Emergency Care Textbook Professional Responders-part-18.pdf

18 Crisis Intervention Key Content Psychological Crisis................. Suicide.................................. Assault.................................. Death and Dying.................. Mental Health Crises............... Anxiety................................. Depression.........................

18 Crisis Intervention Key Content Psychological Crisis................. Suicide.................................. Assault.................................. Death and Dying.................. Mental Health Crises............... Anxiety................................. Depression............................ Psychosis............................... 332 332 332 333 333 334 334 335 Introduction When responding to a stressful situation, minor variations in the way you provide care can help you to address the emotional needs of a patient or other person at the scene. While you should always follow your protocols and training, you might, for example, delay performing a non-critical intervention until the patient has been moved away from any bystanders. Empathy, professionalism, and creativity can help lessen the impact of a crisis on the people involved. CRISIS INTERVENTION As a responder, you will frequently encounter people in crisis. Serious injuries, sudden illnesses, and deaths have an emotional impact on everyone involved. The degree of impact varies from person to person. In some cases, the impact is minimal, and a person can accept and handle an injury or illness that results in hospitalization, disability, or even death. In other cases, even a minor injury can create an extreme emotional crisis. 331 The circumstances of the event (such as a sexual assault) can cause great emotional turmoil even if medical interventions are not necessary. Events such as an attempted suicide or self-inflicted injury can also cause great stress to a patient’s family and friends. Besides providing care for any specific injury or illness, you may also need to provide emotional support to a patient experiencing an emotional or psychological crisis. Being able to understand some of what the patient is feeling can help you cope with the situation. You should also be prepared to refer patients to emergency psychological counselling resources, such as a hotline that specializes in helping those in the patient’s situation. This can be as simple as finding an appropriate service ahead of time and keeping the telephone number with you. PSYCHOLOGICAL CRISIS Many different situations can result in a psychological crisis for a person. Emergency personnel often encounter incidents of attempted suicide, sexual or physical assault, or the sudden death of a loved one. Suicide Suicide is one of the leading causes of death among people aged 15 to 19, although it is also common among adults of all ages. Responding to suicide or attempted suicide can be especially disturbing for responders. If family or friends of the patient are present, they are likely to also be experiencing an emotional crisis. CRISIS INTERVENTION Assault 332 Assault can be physical, sexual, or both. It results in injury and, often, emotional distress to the person. Assault is a crime and should be reported to the police. If the victim is a child, the crime must also be reported to your provincial or territorial child protection service. SEXUAL ASSAULT Sexual assault occurs when someone is forced into any form of sexual activity without his or her consent. A sexual assault is a devastating experience for the patient. Patients often feel degraded, extremely frightened, and at further risk of attack. They require significant emotional support and should be referred to appropriate psychological counselling. Try to control your own reaction and focus on the emotional state and needs of the patient. Emphasizing the steps that should be followed can help reduce feelings of helplessness in the patient. Besides providing emotional support, you must care for any injuries the patient may have received. When caring for a patient who has experienced sexual assault: Cover the patient and protect him or her from unnecessary exposure. Have the patient interact with a responder of the same gender if possible. Clear the area of any bystanders, except friends or family who are able to provide emotional support (if the patient prefers their presence). Remove articles of clothing only if absolutely necessary to provide care for injuries. Discourage the patient from bathing, showering, or douching before a medical examination can be performed. Treat the area as a crime scene. Do not question the patient about the specifics of the assault beyond what is absolutely necessary for providing care. PHYSICAL ASSAULT Physical assault on a child, spouse or partner, or older adult occurs more frequently than reported. Unfortunately, when you are summoned, the assault has often resulted in more serious injuries. The emergency scene where a physical assault has occurred is not always safe. The attacker may still be present or nearby. If the scene involves domestic violence, it may not be clear what has happened. Remember that your first concern is your own safety. If you are not a law enforcement officer, do not approach the scene until it is determined to be safe. The scene is a crime scene, so do not handle items unrelated to the patient’s care. Reassure and comfort the patient while providing care. Death and Dying You may be summoned to an emergency in which one or more people have died or are dying. Although your responses will vary according to the situation, you must recognize that death will have an emotional impact on you, as well as on others who are involved. Be prepared to handle your feelings and be considerate of the feelings of others. Remember that reactions to death and dying vary greatly from person to person: The manner in which a person handles a situation will depend on both personal feelings about death and the nature of the incident. You must be professional while remaining empathetic and tactful. Respect that the people at the scene may have just experienced a life-changing event. Be cautious about what you say in situations in which the death of a patient seems probable. Avoid making statements about the patient’s condition to the patient or to family, friends, and bystanders. You can provide comfort by using positive statements such as: “We are doing everything we can.” Figure 18–1: Assuming a non-threatening posture and getting at eye level are examples of positive nonverbal communication. MENTAL HEALTH CRISES In any behavioural emergency, ensure the safety of responders and the scene first. You may need to take special precautions for concerns that pose a threat to you or other responders: Request additional resources as required by the situation. These could include law enforcement or local mental health or crisis centre personnel. While waiting for others to arrive, continue to talk with the patient. Never leave the patient alone unless there is a threat to your safety. Responding to an emergency involving a behavioural or psychiatric condition creates unique challenges. As a responder, it is not your responsibility to diagnose a psychiatric condition, just as you do not diagnose physical illnesses. After determining that the scene is safe, your most important responsibility is to identify and care for any injuries or illnesses the patient may have, and to reduce the risk of harm to the patient and others. The role of the responder is not to be a therapist but to provide support and to refer the patient to appropriate treatment and/or care. Use active listening and do not pass judgment. People who are upset or angry may express themselves in ways that might seem rude or antagonistic. Remember Next, identify and care for the patient’s potentially life-threatening medical conditions. If the patient has no obvious life-threatening conditions, take extra time to calm the patient and develop a rapport before proceeding with the rest of your assessment. Avoid making judgments or subjective interpretations of the patient’s behaviour. You may need to look beyond the obvious to determine the true nature of the problem. A proper secondary assessment will help you determine whether an underlying medical emergency exists and how to proceed. Transport decisions should be made in accordance with local CRISIS INTERVENTION Mental health crises are those in which the patient’s chief complaint is some disorder of mood, thought, or behaviour that is dangerous or disturbing to the patient or those nearby. that what the patient says is not directed at you and should not be taken personally. Be respectful, listen to the patient, and ensure that your nonverbal communication is positive (Figure 18–1). 333 protocols and any instructions from the medical director: Specialized protocols may exist for the transportation of patients with certain mental health conditions. Throughout management and transport, reassess the patient’s ABCs and mental status at frequent intervals. Continual reassessment of your patient’s mental state is critical, as rapid changes can occur that could put you or others at risk. Mental health conditions can cause physical signs and symptoms. For example, a person with an anxiety disorder may experience a panic attack, with signs and symptoms including hyperventilation, a rapid heart rate, and chest pain. Remember that a patient with a history of mental health conditions may experience injuries or illnesses unrelated to his or her psychiatric history. If care is required for a minor injury, try to get the patient to help you (Figure 18–2). By encouraging the patient to participate, you may help him or her regain a sense of control. Three common mental health conditions resulting in crises are anxiety, depression, and psychosis. Anxiety CRISIS INTERVENTION Anxiety is a term for mental disorders in which the dominant mood is fear and apprehension. A patient with an anxiety disorder may experience persistent, incapacitating anxiety in the absence of an external cause. There are several types of anxiety disorders, but panic disorders are most commonly encountered. 334 A patient with a panic disorder experiences panic attacks, which are unpredictable feelings of terror that strike suddenly and repeatedly. They can occur at any time, even during sleep. Signs and symptoms of panic attacks may include: Hyperventilation. Feelings of weakness or faintness. Chest discomfort. Dizziness. Rapid heart rate. Sweating. Nausea. Smothering sensations. Fear of losing control. Figure 18–2: Having a patient help care for his or her own injury may help provide a sense of regained control. Calming and reassuring the patient may be the only treatment necessary for a panic attack. Help the patient to take deep, controlled breaths, and listen to what he or she tells you. A complete medical history may be necessary to rule out the possibility of an underlying disease. For example, the rapid heart rate often associated with panic attacks or phobias may indicate a pulmonary embolism. Depression Major depression, also referred to as clinical depression, is a mood disorder. The patient may express feelings of worthlessness, hopelessness, guilt, and/or pessimism. Individuals with depression may also experience fatigue, a change in appetite with weight gain or loss, disruption of sleep patterns, and recurring thoughts of death or suicide. The patient may have difficulty concentrating or making decisions and may become restless or irritable. Depression can also be a response to a stressful event, such as the loss of a close friend or relative. Care for a patient with depression includes calmly talking to him or her. It may be possible to temporarily direct the patient’s thoughts away from topics that cause distress—for example, by asking about his or her interests or discussing topics of general interest (e.g., sports, weather). Individuals experiencing depression are at risk for suicide. Any statements about suicide attempts or suicidal ideation should be taken seriously, documented, and reported when care is transferred. If the patient is not being transported for additional assessment or treatments, offer to refer him or her for psychological counselling in the area. Psychosis Psychosis is a serious medical condition that reflects a disturbance in brain function. A person with psychosis experiences some loss of contact with reality, characterized by changes in his or her thinking, beliefs, perception, and/or behaviour. When a person can’t tell the difference between what is real and what is not, he or she is said to be experiencing a psychotic episode. For the person experiencing psychosis, the condition can be very disorienting and distressing. Aggressive behaviour can also arise from psychotic episodes. Before approaching the patient, assess the potential for violence. Request law enforcement personnel if necessary. Assessing a patient during a psychotic episode may be challenging. You may find that responses to your questions reveal bizarre or disorganized thought processes, memory disturbance, and an inability to concentrate. It may be difficult to reason with the patient or have him or her focus on your questions. One example of chronic psychosis is schizophrenia, which is a group of mental disorders that may present with distortions in language and thought. A patient with schizophrenia may also experience delusions, hallucinations, and social withdrawal. CRISIS INTERVENTION Signs and symptoms of psychosis may include: Loss of touch with reality. False beliefs. Hallucinations. Mania. Confusion or disconnected thoughts. Suicidal ideation. 335 SUMMARY Professional Responsibilities Provide emotional support. Cover the patient and protect him or her from unnecessary exposure. Have the patient interact with a responder of the same gender if possible. Clear the area of any bystanders, except friends or family who are able to help  provide emotional support (if the patient prefers their presence). Remove articles of clothing only if absolutely necessary to provide care for injuries. Discourage the patient from bathing, showering, or douching before a medical  examination can be performed. Treat the area as a crime scene. Do not question the patient about the specifics of the assault beyond what is  absolutely necessary for providing care. Responding to Physical Assault If you are not a law enforcement officer, do not approach the scene until it is  determined to be safe. Treat the area as a crime scene. Ensure your own safety as well as that of the patient and others. Reassure and comfort the patient while providing care. CRISIS INTERVENTION Responding to Mental Health Crises 336 Care for any life-threatening and minor injuries accordingly. Try to have the patient assist you when caring for minor injuries. Reduce the risk of harm to the patient, others, and yourself. Be respectful and practise active listening. Ensure positive nonverbal communication. Request additional resources as required by the situation. Never leave the patient alone unless your safety is at risk. Continually reassess the patient.