Behavioral emergencies and

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Behavioral emergencies and

• Silver Cross EMSS
• EMD CE
• September 2013

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Psychological First Aid

• EMDs need to give psychological support as well
  as emergency medical care instructions to callers
• Factors contributing to behavioral changes
• Medical conditions
• Physical trauma
• Psychiatric illnesses
• Mind-altering substances
• Situational stresses

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Scene and Patient Assessment

• Use your All Caller Interrogation and Key
  Questioning to make sure that the scene is safe
  and gather information about the patients
  mental status, ABCs and history.
• Relay any pertinent information to responders and
  determine if police are needed.

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EMDPRS

• PSYCHIATRIC/BEHAVIORAL PROBLEMS
• KEY QUESTIONS
• 1. Is the patient violent or threatening others?
  
• 2. Is the patient suicidal? YES? Go to SUICIDE
  Protocol being careful not to agitate patient
• 3. Does the patient have a history of mental
  problems?
• 4. If under a doctors care, does patient take
  any
• regular medications? Are they current and
  compliant?
• 5. Any drugs or alcohol involved?

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EMDPRS

• PRE-ARRIVAL INSTRUCTIONS
• 1. Send law enforcement to secure the scene
• 2. If caller is not patient, tell caller to
  maintain a safe distance
• 3. If caller is also patient, attempt to maintain
  phone contact and build rapport
• 4. Call back if condition worsens prior to the
  arrival of emergency personnel

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Behavioral Emergencies

• Behavioral emergencies are situations in which
  persons exhibit abnormal, unacceptable behavior
  that cannot be tolerated by the patients
  themselves or by family, friends, or the
  community.

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Behavioral Emergencies

• Medical conditions
• Uncontrolled diabetes
• Respiratory conditions
• High fevers
• Infections
• Inadequate blood supply to the brain
• Physical trauma
• Head injuries
• Injuries that result in shock and an inadequate
  blood supply to the brain

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Behavioral Emergencies

• Psychiatric illnesses
• Depression
• Panic
• Psychotic behavior
• Mind-altering substances
• Alcohol
• A wide variety of chemical substances
• Situational stresses
• Death of a loved one
• Serious injury to a loved one

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What Is a Situational Crisis?

• State of emotional upset or turmoil
• Caused by a sudden and disruptive event
• Most situational crises
• Are sudden and unexpected
• Cannot be handled by the persons usual coping
  mechanisms
• Last only a short time
• Can cause socially unacceptable,
  self-destructive, or dangerous behavior

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Phases of a Situational Crisis

• There are four emotional phases to each
  situational crisis.
• High Anxiety or Emotional Shock
• Denial
• Anger
• Remorse or Grief
• People may not experience every phase, but they
  will experience one or more.

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High Anxiety or Emotional Shock

• High anxiety is characterized by
• Flushed (red) face
• Rapid breathing
• Rapid speech
• Increased activity
• Loud or screaming voice
• General agitation
• Emotional shock is often the result of a sudden
  illness, accident, or sudden death of a loved
  one.
• Emotional shock is characterized by
• Cool, clammy skin
• A rapid, weak pulse
• Vomiting and nausea
• General inactivity and weakness

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Denial

• Refusal to accept the fact that an event has
  occurred
• Your response
• Allow the patient to express denial.
• Do not argue with the patient.
• Try to understand the emotional and psychological
  trauma that the patient is experiencing.

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Anger

• Normal human response to emotional overload or
  frustration
• May follow denial or may replace denial
• People may vent angry feelings at you.
• Do not take the persons anger personally. Be
  alert for violent actions towards responders.
• Frustration and a sense of helplessness can often
  build to anger.
• Always be professional and remain calm.

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Remorse or Grief

• Acceptance of the situation may lead to remorse
  or grief.
• People may feel guilty or apologetic about their
  behavior.
• Be a good listener!

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Communicating With the Patient

• Talk with the person.
• Introduce yourself.
• Ask the patient his or her name.
• Ask what you can do to help.
• Be honest, warm, caring, and empathetic.
• Use a calm, steady voice and provide honest
  reassurance.
• Try not to let negative personal feelings
  interfere with your attempt to provide
  assistance.
• Simple acts of kindness can provide comfort and
  reassurance.

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Communicating With the Patient

• Restatement
• Rephrasing a persons own words and thoughts and
  repeating them back
• Be honest and give the patient hope, but do not
  give false hope.
• Redirection
• Helps focus a patients attention on the
  immediate situation or crisis
• Use redirection to alleviate a patients
  expressed concerns.

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Communicating With the Patient

• Empathy
• Imagining yourself in another persons situation
  and sharing his or her feelings or ideas
• Empathy is one of the most helpful concepts you
  can use.
• Use a calm and caring approach.
• Communication skills
• Identify yourself and let the patient know you
  are there to help.
• Inform the patient of what you are doing. (i.e.
  dispatching units, etc.)
• Ask questions in a calm, reassuring voice.
• Allow the patient to tell you what happeneddo
  not be judgmental.
• Show you are listening by using restatement and
  redirection.
• Acknowledge the patients feelings.
• Assess the patients mental status.

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Domestic Violence

• Common occurrence in todays society
• It takes several different forms
• Elder abuse
• Child abuse
• Spouse and domestic partner abuse
• When dispatching to a domestic call
• Maintain safety for all rescuers as well as for
  the patient.
• Conduct effective questioning and pre-arrival
  instructions as needed.

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Domestic Violence

• Physical signs and symptoms
• Broken bones
• Cuts
• Head injuries
• Bruises
• Burns
• Scars from old injuries
• Injuries in various stages of healing
• Internal injuries

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Domestic Violence

• Emotional symptoms
• Depression
• Suicide attempts
• Abuse of alcohol or drugs
• Feelings of anxiety, distress, and hopelessness
• Abusers may be paranoid, overly sensitive,
  obsessive, or threatening.
• If you suspect abuse, your responsibility is to
  maintain safety for the patient and responders.
• Try to separate the patient from the abuser.
• Try to keep from judging the patient.
• Send law enforcement to secure the scene.

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Domestic Violence

• Cycles of abuse
• Tension phase The abuser becomes angry and often
  blames the victim.
• Explosive phase The abuser becomes enraged and
  loses control as well as the ability to think
  clearly.
• Make-up phase The abuser makes promises, which
  are seldom kept.

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Violent Patients

• Immediately attempt to establish verbal contact
  with the patient.
• Check with the caller about the patients past
  history of violence.
• Signs of potential violence
• History of violence
• Yelling or verbal threatening
• Loud, obscene, or bizarre speech
• Pacing, inability to sit still, and protection of
  personal space
• Abuse of drugs or alcohol

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Attempted Suicide

• Many patients who fail at their first attempt
  will try to commit suicide again.
• The underlying psychiatric disease is usually
  treatable.
• Management
• Obtain a complete history of the incident.
• Determine whether the patient still has a weapon
  or drugs on him or her.
• Support the patients ABCs.
• Provide pre-arrival instructions for the injuries
  or conditions the caller reports.
• Do not judge the patient.
• Provide emotional support.

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Posttraumatic Stress Disorder

• Severe form of anxiety
• People experiencing PTSD relive previous
  traumatic experiences.
• Symptoms include
• Flashbacks
• Sleep disturbances
• Nightmares
• Depression and guilt
• As an EMD, your job is to
• Speak with the patient in a positive and
  supportive way.
• Arrange for the patient to be transported to an
  appropriate medical facility.

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Sexual Assault

• The psychological aspects of treatment are
  important.
• You may have to delay all but the most essential
  treatment until a responder of the same sex as
  the patient arrives.
• Your first priority is the medical well-being of
  the patient.
• Give instructions to treat any injuries the
  person may have.

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Excited or Agitated Delirium

• This controversial subject has become a hot topic
  in the law enforcement and EMS community in
  recent years.
• In 2009, the American College of Emergency
  Physicians released a White Paper report which
  recognized this condition but organizations like
  the American Medical Association, World Health
  Organization and the American Psychiatric
  Association do not. Link to full article here
• http//www.academia.edu/1131068/ACEP_Excited_Delir
  ium_White_Paper_-_Contribution_via_CA_Hall_MD_FRCP
  C
• The following slides contain general information
  about this condition.

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Excited Delirium

• This disorder is usually drug-related (cocaine or
  "crack", PCP or "angel dust", methamphetamine,
  amphetamine), but can occur in non-drug users as
  well. 
• The presentation of excited delirium occurs with
  a sudden onset, with symptoms of bizarre and/or
  aggressive behavior, shouting, paranoia, panic,
  violence toward others, unexpected physical
  strength, and hyperthermia.

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Excited Delirium

• Excited Delirium MnemonicN Patient is naked
  and sweating from hyperthermiaO Patient
  exhibits violence against objects, especially
  glassT Patient is tough and unstoppable, with
  superhuman strength and insensitivity to painA
  Onset is acute (e.g., witness say the patient
  just snapped!)C Patient is confused regarding
  time, place, purpose and perceptionR Patient is
  resistant and wont follow commands to desistI
  Patients speech is incoherent, often with loud
  shouting and bizarre contentM Patient exhibits
  mental health conditions or makes you feel
  uncomfortableE EMS should request early backup
  and rapid transport to the ED

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Excited Delirium

• It has been cited as a cause of sudden death in
  situations where individuals have been restrained
  or Tased after exhibiting bizarre and erratic
  behavior. Dopamine (important brain and CNS
  chemical) disturbances, drugs and/or underlying
  medical conditions may be contributing factors as
  well.
• Recommended management includes safety for
  responders, calming techniques, monitoring of
  vital signs, possible sedation (at medical
  control discretion) and rapid transport to the
  closest Emergency Department. Treat other signs
  and symptoms or injuries as needed.

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Sources

• AAOS Emergency Medical Responder
• Your First Response in Emergency Care,
• 5th Edition
• Will County 9-1-1 EMDPRS
• www.ExcitedDelirium.org
• Journal of Emergency Medical Services,
• www.JEMS.com
• American College of Emergency Physicians
• White Paper report