Behavioral Emergencies Chapter 24

Scenario

• A 45-year-old woman, recently widowed, hasn't been seen by neighbors for three days.
• Neighbors reported the woman as being very depressed.
• Police and EMS were called to check on her.
• The woman's demeanor was observed as problematic.

Patient

• A slide displayed an image of the patient.

What Will You Do?

• This is a question posed.

Chapter 24: Behavioral Emergencies

• This is part of a chapter on the subject.

Overview

• Behavior: Behavior is how a person acts or performs, encompassing all physical and mental activities. Many factors influence behavior, including culture, stress, and psychology.
• Behavioral Emergency: A behavioral emergency arises when abnormal behavior poses potential harm to the individual or others, or is deemed unacceptable by the person, family, or community.
• Conditions Affecting Behavior: These include low blood sugar, lack of oxygen, inadequate blood flow to the brain, head trauma, excessive heat or cold, and mind-altering substances.
• Psychological Crises: This may include panic, agitation, bizarre thinking, paranoia (believing someone is plotting against you), mania (agitated and rapid speech/movement), depression (unwilling to engage or move), self-destructive behavior (like suicide), and threats or violence to others.
• Suicidal Gestures: Thoughts of death or taking one's life are considered a suicidal gesture. EMT-Basics must recognize and intervene in self-destructive behavior before the act of suicide.

Risk Factors for Suicidal Gestures

• Individuals over 40.
• Single, widowed or divorced individuals.
• Alcoholics.
• Depressed individuals.
• Individuals with a defined, lethal plan of action, verbalized.
• Unusual gathering of items capable of causing death.
• Previous history of self-destructive behavior.
• Recent diagnosis of serious illness.
• Recent loss of a significant loved one.
• Arrest or imprisonment.
• Loss of job.
• Previous episodes of self-harming acts.
• Previous history of severe or repeated psychological issues.

Review Questions

• Define behavior: Behavior is how a person acts or performs, encompassing all their physical and mental actions.
• Risk factors for suicide: Previous destructive behavior and being recently widowed are considered risk factors.

Assessment and Emergency Care

• Scene Size-Up: Assess the patient's environment for safety, including if they are holding unsafe objects. Assess for self-destructive behavior during the initial assessment.
• Signs of Potential Violence: Signs include sitting on the edge of a seat, clenched fists, yelling or using profanity, moving or standing towards an EMT, throwing things, holding a potentially dangerous object, and unusual behavior making the EMT uneasy or uncomfortable.
• Focused History and Physical Exam: Determine how the patient feels, assess for suicidal tendencies, if they are a threat to themselves or others, if a medical issue is present, and if prior interventions have been attempted.
• Assessment of Potential Violence: Check with family or bystanders to find out if the patient has a history of aggression or combativeness. Note the patient's posture and if they are in a position threatening themselves or others, note use of aggression or combativeness (clenched fists, objects), vocalizations indicative of intent to harm. Assess the patient's physical activities, and observe if they are moving towards caregiver and carrying heavy or threatening objects. Muscles should be noted.

Communication and Emergency Care

• Scene Size-up, Personal Safety: Prioritize the scene's safety for yourself.
• Patient Assessment: Evaluate the patient.
• Calm the Patient: Calm the patient without judgment.
• Do Not Leave Alone: Do not leave the patient alone.
• Restraints: Restraint should be used cautiously if the patient is a risk to themselves or others. Always have law enforcement present if possible.
• Consider Need for Law Enforcement: Determine if law enforcement is required or needed.
• Principles for Assessing Behavioral Emergency Patients: Principles include identifying yourself, informing the patient what you're doing, employing a calm, reassuring voice, allowing the patient to speak without being judged, showing you understand them through rephrasing or echoing, and acknowledging the patient's feelings.
• Assessing Mental Status: Evaluate the patient's appearance, activity, speech, and orientation regarding time, place and person.
• Overdose: If an overdose, retrieve any medications or drugs.

Calming the Patient

• Maintain a comfortable distance from the patient.
• Encourage the patient to articulate their concerns.
• Respond honestly to the patient's questions.
• Do not threaten, challenge, or argue with troubled patients.
• Tell the truth; do not lie to the patient.
• Do not "play along" with visual or auditory disturbances of the patient.
• Include trusted family members or friends, if appropriate.
• Be prepared to remain on site for an extended period of time.
• Avoid unnecessary physical contact; call additional help if needed.

Restraints

• Restraints should only be used if the patient is a danger to themselves or others. Police presence, when possible, and medical approval are required.
• Techniques involve using only necessary force, estimating the patient's range of motion, planning actions, and acting quickly.
• Approach with appropriate staff, assigning one staff member to each limb.
• Secure limbs together using approved medical equipment.
• Secure the patient to a stretcher with multiple straps.

Medicolegal Considerations

• Consent: Determine if the patient is capable of making decisions; if so, obtain their consent.
• Resistance to Treatment: Disturbed patients frequently resist treatment and may threaten EMTs and bystanders.
• Providing Care Against Will: Justification is required to provide care without consent. If the patient poses a threat to self or others, contact medical direction after assessing and before using force.
• Law Enforcement: Law enforcement is generally involved in situations where care must be provided against the patient's will.

Summary

• Behavior, Changes, Crises, and Gestures: Covers behavior changes (or crises), suicidal gestures.
• Assessment/Emergency Care: This section discusses assessment and care including scene size-up, communication with patient, calming, and restraints.
• Medical/Legal Considerations: Consent, resistance to treatment, use of force and documentation fall in this section.