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National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Medicine
Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint.
National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Psychiatric
• Recognition of− Behaviors that pose a risk to the EMS provider,
patient, or others
• Assessment and management of− Basic principles of the mental health system
− Suicidal/risk
National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of
− Acute psychosis
− Agitated delirium
− Cognitive disorders
− Thought disorders
− Mood disorders
− Neurotic disorders
National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of (cont’d)
− Substance-related disorders/addictive behavior
− Somatoform disorders
− Factitious disorders
− Personality disorders
− Patterns of violence/abuse/neglect
− Organic psychoses
IntroductionIntroduction
• The mind and body are inseparable.− Illness affects a person’s behavior.
− Changes in mental state affect physical health.
Definition of Behavioral Emergency
Definition of Behavioral Emergency
• Most experts define behavior as the way people act or perform. − Overt behavior is generally understood by those
around the person.
− Covert behavior has hidden meanings or intentions.
Definition of Behavioral Emergency
Definition of Behavioral Emergency
• Behavioral emergency− Some disorder of
mood, thought, or behavior that interferes with ADLs
• Psychiatric emergency− Behavior that
threatens a person’s health or safety and the health and safety of another person
Definition of Behavioral Emergency
Definition of Behavioral Emergency
• A behavioral or psychiatric emergency is defined by the person who dials 9-1-1.
• It can be difficult to understand the patient’s confused and frayed feelings.
PrevalencePrevalence
• Average number of mentally unhealthy days for Americans has increased− 1993: 2.9 days/month
− Today: 3.5 days/month
• 45.1 million US adults with any mental illness in the past year
Medicolegal Considerations Medicolegal Considerations
• When behavior, speech, and thoughts are erratic, it can be difficult to communicate.− Spend time with the patient.
− Obtain consent when possible.
− Be clear in your explanations.
Causes of Abnormal BehaviorCauses of Abnormal Behavior
• Four broad categories− Biologic or organic in nature
− Resulting from the environment
− Resulting from acute injury or illness
− Substance-related
Causes of Abnormal BehaviorCauses of Abnormal Behavior
• Biologic or organic − Organic brain syndrome
− Conditions alter the functioning of the brain
Causes of Abnormal BehaviorCauses of Abnormal Behavior
• Environmental − Psychosocial and sociocultural influences
• When consistently exposed to stressful events patients develop abnormal reactions.
• Sociological factors affect biology, behavior, and responses to the stress of emergencies.
Causes of Abnormal BehaviorCauses of Abnormal Behavior
• Injury and illness − Illness results in
stress on coping mechanisms.
− Acute trauma creates stress. • Post-traumatic
stress disorder (PTSD)
Courtesy of Captain David Jackson, Saginaw Township Fire Department
Causes of Abnormal BehaviorCauses of Abnormal Behavior
• Substance-related − Alcohol
− Cigarettes
− Illicit drugs
− Other substances
Psychiatric Signs and Symptoms
Psychiatric Signs and Symptoms
• When mental health is challenged, mechanisms or behaviors work to return homeostasis.− Present as psychiatric signs and symptoms
Patient AssessmentPatient Assessment
• Assessment of the patient with a behavioral emergency differs from other methods. − You are the diagnostic instrument.
− The assessment is part of the treatment.
Scene Size-UpScene Size-Up
• Situations with a strong behavioral component may have a sudden and unexpected turn of events.− Determine whether it is dangerous to you and
your partner.
Scene Size-UpScene Size-Up
• The environment can give clues.− Social history
− Living conditions
− Availability of support
− Activity level
− Medications
− Overall appearance
− Attitude/well-being
Primary AssessmentPrimary Assessment
• Clearly identify yourself.
• Form a general impression.− Assess appearance, posture, and pupils.
− Limit the number of people around the patient.
− Stay alert to potential danger.
Primary AssessmentPrimary Assessment
• Airway and breathing− Assess the airway and evaluate breathing.
− Provide interventions based on your findings.
Primary AssessmentPrimary Assessment
• Circulation− Assess the pulse rate, quality, and rhythm.
− Obtain systolic and diastolic blood pressures.
− Evaluate for shock and bleeding.
− Assess the patient’s perfusion level.
Primary AssessmentPrimary Assessment
• Transport decision− Disturbed patients should see a physician.
− If a patient withholds consent, they may be taken against their will at the request of:• Police
• County mental health physician
Primary AssessmentPrimary Assessment
• Transport decision (cont’d)− The same applies to the use of forcible restraint.
• Law enforcement officers should be summoned.
• Consult medical command as necessary.
History TakingHistory Taking
• Mental status examination − Key part of
assessment
− Check each system using COASTMAP.
COASTMAPCOASTMAP
• Consciousness− Level
− Concentration
• Orientation− Year/month
− Location
• Activity− Behavior
− Movement
• Speech− Rate, volume,
flow, articulation, and intonation
COASTMAPCOASTMAP
• Thought− Is the patient
making sense?
• Memory− Recent
− Remote
− Immediate
• Affect and mood− Do the inner
feelings seem appropriate?
• Perception− “Do you hear
things others can’t?”
Secondary AssessmentSecondary Assessment
• Obtain vital signs.
• Examine skin temperature and moisture.
• Inspect the head and pupils.
• Note unusual odors on the breath.
Secondary AssessmentSecondary Assessment
• In examining the extremities, check for:− Needle tracks
− Tremors
− Unilateral weakness or loss of sensation
ReassessmentReassessment
• Routinely performed during transport
• Your radio report should include:− Medical and mental health history
− Medications prescribed
− Assessment findings
− Information from the mental status examination
ReassessmentReassessment
• Discuss with the hospital the need for restraints or medications.− If the patient is aggressive or violent, provide
advance notice to the emergency department.
Emergency Medical CareEmergency Medical Care
• If the erratic behavior could be caused by a medical disorder: − Treat that before presuming the behavior is due
to an emotional or psychiatric cause.
Communication TechniquesCommunication Techniques
• Begin with an open-ended question.
• Let the patient talk.
• Listen, and show that you are listening.
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Communication TechniquesCommunication Techniques
• Don’t be afraid of silences.
• Acknowledge and label feelings.
• Don’t argue.
• Facilitate communication.
• Direct the patient’s attention.− Confrontation
Communication TechniquesCommunication Techniques
• Ask questions.− Avoid “yes-no” or leading questions.
− Use “how” and “what” questions.
• Adjust your approach as needed.
Crisis Intervention SkillsCrisis Intervention Skills
• Be as calm and direct as possible.
• Exclude disruptive people.
• Sit down.− Preferably at a
45-degree angle
Crisis Intervention SkillsCrisis Intervention Skills
• Maintain a nonjudgmental attitude.
• Provide honest reassurance.
• Develop a plan of action.− Once the plan is
set, allow the patient to exercise some control.
Crisis Intervention SkillsCrisis Intervention Skills
• Encourage some motor activity.
• Stay with the patient at all times.
• Bring all medications to the hospital.
• Never assume that it is impossible to talk with any patient until you have tried.
Physical RestraintPhysical Restraint
• Improvised or commercially made devices
• Be familiar with restraints used by your agency.
• Make sure you have sufficient personnel.− Minimum of four trained, able-bodied people
Physical RestraintPhysical Restraint
• Discuss the plan of action before you begin.− Include law enforcement.
− Use the minimum force necessary.
− Don’t immediately move toward the patient.
Physical RestraintPhysical Restraint
• If the show of force doesn’t calm the patient, move quickly.− Grasp at the elbows, knees, and head.
− Apply restraints to all four extremities.
− The best position is supine.
Physical RestraintPhysical Restraint
• Never:− Tie ankles and
wrists together
− Hobble tie
− Place a patient facedown in a Reeves stretcher
• Once in place:− Don’t remove
restraints.
− Don’t negotiate or make deals.
− Place a mask over the face of a spitting patient.
Physical RestraintPhysical Restraint
• Continuously monitor the patient.
• Never place your patient face down.
• Check peripheral circulation every few minutes.
© Jones & Bartlett Learning. Courtesy of MIEMSS.
Physical RestraintPhysical Restraint
• Be careful if a combative patient suddenly becomes calm.
• Document everything in the patient’s chart.
• You may defend yourself against an attack.
Chemical RestraintChemical Restraint
• Use of medication to subdue a patient− Only use with approval from medical control
− Follow local protocols and guidelines.
Chemical RestraintChemical Restraint
• Haloperidol− Administered either IM or IV
− Should not be administered to: • Patients younger than 14 years
• Those with a suspected head injury
• Those who may be pregnant
Chemical RestraintChemical Restraint
• Benzodiazepines − Shorter-acting ones may be given intranasally.
− Only midazolam and lorazepam have reliable intramuscular absorption.
− Side effects are usually mild and easily treated.
Chemical RestraintChemical Restraint
• Closely monitor the patient’s:− Pulse rate
− Blood pressure
− Respiratory rate
• Be prepared to support ventilation.
Pathophysiology, Assessment, and Management of Specific EmergenciesPathophysiology, Assessment, and
Management of Specific Emergencies
• Many factors contribute to disturbances of behavior.
Acute PsychosisAcute Psychosis
• Pathophysiology− Person is out of touch with reality
− Occur for many reasons
− Episodes can be brief or last a lifetime.
Acute PsychosisAcute Psychosis
• Assessment− Characteristic: profound thought disorder
− A thorough examination is rarely possible.
− Transport the patient in an atraumatic fashion.
− Use COASTMAP.
Acute PsychosisAcute Psychosis
• Consciousness− Awake and alert
− Easily distracted
• Orientation− Disturbances
more common in organic disorders
• Activity− Most commonly
accelerated
• Speech− Neologisms
Acute PsychosisAcute Psychosis
• Thought− Disturbed in
progression and content
• Memory− Relatively or
entirely intact
• Affect and mood− Mood is likely to
be disturbed.
− Affect may reflect mood or be flat.
• Perception− Auditory
hallucinations
Acute PsychosisAcute Psychosis
• Management− Reasoning doesn’t always work.
− Explain what is being done.
− Directions should be simple and consistent.
− Keep orienting the patient.
Acute PsychosisAcute Psychosis
• Management (cont’d)− Before pharmacologic treatments, try:
• Maintaining an emotional distance
• Explaining each step of the assessment
• Involving people the patient trusts
Acute PsychosisAcute Psychosis
• Management (cont’d)− When methods fail, it may be appropriate to:
• Safely restrain the patient.
• Administer a medication to help the behavior.
Agitated DeliriumAgitated Delirium
• Pathophysiology− Delirium: a state of global cognitive impairment
− Dementia: more chronic process
− Patients may become agitated and violent.
Agitated DeliriumAgitated Delirium
• Assessment− Try to reorient patients.
− Perform a thorough assessment.
• Management− Identify the stressor or metabolic problem.
Suicidal IdeationSuicidal Ideation
• Pathophysiology− Suicide: any willful act designed to end one’s
life
Suicidal IdeationSuicidal Ideation
• Assessment− Every depressed
patient must be evaluated for suicide risk.
− Most patients are relieved when the topic is brought up.
Suicidal IdeationSuicidal Ideation
• Assessment (cont’d)− Broach the subject in a stepwise fashion.
− Higher-risk patients include patients who have:• Made previous attempts
• Detailed, concrete plans
• A history of suicide among close relatives
Suicidal IdeationSuicidal Ideation
• Management− Don’t leave the patient alone.
− Collect implements of self-destruction.
− Acknowledge the patient’s feelings.
− Encourage transport.
Patterns of Violence, Abuse, and Neglect
Patterns of Violence, Abuse, and Neglect
• Abuse and neglect− Assess the following:
• The patient
• The environment
• Other persons involved
− Document your findings, and report your concerns according to local protocols.
Patterns of Violence, Abuse, and Neglect
Patterns of Violence, Abuse, and Neglect
• Violence− Most angry patients can be calmed by a trained
person who conveys confidence.
− EMS personnel should prepare to deal with hostile or violent behavior.• Preventive action is best to ensure no harm.
Patterns of Violence, Abuse, and Neglect
Patterns of Violence, Abuse, and Neglect
• Identify situations with the potential for violence.− Preventive action starts with being prepared for
a possible violent encounter.
− Develop “survival awareness.”
Patterns of Violence, Abuse, and Neglect
Patterns of Violence, Abuse, and Neglect
• Warning signs include:− Posture: sitting tensely
− Speech: loud, critical, threatening
− Motor activity: unable to sit still, easily startled
− Clenched fists, avoidance of eye contact
− Your own feelings
Patterns of Violence, Abuse, and Neglect
Patterns of Violence, Abuse, and Neglect
• Management of the violent patient− Assess the whole situation.
− Observe your surroundings.
− Maintain a safe distance.
− Try verbal interventions first.
Mood DisordersMood Disorders
• Unipolar mood disorder: mood remains at one pole of the continuum
• Bipolar mood disorder: mood alternates between mania and depression
Mood DisordersMood Disorders
• Manic behavior− Patients typically have abnormally exaggerated
happiness with hyperactivity and insomnia.• Pressured and rapid speech
• “Tangential thinking”
• Grandiose and unrealistic ideas
Mood DisordersMood Disorders
• Manic behavior (cont’d)− Be calm, firm, and patient.
− Minimize external stimulation.
− If the patient refuses transport, consult medical control.
Mood DisordersMood Disorders
• Depression− Leading cause of disability in people 15- to
44-year olds
− Can occur in episodes with sudden onset and limited duration
− Onset can also be insidious and chronic.
Mood DisordersMood Disorders
• Depression (cont’d)− Diagnostic features (GAS PIPES)
• Guilt
• Appetite
• Sleep disturbance
• Paying attention
• Interest
• Psychomotor abnormalities
• Energy
• Suicidal thoughts
SchizophreniaSchizophrenia
• Typical onset occurs during early adulthood.
• Experience may include:− Delusions
− Hallucinations
− A flat affect
− Erratic speech
Neurotic DisordersNeurotic Disorders
• Collection of psychiatric disorders without psychotic symptoms− Includes anxiety disorders
• Mental disorders in which dominant moods are fear and apprehension
Neurotic DisordersNeurotic Disorders
• Generalized anxiety disorder (GAD)− Patient worries for no particular reason or
worrying prevents decision-making abilities.
− Treated with pharmacologic agents and counseling
Neurotic DisordersNeurotic Disorders
• Generalized anxiety disorder (GAD) (cont’d)− When dealing with a patient with GAD:
• Identify yourself in a calm, confident manner.
• Listen attentively.
• Talk with the person about their feelings.
Neurotic DisordersNeurotic Disorders
• Phobias− Unreasonable fear, apprehension, or dread of a
specific situation or thing• Simple phobias focus all anxieties on one class of
objects or situations.
Neurotic DisordersNeurotic Disorders
• Phobias (cont’d)− When managing a patient, explain each step of
treatment in detail.
Neurotic DisordersNeurotic Disorders
• Panic disorder− Sudden feelings of fear and dread
− If allowed to continue, panic attacks can cause severe lifestyle restrictions.• Agoraphobia: fear of going into public places
Neurotic DisordersNeurotic Disorders
• Panic disorder (cont’d)− Signs and
symptoms usually peak in 10 minutes.
Neurotic DisordersNeurotic Disorders
• Panic disorder (cont’d)− Separate from panicky bystanders.
− Provide a calm environment.
− Be tolerant of the disability.
− Reassure the patient.
− Give the symptoms a name.
− Help the patient regain control.
Substance-Related DisordersSubstance-Related Disorders
• Regarded on four levels: − Substance use
− Substance intoxication
− Substance abuse
− Substance dependence
• Determining the most effective treatment requires an integrative approach.
Eating DisordersEating Disorders
• Persons may experience severe electrolyte imbalances.
• Two thirds report anxiety, depression, and substance abuse disorders.
Eating DisordersEating Disorders
• Bulimia nervosa− Consumption of large amounts of food
− Compensated by purging techniques
Eating DisordersEating Disorders
• Anorexia nervosa− Weight loss jeopardizes health and lives
− Typical patient:• Decreased body weight based on age and height
• Intense fear of obesity
• Experience amenorrhea
Somatoform DisordersSomatoform Disorders
• Preoccupation with physical health and appearance − Hypochondriasis: Anxiety or fear that the person
may have a serious disease
− Conversion disorders: a physical problem results from faking a physical disorder
Factitious DisordersFactitious Disorders
• Patient produces or feigns physical or psychological signs or symptoms.− Symptoms are under voluntary control.
• Factitious disorder by proxy: a parent makes a child sick for attention and pity
Impulse Control DisordersImpulse Control Disorders
• Lack of ability to resist a temptation
• Examples include:− Intermittent explosive disorder
− Kleptomania
− Pyromania
− Pathologic gambling
Personality DisordersPersonality Disorders
• Maladaptive patterns of thinking about the environment and one’s self − Cause functional impairment or subjective
distress
• Be calm and professional.
Medications for Psychiatric Disorders and Behavioral Emergencies
Medications for Psychiatric Disorders and Behavioral Emergencies
• Patients may be taking any of several types of psychotropic drugs.
• During your assessment, determine:− Which medications have been prescribed
− Whether they are being taken
Psychiatric Medication TypesPsychiatric Medication Types
• Antidepressants− Combat the
symptoms of depressive illness
− Alter levels of neurotransmitters in the autonomic nervous system
Psychiatric Medication TypesPsychiatric Medication Types
• Antidepressants (cont’d)− Fluoxetine: the most commonly prescribed
• Side effects are minimal.
− Heterocyclic: used for major depression• Side effects are common.
Psychiatric Medication TypesPsychiatric Medication Types
• Antidepressants (cont’d)− Monoamine oxidase inhibitors: recommended
for atypical major depressive episodes• Potential side effects
Psychiatric Medication TypesPsychiatric Medication Types
• Benzodiazepines− May be prescribed for severe emotional distress
− Contraindicated in patients with:• Known hypersensitivity to benzodiazepines
• Acute, narrow-angle glaucoma
• First-trimester pregnancy
Psychiatric Medication TypesPsychiatric Medication Types
• Antipsychotics− Newer medications have less risk of adverse
effects and are more effective.• Known as atypical antipsychotic (AAP) drugs
− Relieve delusions and hallucinations.
− Improve symptoms of anxiety and depression.
Psychiatric Medication TypesPsychiatric Medication Types
• Antipsychotics (cont’d)− May cause metabolic side effects
− Cardiovascular effects depend on medication.
− May cause an acute dystonic reaction
− May cause atropine-like effects
Psychiatric Medication TypesPsychiatric Medication Types
• Amphetamines− CNS and PNS stimulants
− Help with ADHD.
− Raise systolic and diastolic blood pressure.
Psychiatric Medication TypesPsychiatric Medication Types
• Amphetamines− Psychological
effects depend on:• Dose
• Mental state
• Personality
− Results include:• Alertness
• Elevated mood
• Increased motor and speech activities
Problems Associated with Medication NoncomplianceProblems Associated with Medication Noncompliance
• Increases the likelihood that a person with mental illness will commit a violent act
• When obtaining medication history, include:− Previously prescribed medications
− Missed doses
Emergency Use of MedicationsEmergency Use of Medications
• Emergency use of medications are often required with violence.− The potential danger is too great not to
intervene.
Emergency Use of MedicationsEmergency Use of Medications
• Before administering chemical restraint, complete your assessment with:− A thorough understanding of the chief complaint
− Attention to allergies
− Medical and medication history
Pediatric Behavioral ProblemsPediatric Behavioral Problems
• 50% of childhood mental illnesses will present by age 14 years.− More likely to have
coexisting problems
− Difficult to diagnose
© Leah-Anne Thompson/ShutterStock, Inc.
Pediatric Behavioral ProblemsPediatric Behavioral Problems
• Mental status assessment is similar to that of an adult.− Exception: Consider developmental level.
• Abnormal findings are often related to adjustment disorders and stress.
Geriatric Behavioral ProblemsGeriatric Behavioral Problems
• Distress and pain may be caused by:− Exposure to new
experiences
− Alterations to routines
© Leah-Anne Thompson/ShutterStock, Inc.
Geriatric Behavioral ProblemsGeriatric Behavioral Problems
• Anxiety and depression are too often considered a “normal part of aging.”− Ageism: discrimination against older people
• Take stock of your own attitudes.
SummarySummary
• Behavioral emergencies can present unique challenges in patient management. Focus on reducing the patient’s stress without exposing yourself to unnecessary risks.
• A behavioral or psychiatric emergency is any reaction to events that interferes with activities of daily living.
SummarySummary
• Behavioral emergencies can be a temporary response to a traumatic event.
• Calls for behavioral emergencies have special medical and legal considerations.
• You have limited legal authority to require a patient to undergo care in the absence of a life-threatening emergency. Always involve law enforcement personnel when you are called to assist a patient with a severe behavior or psychiatric crisis.
SummarySummary
• If a patient poses an immediate threat, leave the area until law enforcement personnel secure the scene.
• Underlying causes of behavioral emergencies fall into four categories: biologic (organic) causes, causes resulting from the person’s environment, causes resulting from acute injury or illness, and causes that are substance related.
SummarySummary
• Psychiatric signs and symptoms occur when mental health is challenged and psychological mechanisms or behaviors mobilize to return the person’s mental state to homeostasis.
• Assessment of a disturbed patient differs from other assessment methods in that you are the diagnostic instrument. Assessment is also part of the treatment.
SummarySummary
• When providing care, be direct, honest, and calm; have a definitive plan of action; stay with the patient at all times; and express interest in the patient’s story.
• When sizing up the scene, pay special attention to potential dangers and objects that may be used as potential weapons, hazardous chemicals, etc. Remove potentially harmful objects.
SummarySummary
• Primary assessment includes identifying yourself, forming a general impression of the patient’s condition and the nature of the problem, assessing the ABCs, making a decision about transport, and taking a history via the mental status examination.
• Secondary assessment involves looking for signs of an organic cause of the behavioral emergency.
SummarySummary
• Management is focused on ensuring scene safety and maintaining awareness of life-threatening conditions, while treating the patient for any medical disorders.
• Effective communication techniques include beginning with an open-ended question, showing that you are listening, allowing silence when appropriate, avoiding argument, facilitating communication, and asking questions.
SummarySummary
• Crisis intervention skills include staying calm and being direct, excluding disruptive people from the scene, maintaining a nonjudgmental attitude, developing a plan of action, encouraging motor activity, and assuming that the patient can hear and understand everything you say.
• Use of chemical or physical restraints is reserved for times when verbal intervention fails to reduce severe agitation.
SummarySummary
• Pathophysiologic factors that contribute to behavioral disturbances include cognitive impairment, thought disorders, mood disorders, neurotic disorders, substance-related disorders and addictive behavior, somatoform disorders, factitious disorders, impulse control disorders, and personality disorders.
SummarySummary
• You may encounter patients with psychosis, a thought disorder characterized by a statue of delusion in which the person is out of touch with reality.
• You may encounter patients with agitated delirium. This is impairment of cognitive function that can present with disorientation, hallucinations, or delusions, and is characterized by restless and irregular physical activity.
SummarySummary
• The threat of suicide requires immediate intervention. Depression is the most significant risk factor for suicide.
• Situations involving violence, abuse, and neglect can have the potential for escalation and the possibility of evoking emotional responses in you.
SummarySummary
• Patients with psychiatric emergencies may be taking any of several types of psychotropic drugs. During assessment, determine which medications have been prescribed and whether the patient is actually taking them.
CreditsCredits
• Chapter opener: © Mark C. Ide
• Backgrounds: Orange—© Keith Brofsky/Photodisc/Getty Images; Blue—Jones & Bartlett Learning. Courtesy of MIEMSS; Blue—Courtesy of Rhonda Beck; Green—Courtesy of Rhonda Beck; Purple—Courtesy of Rhonda Beck.
• Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.