Behavioral and psychiatric emergencies can be some of the most difficult calls a paramedic will need to handle. These are emergencies where the behavior of the patient interferes with activities of daily living (ADLs) primarily caused by depression or anxieties. Psychiatric emergencies exist when the abnormal behavior threatens a person’s safety, whether that person is the patient or someone else. Ultimately, however, the person calling for the ambulance has determined that this situation is beyond his or her ability to handle and has become an emergency. Now the paramedic will enter an already escalated situation that must be sorted out and handled safely for everyone on the scene. Skills with psychiatric emergencies are arguably more important than any of the other skills discussed thus far in the paramedic training because they can be the difference between calming the patient down and maintaining a safe, secure scene and having the scene escalate out of control and becoming increasingly dangerous and possibly putting the crew, patient, and bystanders at unnecessary risk.
This section first discusses the pathophysiologies and presentations of abnormal behavior and specific behavioral emergencies. Toward the end of the section, global assessment guidelines will be discussed for psychiatric patients, including communication techniques and crisis intervention skills. Medicolegal considerations for the psychiatric patient also will be discussed here. Finally, the section rounds out with a discussion on chemical and physical restraints for patients.
Most of the psychiatric illnesses or diagnoses that follow have their causes rooted in 1 of the following 4 broad categories.
Acute psychosis is characterized by a person being out of touch with reality in such a way that the person has his or her own internal, personal reality. The interaction of the common reality and the personal reality of a psychotic episode can either make the patient act out toward others in a violent or combative way or act withdrawn and possibly mute. Any of the reasons listed above can contribute to the onset of a psychotic episode. Patients present with disorganized thought and disorientation to any person, place, or time; however, these can be symptoms of any of a variety of ailments, not just the patient with psychosis.
A thorough assessment, particularly the part of the assessment that involves evaluation of the history of present illness and interrogation, is usually very difficult to obtain because of the disorganized thought patterns in a patient experiencing psychosis. The COASTMAP mnemonic is helpful to assess patients with any level of mental disorder, particularly psychosis.
Delirium differs from dementia in that dementia is a chronic, often irreversible problem. Delirium, on the other hand, tends to be acute; reversible; and tied to substance abuse, infection, or nutrient or electrolyte imbalance. Delirium can be agitated (sometimes referred to as hyperactive) or hypoactive in nature. The delirium is said to be agitated whenever the patient is active; this can be violent or combative actions, seizures, or simply walking around but unaware of surroundings. Some causes for this type of delirium include hypoxia, hypoglycemia, hallucinations, brain injuries, and often stimulant drug overdoses. Hypoactive delirium is generally an acute onset of altered mental status accompanied by a decrease in activity. Some conditions where hypoactive delirium may be seen include hyperglycemia, fever or hyperthermia, sedative or opiate overdoses, and hypothermia.
Suicide is the taking of one’s own life. Below is a list of factors that, if present, particularly if more than 1 is present, increases a person’s risk for attempting suicide. Patients contemplating suicide will develop a plan; if a patient ever communicates a clear plan, an attempt is nearly certain to happen. Evaluate every patient who complains of depression for suicidal ideation. Although it may seem like a bad idea to bring up suicide to the patient who is depressed, rest assured that the person most likely has already contemplated it, if not actually made an attempt at it; asking the person about it will give the person an opportunity to open up and possibly face the problems that are leading him or her down this pathway in the first place. When in the presence of these patients, remember to carefully evaluate the scene and continually be aware of the surroundings; if the person is willing to take his or her own life, there is often little hesitation in taking someone else along with them.
The risk factors for suicide are as follows:
This section will discuss the diagnoses a patient may have in his or her medical history that may impact the paramedic’s patient assessment.
Everyone has had their moments of extreme elation and joy accompanied by long bouts of sadness. But the person is not said to be manic or depressed, respectively, during these times. When it comes to mood disorders, people experience sadness with depression, for example, but they also have other symptoms accompanying the sadness or the elation, which together impact the person’s ability to function in society. Mood disorders can be unipolar, such as major depression or mania, or bipolar, where patients bounce back and forth between clinically significant mania and depression.
Mania is characterized by extreme joy or exaggerated happiness, which sounds like a great way to be except that it often is accompanied with hyperactivity and insomnia. These patients often are hyperactive to the point of not being able to concentrate, so they become easily distracted. They display nonlinear or tangential thinking, where thoughts and speech jump wildly from one topic to another, likely without a discernible connection.
For these patients, it is not always wonderful. They can get into trouble by becoming promiscuous, spending wildly, and often picking fights with people who question them or try to pull them down. This behavior is typically so boisterous and over the top that an ambulance is called at that time. The patient likely will not think anything is wrong, so you will need to talk to the person removed from any other distractions while avoiding a power struggle or being confrontational. If the patient will not agree to go, medical control can be contacted to see if the patient can be taken against his or her will because the patient is still usually well oriented to person, place, and time. No major treatment needs to be considered at this time.
Depression is far more common than mania and is a cause of disability in a broad swath of the population. Depression can sometimes be linked to one adverse event, or a couple of negative events in the patient’s life that happened in close succession; however, most clinically diagnosed depression is without identifiable cause. Symptoms of depression can be summarized with the mnemonic DEPRESSED:
Patients diagnosed with bipolar disorder often swing from one extreme to the other: manic for a period of time then back to normal for a period of time, then either back to manic or over to depression. Although there are some medications for this, triggers for each are not well understood. As a paramedic, understanding what this may mean for the overall treatment of the patient can help. Patients will not typically swing from one extreme to the other in the short period of time they are with the paramedics.
Neurotic disorders are a group of disorders characterized by excessive reactions to fear and apprehension. Anxiety or stress can help the average person through difficult situations or issues with unknown outcomes. Writing this book gave the author anxiety about finishing on time, but it did not prevent the author from working or living. People with neurotic disorders are completely unable to face fears and panic easily. Neurotic disorders include generalized anxiety disorder, panic disorder, and phobias.
In generalized anxiety disorder, the patient has anxiety or intense worry that is difficult to control and impacts day-to-day life. The patient finds it difficult to turn off the level of worry, resulting in an inability to make a decision because each possible result brings with it separate anxieties. For these patients, the best thing the paramedic can do for them is to approach them in a calm, reassuring, and confident manner. Seeing another person in control of the situation and receiving constant assurance that the outcome will be favorable will help temper the patient’s fears.
Phobias are fears that prevent people from behaving in a predictable fashion when encountered with the source of their phobia. Typically, the patient has a phobia of a particular object or situation, and the phobia tends to be isolated and not transmitted to other situations. As long as the patient does not encounter the phobia during interaction with the paramedics, he or she should be otherwise appropriate for the duration of contact. The ambulance, however, can be enough of an enclosed space for claustrophobics (those with a fear of enclosed spaces) to have an exacerbation of fear and anxiety. They may be able to be coached into accepting the space they are in by being told to look out the windows or to close their eyes and imagine an open field. They also may need a small dose of an anxiolytic, such as lorazepam, to make it through the trip.
Panic disorders are the ultimate form of anxiety-related issue. Panic attacks can come on out of the blue and prevent a person from performing ADLs; in extreme cases, it can prevent the patient from even leaving his or her home or other place of security because of an intense fear of the unknown. The signs and symptoms of a panic attack are rooted in sympathetic nervous system effects, which makes sense because the patient is preparing himself or herself for flight, though usually in a situation that would not be threatening to a person who does not suffer from panic attacks. The signs and symptoms include sweating, nausea (sometimes with vomiting, though less common), palpitations, chest pain, dizziness, weakness, shortness of breath and/or tachypnea, shakiness, and tension. When treating a patient having a panic attack, provide him or her with a quiet, stress-free environment where the patient and paramedic can talk quietly and calmly. Use the word safe often; frequently this is the most important thing a person with a panic attack needs to know. He or she may need to hear it over and over again during the transport, but this will help the patient gain control without needing pharmacologic intervention.
The 2 major types of eating disorders are bulimia nervosa and anorexia nervosa. Both disorders are largely seen in women, particularly of affluent communities where stereotypes of perfection are rewarded and need to be maintained. The woman does everything she can to achieve the thin appearance that is perceived and often competed for in such places.
Bulimia nervosa is a condition where the person eats as much as possible, often in a short amount of time. The consumption is seldom of a particularly nutritive variety—usually junk food. The patient will then purge his or her system, most often intentionally vomiting the entire contents back up within a relatively short period of time after eating. Some bulimics will use excessive amounts of laxatives or diuretics to help the purge.
Anorexia nervosa is characterized by a patient who eats extremely low quantities of food because of an intense fear of becoming overweight or an intense belief that he or she already is overweight. Career anorexics appear emaciated and have a body weight well below average for their age. They consume so few calories and often do not take vitamin supplements, so their health is compromised. They often can have weaker, thinner bones than others because of the lack of calcium in their diets. Women also experience amenorrhea (no menstrual periods).
In somatoform disorders, the patient is so convinced that he or she is sick that even a physician after running every test possible cannot convince the person that he or she is, in fact, well. Hypochondriacs fall into this category because they have an intense anxiety that they have a serious disease. Here, anxiety is the root of the problem, even though the person is concerned with the symptoms. In somatization disorder, another variety of somatoform disorders, the patient will offer multiple complaints but is concerned with meaning to his or her health. Finally, in patients with conversion disorder, the patient actually manifests a physical problem that has no other identifiable cause beyond the patient extensively believing it is happening.
Factitious disorder, also called Munchausen syndrome, is a condition where a person fakes actual symptoms, including physical signs of a problem. Although there is no physiologic reason for the symptoms, the patient is actually in control over the symptoms being displayed. The patient does this typically to try to get out of trouble with the law or get attention from people around him or her. There also is Munchausen syndrome by proxy, where a parent intentionally makes a child sick to gain attention. After a child is born, the attention bestowed on the mother subsides, and the child now garners the attention directly. The mother, essentially jealous, makes the child sick so that people can pity her and her situation.
Impulse control disorders are a family of disorders where the patient compulsively behaves in a generally unacceptable way where the patient cannot keep himself or herself from acting on an impulse. These include intermittent explosive disorder, kleptomania, pyromania, and pathologic gambling.
Assessment of the psychiatric patient during a behavioral emergency can test even the most skillful of paramedics because the assessment of this type of patient involves strong communication skills and getting the patient to open up to what is bothering him or her. It also can be a challenge to gain permission to treat the patient or take the patient to the hospital. Throughout the assessment, do not forget to be alert to clues of other problems that may be present that could be of serious consequence to your patient, such as shortness of breath, chest pain, or altered mentation beyond what caregivers identify as baseline for the patient based on his or her psychiatric history. This section will focus on communication techniques to use to not only assess the patient but also deescalate potentially explosive scenes or combative patients.
Psychiatric patients can present in a wide variety of ways. With that in mind, there can be a higher degree of unpredictability in their behavior, so it is worth taking some time to set ground rules for the patient’s behavior. This will help everyone be on the same page about what is and is not acceptable; it also helps the paramedic assert who is in charge in a friendlier manner. Once ground rules have been established, begin the assessment as for any other patient with open-ended, free response questions. The questions should be geared to allow the patient to tell the story in his or her own way and at his or her own pace. The patient then can begin to gain control over the situation while still providing valuable information. Open-ended questions also do not hint at possible answers that the patient can then select from.
Make the patient and his or her story the overall priority by demonstrating active listening skills. This can be accomplished by summarizing what the patient has already relayed while avoiding injecting personal feelings, biases, or judgment. The paramedic should be positioned to be able to look at the patient and so that the patient can see the paramedic; this can help decrease the patient’s anxiety and discomfort. Acknowledge the patient’s feelings displayed and help the patient express his or her feelings in a controlled and appropriate manner. Facilitation of further communication can be accomplished with simple phrases such as “I see,” or “go on,” and asking more nonleading questions such as “How did that make you feel?” or “What did you do then?”
The patient may stop and start the conversation, and silence on the part of the patient is not necessarily something that needs to be avoided or broken. Sometimes, the paramedic may be able to restart the conversation by commenting on something that was said earlier of particular concern or interest. If the conversation needs to be continued, try to accomplish that without sounding intrusive, nagging, or judgmental. The patient may say some things with which the paramedic does not agree or are simply untrue. These may be the result of the altered reality the patient is facing and should not be contradicted or argued; that said, the patient should not necessarily be substantiated or played into either. For example, perhaps there is an intravenous bag hanging from the ceiling of the ambulance, and the patient remarks about the bag, “It looks like that big condor is going to swoop down and kill us!” It may be tempting, in an effort not to play into the patient’s delusions, to simply say, “That’s just an intravenous bag. It’s not a condor!” This can spark an argument and escalate the situation. Perhaps it would be better to say, “I can see how that might look like a large bird, but it is an intravenous bag. Let me take it down and put it away so it cannot hurt us.” This legitimizes what the patient may, in fact, be seeing, provides him or her with real context to help establish common reality, and minimizes the patient’s fear overall.
Many patients will go to the hospital willingly, cooperating the whole time whether they request to be carried on the stretcher or walk to the ambulance themselves. A very few number of patients present a problem for the responders. Patients who need to go to the hospital for a psychiatric evaluation and become combative with the paramedics may need to be restrained for transport. Restraint should be performed only if the patient poses an immediate risk of harm to himself, herself, or others, not simply as a matter of course for the routine treatment of psychiatric patients. The minimum amount of force should be employed to restrain the patient.
Ensure that you have enough manpower to accomplish the task at hand. There should be 1 person for each limb at a minimum. The mere presence of that many people may be enough to have the patient acquiesce; other times it just hypes the person up even more. Law enforcement personnel should be involved in restraining a patient because they have had special training in this that EMS does not typically receive. Ensure that patient cannot get a hold of any weapons, either on your person or in the area where the restraint application will take place. This includes the police officer’s sidearm, whenever possible, which should not be accessible by the patient. When the team is ready to approach the patient, there should be at least 1 restraint for each extremity ready to be applied within reach of the patient.
Secure the patient in the supine position ONLY. Patients have died in the hands of EMS when they have been secured to the stretcher in the prone position, hog tied, or hobble tied (ankles tied together). Tie each leg and each wrist independently to the stretcher. Always use 4-point restraints in the prehospital environment. Once the restraints are secure, leave them tied until it comes time to move the patient at the hospital. During the act of restraining the patient, be aware of the behavior of the patient so that he or she does not bite you or a team member. If the patient is spitting, place a surgical mask over his or her mouth or sometimes, more appropriately, an O2 mask with O2 flowing.
Once the patient is restrained, continually monitor the patient’s status, especially the ABCs. The patient will not be able to move well if he or she vomits so always be prepared to suction the airway if needed. Recheck the restraints to make sure that they are tight enough to maintain restraint but not so tight that they are serving as a venous or, worse, an arterial tourniquet. Generally, the dorsalis pedis pulse and the radial pulse will be accessible to check.
Patients also may be restrained chemically in lieu of or in addition to the physical restraint method above. Employing a chemical restraint should be used only on the order of the medical control physician. Haloperidol is frequently used in patients older than 14 years old who are not known or suspected to be pregnant, but it comes with an increased possibility of side effects compared with benzodiazepines. The most common drugs used for chemical restraint include short-acting benzodiazepines, preferably lorazepam or midazolam, although diazepam is used whenever a patient may need to be sedated for a longer period of time.
Lorazepam can be administered 1–2 mg intramuscularly or intravenously, but in a patient who is combative, the intramuscular route is preferred for the initial route of administration. Midazolam also can be administered intramuscularly or intranasally at 0.2 mg/kg up to 10 mg total. Once adequately sedated, the patient can have an intravenous line established, and sedatives can be administered via the intravenous line. After a benzodiazepine is given to a patient, continuously monitor the patient for respiratory depression or compromise and be prepared to assist with ventilations.
Some patients having a psychiatric or medical emergency may need exceedingly high doses of a benzodiazepine to achieve sedation. Serotonin syndrome and neuroleptic malignant syndrome can each present as extremely violent patients requiring doses of benzodiazepines in excess of 5 times the normal dose to even begin to sedate the patient.