Behavioral Emergencies

1. Chapter 23 Behavioral Emergencies

2. 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.

3. 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

4. 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. 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. 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. 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. 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. Suicide – Assessment Findings • Patient in an unsafe environment? • With unsafe objects in hands? • Displaying self-destructive behavior?

10. 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. Emergency Medical Care • Perform scene size-up. • Personal safety is a priority. • Conduct patient assessment. • Calm the patient. • Do not leave patient alone.

12. Emergency Medical Care • Restrain, if necessary. • Consider need for law enforcement. • Transport. • If overdose, bring medications or drugs.

13. Behavioral Change • General factors that may alter a patient's behavior • Situational stresses • Medical illnesses • Psychiatric problems • Alcohol or drugs

14. Common Factors • Low blood sugar • Lack of oxygen • Inadequate blood flow to the brain • Head trauma

15. Common Factors • Mind-altering substances • Psychogenic – resulting in psychotic thinking, depression, or panic • Excessive cold • Excessive heat

16. Situational Reactions • Panic • Agitation • Anger • Anxiety • Paranoia • Denial • Withdrawal

17. 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. 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. Organic Brain Syndrome • Medically caused brain syndrome • Disordered thoughts • Disorientation • Delirium • Hallucinations • Numerous causes • Tumor • Trauma • Infection

20. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Reasonable Force Definition: Action necessary to keep patient from injuring self or others

34. Determining Reasonable Force • Patient’s size and strength • Type of abnormal behavior • Sex of patient • Mental state of patient • Method of restraint

35. 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. 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. 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. 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. 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. 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. Restraint Technique • Secure limbs together with equipment approved by medical direction. • Turn patient face up on stretcher.

42. Restraint Technique • Secure patient to stretcher with multiple straps. • Cover patient’s face with surgical mask if spitting.

43. Restraining Technique • Reassess circulation frequently. • Document indication for restraining patient and technique of restraint. • Avoid unnecessary force.

44. 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. 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.