© 2011 National Safety Council 13-1 BEHAVIORAL EMERGENCIES LESSON 13

© 2011 National Safety Council 13-1

BEHAVIORAL EMERGENCIESLESSON 13


Behavioral Emergencies

• Process of giving emergency care may be complicated by patient’s behavior

• Many injuries and medical emergencies may cause altered mental status or emotional responses

• Patients may have emotional problems

• Patient may be a danger to self or others


Common Causes of Altered Behavior

• Situational stresses

• Illness or injury

• Psychiatric problems

• Not taking a prescribed psychiatric medication

• Low blood sugar

• Shock

• Inadequate blood flow to brain

• Head trauma


Common Causes of Altered Behavior (continued)

• Temperature extremes

• Poisoning or overdose

• Mind-altering substances, alcohol, drugs

• Seizure disorders

• Brain infection

• High fever


Assessing Behavioral Emergencies

• Perform standard assessment

• Assess mental status by observing:

- Appearance

- Actions

- Speech

- Posture and gait

- Orientation for time, person and place

- Mood, thought processes


Signs Violent Behavior May Occur

• Person holding weapon or something that can be used as weapon

• Person in threatening posture

• Person is verbally abusive, threatening


• Person agitated, uncontrollably elated, uncontrollably angry or kicking or throwing things

• Person known to be violent

• Hallucinations, paranoia

Signs Violent Behavior May Occur (continued)


Is Patient Dangerous?

• Self-destructive behavior or suicide attempts represent danger to the patient

• Threatening behavior, violence and the presence of weapons represent a danger to responders and others


Assessment for Suicide Risk

• How does the patient feel?

• Is the patient thinking about hurting or killing himself or herself or others?

• Does the patient have cultural or religious beliefs consistent with suicide or violence?

• Does the patient have a medical problem or trauma?

• Might the patient have a weapon?

• Is it safe to attempt an intervention?


Suicide Risk Factors

• Mental disorders (including depression)

• History of substance abuse

• Feelings of hopelessness

• Recent emotional crisis or painful illness

• Impulsive or aggressive tendencies

• Previous attempts

• More common in teenagers


Suicide Warning Signs

• Talking about suicide

• Comments about hopelessness or worthlessness

• Taking risks that could cause death

• Loss of interest in past activities

• Suddenly and unexpectedly seeming calm or happy after being sad


Emergency Care forBehavioral Emergencies

• Perform standard patient care

• Protect the patient and yourself

• Do not leave patient alone

• Consider need for law enforcement

• Be prepared to leave scene

• Give medications or drugs to arriving EMS

• Don’t assume patient is drug impaired


Emergency Care forBehavioral Emergencies (continued)

• Try to reduce any distressing stimuli at scene

• Always try to talk patient into cooperation

• Call for additional help if needed, including law enforcement if appropriate

• Avoid restraints unless necessary

• Calm and reassure patient


Calming a Behavioral Patient

• Approach slowly but purposefully

• Identify yourself

• Say you are there to help

• Ask patient for name, and use it

• Tell patient what you plan to do

• Treat patient with respect


Calming a Behavioral Patient (continued)

• Ask questions in calm, reassuring voice

• In cultures where acceptable, make eye contact

• Encourage patient to tell you what happened and what troubles him or her

• Show you care

• Rephrase or repeat what patient says



• Acknowledge patient’s feelings

• Maintain a comfortable distance

• Avoid unnecessary physical contact

• Avoid any posture that may seem threatening

• Do not make quick moves

• Respond honestly to questions

• Don’t belittle, threaten, challenge or argue

• Don’t “play along” with hallucinations

• Involve family members or friends



• Be patient, and be prepared to stay at scene for a long time

• Always remain with patient

• Call for additional help if needed


Victims of Abuse and Sexual Assault

• Child abuse, spouse abuse (domestic violence), elder abuse and sexual assault often cause injuries treated by EMRs

• These situations may also be behavioral emergencies

• Be sensitive to situation while providing medical care

• Report your observations to responding EMS personnel and in your run report

• Take special crime scene considerations


Domestic Violence

• Victim often does not report abuse to authorities

• Victim stays with abusing spouse or partner

• Signs of potential domestic violence:

- Patient seems unusually fearful

- Patient’s account of injury seems inconsistent or unlikely

- Patient is uneasy in presence of spouse or partner

- Patient’s spouse or partner aggressively blames patient


Emergency Care for Domestic Violence

• Provide emergency care as usual for injuries

• Ensure privacy for patient

• Tell responding EMS personnel in private about your suspicions

• Do not directly confront patient with suspicions, especially if spouse or partner is present

• Do not confront patient’s spouse or partner

• Try to involve a friend or family member of patient in care giving


Emergency Care for Domestic Violence (continued)

• Follow local protocol to report suspected cases to appropriate authorities

• If patient communicates information to you suggesting abuse, report this to responding EMS personnel and document it

• If appropriate, call for law enforcement personnel

• If necessary, withdraw from scene to ensure your safety


Sexual Assault and Rape

• Victim of sexual assault or rape may have other injuries

• Patient may or may not say what happened

• Be aware of likely psychological trauma

• Do not push for answers when taking patient’s history


Emergency Care forSexual Assault and Rape

• Be sensitive to patient’s psychological trauma

• Patient may be hysterical, crying, hyperventilating or in a dazed, unresponsive state

• Provide emotional support

• Ensure appropriate responders have been summoned

• Rape requires law enforcement personnel

• Ensure privacy for patient

• Try to involve a friend or family member of patient in care giving or EMS responder of same sex


Emergency Care forSexual Assault and Rape (continued)

• Ensure patient is not left alone

• Provide medical care as needed for any injury

• Preserve evidence of rape – ask patient not to urinate (unless necessary), bathe or wash before EMS personnel arrive


Restraining Patients

• If patient is danger to self or others

• Most EMRs do not restrain patients

• Restrain only if you have been trained and it is part of local protocol

• Before using restraint, have police present and work with responding EMS


Restraining Patients (continued)

• Avoid unreasonable force

- Use only as much force as needed to keep patient from injuring him or herself or others

- Use reasonable force to defend yourself

• Avoid acts or physical force that may injure patient


Reasonable Force for Restraints Depends On

• Patient’s size, strength and gender

• Patient’s abnormal behavior

• Patient’s mental state

• Method of restraint


Guidelines for Restraining

• Act only as you have been trained, following local protocol

• Ensure adequate personnel are present to help

• Plan approach you will use – then act quickly

• One responder should talk to patient throughout process

• Four responders approach together, 1 assigned to each extremity

• Extremities restrained with equipment approved by medical direction, avoiding unnecessary force


Guidelines for Restraining (continued)

• Do not restrain patient face down; maintain airway access at all times

• Assess patient’s breathing and circulation frequently

• Provide oxygen by non-rebreather mask if appropriate

• Once a patient is restrained, do not remove restraints

• Document indications and technique used


Legal Considerations in Behavioral Emergencies

• Patients may threaten or falsely accuse responders

• Document abnormal behavior factually

• Ensure others are present (witnesses)

• When possible, have same-sex responders provide care


Emotionally DisturbedPatients Resisting Treatment

• Get patient’s consent, witnessed by others

• If patient threatens self-harm or you believe this may occur, follow local protocol to provide care against patient's will if safe to do so

• Assistance of law enforcement usually required

Documents

© 2011 National Safety Council 13-1 BEHAVIORAL EMERGENCIES LESSON 13