Will Grundy EMS System Psych/Behavioral/Petitions September 2010 CME 3 rd Trimester

1. Everything you ever wanted to know about psychiatric patients, behavioral issues and petitions but were afraid to ask. Will Grundy EMS System Psych/Behavioral/Petitions September 2010 CME 3rd Trimester Sources: Mosby Paramedic, Ahlert Paramedic

2. Definitions • What is “Normal”? • Meets the norms, expectations of society • Religious, cultural factors affect what each person perceives as “normal” • Mental (psychiatric) disorder • Abnormal behavior affects life functions • Behavioral emergency • Actions, ideations (thoughts) harmful, potentially harmful to patient, others

3. The Great Pretender….. • Other conditions may show psychiatric symptoms • Alzheimer’s disease • Brain abscess • Brain neoplasm • Brain trauma • Hypoglycemia • Dehydration • Hypoxia • Hypothermia • Sepsis • Substance intoxication • Substance withdrawal • Stroke

4. Why Do Some People Have Psychiatric Issues? Many possible reasons: • Genetic predisposition • Some genes may make mental illness more likely • Imbalances in neurotransmitter levels • Serotonin - regulates intestinal movement, mood, appetite, sleep, muscle contraction, some cognitive functions. • Dopamine - important roles in behavior, cognition, voluntary movement, motivation, punishment and reward, sexual gratification, lactation, sleep, mood, attention, working memory, learning. • Norepinephrine - affects parts of the brain where attention and responding actions are controlled. Along with epinephrine, also underlies the fight-or flight response.

5. More Possible Reasons • Psychosocial factors • Life events affect emotional state • Developmental factors • Emotional crisis early in life may predispose some to psych issues • “Bio-psycho-social” concept • A mixture of things (biologic makeup, behavior, surroundings) relate, interact to create psychiatric problems

6. Responding to the “Psych Eval” • Consider number of fire dept. responders. • Do you really need an engine to respond on ALL psych calls along with the ambulance? • Crowds of cops and firefighters not going to help calm down a scared, panicky, reluctant patient. • Hard to develop trust relationship between medics and psych patient if other personnel constantly step into conversation. • If pre-set or automatic aid response, consider staging engine unless/until the engine company is needed. • Of course if patient known to be dangerous, then by all means send the entire station if necessary.

7. More Response Advice Private ambulance companies - often your patients are medicated ahead of time for transports, but don’t assume anything! • Just because they “recently got two of Ativan” doesn’t mean they will be happy to go with you.

8. More Response Information • Staging for police – if the police aren’t there, park a block away and wait until they are. • If the cops are not available, remember tactical considerations. • Observe surroundings, living conditions • Approach residence from side, listen before knocking • Violence signs – blood, loud noises, broken glass, gunshots -- you shouldn’t be there. • Never put anything between yourself and the door. Always leave yourself an out… just in case.

9. Good Paramedics Almost Never Have to Use Force • 90 times out of 100, you can persuade psychiatric patient to get into ambulance without force. • Sometimes takes more time and effort on scene than you might like. • Sometimes takes strong words directed to patient (“We can do this the easy way or the hard way.”) • Outcome worth it – less danger, less chance of lawsuits, less documentation needed. • If you can’t get petition signed, but think patient REALLY needs ER care, talking is the only tool you have anyway (more on that soon).

10. You Are the Patient’s Advocate • That means if… • mom • dad • wife • husband • fellow paramedic • cop • anyone else… • …. makes it hard for you to persuade a psychatric patient to come with you the easy way (either with inappropriate comments toward the patient or inappropriate actions), you have the right to kick them out so you can do your job. • Of course, kicking them out with tact and diplomacy is always the wiser move… “busy work” is always a good choice • “Hey ma’am, could you go outside and give the police his information?” is a favorite of many medics.

11. Patient Contact • As you approach, be aware of patient actions, behavior, posture. • Don’t stand over them. Sit next to them, at their level, if possible. • Watch patient personal space. If sitting near them makes them uncomfortable, move. • Remember life-threatening problems are your first priority • Someone who OD’s on pills is an ALS medical patient, not just a psych patient.

12. Patient Contact • Give the appearance of being quiet, non-threatening, there to help. • Remember: Psych patients assume anyone in a blue shirt is a cop. • Gain trust. Don’t lie. Most psych patients can sense BS. • But if you think patient will react badly to news of a possible long-term psychiatric hold, the full truth may not be a good idea. • Try some non-threatening (but still true) statements instead: • “We’ll just go in so a doctor can look at your medication doses and make some adjustments.” • “We’ll go find you someone to talk to.” • “If you are as calm and rational with the ER staff as you were with me, they may consider alternatives.”

13. Shut Off the Noise • If you feel patient will be calmer without lights/sirens, tell medical control and dispatch that you will transport non-emergency. • FYI - your department or company may have additional SOP’s regarding non-emergency transports.

14. Documentation Concerns • Allergies, medication, past medical history, psychiatric disorders • Past psychiatric hospitalizations • Medication compliance • Med non-compliance a common cause of psych crisis. • Psychotropic medications are expensive, make patients feel sleepy, confused, shaky, nauseous, fat… which is less likely to make them want to take their medication.

15. More Documentation Items • Note speech patterns – racing, disjointed, quiet? • Behavior – agitated? Calm? Confused? • Motor tics – shaking limbs, tapping, grimacing. • Thought processes – suicidal ideation, not in touch with reality, hallucinations. • Delirium or dementia • Delirium rapid onset, can often be reversed. • Dementia more gradual, usually affects older people.

16. Document Mood • “Affect” – the experience of feeling or emotion • Labile – changes quickly • Flat - emotionless • Constricted - contained • Intense – often angry or “emotional” • Mood - dominant, sustained emotional state • In adults with bipolar syndrome, can change over course of days, weeks or months. • In children with bipolar syndrome, can change rapidly over the course of hours or days. • Document with direct quotes references to suicidal thoughts and ideation, as well as references to hurting self or others. • If the patient didn’t say anything to you, but said something to police or family, mention that instead (more on this coming up).

17. Consider Substance Abuse • Substance abuse often goes hand-in-hand with psychiatric problems. • Patients “self-medicate” with drugs/alcohol before realizing they have treatable problem… or after realizing they can’t afford treatment. • Assessing for substance abuse • Direct questions • Needle marks, breath smell

18. Depression • Different levels of depression • Dysphoria (diss-for-ee-uh) – melancholy or depressed mood • Dysthymia (diss-thy-mee-uh) – not as extreme • Postpartum – after giving birth • Seasonal Affective Disorder (SAD) – depression during the late fall and winter months • Often related to alterations in serotonin levels in body. • May also be caused by psychosocial events in a person’s life (death in family, shock, sad event, etc).

19. Medications for Depression • What might your patient be taking? • Selective serotonin-reuptake inhibitors (SSRIs)– most common depression medications. Celexa, Lexapro, Prozac, Paxil, Zoloft • Other common antidepressants – Effexor, Cymbalta, Wellbutrin • Monoamine oxidase inhibitors (MAOIs) – rarely in use anymore: Nardil, Marplan, Parnate • Tricyclic antidepressants (TCA) – rarely used now for depression, still used for migraine sufferers and other applications: Elavil, Tofranil, Pamelor

20. Herbal • “Herbal” – St. John’s Wort, SAM-e, Valerian, Chamomile • Patients won’t tell you they are taking these since they don’t consider them “real” medications • But they have real actions and real side-effects.

21. The Lesson Here: • Know your drug names, both generic and brand. You may not know you’re dealing with a psychiatric patient until you see their medication list.

22. Some of the more common psychiatric/behavioral/mood disorders….

23. Bipolar Disorder • Definition • The presence of one or more episodes of abnormally elevated energy levels, cognition and mood (mania) with or without one or more depressive episodes (depression).

24. Bipolar Disorder • Hypomania • Overwhelming sense of well-being, confidence • Mind moves quickly • Poor judgment, distractibility • Less energetic than mania • Mania • Self-worth dangerously inflated, grandiose delusions (can fly from tops of buildings, can beat anyone in any game) • Elevated mood, limitless energy • Judgment impaired, irrational, risk • Mixed episodes • Guilt, worthlessness of depression with energy, agitation of mania • Suicidal ideations

25. Pediatric (childhood) Bipolar • Controversial diagnosis – experts are not sure if really bipolar or something else, but often responds well to bipolar medications. • Can be diagnosed at a very early age. • Mimics ADHD or depression, but treatment with stimulants or antidepressants aggravates the child’s manic episodes. • Bipolar children cycle more quickly… while a bipolar adult may change moods weekly or monthly, children can change moods several times a day. • Seen more and more by prehospital providers when parents call 911 for children and teens who are threatening suicide or in a manic crisis.

26. Common Bipolar Medications(don’t be surprised, all are used for both children and adults) • Mood Stabilizers – include Lithium, Lamictal, Depakote, Trileptal, Tegretol • Many mood stabilizers were originally developed as seizure medications. • If patient on Depakote, Trileptal or Tegretol, ask if they are being taken for seizures or for bipolar disorder. • Lithium, some others, require close monitoring of blood levels to avoid toxicity • Atypical Antipsychotics – include Abilify, Risperdal, Zyprexa, Seroquel, Geodon • Linked to obesity and Type II diabetes in many users. • Also used for schizophrenia, ADHD, autism, aggression and dementia

27. More Bipolar Medications • Older Antipsychotics – Haldol, Thorazine, still seen in the hospital setting • Antidepressants – sometimes prescribed for bipolar adults during depressed periods. • No matter what a bipolar patient is taking, medication compliance a problem • Many of these drugs cause side-effects that are almost as bad as being bipolar.

28. How Can You Treat a Patient With Depression or Bipolar Disorder? • It’s the law… if the patient threatens harm to him/herself or others, he/she must be taken to the hospital (more on that later). • Follow the Region VII SMO’s for psychiatric and behavioral emergencies. • We are not psychiatrists, no matter how much Dr. Phil we watch. • This is NOT the time for in-depth interviews, telling the patient to take a “big boy pill”, telling him all will seem better tomorrow. • Just listen, express empathy, keep your patient and yourself safe, and treat any medical conditions.

29. Some other common psychiatric/behavioral issues…

30. Anxiety and Related Disorders • Anxiety • Apprehension, worry about real/perceived future threats • Phobia • Intense fear of object/situation • Generalized anxiety disorder (GAD) • Not controlled • Prolonged stress symptoms • Post traumatic stress disorder (PTSD) • Witnessing something terrible • “Shell-shock”

31. Panic Attacks • Panic attack • Sudden, paralyzing anxiety reaction • Often comes in as a chest pain or trouble breathing call, due to hyperventilation. • Also may have feeling of terror, nausea, diaphoresis, lightheadedness, dizziness. • Hyperventilation may lead to hand, foot cramps. • May come on suddenly, with no obvious cause, or may be triggered by event • sudden shock, closed spaces, heights, emotional event

32. Treating Anxiety Disorders • Don’t ignore possible medical reasons for what seems like anxiety or panic attack. • Chest pain, fear, hyperventilation also possible heart attack signs! • Remove external stimuli (noise, lights, crowds). • Make eye contact, reassure the patient. • Attempt oxygen if the patient’s condition calls for it. • Region VII does not have SMO for “pseudo-mask”, paper bags or other non-oxygen treatments for hyperventilation. • When in doubt, ask medical control. • Medical control may also authorize Versed if the patient at risk of harming him/herself or others.

33. Schizophrenia • Description & definition • Paranoid • Frequent hallucinations • Delusions of persecution • Disorganized • Extreme disorders of thought • Disorganized speech • Severe social impairment • Catatonic • Movement disorders

34. Schizophrenia Causes • Genetic predisposition – more likely to be schizophrenic if one or both of your parents is. • Dopamine excess in brain • Brain abnormalities –from birth or injury • Affects 1 in 100 adults worldwide • More severe in men, earlier onset (older teen or young adult) • Blacks, 2 x general population

35. What To Do for a Patient with Schizophrenia • Assess, treat suicidal, homicidal ideations • Calm violent, distressing psychotic episodes • Transport to facility with previous records if possible, since patient may not be able to tell you much about him/herself.

36. Tardive Dyskinesia • Cause: long-term use of antipsychotic drugs • Degenerative neurologic disorder • Dopamine pathway suppression in brain by antipsychotic drugs • Causes repetitive movements of mouth, face • Rocking • Repetitive, involuntary motions of extremities

37. Tardive Dyskinesia • Epidemiology & demographics • 15-30% antipsychotic users – on the increase as antipsychotics gain favor for psychiatric disorders • Affects older women, blacks more

38. What Can You Do? • Not much. You are likely to be called if the involuntary movement causes a fall or other injury, so treat the injury and transport. • In the hospital… • Lowering dose helpful, but no cure, and can cause psychiatric symptoms to return

39. Restraints • Law says if patient is threat to themselves or others, you need to take them to the hospital. • Sometimes, despite best efforts, you will need to use restraints to get this accomplished. • Restraints are last-resort. But if they are needed…. learn how to do it right.

40. Restraint Types • Foley-type restraints – soft restraints, required to carry by IDPH. • Practice using them. Chaotic call is not good time to mess with unfamiliar restraints.

41. Restraint Types • Leather restraints • More common in hospitals, but you may be asked to help with them in the ER.

42. Restraint Types • “Homemade” • Your body • Kerlix • Tape • Blankets • Pillow cases, etc • None approved for long-term restraint use. • Per Region VII SMO’s, “At no time will towels, washclothes or other devices be placed over the mouth and/or nose of restrained patient for any reason.”

43. Restraint Types • Police handcuffs • Patients must be handcuffed by police, not by paramedics. • Per Region VII SMO’s, police officer MUST accompany handcuffed patient in ambulance • Or give EMS personnel the keys. • Handcuffed patients may not be face-down on cot. • Lateral recumbent position may be more comfortable, if airway not compromised.

44. Restraint Documentation • Document continuous airway assessment after application of restraints. • Document whether restraints applied over or under clothing. • Document restraints were not placed over patient’s chest or the abdomen of a pregnant patient. • Document routine medical care and neuro-checks done distal to the restraints before and after applied. • Document neuro rechecks every five minutes distal to restraints.

45. Restraint Documentation Cont… • Document reason for restraints (and alternatives attempted), time of application, type of restraints, how applied. • Document position of patient (supine, lateral recumbent) after restraint application. • Document, document, document!!!!!! • Remember: proper restraint use and documentation will save your license in court!

46. And now, what you really have been waiting for…. Psychiatric Petitions

47. Patients who don’t need to go Adult psychiatric patients who are… • Alert • Oriented, • Answer questions appropriately • And are no danger to themselves or others …have the right to refuse care. Must sign refusal like anyone else, mental status must be completely documented on PCR.

48. When Do They Have to Go? Patients who… • display an inability to make a rational judgment • pose a threat to themselves or others …may be treated/transported despite their refusal.

49. So Who Has to Take Them? • Illinois law says police can take pt. into custody and transport them to hospital for mental health reasons. • Unfortunately, some police have fallen into habit of always calling ambulance to transport psych patients. • This makes sense if the patient has medical complications, such as a drug overdose. • But we tend to get called whether or not medical issues are involved.

50. 405 ILCS 5/3-606    Sec. 3‑606. “A peace officer may take a person into custody and transport him to a mental health facility when the peace officer has reasonable grounds to believe that the person is subject to involuntary admission and in need of immediate hospitalization to protect such person or others from physical harm. Upon arrival at the facility, the peace officer may complete the petition under Section 3‑601. If the petition is not completed by the peace officer transporting the person, the transporting officer's name, badge number, and employer shall be included in the petition as a potential witness as provided in Section 3‑601 of this Chapter.”