BEHAVIORAL EMERGENCIES

1. LESSON 13 BEHAVIORAL EMERGENCIES

2. 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

3. 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

4. Common Causes of Altered Behavior (continued) • Temperature extremes • Poisoning or overdose • Mind-altering substances, alcohol, drugs • Seizure disorders • Brain infection • High fever

5. 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

6. 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

7. Signs Violent Behavior May Occur (continued) • Person agitated, uncontrollably elated, uncontrollably angry or kicking or throwing things • Person known to be violent • Hallucinations, paranoia

8. 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

9. 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?

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Calming a Behavioral Patient(continued) • 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

17. Calminga Behavioral Patient(continued) • Be patient, and be prepared to stay at scene for a long time • Always remain with patient • Call for additional help if needed

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. Reasonable Force for Restraints Depends On • Patient’s size, strength and gender • Patient’s abnormal behavior • Patient’s mental state • Method of restraint

28. 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

29. 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

30. 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

31. 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