to stress can be acute or develop over time. Either situation can create a crisis. a. The change in behavior may considered inappropriate or “not normal” by the person who calls 911.

A behavioral crisis or psychiatric emergency may involve patients who exhibit agitated, violent, or uncooperative behavior or who are a danger to themselves or others. EMS is called when behavior has become unacceptable to patient, family, or community. Lecture Outline B. A behavioral crisis or psychiatric emergency may involve patients of all ages who exhibit agitated, violent, or uncooperative behavior or who are a danger to themselves or others. 1. EMS is called when the behavior has become unacceptable to the patient, family, or community.

If an abnormal or disturbing pattern of behavior lasts for a month or more, it is a matter of concern. When a psychiatric emergency arises, the patient: May show agitation or violence May become a threat to self or others Lecture Outline C. Usually, if an abnormal or disturbing pattern of behavior lasts for a month or more, it is a matter of concern from a mental health standpoint. D. When a psychiatric emergency arises, the patient may: 1. Show agitation or violence 2. Become a threat to self or others

The Magnitude of Mental Health Disorders (1 of 4)
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. Lecture Outline IV. The Magnitude of Mental Health Disorders A. According to the National Institute of Mental Health, mental disorders are common throughout the United States, affecting tens of millions of people each year. 1. A psychiatric disorder is an illness with psychological or behavioral symptoms that may result in impaired functioning.

Anxiety disorders: Generalized anxiety disorder Panic disorder Social and other phobias Posttraumatic stress disorder (PTSD) Obsessive–compulsive disorder Lecture Outline 2. Anxiety disorders are among the most common mental health disorders: a. Generalized anxiety disorder b. Panic disorder c. Social and other phobias d. Posttraumatic stress disorder (PTSD) e. Obsessive–compulsive disorder

The US mental health system provides many levels of assistance. Most psychological disorders can be handled through outpatient visits. Some people require hospitalization in specialized psychiatric units. Lecture Outline B. The US mental health system provides many levels of assistance to people with psychological conditions 1. Professional counselors are available for marital conflicts and parenting issues. 2. More serious issues such as clinical depression are often handled by a psychologist. 3. Severe psychological conditions, such as schizophrenia and bipolar disorder, require psychiatrists to prescribe medication. 4. Most psychological disorders can be handled through outpatient visits, but some people may require hospitalization in specialized psychiatric units.

Psychiatric disorders have many underlying causes: Social and situational stress such as divorce or death of a loved one Diseases such as schizophrenia Physical illnesses such as diabetic emergencies Chemical problems such as alcohol or drug use Biological disturbances such as electrolyte imbalances Lecture Outline C. Psychiatric disorders have many underlying causes: 1. Social and situational stress such as divorce or death of a loved one 2. Diseases such as schizophrenia 3. Physical illnesses such as diabetic emergencies 4. Chemical problems such as alcohol or drug use 5. Biological disturbances such as electrolyte imbalances D. These conditions can be compounded by noncompliance with prescribed medication regimens.

Pathophysiology (1 of 3) An EMT is not responsible for diagnosing the underlying cause of a behavioral crisis or psychiatric emergency. Two basic categories of diagnosis: organic and functional. Lecture Outline V. Pathophysiology A. An EMT is not responsible for diagnosing the underlying cause of a behavioral crisis or psychiatric emergency. 1. You should understand the two basic categories of diagnosis a physician will use: organic (physical) and functional (psychological).

Pathophysiology (2 of 3) Organic disorders
Organic brain syndrome: a temporary or permanent dysfunction of the brain caused by a disturbance in the physical or physiologic functioning of the brain tissue Causes may include sudden illness, traumatic brain injury (TBI), seizure disorders, drug and alcohol abuse, overdose, or withdrawal, and diseases of the brain Lecture Outline B. Organic disorders 1. Organic brain syndrome: a temporary or permanent dysfunction of the brain caused by a disturbance in the physical or physiologic functioning of the brain tissue a. Causes: i. Sudden illness ii. Traumatic brain injury iii. Seizure disorders iv. Drug and alcohol abuse, overdose, or withdrawal v. Diseases of the brain, such as Alzheimer disease and meningitis 2. In the absence of a physiologic cause, altered mental status may be an indicator of an underlying psychiatric disorder.

Pathophysiology (3 of 3) Functional disorders
A physiological disorder that impairs bodily functions when the body seems to be structurally normal Examples: schizophrenia, anxiety conditions, depression Lecture Outline C. Functional disorders 1. Functional disorder: a physiological disorder that impairs bodily function when the body seems to be structurally normal a. Examples: schizophrenia, anxiety conditions, depression

Safe Approach to a Behavioral Crisis (1 of 2)
All regular EMT skills are used in a behavioral crisis. Other management techniques are also involved. Lecture Outline VI. Safe Approach to a Behavioral Crisis A. All regular EMT skills are used in a behavioral crisis. 1. Refer to Table 22-1 for safety guidelines. © Jones & Bartlett Learning

Scene Size-up (1 of 2) Scene safety
Consider the scene safety and the patient’s response to the environment. Take appropriate standard precautions. Request any additional resources you may need early. Lecture Outline VII. Patient Assessment A. Scene size-up 1. Scene safety a. The first things to consider are the scene safety and the patient’s response to the environment. b. Take appropriate standard precautions and request any additional resources you may need (law enforcement, additional personnel) early.

Scene Size-up (2 of 2) Mechanism of injury/nature of illness
Note any medications or substances that may contribute to the complaint or be treatment of a relevant medical condition. Lecture Outline 2. Mechanism of injury/nature of illness a. Note any medications or substances that may contribute to the complaint or that may be for treatment of a relevant medical condition.

Primary Assessment (1 of 2)
Form a general impression. Begin your assessment from the doorway or from a distance. Perform a rapid physical exam. Observe the patient closely. Establish a rapport with the patient. Lecture Outline B. Primary assessment 1. Form a general impression. a. Begin your assessment from the doorway or from a distance. b. Perform a rapid physical exam; look for any signs of trauma. c. Observe the patient’s behavior closely. d. Establish a rapport with the patient and family members. e. Most medical or trauma situations will include a behavioral component.

Primary Assessment (2 of 2)
Airway and breathing Circulation Transport decision Unless the patient is unstable from a medical problem or trauma, prepare to spend time with the patient. Lecture Outline 2. Airway and breathing 3. Circulation 4. Transport decision a. Unless the patient is unstable from a medical problem or trauma, prepare to spend time at the scene with the patient.

History Taking (1 of 3) Investigate the chief complaint.
Three major areas to consider: Is the patient’s central nervous system functioning properly? Are hallucinogens or other drugs or alcohol a factor? Are significant life changes, symptoms, or illness involved? Lecture Outline C. History taking 1. Investigate the chief complaint; refer to Table 22-2. a. Consider three possible contributing factors: i. Patient’s central nervous system function ii. Involvement of drugs and/or alcohol iii. Significant life changes, symptoms, or illness (caused by mental rather than physical factors)

History Taking (2 of 3) SAMPLE history
You may be able to elicit information not available to the hospital staff. Use reflective listening. Lecture Outline 2. SAMPLE history a. You may be able to elicit information not available to the hospital staff. i. Ask about previous episodes, treatments, hospitalizations, and medications related to behavioral problems. b. In geriatric patients, consider Alzheimer disease and dementia as possible causes of abnormal behavior. i. Identify the patient’s baseline mental status. c. Use reflective listening to gain insight into the patient’s thinking.

© Jones & Bartlett Learning
History Taking (3 of 3) The table on this slide lists the questions to ask when evaluating a mental health disorder. © Jones & Bartlett Learning

Secondary Assessment (1 of 3)
Physical examination In an unconscious patient, begin with a physical exam. A conscious patient may not respond to your questions. Lecture Outline D. Secondary assessment 1. Physical examination a. In an unconscious patient, begin with a physical exam to look for a reason for the unresponsiveness. i. Rule out trauma, especially to the head. ii. Consider whether prior events such as physical agitation, use of stimulants, alcohol withdrawal, or Taser exposure may be contributing to the patient’s condition. iii. When examining a patient with a behavioral emergency, check for track marks indicating drug abuse and for signs of self-mutilation. b. A conscious patient may not respond to your questions.

Physical examination (cont’d) You can tell a lot about a patient’s emotional state from: Facial expressions Pulse rate Respirations A blank gaze or rapidly moving eyes could mean central nervous system dysfunction. Lecture Outline c. You can tell a lot about a patient’s emotional state from: i. Facial expressions ii. Pulse rate iii. Respirations d. Tears, sweating, and blushing may be significant indicators of state of mind. e. Look in the patient’s eyes: A blank gaze or rapidly moving eyes may mean the patient is experiencing central nervous system dysfunction.

Transport decision Have law enforcement or firefighters accompany you if possible. Take the patient to a facility capable of caring for patients with psychiatric problems. Transport the patient by ground. Lecture Outline 2. Transport decision a. When available, have law enforcement personnel or firefighters accompany you in the back of the ambulance during transport. b. There may be a specific facility to which the patients with psychiatric emergencies are transported. c. Transport the patient by ground rather than by air. d. Try to make the patient comfortable.

Reassessment (1 of 3) Never let your guard down.
If restraints are necessary, reassess and document every 5 minutes: Respirations Pulse, motor, and sensory function in all restrained extremities Lecture Outline E. Reassessment 1. Never let your guard down. 2. If restraints are necessary, reassess and document the patient’s respirations, as well as pulse, motor, and sensory function in all restrained extremities, every 5 minutes.

Reassessment (2 of 3) Interventions Diffuse and control the situation.
Intervene only as much as it takes to accomplish these tasks. If you think a pharmacologic restraint is necessary, request ALS assistance as early as possible Lecture Outline 3. Interventions a. Diffuse and control the situation. b. Intervene only as much as it takes to accomplish these tasks. c. If you encounter a situation where you think a pharmacologic restraint might be necessary, request ALS assistance as early as possible.

Reassessment (3 of 3) Communication and documentation
Give the receiving hospital advance warning of the psychiatric emergency. Document thoroughly and carefully. If restraints are used, identify which types and why they were used. Lecture Outline 4. Communication and documentation a. Give the receiving hospital advance warning when a patient experiencing a psychiatric emergency is arriving. i. Report whether restraints will be required when the patient arrives at the hospital. b. Document thoroughly and carefully. i. If restraints are used, identify which types and why they were used.

Acute Psychosis (1 of 4) Psychosis: 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 Lecture Outline VIII. Acute Psychosis A. Psychosis: a state of delusion in which the person is out of touch with reality 1. Affected people live in their own reality of ideas and feelings. 2. May cause psychotic episodes

Acute Psychosis (2 of 4) Schizophrenia is a complex disorder that is not easily defined or treated. Symptoms and signs: Delusions Hallucinations A lack of interest in pleasure Erratic speech Lecture Outline B. Schizophrenia 1. A complex disorder that is not easily defined or easily treated 2. The typical onset occurs during early adulthood, with symptoms becoming more prominent over time. 3. Signs and symptoms: a. Delusions b. Hallucinations c. A lack of interest in pleasure d. Erratic speech

Acute Psychosis (3 of 4) Guidelines for dealing with a psychotic patient: Determine if the situation is dangerous. Clearly identify yourself. Be calm, direct, and straightforward. Maintain an emotional distance. Do not argue. Lecture Outline 5. Guidelines for dealing with a psychotic patient: a. Determine if the situation is dangerous. b. Clearly identify yourself. c. Be calm, direct, and straightforward. d. Maintain an emotional distance. e. Do not argue.

Acute Psychosis (4 of 4) Guidelines (cont’d)
Explain what you would like to do. Involve people whom the patient trusts, such as family or friends, to gain the patient’s cooperation. Lecture Outline f. Explain what you would like to do. g. Involve people whom the patient trusts, such as family or friends, to gain the patient’s cooperation.

Excited Delirium (1 of 5) Delirium: a condition of impairment in cognitive function that can present with disorientation, hallucinations, or delusions Agitation: behavior characterized by restless and irregular physical activity Lecture Outline IX. Excited Delirium A. Also known as agitated delirium or exhaustive mania 1. Delirium: a condition of impairment in cognitive function that can present with disorientation, hallucinations, or delusions 2. Agitation: a behavior characterized by restless and irregular physical activity

Excited Delirium (2 of 5) Symptoms: Hyperactive irrational behavior
Vivid hallucinations Hypertension Tachycardia Diaphoresis Dilated pupils Lecture Outline 3. Symptoms: a. Hyperactive irrational behavior b. Vivid hallucinations c. Hypertension d. Tachycardia e. Diaphoresis f. Dilated pupils

Excited Delirium (3 of 5) Be calm, supportive, and empathetic.
Approach the patient slowly and respect the patient’s personal space. Limit physical contact. Do not leave the patient unattended. Lecture Outline B. If you think you can safely approach the patient, be calm, supportive, and empathetic. 1. Approach the patient slowly and purposefully and respect the patient’s personal space. 2. Limit physical contact as much as possible. 3. Do not leave the patient unattended.

Excited Delirium (4 of 5) Use careful interviewing to assess the patient Observe the patient’s ability to communicate, appearance, dress, and personal hygiene. If the patient has overdosed, take all medication bottles or illegal substances to the medical facility. Lecture Outline C. Use careful interviewing to assess the patient’s cognitive functioning. 1. Determine the patient’s ability to communicate clearly. 2. Observe the patient’s appearance, dress, and personal hygiene. D. If the patient appears to be experiencing an overdose, take all medication bottles or illegal substances with you to the medical facility. 1. The patient should be transported to a hospital with psychiatric facilities if possible. 2. Refrain from using lights and sirens.

Excited Delirium (5 of 5) If the patient’s agitation continues, request ALS assistance so chemical restraint can be considered. Uncontrolled or poorly controlled patient agitation can lead to the patient’s sudden death. Lecture Outline E. If the patient’s agitation continues, request ALS assistance so chemical restraint can be considered. 1. Excited delirium can lead to sudden death from: a. Sudden cardiopulmonary arrest b. Physical agitation, thought to result from metabolic acidosis c. Physical control measures (including Tasers) d. Positional asphyxia

Restraint (1 of 8) Every prehospital care transport provider should create and follow a prehospital patient restraint protocol. Protocols vary widely. The restraint chosen should be the least restrictive option that ensures the safety of the patient and providers. Lecture Outline X. Restraint A. Prehospital patient restraint reduces the possibility of patient injury, decreases the potential for injury to EMS providers, and allows for safe and appropriate treatment of an uncooperative patient. 1. The National Association of Emergency Medical Services Physicians (NAEMSP) recommends that every prehospital care transport provider create and follow a prehospital patient restraint protocol. a. Protocols address: i. Appropriateness of restraint ii. Types of restraints iii. Care provided to the patient following restraint b. Protocols must comply with the laws of your state. 2. Prehospital patient restraint protocols vary widely. a. Protocols should include only the use of restraint devices that have been approved by the state health department or local EMS agency. b. The method of restraint chosen should be the least restrictive option that will ensure the safety of the patient and providers.

Restraint (2 of 8) Personnel must be properly trained.
If you restrain a person without authority in a nonemergency situation, you expose yourself to a possible lawsuit. Legal actions can involve charges of assault, battery, false imprisonment, and violation of civil rights. Lecture Outline B. Risks associated with patient restraint 1. Improper use of restraints can lead to life-threatening conditions including cardiac arrest. 2. Restraint of a person without authority in a nonemergency situation can result in legal actions: a. Assault b. Battery c. False imprisonment d. Violation of civil rights

Restraint (3 of 8) You may use restraints only: To protect yourself or others from bodily harm To prevent the patient from injuring himself or herself Lecture Outline 3. Restraints are used only to protect yourself or others from bodily harm or to prevent the patient from injuring himself or herself. © Jones & Bartlett Learning

Restraint (4 of 8) Involve law enforcement if the patient is in a severe behavioral crisis or psychiatric emergency. Before considering physical restraint, use verbal de-escalation techniques. Lecture Outline 4. Involve law enforcement personnel if you are called to assist a patient in a severe behavioral crisis or psychiatric emergency. 5. Prior to using physical restraint, use verbal de-escalation techniques to defuse the situation.

Restraint (5 of 8) Process of restraining a patient
Carry out the decision quickly. There should be 5 people to help, one responsible for each extremity and one responsible for the head. There should be a team leader and plan of action. Use the minimum force necessary. Lecture Outline C. The process of restraining a patient 1. Once the decision has been made to restrain a patient, you should carry it out quickly and safely. a. Ideally, five people should be present to carry out the restraint—one responsible for each extremity and one responsible for the head. b. There should be a team leader who directs the process and a plan of action before you begin. c. Use the minimum force that is necessary to control the patient.

Restraint (6 of 8) The level of force will vary, depending on these factors: The degree of force that is necessary to keep the patient from injuring self and others The patient’s sex, size, strength, and mental status The type of abnormal behavior the patient is exhibiting Lecture Outline 2. The level of force will vary, depending on the following factors: a. The degree of force that is necessary to keep the patient from injuring self and others b. The patient’s sex, size, strength, and mental status, including the possibility of drug-induced states c. The type of abnormal behavior the patient is exhibiting

Restraint (7 of 8) Talk to the patient throughout the process.
Treat the patient with dignity and respect. If possible, a provider of the same gender should attend to the patient. Wear appropriate barrier protection. Lecture Outline 3. You or your partner should talk to the patient throughout the process. 4. Treat the patient with dignity and respect at all times. 5. If possible, a provider of the same gender should attend to the patient. 6. Wear appropriate barrier protection during patient restraint activities.

Restraint (8 of 8) Avoid direct eye contact and respect personal space. Never leave a restrained person unattended. Four-point restraints (both arms and both legs) are preferred. Monitor the patient closely. Lecture Outline 7. Avoid direct eye contact and respect the patient’s personal space until necessary. 8. Never leave a restrained patient unattended. 9. Four-point restraints (both arms and both legs) are preferred for uncooperative patients. 10. Respiratory and circulatory problems have been known to occur in combative patients who are restrained; monitor the patient closely. 11. Restraints applied in the field should not be removed until the patient is evaluated at the receiving facility. D. Performing patient restraint 1. Follow the steps in Skill Drill 22-1 to apply a four-point restraint.

The Potentially Violent Patient (1 of 5)
Violent patients make up only a small percentage of patients undergoing a behavioral or psychiatric crisis. Be alert for signs of potential violence. Lecture Outline XI. The Potentially Violent Patient A. Violent patients make up only a small percentage of the patients undergoing a behavioral or psychiatric crisis.

History Has the patient previously exhibited hostile, overly aggressive, or violent behavior? Posture How is the patient sitting or standing? Is the patient tense, rigid, or sitting on the edge of his or her seat? Lecture Outline B. Assess the level of danger based on the following risk factors: 1. History a. Has the patient previously exhibited hostile, overly aggressive, or violent behavior? 2. Posture a. How is the patient sitting or standing? b. Is the patient tense, rigid, or sitting on the edge of his or her seat?

The scene Is the patient holding or near potentially lethal objects? Vocal activity Which kind of speech is the patient using? Loud, obscene, erratic, and bizarre speech patterns usually indicate emotional distress. Lecture Outline 3. The scene a. 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)? 4. Vocal activity a. Which kind of speech is the patient using? b. Loud, obscene, erratic, and bizarre speech patterns usually indicate emotional distress.

Physical activity Most telling factor of all A patient requiring careful watching is one who: Has tense muscles, clenched fists, or glaring eyes Is pacing Cannot sit still Is fiercely protecting personal space Lecture Outline 5. Physical activity a. The motor activity of a person undergoing a psychiatric emergency may be the most telling factor of all. b. A patient requiring careful watching is one who: i. Has tense muscles, clenched fists, or glaring eyes ii. Is pacing iii. Cannot sit still iv. Is fiercely protecting personal space

Other factors to consider: Poor impulse control History of truancy, fighting, and uncontrollable temper History of substance abuse Depression Functional disorder Lecture Outline C. Other factors to consider: 1. Poor impulse control 2. History of truancy, fighting, and uncontrollable temper 3. History of substance abuse 4. Depression, which accounts for 20% of violent attacks 5. Functional disorder (If the patient tells you voices are telling him or her to kill, believe it.)

Suicide (1 of 5) Depression is the single most significant factor that contributes to suicide. It is a common misconception that people who threaten suicide never commit it. Lecture Outline XII. Suicide A. Depression is the single most significant factor that contributes to suicide (Table 22-3). B. It is a common misconception that people who threaten suicide never commit it. 1. Threatening suicide is an indication that someone is in a crisis that he or she cannot handle alone. 2. Immediate intervention is necessary.

Suicide (2 of 5) Be alert to these warning signs:
Air of tearfulness, sadness, deep despair, or hopelessness Avoiding eye contact, speak slowly, and project a sense of vacancy Unable to talk about the future Suggestion of suicide Having any plans related to death Lecture Outline C. Be alert to these warning signs: 1. Feelings of sadness, deep despair, or hopelessness that suggests depression 2. Appearing detached from the situation 3. Inability to talk about the future 4. Suggestions of suicide 5. Specific plans for committing suicide or related to death

Suicide (3 of 5) The table on this slide lists the risk factors for suicide. © Jones & Bartlett Learning

Suicide (4 of 5) Consider these additional risks:
Are there any unsafe objects nearby? Is the environment unsafe? Is there evidence of self-destructive behavior? Is there an imminent threat to the patient or others? Lecture Outline D. Additional risk factors for suicide: 1. The presence of unsafe objects in the patient’s hands or nearby 2. An unsafe environment 3. Evidence of self-destructive behavior 4. An imminent threat to the patient or others

Suicide (5 of 5) Additional risks (cont’d)
Is there an underlying medical problem? Are there cultural or religious beliefs promoting suicide? Has there been trauma? A suicidal patient may be homicidal as well. Lecture Outline 5. Underlying medical problems 6. Cultural, religious, or social beliefs promoting suicide 7. Recent physical or psychological trauma E. A suicidal patient is often homicidal.

Posttraumatic Stress Disorder and Returning Combat Veterans (1 of 6)
PTSD occurs after exposure to, or injury from, a traumatic event. An estimated 7% to 8% of the general population will experience PTSD at some point in their lives. Military personnel with combat experience have a high incidence. Lecture Outline XIII. Posttraumatic Stress Disorder and Returning Combat Veterans A. PTSD can occur after exposure to, or injury from, a traumatic event. 1. PTSD is not necessarily the result of one isolated or recent event. 2. An estimated 7% to 8% of the general population will experience signs of PTSD at some point in their lives. 3. Military personnel who have experienced combat have a high incidence of PTSD.

Symptoms of PTSD include feelings of: Helplessness Anxiety Anger Fear Lecture Outline B. Signs and symptoms of PTSD 1. Feelings of: a. Helplessness b. Anxiety c. Anger d. Fear

People with PTSD: May avoid reminders of the trauma Suffer constant nervous system arousal Can relive the traumatic event through thoughts, nightmares, and flashbacks Lecture Outline 2. People with PTSD: a. Frequently avoid things that remind them of the trauma b. Suffer constant nervous system arousal that is not easily suppressed i. Heart rate increases, pupils dilate, and systolic blood pressure increases. ii. Senses are sharpened and mental acuity is heightened. c. Often relive the traumatic event through intrusive thoughts, nightmares, or even flashbacks 3. Dissociative PTSD occurs when the person attempts to find an escape from constant internal distress or a particularly disturbing event.

Veterans have an increased risk of suicide. Veterans may develop a variety of physical conditions related to combat injuries. Combat veterans have a higher incidence of traumatic brain injury (TBI). Lecture Outline 4. Veterans have an increased risk of suicide. 5. 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. 6. Combat veterans have a higher incidence of traumatic brain injury (TBI) sustained from trauma secondary to the explosion of an improvised explosive device (IED). a. Health care providers should eliminate excess noise, refrain from touching or doing anything to the veteran without an explanation, and keep their diesel equipment far away.

Caring for the combat veteran Requires a unique level of understanding Be careful how you phrase your questions. Use a calm, firm voice, but be in charge. Respect a veteran’s personal space. Limit the number of people involved. Ask about suicidal intentions. Lecture Outline C. Caring for the combat veteran 1. The returning combat veteran will require a unique level of understanding, compassion, and specialized attention. a. Be careful how you phrase your questions. b. Use a calm, firm voice, but be in charge. c. Respect a veteran’s personal space. d. Limit the number of people involved or move to a private and quiet space. e. Ask about suicidal intentions.

Caring for the combat veteran Ensure that there is nothing the patient can access and use as a weapon. Physical restraints may simply escalate the problem. Lecture Outline 2. Military personnel are resourceful at improvising weapons. Ensure there is nothing the patient can access and use as a weapon. 3. Physical restraint will not be effective with this population and may simply escalate the problem.

Medicolegal Considerations (1 of 4)
More complicated with a patient undergoing behavioral crisis or psychiatric emergency You must decide whether the patient needs immediate emergency medical care. The patient may resist your attempt to provide care. Never leave the patient alone. Request law enforcement personnel to assist with the patient. Lecture Outline XIV. Medicolegal Considerations A. The medical and legal aspects of emergency medical care become more complicated when the patient is undergoing a behavioral crisis or psychiatric emergency. B. Once you have determined that a patient has impaired mental capacity, you must decide whether he or she requires immediate emergency medical care. 1. A patient in a mentally unstable condition may resist your attempt to provide care. 2. Do not leave the patient alone. 3. Request law enforcement personnel to assist with the patient.

Consent Implied consent is assumed with a patient who is not mentally competent to grant consent. Consent matters are not always clear-cut in psychiatric emergencies. If you are not sure, request the assistance of law enforcement personnel or guidance from medical control. Lecture Outline C. Consent 1. Implied consent is assumed with a patient who is not mentally competent to grant consent. 2. Consent matters are not always clear-cut in psychiatric emergencies. a. If you are not sure, request the assistance of law enforcement personnel or guidance from medical control.

Limited legal authority The EMT has limited legal authority to require a patient to undergo emergency medical care when no life-threatening emergency exists. Competent adults have the right to refuse care. Lecture Outline D. Limited legal authority 1. The EMT has limited legal authority to require or force a patient to undergo emergency medical care when no life-threatening emergency exists. 2. A competent adult has the 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 to be appropriate. A patient who is in any way impaired may not be considered competent. Maintain a high index of suspicion about the patient’s condition. Err on the side of treatment and transport. Lecture Outline 3. In psychiatric cases, a court of law would probably consider your actions in providing life-saving care to be appropriate. a. A patient who is in any way impaired may not be considered competent to refuse treatment or transportation. b. Always maintain a high index of suspicion regarding the patient’s condition—assume the worst and hope for the best. c. Err on the side of treatment and transport. d. Carefully document the patient’s statements and behavior.

Review (1 of 2) A behavioral crisis is MOST accurately defined as:
a severe, acute psychiatric condition in which the patient becomes violent and presents a safety threat to self or to others. any reaction to events that interferes with activities of daily living or has become unacceptable to the patient, family, or community.

a normal response of a patient to a situation that causes an overwhelming amount of stress, such as the loss of a job or marital problems. a reaction to a stressful event that the patient feels is appropriate, but is considered inappropriate by the patient’s family or the community.

Review Answer: B Rationale: A behavioral crisis is any reaction to events that interferes with the patient’s activities of daily living or has become acceptable to the patient, his or her family, or the community. Not all patients with an emotional crisis are “psychotic,” nor are all violent patients experiencing a psychiatric condition; these are common misconceptions. Various medical conditions can cause a behavioral crisis (eg, hypoglycemia, hypoxemia, brain tumors).

a severe, acute psychiatric condition in which the patient becomes violent and presents a safety threat to self or to others. Rationale: This could be considered a symptom of a mental disorder. any reaction to events that interferes with activities of daily living or has become unacceptable to the patient, family, or community. Rationale: Correct answer

a normal response of a patient to a situation that causes an overwhelming amount of stress, such as the loss of a job or marital problems. Rationale: This could be normal behavior or could progress to depression. a reaction to a stressful event that the patient feels is appropriate, but is considered inappropriate by the patient’s family or the community. Rationale: This could be normal behavior.

Review Depression and schizophrenia are examples of:
functional disorders. altered mental status. behavioral emergencies. organic brain syndrome.

Review Answer: A Rationale: Unlike an organic disorder, a functional disorder cannot be linked to any physical dysfunction or failure of an organ. Depression, schizophrenia, obsessive–compulsive disorder (OCD), and bipolar disorder are examples of functional disorders. They are usually caused by a chemical imbalance in the brain—not a structural or physical abnormality.

Review (1 of 2) Depression and schizophrenia are examples of:
functional disorders. Rationale: Correct answer altered mental status. Rationale: Altered mental status is a common presentation in patients with a wide variety of medical problems.

Review (2 of 2) Depression and schizophrenia are examples of:
behavioral emergencies. Rationale: These are emergencies that do not have a clear physical cause and that result in aberrant behavior. organic brain syndrome. Rationale: Organic brain syndrome is a psychiatric disorder caused by a permanent or temporary physical change in the brain.

Review When assessing a patient with a behavioral crisis, your primary concern must be: allowing the patient to express himself or herself to you in his or her own words. setting your personal feelings aside and providing needed care. gathering the patient’s belongings and taking them to the hospital. whether the patient will cause harm to you or your partner.

Review Answer: D Rationale: There are many things that you should be concerned with when assessing a patient with a behavioral crisis, including all of the items listed in this question. Your primary concern, however, must be the safety of yourself and your partner.

Review (1 of 2) When assessing a patient with a behavioral crisis, your primary concern must be: allowing the patient to express himself or herself to you in his or her own words. Rationale: This is a good technique to use in assessment. setting your personal feelings aside and providing needed care. Rationale: It is important not to allow your own prejudice to interfere with your treatment of patients.

Review (2 of 2) When assessing a patient with a behavioral crisis, your primary concern must be: gathering the patient’s belongings and taking them to the hospital. Rationale: Good patient skills are utilized in the treatment of every patient. whether the patient will cause harm to you or your partner. Rationale: Correct answer

Review General guidelines to follow when caring for a patient with a behavioral crisis include all of the following, EXCEPT: being honest and reassuring. rapidly transporting the patient. having a definite plan of action. avoiding arguing with the patient.

Review Answer: B Rationale: When caring for a patient with a behavioral crisis, the EMT must be prepared to spend extra time with the patient. It may take longer to assess and listen to the patient prior to transport.

Review General guidelines to follow when caring for a patient with a behavioral crisis include all of the following, EXCEPT: being honest and reassuring. Rationale: This is part of proper treatment. rapidly transporting the patient. Rationale: Correct answer having a definite plan of action. Rationale: This is part of proper treatment. avoiding arguing with the patient. Rationale: This is part of proper treatment.

Review Reflective listening, an assessment technique used when caring for patients with an emotional crisis, involves: asking the patient to repeat his or her statements. simply listening to the patient, without speaking. asking the patient to repeat everything that you say. repeating, in question form, what the patient tells you.

Review Answer: D Rationale: Reflective listening—a technique in which you repeat, in question form, what the patient tells you—allows the patient to further expand on his or her thoughts; it also helps the EMT gain insight into the patient’s situation.

Review (1 of 2) Reflective listening, an assessment technique used when caring for patients with an emotional crisis, involves: asking the patient to repeat his or her statements. Rationale: This is considered to be clarification of a response. simply listening to the patient, without speaking. Rationale: This is considered to be active listening.

Review (2 of 2) Reflective listening, an assessment technique used when caring for patients with an emotional crisis, involves: asking the patient to repeat everything that you say. Rationale: Simplify and summarize the patient’s response when a patient gives confusing or disorganized responses. repeating, in question form, what the patient tells you. Rationale: Correct answer

Review Which of the following patients is at HIGHEST risk for suicide?
A 24-year-old woman who is successfully being treated for depression A 29-year-old man who was recently promoted with a large pay increase A 33-year-old man who regularly consumes alcohol and purchased a gun A 45-year-old woman who recently found out her cancer is in full remission

Review Answer: C Rationale: Situations or indications that place a patient at high risk for suicide include, but are not limited to, recent diagnosis of a serious illness; financial setback; marital discord; death of a loved one; untreated psychiatric illness; recent acquisition of items that can cause death, such as a gun or knife; and chronic alcohol use.

Review (1 of 2) Which of the following patients is at HIGHEST risk for suicide? A 24-year-old woman who is successfully being treated for depression Rationale: This woman is not a high risk for suicide. A 29-year-old man who was recently promoted with a large pay increase Rationale: This man is not a high risk for suicide.

Review (2 of 2) Which of the following patients is at HIGHEST risk for suicide? A 33-year-old man who regularly consumes alcohol and purchased a gun Rationale: Correct answer A 45-year-old woman who recently found out her cancer is in full remission Rationale: This woman is not a high risk for suicide.

Review When caring for a patient with an emotional crisis who is calm and not in need of immediate emergency care, your BEST course of action is to: advise the patient that he or she cannot refuse treatment. leave the patient with a trusted friend or family member. attempt to obtain consent from the patient to transport. apply soft restraints in case the patient becomes violent.

Review Answer: C Rationale: Just because a patient is experiencing an emotional crisis does not mean that he or she is “mentally incompetent” and cannot refuse EMS treatment and/or transport. You should attempt to obtain consent from any conscious patient unless he or she clearly does not have decision-making capacity (eg, underage, altered mental status, alcohol intoxication).

Review (1 of 2) When caring for a patient with an emotional crisis who is calm and not in need of immediate emergency care, your BEST course of action is to: advise the patient that he or she cannot refuse treatment. Rationale: Do this only if the patient clearly does not have decision-making capacity (eg, underage, intoxicated). leave the patient with a trusted friend or family member. Rationale: Attempt to obtain verbal consent for transport to a medical facility.

Review (2 of 2) When caring for a patient with an emotional crisis who is calm and not in need of immediate emergency care, your BEST course of action is to: attempt to obtain consent from the patient to transport. Rationale: Correct answer apply soft restraints in case the patient becomes violent. Rationale: Restraints are not often used in situations where a patient might become violent, but they are considered.

Review When physically restraining a violent patient, the EMT should:
continually talk to the patient as he or she is being restrained. check circulation in all extremities only if the patient is prone. remove the restraints if the patient appears to be calming down. use additional force if the restrained patient begins to yell at you.

Review Answer: A Rationale: When physically restraining a violent patient, the EMT or his or her partner should continually talk to the patient throughout the process. Treat the patient with dignity and respect—regardless of the situation. Once restraints are placed, they should not be removed, even if the patient appears to be calm. Circulation in all extremities should be monitored, regardless of the position in which the patient is restrained.

Review (1 of 2) When physically restraining a violent patient, the EMT should: continually talk to the patient as he or she is being restrained. Rationale: Correct answer check circulation in all extremities only if the patient is prone. Rationale: Always check the patient’s extremity circulation frequently when physical restraints are applied.

Review (2 of 2) When physically restraining a violent patient, the EMT should: remove the restraints if the patient appears to be calming down. Rationale: Once restraints are applied, they should not be removed. use additional force if the restrained patient begins to yell at you. Rationale: Use only the force necessary to initially restrain a patient.

Review Upon arrival at the residence of a young male with an apparent emotional crisis, a police officer tells you that the man is acting bizarrely. You find him sitting on his couch; he is conscious, but confused. He takes medications, but cannot remember why. His skin is pale and diaphoretic, and he has noticeable tremors to his hands. You should FIRST rule out: hypoglycemia. suicidal thoughts. severe depression. schizophrenia.

Review Answer: A Rationale: Numerous physical problems can cause bizarre behavior, such as hypoglycemia, hypoxemia, and brain tumors, among others. The EMT should rule out an underlying medical cause first. The patient’s pallor, diaphoresis, and motor tremors suggest hypoglycemia. The EMT should assess the patient’s blood glucose level, if trained to do so, and consider administering oral glucose. Psychiatric illnesses, such as clinical depression and schizophrenia, cannot be ruled in or out in the field.

Review (1 of 2) Upon arrival at the residence of a young male with an apparent emotional crisis, a police officer tells you that the man is acting bizarrely. You find him sitting on his couch; he is conscious, but confused. He takes medications, but cannot remember why. His skin is pale and diaphoretic, and he has noticeable tremors to his hands. You should FIRST rule out: hypoglycemia. Rationale: Correct answer suicidal thoughts. Rationale: This is a symptom, something that the patient tells you. It does not produce visible signs.

Review (2 of 2) Upon arrival at the residence of a young male with an apparent emotional crisis, a police officer tells you that the man is acting bizarrely. You find him sitting on his couch; he is conscious, but confused. He takes medications, but cannot remember why. His skin is pale and diaphoretic, and he has noticeable tremors to his hands. You should FIRST rule out: severe depression. Rationale: Depression cannot be ruled out in the prehospital setting. schizophrenia. Rationale: Schizophrenia cannot be ruled out in the field.

Review Which of the following signs is LEAST indicative of a patient’s potential for violence? The patient appears tense and “edgy.” The patient is 6'5" tall and weighs 230 lb. The patient is loud and shouting obscenities. The patient is facing you with clenched fists.

Review Answer: B Rationale: When assessing a patient’s potential for violence, you should observe for suggestive physical activity, such as clenching of the fists; glaring eyes; shouting obscenities; and rapid, disorganized speech. There is no correlation between a patient’s physical size and his or her potential for violence.

Review (1 of 2) Which of the following signs is LEAST indicative of a patient’s potential for violence? The patient appears tense and “edgy.” Rationale: This is a signal of possible physical aggression and anger. The patient is 6'5" tall and weighs 230 lb. Rationale: Correct answer

Review (2 of 2) Which of the following signs is LEAST indicative of a patient’s potential for violence? The patient is loud and shouting obscenities. Rationale: This is a signal of possible physical aggression and anger. The patient is facing you with clenched fists. Rationale: This is a signal of possible physical aggression and anger.

Psychiatric Emergencies

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Psychiatric Emergencies

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