1. Slide 1 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Behavioral Emergencies Chapter 23

2. Slide 2 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Case History You arrive at the scene of a disturbance. You find a 30-year-old male throwing articles out the window of the house. He is screaming that everyone is out to get him and he tells you that he will not let anyone touch him. You arrive at the scene of a disturbance. You find a 30-year-old male throwing articles out the window of the house. He is screaming that everyone is out to get him and he tells you that he will not let anyone touch him.

3. Slide 3 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Behavioral Emergency Definition: An occurrence in which the patient exhibits abnormal behavior within a given situation that is unacceptable or intolerable to the patient, family, or community An occurrence in which the patient exhibits abnormal behavior within a given situation that is unacceptable or intolerable to the patient, family, or community

4. Slide 4 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Scope of the Problem  Depression is often underemphasized in EMS.  Depression is present in at least 11% of population in U.S.  20% of adults experience at least one episode of clinical depression.

5. Slide 5 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Depression and Suicide  Symptoms of depression  Loss of sleep, appetite, sex drive  Sad, tearful  Guilt  Hopelessness  Thoughts of death or taking one’s life  Physical symptoms

6. Slide 6 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Suicide – Scope of the Problem  28,000 suicides each year  Men >65 y/o have three times higher suicide rate.  Young person attempts suicide every 90 seconds.  Successful suicide every 90 minutes

7. Slide 7 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Suicide – Assessment of Risk Factors  Male  Individuals over 40  Single, widowed, or divorced  Socially isolated  Alcoholic, drug abuse  Recent diagnosis of serious illness  Recent loss of significant loved one

8. Slide 8 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Suicide – Assessment of Risk Factors  Previous history of self-destructive behavior  Arrest, imprisonment, loss of job  Lethal plan of action that has been verbalized  Gathering of articles that can cause death  Gun  Large volumes of pills

9. Slide 9 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Suicide – Assessment Findings  Patient in an unsafe environment?  With unsafe objects in hands?  Displaying self-destructive behavior?

10. Slide 10 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Suicide – Important Questions  How does the patient feel?  Suicidal tendencies in the past?  If so, what interventions have occurred?  Is patient a threat to self or others?  Is there a medical problem?

11. Slide 11 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Emergency Medical Care  Perform scene size-up.  Personal safety is a priority.  Conduct patient assessment.  Calm the patient.  Do not leave patient alone.

12. Slide 12 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Emergency Medical Care  Restrain, if necessary.  Consider need for law enforcement.  Transport.  If overdose, bring medications or drugs.

13. Slide 13 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Behavioral Change  General factors that may alter a patient's behavior  Situational stresses  Medical illnesses  Psychiatric problems  Alcohol or drugs

14. Slide 14 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Common Factors  Low blood sugar  Lack of oxygen  Inadequate blood flow to the brain  Head trauma

15. Slide 15 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Common Factors  Mind-altering substances  Psychogenic – resulting in psychotic thinking, depression, or panic  Excessive cold  Excessive heat

16. Slide 16 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Situational Reactions  Panic  Agitation  Anger  Anxiety  Paranoia  Denial  Withdrawal

17. Slide 17 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Personality Disorders  Definition: Character traits that interfere with a person’s ability to function successfully in work or personal relationships  Patient can be manipulative and self-focused.  Avoid getting angry with the patient.  Be positive but establish limits.

18. Slide 18 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Psychosis  Disordered thoughts  Disordered perceptions of reality  Hallucinations  Inappropriate responses to environment  Possible communication difficulty  Speaks incoherently  Out of control  May need to obtain history from others

19. Slide 19 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Organic Brain Syndrome  Medically caused brain syndrome  Disordered thoughts  Disorientation  Delirium  Hallucinations  Numerous causes  Tumor  Trauma  Infection

20. Slide 20 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Scene Size-up  Most important aspect of assessment  Can present a serious threat to EMT safety  Try to identify potential causes of presenting problem.  Aggressive or bizarre behavior  Open bottles of medications, syringes, track marks

21. Slide 21 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Scene Safety  Be aware of potential dangers  If notified of a violent patient, wait for police before entering scene.  First priority is prevention of further injuries.  Environmental dangers may exist.  Gas exhaust  Carbon monoxide

22. Slide 22 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Violent Behavior  Recognizing impending violence is vital.  Do not put yourself in jeopardy.  Assess what can be done to avoid outburst.  Leave yourself an escape route.

23. Slide 23 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Signs of a Potentially Violent Patient  Angry voice  Pressured speech  Pacing  Expressions of violence  Psychiatric history of emotional disturbance  Drug intoxication  Situational frustration  Threatening posture or movements  Presence of heavy or threatening objects

24. Slide 24 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Principles for Assessing Behavioral Emergency  Identify yourself.  Let the person know you are there to help.  Inform the patient of what you are doing.  Ask questions in a calm, reassuring voice.  Allow the patient to tell what happened.  Do not be judgmental.

25. Slide 25 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Principles of Assessing Behavioral Emergency  Rephrase or repeat to confirm communication.  Acknowledge the patient’s feelings.  Assess the patient's mental status.  Appearance  Activity  Speech  Orientation for time, person, and place

26. Slide 26 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Assessment of Potential Violence  Scene size-up  History  Check with family and bystanders.  Known history of aggression or combativeness?  Posture  Stands or sits in a position which threatens self or others  Fists clinched or lethal objects in hands

27. Slide 27 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Assessment of Potential Violence  Vocal activity  Yells or verbally threatens harm to self or others  Physical activity  Moves toward caregiver  Carries heavy or threatening objects  Has quick, irregular movements  Tenses muscles

28. Slide 28 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Methods to Calm Behavioral Emergency Patients  Acknowledge that the person seems upset.  Restate that you are there to help.  Inform the patient of what you are doing.  Ask questions in a calm, reassuring voice.  Maintain a comfortable distance.  Encourage the patient to state what is troubling him.

29. Slide 29 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Methods to Calm Behavioral Emergency Patients  Do not make quick moves.  Respond honestly to patient's questions.  Do not threaten, challenge, or argue.  Tell the truth.  Do not “play along” with visual or auditory disturbances.

30. Slide 30 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Methods to Calm Behavioral Emergency Patients  Involve trusted family members or friends.  Be prepared to stay at scene for a long time.  Always remain with the patient.  Avoid unnecessary physical contact.  Call additional help, if needed.  Maintain good eye contact.

31. Slide 31 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Medicolegal Considerations  Management of emotionally or mentally disturbed patient presents high legal risk.  When emotionally disturbed patients consent to care, legal problems are greatly reduced.  Patient will often resist treatment.  Patient may threaten EMT-Basics and others.  To provide care against patient's will, you must show a reasonable belief patient would harm self or others.

32. Slide 32 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. If Patient Resists Treatment  If a threat to self or others, may be transported without consent.  Contact medical direction.  Law enforcement is usually required.

33. Slide 33 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Reasonable Force Definition: Action necessary to keep patient from injuring self or others Action necessary to keep patient from injuring self or others

34. Slide 34 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Determining Reasonable Force  Patient’s size and strength  Type of abnormal behavior  Sex of patient  Mental state of patient  Method of restraint

35. Slide 35 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Using Force  Calm patients may cause unexpected and sudden injury to self and others.  EMS personnel may use reasonable force to defend against an attack.  Avoid acts or physical force that may cause injury to the patient.

36. Slide 36 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Police and Medical Direction  Seek medical direction when considering restraining a patient.  Ask for police assistance, if during scene size-up the patient appears or acts aggressive or combative.

37. Slide 37 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Accusations  Protection against false accusations  Documentation of abnormal behavior important  Witnesses in attendance, especially during transport  Accusations of sexual misconduct are common.  Same-sex attendants and third-party witnesses can prove beneficial.

38. Slide 38 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Restraining Patients  Avoid restraints, if possible.  Use only when patient is a danger to self or others.  Have police present.  Get approval from medical direction.

39. Slide 39 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Restraining Patients  Be sure to have adequate help.  Plan your activities.  Use only the force necessary for restraint.  Estimate range of motion of patient’s arms and legs.

40. Slide 40 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Restraint Technique  Act quickly.  Have one EMT-Basic talk to patient.  Approach with four persons.  One assigned to each limb, all at the same time

41. Slide 41 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Restraint Technique  Secure limbs together with equipment approved by medical direction.  Turn patient face up on stretcher.

42. Slide 42 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Restraint Technique  Secure patient to stretcher with multiple straps.  Cover patient’s face with surgical mask if spitting.

43. Slide 43 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Restraining Technique  Reassess circulation frequently.  Document indication for restraining patient and technique of restraint.  Avoid unnecessary force.

44. Slide 44 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Other Behavioral Problems – General Principles  Always try to talk patient into cooperating.  Do not belittle or threaten patients.  Be calm and tolerant in your attitude.  Do not agree with disturbed thinking.  Be reassuring.

45. Slide 45 Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Other Behavioral Problems – General Principles  Avoid arguing with irrational patients.  Suggest appropriate steps to take.  Lower distressing stimuli.  Avoid restraints unless necessary.  Treat with respect.