Silver Cross EMSSEMD CE

September 2013

EMDs need to give psychological support as well as emergency medical care instructions to callers

Factors contributing to behavioral changes Medical conditions Physical trauma Psychiatric illnesses Mind-altering substances Situational stresses

Use your All Caller Interrogation and Key Questioning to make sure that the scene is safe and gather information about the patient’s mental status, ABC’s and history.

Relay any pertinent information to responders and determine if police are needed.

PSYCHIATRIC/BEHAVIORAL PROBLEMS KEY QUESTIONS

1. Is the patient violent or threatening others? 2. Is the patient suicidal? YES? Go to SUICIDE Protocol being careful not to agitate patient 3. Does the patient have a history of mental problems? 4. If under a doctor’s care, does patient take any regular medications? Are they current and compliant? 5. Any drugs or alcohol involved?

PRE-ARRIVAL INSTRUCTIONS1. Send law enforcement to secure the

scene2. If caller is not patient, tell caller to

maintain a safe distance3. If caller is also patient, attempt to

maintain phone contact and build rapport

4. Call back if condition worsens prior to the arrival of emergency personnel

Behavioral emergencies are situations in which persons exhibit abnormal, unacceptable behavior that cannot be tolerated by the patients themselves or by family, friends, or the community.

Medical conditions Uncontrolled diabetes Respiratory conditions High fevers Infections Inadequate blood supply to the brain

Physical trauma Head injuries Injuries that result in shock and an

inadequate blood supply to the brain

Psychiatric illnesses Depression Panic Psychotic behavior

Mind-altering substances Alcohol A wide variety of chemical substances

Situational stresses Death of a loved one Serious injury to a loved one

State of emotional upset or turmoil Caused by a sudden and disruptive

event Most situational crises:

Are sudden and unexpected Cannot be handled by the person’s usual

coping mechanisms Last only a short time Can cause socially unacceptable, self-

destructive, or dangerous behavior

There are four emotional phases to each situational crisis. High Anxiety or Emotional Shock Denial Anger Remorse or Grief

People may not experience every phase, but they will experience one or more.

High anxiety is characterized by: Flushed (red) face Rapid breathing Rapid speech Increased activity Loud or screaming voice General agitation

Emotional shock is often the result of a sudden illness, accident, or sudden death of a loved one.

Emotional shock is characterized by: Cool, clammy skin A rapid, weak pulse Vomiting and nausea General inactivity and weakness

Refusal to accept the fact that an event has occurred

Your response: Allow the patient to express denial. Do not argue with the patient. Try to understand the emotional and

psychological trauma that the patient is experiencing.

Normal human response to emotional overload or frustration

May follow denial or may replace denial People may vent angry feelings at you.

Do not take the person’s anger personally. Be alert for violent actions towards responders.

Frustration and a sense of helplessness can often build to anger. Always be professional and remain calm.

Acceptance of the situation may lead to remorse or grief.

People may feel guilty or apologetic about their behavior.

Be a good listener!

Talk with the person. Introduce yourself. Ask the patient his or her

name. Ask what you can do to

help. Be honest, warm, caring,

and empathetic. Use a calm, steady voice

and provide honest reassurance.

Try not to let negative personal feelings interfere with your attempt to provide assistance.

Simple acts of kindness can provide comfort and reassurance.

Restatement Rephrasing a person’s own words and

thoughts and repeating them back Be honest and give the patient hope, but do

not give false hope.

Redirection Helps focus a patient’s attention on the

immediate situation or crisis Use redirection to alleviate a patient’s

expressed concerns.

Empathy Imagining yourself in another person’s situation and sharing his

or her feelings or ideas Empathy is one of the most helpful concepts you can use. Use a calm and caring approach.

Communication skills Identify yourself and let the patient know you are there to help. Inform the patient of what you are doing. (i.e. dispatching units,

etc.) Ask questions in a calm, reassuring voice. Allow the patient to tell you what happened—do not be

judgmental. Show you are listening by using restatement and redirection. Acknowledge the patient’s feelings. Assess the patient’s mental status.

Common occurrence in today’s society It takes several different forms:

Elder abuse Child abuse Spouse and domestic partner abuse

When dispatching to a domestic call: Maintain safety for all rescuers as well as for

the patient. Conduct effective questioning and pre-arrival

instructions as needed.

Physical signs and symptoms Broken bones Cuts Head injuries Bruises Burns Scars from old injuries Injuries in various stages of healing Internal injuries

Emotional symptoms Depression Suicide attempts Abuse of alcohol or drugs Feelings of anxiety, distress, and hopelessness

Abusers may be paranoid, overly sensitive, obsessive, or threatening.

If you suspect abuse, your responsibility is to maintain safety for the patient and responders. Try to separate the patient from the abuser. Try to keep from judging the patient. Send law enforcement to secure the scene.

Cycles of abuse Tension phase: The abuser becomes angry

and often blames the victim. Explosive phase: The abuser becomes

enraged and loses control as well as the ability to think clearly.

Make-up phase: The abuser makes promises, which are seldom kept.

Immediately attempt to establish verbal contact with the patient.

Check with the caller about the patient’s past history of violence.

Signs of potential violence History of violence Yelling or verbal

threatening Loud, obscene, or bizarre

speech Pacing, inability to sit still,

and protection of personal space

Abuse of drugs or alcohol

Many patients who fail at their first attempt will try to commit suicide again.

The underlying psychiatric disease is usually treatable.

Management Obtain a complete history of the incident. Determine whether the patient still has a weapon or

drugs on him or her. Support the patient’s ABCs. Provide pre-arrival instructions for the injuries or

conditions the caller reports. Do not judge the patient. Provide emotional support.

Severe form of anxiety People experiencing PTSD relive previous

traumatic experiences. Symptoms include:

Flashbacks Sleep disturbances Nightmares Depression and guilt

As an EMD, your job is to: Speak with the patient in a positive and supportive

way. Arrange for the patient to be transported to an

appropriate medical facility.

The psychological aspects of treatment are important.

You may have to delay all but the most essential treatment until a responder of the same sex as the patient arrives.

Your first priority is the medical well-being of the patient. Give instructions to treat any injuries the

person may have.

This controversial subject has become a hot topic in the law enforcement and EMS community in recent years.

In 2009, the American College of Emergency Physicians released a White Paper report which recognized this condition but organizations like the American Medical Association, World Health Organization and the American Psychiatric Association do not. Link to full article here:

http://www.academia.edu/1131068/ACEP_Excited_Delirium_White_Paper_-_Contribution_via_CA_Hall_MD_FRCPC

The following slides contain general information about this condition.

This disorder is usually drug-related (cocaine or "crack", PCP or "angel dust", methamphetamine, amphetamine), but can occur in non-drug users as well. 

The presentation of excited delirium occurs with a sudden onset, with symptoms of bizarre and/or aggressive behavior, shouting, paranoia, panic, violence toward others, unexpected physical strength, and hyperthermia.

Excited Delirium MnemonicN: Patient is naked and sweating from hyperthermiaO: Patient exhibits violence against objects, especially glassT: Patient is tough and unstoppable, with superhuman strength and insensitivity to painA: Onset is acute (e.g., witness say the patient “just snapped!”)C: Patient is confused regarding time, place, purpose and perceptionR: Patient is resistant and won’t follow commands to desistI: Patient’s speech is incoherent, often with loud shouting and bizarre contentM: Patient exhibits mental health conditions or makes you feel uncomfortableE: EMS should request early backup and rapid transport to the ED

It has been cited as a cause of sudden death in situations where individuals have been restrained or Tased after exhibiting bizarre and erratic behavior. Dopamine (important brain and CNS chemical) disturbances, drugs and/or underlying medical conditions may be contributing factors as well.

Recommended management includes: safety for responders, calming techniques, monitoring of vital signs, possible sedation (at medical control discretion) and rapid transport to the closest Emergency Department. Treat other signs and symptoms or injuries as needed.

AAOS Emergency Medical Responder Your First Response in Emergency Care,

5th Edition

Will County 9-1-1 EMDPRS

www.ExcitedDelirium.org

Journal of Emergency Medical Services, www.JEMS.com

American College of Emergency Physicians White Paper report