Behavioral Emergencies for the EMT Basic

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Behavioral Emergencies for the EMT Basic

• Travis R. Welch, NREMT, PA-S
• EMS Director, Zionsville Fire Department
• www.zionsvillefire.com

Reference Bradys Fire Service Emergency Care
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Objectives

• Define Behavioral Emergencies (p.445)
• Discuss the general factors that may cause an
  alteration in a patients behavior (p. 448-449)
• State the various reasons for psychological
  crises (p. 446, 448-449)
• Discuss behavior characteristics that suggest a
  patient is at risk for suicide (p. 448-449)
• Discuss special medicolegal aspects of managing
  behavioral emergencies (p. 450, 452-453)
• Discuss special considerations for assessing a
  patient with behavioral problems (p. 446-450)
• Discuss principles of behavior that suggest a
  patient is at risk of violence (p. 449)
• Discuss methods to calm behavioral emergency
  patients (p. 446-447, 449-450)

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Behavior

• Manner in which a person acts or performs any or
  all activities of a person including physical and
  mental activities.
• Behavioral emergency-situation in which a patient
  exhibits abnormal behavior within a given
  situation that is unacceptable or intolerable to
  the patient, family or community
• Meaning of given situation
• Acceptable behavior is a reflection of the
  patients culture
• EMT must remain nonjudgmental

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Behavioral Changes

• General factors may alter a patients behavior
• Situational stresses
• Medical illnesses
• Psychiatric problems
• Alcohol and drug intoxication/withdrawal

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Common causes

• Low blood sugar, particularly in Pts w/ DM
• Lack of O2
• Inadequate blood flow to brain
• Head trauma
• Mind-altering substances
• Excessive cold
• Excessive heat

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S/Sx of physiological causes of behavioral
emergencies

• Unusual odors on the patients breath
• Dilated, constricted, or unequally reactive
  pupils
• Rapid rather than gradual onset of symptoms
• Excessive salivation
• Loss of bladder control
• Visual rather than auditory hallucinations

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General guidelines for managing situational
stress RXNs (such as fires, accidents or deaths)

• Act in calm manner
• Give patient time to gain control of emotions
• Quietly and carefully evaluate the situation
• Keep your won emotions under control
• Honestly explain things to the patient
• Let the patient know that you are listening to
  what s/he is saying
• Stay alert for sudden changes in behavior

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Psychiatric Emergencies

• Types of psychiatric conditions
• Anxiety
• Phobia
• Depression
• Bipolar disorder
• Paranoia
• Schizophrenia

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Methods of calming patient(Fig. 18-1, p. 446)

• Identify yourself and your role
• Speak slowly and clearly
• Use a calm, reassuring tone
• Show you are listening to the patient by
  rephrasing back parts of what s/he says
• Do not be judgmental. Show compassion
• Use positive body language
• Acknowledge the patients feelings
• Do not enter the patients space, stay about 3
  away
• Be alert for changes in the patients emotional
  status

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Patient Assessment

• Common S/Sx
• Panic or anxiety
• Fear
• Agitated or unusual activity
• Unusual appearance
• Unusual speech patterns
• Depression
• Withdrawal
• Confusion
• Anger, often inappropriately directed
• Bizarre behavior or thought patterns
• Loss of contact with reality, hallucinations
• Suicidal or aggressive behavior with threats or
  intend to harm self or others

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Emergency Care

• Be alert for personal or scene safety problems
  during size up and during incident
• Treat any life threatening problems during
  primary survey
• Be prepared to spend time talking to patient an
  stay with patient
• Encourage the patient to discuss what is
  troubling them
• NEVER PLAY ALONG WITH HALLUCINATIONS OR
  DELUSIONS. DO NOT LIE TO THE PATIENT

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Emergency Care

• If it appears to help, involve family or friends
  in conversation
• As possible perform a focused HP and provide
  necessary emergency care
• Perform a detailed PE only if it is safe and you
  suspect the patient may have an injury
• Consider restraints if necessary to keep the
  patient from harming himself or others

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Emergency Care

• If necessary transport the patient to the
  appropriate facility
• Perform ongoing assessment en route
• Contact the receiving hospital and report on
  current patient status including mental status

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Special considerations

• Suicide
• Ideations can afflict people of any gender, age,
  race or SES
• Variety of reasons and/or methods may be involved
• First concern is responder safety
• Suicide Risk factors
• Depression
• Current or recent high stress levels
• Recent emotional distress/trauma
• Age-higher rates between 15-25 and gt40
• Substance abuse
• Threats of suicide communicated to others
• Suicide plan
• Previous attempts or threats
• Sudden improvement from depression

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Special considerations

• Suicide emergency care
• Personal interaction is important
• Establish visual and verbal contact
• Avoid arguments
• Make no threats
• Show no indications of using force
• Ensure scene safety
• LEOs on scene?
• Do not leave patient unless due to responder risk
• Look for and treat life threatening injuries as
  possible
• Seek LEO assistance in restraining patient PRN
• Back off from scene PRN
• Transport all suicidal patients

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Special considerations

• Hostile or aggressive patients
• Possible causes
• Trauma to CNS
• Metabolic disorders
• Stress
• Substance intoxication
• Psychological disorders

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Special considerations

• Hostile or aggressive patients
• Signs
• Clues at scene
• Info provided by bystanders or other responders
• Patients stance or position in room (Fig. 18-2)
• Actions by patient
• Respond to people inappropriately
• Tries to hurt himself or others
• May have rapid pulse, respirations
• Usu. displays rapid speech and physical movements
• May appear nervous, anxious, panicky

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Special considerations

• Hostile or aggressive patients
• General precautions
• Do not isolate your self from partner or other
  sources of help
• Do not take any action that may be considered
  threatening by patient
• Always be aware of surroundings and be aware of
  weapons
• Anything can be a weapon
• Watch the patient's hands!
• Be alert for sudden behavior changes
• Maintain verbal or radio contact with other
  responders on the scene

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Reasonable Force and Restraint

• The force necessary to keep the patient from
  injuring himself or others
• Reasonableness is determined by looking at all
  the circumstances involved-patients size and
  strength, type of abnormal behavior, mental
  status, and available methods of restraint

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Restraint

• In many localities an EMT may not legally
  restrain a patient against his will
• Need for LEOs
• Make sure restraints used are humane
• Avoid handcuffs or flex-cuffs
• Follow local protocols
• If involved in restraint, follow these guidelines
• Be sure you have adequate help
• Plan the activities
• Estimate ROM of Pts arms and legs and stay out of
  that area until ready.

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Restraint

• Once the decision to restrain a patient has been
  made, act quickly
• One crew member should talk to and try to
  reassure the patient during the restraint
  procedure
• Approach with a minimum of four people
• Secure all 4 limbs with restraints approved by
  medical direction
• Position the patient either face up or face down,
  remain alert to the danger of positional asphyxia
• Use multiple straps or other restraints to ensure
  the patient is adequately restrained

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Restraint

• If the patient is spitting on rescuers, place a
  surgical mask on the patient if he had no
  difficulty breathing, no likelihood of vomiting,
  and if local protocols permit
• Reassess the patients distal circulation
  frequently
• Use sufficient force but avoid unnecessary force
• Document the reason why the patient was
  restrained and the methods used.

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Documentation

• Guidelines
• Document observations in an objective and
  professional manner
• Describe behavior in exact terms
• Document the scene thoroughly
• Include statements to support your decision that
  the patient may have harmed himself or others
• Document use or suspicion of intoxicating
  substances
• Record evidence of illness or injuries
• Include names of LEOs, other members present,
  witnesses

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Medical-Legal Considerations

• If an emotionally disturbed patient can be
  persuaded to consent to care, legal problems can
  be greatly reduced
• How to handle the patient who resists treatment
• Know state laws and local procedures for treating
  patients without consent
• Involve medical direction and LEOs
• Involve mental health teams if available
• Avoid unreasonable force
• Take steps to avoid charges of sexual misconduct
• Have LEOs accompany potentially violent Pts to
  the hospital with EMS personnel

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What do you think?

• Can a severely emotionally disturbed patient or
  one with altered mental status/behavior sign a
  refusal of service form?
• Do DNRs apply in cases of suicide attempts?
• What might you be charged with if you restrain a
  patient without proper justification/approval?

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Any questions?

• Take 10 minutes, then return for the second
  portion of tonights class