Behavioral Emergencies for the EMT Basic

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					Behavioral Emergencies
   for the EMT Basic
   Travis R. Welch, NREMT, PA-S
 EMS Director, Zionsville Fire Department

       Reference: Brady’s Fire Service Emergency Care
   Define Behavioral Emergencies (p.445)
   Discuss the general factors that may cause an alteration
    in a patient’s behavior (p. 448-449)
   State the various reasons for psychological crises (p.
    446, 448-449)
   Discuss behavior characteristics that suggest a patient is
    at risk for suicide (p. 448-449)
   Discuss special medicolegal aspects of managing
    behavioral emergencies (p. 450, 452-453)
   Discuss special considerations for assessing a patient
    with behavioral problems (p. 446-450)
   Discuss principles of behavior that suggest a patient is at
    risk of violence (p. 449)
   Discuss methods to calm behavioral emergency patients
    (p. 446-447, 449-450)
   Manner in which a person acts or performs; any
    or all activities of a person including physical and
    mental activities.
   Behavioral emergency-situation in which a
    patient exhibits abnormal behavior within a
    given situation that is unacceptable or
    intolerable to the patient, family or community
       Meaning of “given situation”
       Acceptable behavior is a reflection of the patient’s
       EMT must remain nonjudgmental
       Behavioral Changes
•General factors may alter a patient’s
  •Situational stresses
  •Medical illnesses
  •Psychiatric problems
  •Alcohol and drug intoxication/withdrawal
             Common causes

   Low blood sugar, particularly in Pts w/ DM
   Lack of O2
   Inadequate blood flow to brain
   Head trauma
   Mind-altering substances
   Excessive cold
   Excessive heat
     S/Sx of physiological causes of
        behavioral emergencies
   Unusual odors on the patient’s breath
   Dilated, constricted, or unequally reactive
   Rapid rather than gradual onset of
   Excessive salivation
   Loss of bladder control
   Visual rather than auditory hallucinations
    General guidelines for managing
        situational stress RXNs
              (such as fires, accidents or deaths)

   Act in calm manner
   Give patient time to gain control of
   Quietly and carefully evaluate the situation
   Keep your won emotions under control
   Honestly explain things to the patient
   Let the patient know that you are listening
    to what s/he is saying
   Stay alert for sudden changes in behavior
          Psychiatric Emergencies

   Types of psychiatric conditions
       Anxiety
       Phobia
       Depression
       Bipolar disorder
       Paranoia
       Schizophrenia
        Methods of calming patient
                      (Fig. 18-1, p. 446)

   Identify yourself and your role
   Speak slowly and clearly
       Use a calm, reassuring tone
   Show you are listening to the patient by
    rephrasing back parts of what s/he says
   Do not be judgmental. Show compassion
   Use positive body language
   Acknowledge the patient’s feelings
   Do not enter the patient’s space, stay about 3`
   Be alert for changes in the patient’s emotional
               Patient Assessment
   Common S/Sx
       Panic or anxiety
       Fear
       Agitated or unusual activity
       Unusual appearance
       Unusual speech patterns
       Depression
       Withdrawal
       Confusion
       Anger, often inappropriately directed
       Bizarre behavior or thought patterns
       Loss of contact with reality, hallucinations
       Suicidal or aggressive behavior with threats or intend to harm
        self or others
              Emergency Care
   Be alert for personal or scene safety problems
    during size up and during incident
   Treat any life threatening problems during
    primary survey
   Be prepared to spend time talking to patient an
    stay with patient
   Encourage the patient to discuss what is
    troubling them
             Emergency Care
   If it appears to help, involve family or
    friends in conversation
   As possible perform a focused H&P and
    provide necessary emergency care
   Perform a detailed PE only if it is safe and
    you suspect the patient may have an
   Consider restraints if necessary to keep
    the patient from harming himself or others
             Emergency Care

   If necessary transport the patient to the
    appropriate facility
   Perform ongoing assessment en route
   Contact the receiving hospital and report
    on current patient status including mental
              Special considerations
   Suicide
       Ideations can afflict people of any gender, age, race or SES
       Variety of reasons and/or methods may be involved
       First concern is responder safety
   Suicide Risk factors
       Depression
       Current or recent high stress levels
       Recent emotional distress/trauma
       Age-higher rates between 15-25 and >40
       Substance abuse
       Threats of suicide communicated to others
       Suicide plan
       Previous attempts or threats
       Sudden improvement from depression
              Special considerations
   Suicide emergency care
       Personal interaction is important
            Establish visual and verbal contact
            Avoid arguments
            Make no threats
            Show no indications of using force
       Ensure scene safety
            LEOs on scene?
            Do not leave patient unless due to responder risk
       Look for and treat life threatening injuries as possible
       Seek LEO assistance in restraining patient PRN
       Back off from scene PRN
       Transport all suicidal patients
             Special considerations

   Hostile or aggressive patients
       Possible causes:
          Trauma to CNS
          Metabolic disorders

          Stress

          Substance intoxication

          Psychological disorders
                 Special considerations

   Hostile or aggressive patients
       Signs
          Clues at scene
          Info provided by bystanders or other responders

          Patient’s stance or position in room (Fig. 18-2)

          Actions by patient
                Respond to people inappropriately
                Tries to hurt himself or others
                May have rapid pulse, respirations
                Usu. displays rapid speech and physical movements
                May appear nervous, anxious, “panicky”
            Special considerations
   Hostile or aggressive patients
          General precautions
               Do not isolate your self from partner or other sources of
               Do not take any action that may be considered
                threatening by patient
               Always be aware of surroundings and be aware of
                   Anything can be a weapon

                   Watch the patient's hands!

               Be alert for sudden behavior changes
               Maintain verbal or radio contact with other responders
                on the scene
  Reasonable Force and Restraint

•The force necessary to keep the patient from
injuring himself or others

•Reasonableness is determined by looking at all the
circumstances involved-patient’s size and strength,
type of abnormal behavior, mental status, and
available methods of restraint
   In many localities an EMT may not legally
    restrain a patient against his will
       Need for LEOs
       Make sure restraints used are humane
            Avoid handcuffs or flex-cuffs
            Follow local protocols
   If involved in restraint, follow these guidelines
       Be sure you have adequate help
       Plan the activities
       Estimate ROM of Pts arms and legs and stay out of
        that area until ready.
   Once the decision to restrain a patient has been
    made, act quickly
   One crew member should talk to and try to
    reassure the patient during the restraint
   Approach with a minimum of four people
   Secure all 4 limbs with restraints approved by
    medical direction
   Position the patient either face up or face down,
    remain alert to the danger of positional asphyxia
   Use multiple straps or other restraints to ensure
    the patient is adequately restrained
   If the patient is spitting on rescuers, place
    a surgical mask on the patient if he had
    no difficulty breathing, no likelihood of
    vomiting, and if local protocols permit
   Reassess the patient’s distal circulation
   Use sufficient force but avoid unnecessary
   Document the reason why the patient was
    restrained and the methods used.
   Guidelines
       Document observations in an objective and
        professional manner
       Describe behavior in exact terms
       Document the scene thoroughly
       Include statements to support your decision that the
        patient may have harmed himself or others
       Document use or suspicion of intoxicating substances
       Record evidence of illness or injuries
       Include names of LEOs, other members present,
    Medical-Legal Considerations
   If an emotionally disturbed patient can be
    persuaded to consent to care, legal problems
    can be greatly reduced
   How to handle the patient who resists treatment
       Know state laws and local procedures for treating
        patients without consent
       Involve medical direction and LEOs
       Involve mental health teams if available
       Avoid unreasonable force
       Take steps to avoid charges of sexual misconduct
       Have LEOs accompany potentially violent Pts to the
        hospital with EMS personnel
            What do you think?
   Can a severely emotionally disturbed patient or
    one with altered mental status/behavior sign a
    refusal of service form?

   Do DNRs apply in cases of suicide attempts?

   What might you be charged with if you restrain
    a patient without proper justification/approval?
     Any questions?

Take 10 minutes, then return for
 the second portion of tonight’s

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