Behavioral Emergencies

1. Behavioral Emergencies Trinity EMS

2. Behavior The manner in which a person acts. Behavioral Emergency – when a patient’s behavior is not typical for the situation; when the patient’s behavior is unacceptable or intolerable to the patient, his family, or the community, or when the patient may harm himself or others.

3. Physical Causes of Altered Behavior There are many medical and traumatic conditions that are likely to alter a patient’s behavior. These may include: Low blood sugar Lack of oxygen Inadequate blood to brain or stroke Head trauma Mind-altering substances Excessive cold Excessive heat

4. When dealing with someone who appears to be having a behavioral emergency, always consider the possibility that his unusual behavior is caused by something other than a psychological problem.

5. Psychiatric Emergencies The is a wide range of psychiatric problems. One patient with a psychiatric condition may be with withdrawn and not wish to communicate while another may be agitated, talkative, or exhibiting bizarre behavior or threatening behavior. Some patients may act as if they wish to harm themselves or others.

6. Identify yourself and your role. Speak slowly and clearly. Use a calm and reassuring tone. Listen to the patient. You can show you are listening by repeating part of what the patient says back to him. Do not be judgmental. Show compassion, not pity. Use positive body language. Avoid crossing your arms or looking uninterested.

7. Acknowledge the patient’s feelings. Do not enter the patient’s personal space. Stay at least 3 feet from the patient. Making the patient feel closed in can cause an emotional outburst. Be alert for changes in the patient’s emotional status. Watch for increasingly aggressive behavior and take appropriate safety precautions.

8. Patient Assessment To assess a patient who appears to be suffering a behavioral or psychiatric emergency: Perform a careful scene size-up. Identify yourself and your role. It may be obvious to the patient who you are and what you intend to do. Complete an initial assessment, including assessment of the patient’s mental status (level of responsiveness; orientation to person, place, and time).

9. Perform as much of the focused and detailed examination as possible. Be alert for medical and traumatic conditions that could be causing the patient’s behavior. Gather a thorough patient history. This will alert you to past psychiatric problems, psychiatric medications, the patient may be taking (or not taking – causing the outburst). This may also alert you to conditions such as diabetes that can closely mimic a psychiatric condition.

10. Common presentations, or signs and symptoms, of patients experiencing psychiatric emergencies include: Panic or anxiety. Unusual appearance, disordered clothing, poor hygiene. Agitated or unusual activity, such as repetitive motions, threatening movements, or withdrawn stance. Unusual speech patterns, such as too rapid or pressured-sounding speech (as if being forced out), or inability to carry on a coherent conversation. Bizarre behavior or thought patterns. Suicidal or self-destruction behavior. Violent or aggressive behavior with threats or intent to arm others.

11. Patient Care Emergency care of a patient having a behavioral or psychiatric emergency includes: Be alert for personal or scene safety problems throughout the call. Treat any life-threatening problems Be alert for medical or traumatic conditions that could mimic a behavioral emergency. Treat conditions you identify (e.g., low blood sugar).

12. Be prepared to spend time talking to the patient. Use the skills listed earlier in dealing with the patient. Remember to talk in a calm, reassuring voice. Use positive body language and good eye contact. Avoid unnecessary physical contact and quick movements. Encourage the patient to discuss what is troubling him. Never play along with any visual or auditory hallucinations that a patient may be experiencing. Do not lie to the patient. If it appears it will help, involve family members or friends in the conversation. Evaluate the response of the patient to the presence of others. If it agitates the patient, ask the others to leave.

13. Suicide Each year thousands of people commit suicide. Suicide is the 8th leading cause of death. Suicide is the 3rd leading cause of death in the 15-24 year age group. Depression and suicide are also common in the senior citizen bracket.

14. People attempt suicide for many reasons: Depression caused by a chemical imbalance Death of a loved one Financial problems End of a love affair Poor health Loss of esteem Divorce Fear of failure Alcohol and drug abuse

15. Methods of choice: Drug overdose Hanging Jumping from high places Ingesting poisons Inhaling gases Wrist-cutting Self-mutilation Stabbing Shooting

16. Whenever you are called to care for a patient who has attempted or may be about to attempt suicide, your first concern must be your own safety. Not all patients will wish to harm you, but the mechanism used to attempt suicide will be capable of causing death. It could intentionally or accidentally be turned on you.

17. Patient Assessment Factors often associated with a risk for suicide are listed below. Although some or even all of them may be present in a patient, it is not possible to use these characteristics to predict who will or who will not commit suicide. Depression. Take seriously a patient’s feelings and expressions of despair or suicidal thoughts.

18. High current or recent stress levels. If so, take the threat of suicide seriously. Recent emotional trauma, such as job loss, loss of a significant relationship, serious illness, arrest, imprisonment. Age. High suicide rates occur at ages 15-25 and over age 40. The elderly are a population where suicide rates are increasing. Alcohol and drug abuse. Threats of suicide. The patient may have told others that he is considering suicide. Take all threats of suicide seriously.

19. Suicide plan. A patient who has a detailed suicide plan is more likely to commit suicide. Look for a plan that includes a method to carry out the suicide, notes, giving away personal possessions, or getting affairs in order. Previous attempts or suicidal threats, including a history of self-destructive behavior. Often patients who have attempted suicide on a previous occasion or considered to be “looking for attention” and are not taken seriously on subsequent attempts.

20. Sudden improvement from depression. A patient who has made the decision to commit suicide may actually appear to be coming out of a depression. The fact that the decision has been made and an end is in sight can cause this apparent “improvement.” You may find family members and friends of suicidal patients who will report that the patient had seemed “better” in the past few days.

21. Patient Care Potential or Attempted Suicide Treatment must begin with scene size-up. Make sure it is safe to approach the patient. Look for life-threatening problems to the extent that the patient will permit it. Perform focused history and physical exam if you suspect the patient has an injury. Perform ongoing assessment. Watch for sudden changes in the patient’s behavior and physical condition. Contact the ER and report on current mental status and other essential information.

22. Aggressive or Hostile Patients When a patient acts as if he may hurt himself or others, your first concern must be your own safety. Take the following precautions: Do not isolate yourself from your partner or other sources of help. Make certain that you have an escape route. Do not let the patient come between you and the door. Should a patient become violent, retreat and wait for police assistance.

23. Do not take any action that may be considered threatening by the patient. To do so may bring about hostile behavior directed against you or others. Always be on the watch for weapons. Stay out of kitchens. They are filled with dangerous weapons. Stay in a safe area until the police can control the scene. Be alert for sudden changes in the patient’s behavior.

24. Patient Care Follow these steps for the emergency care of an aggressive or hostile patient. Treatment begins with the scene size-up. Make sure it is safe to approach the patient. Request assistance from law enforcement before approaching if necessary. Practice BSI precautions. Seek advice from medical direction if the patient’s behavior prevents normal assessment and care procedures. As part of the ongoing assessment, watch for sudden changes in the patient’s behavior. Seek assistance from law enforcement, as well as from medical direction, if restraint seems necessary.

25. Restraining A Patient Be sure to have adequate help. Plan your activities. Estimate the range of motion of the patient’s arms and legs and stay beyond range until ready. Once the decision to restrain the patient has been reached, act quickly. Have one EMT talk to and reassure the patient throughout the restraining procedure. Approach with a minimum of four persons, one assigned to each limb, all to act at the same time.

26. Secure all four limbs with restraints approved by medical direction. Position the patient face up. NO PATIENT SHOULD EVER BE RESTRAINED FACE DOWN! Use multiple straps or other restraints to ensure that the patient is adequately secured. Anticipate that the patient’s behavior may turn more violent. If patient is spitting on rescuers, place a surgical mask on the patient if he has no breathing difficulty or likelihood of vomiting. Reassess the patient’s distal circulation frequently and adjust restraints. Use sufficient force, but avoid unnecessary force. Document the reasons why the patient was restrained and the technique of restraint.

32. Spider Straps and Backboard

33. Medical Legal Considerations: Patient must be a danger to himself or others. Cooperate with law enforcement personnel as they know the laws for detainment. Make sure you always have a witness in the back of the ambulance in case the patient makes false accusations (sexual assault, physical assault etc.)