CH 23 - Behavioral Health Emergencies

Define "behavior" in the EMS context

The way in which individuals interact with their environment.

List 5 possible causes of a behavioral crisis

Acute medical situation; mental illness; mind-altering substances; stress; other causes.

Do most behavioral emergency calls involve a patient with a diagnosed mental illness?

No — many behavioral emergency calls do not involve patients with a mental illness.

What often triggers a behavioral health emergency in an otherwise healthy person?

An extreme or dangerous reaction to a stressor.

Define mental illness

A chronic health condition involving changes in behavior, thinking, and/or emotion that significantly interferes with a person's ability to function in daily life.

What are 3 key features of mental illness?

Signs/symptoms present for several weeks or longer; may have a biologic cause; without treatment the patient may have trouble relating to people, holding a job, or caring for basic needs.

List 6 examples of mental illness

Schizophrenia, bipolar disorder, major depressive disorder, eating disorders, anxiety disorders, substance use disorders.

Define a behavioral health emergency

Any situation in which a person's behavior poses a threat to themselves or others, or prevents them from caring for themselves or functioning effectively.

In many communities, who acts as the default crisis response system?

Emergency medical services (EMS) and law enforcement.

What can integrated mental health crisis systems improve?

Patient outcomes; they also reduce justice system involvement and end the practice of psychiatric boarding in EDs.

What are the 3 core elements of a mental health crisis system?

A crisis call center, Mobile Integrated Healthcare (MIH), and crisis receiving/stabilization facilities.

What is 9-8-8?

The National Suicide Prevention Line, designed to assist people with behavioral crises including emotional distress, suicidal ideation, or problematic substance use.

What is Mobile Integrated Healthcare (MIH)?

A community-based intervention program (which EMTs may be part of) that includes clinicians capable of assessing a patient's needs wherever they are.

What does "no wrong door" access mean for crisis receiving facilities?

They accept referrals from EMS, law enforcement, other health care professionals, or walk-ins.

When assessing bizarre or abnormal behavior, what must you always consider?

That the person may be experiencing an underlying medical emergency or traumatic injury.

List conditions that can cause altered mental status and mimic a behavioral emergency (11)

Stroke; hypo-/hyperglycemia; traumatic brain injury; brain tumor; postictal seizure; drug or alcohol intoxication; poisoning/toxin exposure; sepsis; urinary tract infection (esp. geriatric patients); electrolyte imbalance; any condition reducing blood/oxygen delivery to the brain.

Who typically must make a psychiatric diagnosis?

A physician — a psychiatric diagnosis typically requires physician evaluation.

Define depression (major depressive disorder)

A condition that negatively affects a person's mood, with feelings of sadness, despair, and hopelessness that interfere with normal daily functioning.

How many symptoms, and over what time period, are needed to diagnose depression?

At least 5 of the listed symptoms over a 2-week period, not explained by other medical conditions.

List the 9 possible symptoms of depression

Depressed mood; greatly decreased interest/pleasure in activities; significant weight loss or gain; insomnia or excessive sleeping; motor agitation or slowing; fatigue/loss of energy; feelings of worthlessness or excessive guilt; decreased ability to think/concentrate/decide; thoughts of suicide.

What should you ask a patient with depression during history taking?

Whether they have thought about hurting or killing themselves.

What should you keep on hand to give depressed/at-risk patients?

A list of helpful numbers, such as the local crisis center, psychiatric centers, and the suicide and crisis lifeline (9-8-8).

Is depression a normal part of aging?

No — depression is not part of normal aging; it is a medical disease.

Which older adults are more likely to experience depression?

Those residing in long-term care facilities.

List 7 risk factors for depression in older adults

History of depression; chronic disease; loss of function, independence, or significant others; substance use disorder; isolation; prescription medication use; chronic medical conditions.

What age group has the highest suicide rate associated with depression?

Age 75 and older — depression in this group is associated with a higher suicide rate than any other age group.

Define bipolar disorder

A type of mental illness characterized by alternating periods of depression and manic episodes.

How long does a manic episode typically last?

A week or more.

List 7 possible symptoms of a manic episode

Exaggerated feelings of self-importance; little need for sleep or food; talkativeness or racing thoughts; distractibility; increased activity; increased impulsivity/reckless behavior; if severe, delusions or hallucinations.

What is the typical treatment for bipolar disorder?

Medications and psychotherapy.

How does suicide risk compare between bipolar patients and the general population?

Bipolar patients are at much higher risk than the general population for suicide.

When does schizophrenia typically have its onset?

Early adulthood, with symptoms becoming more prominent over time.

List 3 influences thought to contribute to schizophrenia

Genetics; brain chemistry or structure; social influences.

List 5 signs/symptoms of schizophrenia

Hallucinations and delusions; paranoia; lack of interest in activities/relationships; erratic, disorganized speech; flat affect (emotionless appearance).

List questions/warning signs to assess suicide risk (10)

Is the environment safe? Tearfulness/deep despair/hopelessness? Avoids eye contact, speaks slowly, seems vacant? Unable to talk about the future? Any suggestion of suicide? Specific plans related to death? Recently prepared a will? Evidence of self-destructive behavior? Underlying medical problem? Cultural/religious/social beliefs promoting suicide?

What should you determine regarding a suicidal patient besides risk?

Whether interventions such as restraints are needed.

A patient who is suicidal may also be…

Homicidal.

What is the most important service you can provide a suicidal patient?

Compassionate transport to a medical facility where they can receive proper treatment.

Suicide is the ___ leading cause of death for people ages 10-24

Second leading cause of death.

List common factors leading to teen suicide attempts (8)

End of a relationship; drug or alcohol use disorder; history of disciplinary problems; unstable home life; social pressures; peer approval; suicide pact; children of parents who died from suicide.

How should teen expressions/attempts of suicide be treated?

Always seriously — take action to ensure the teenager is evaluated by a professional.

Do geriatric patients typically make suicidal gestures before attempting?

No — geriatric patients typically do not make suicidal gestures.

Why might an older adult attempt suicide?

They may see no other way out when facing a terminal or debilitating condition.

Should you assume an older adult who threatens suicide won't carry it out?

No — never assume this; immediate intervention is necessary.

What can cause PTSD?

Exposure to, or injury from, a traumatic event, or repeated exposure to very unpleasant situations.

What percentage of the general population will experience signs of PTSD in their lifetime?

An estimated 7%.

Which groups have a high incidence of PTSD?

Military personnel who have experienced combat, and health care workers returning from warfare or disaster environments.

List the 4 core feelings associated with PTSD

Helplessness, anxiety, anger, fear.

List 6 behaviors common in people with PTSD

Avoid trauma reminders; suffer constant nervous system arousal; may feel numb or be hypervigilant; trouble sleeping; exaggerated startle response; relive trauma via intrusive thoughts, nightmares, or flashbacks.

What physiologic signs occur with the nervous system arousal of PTSD?

Increased heart rate, dilated pupils, increased systolic blood pressure; senses sharpened and mental acuity heightened.

Define dissociative PTSD

Occurs when the person attempts to find an escape from constant internal distress or a particularly disturbing event.

Is alcohol/drug use common in PTSD patients?

Yes, it is common, and these patients have an increased risk of suicide.

Are combat veterans more or less likely to self-harm?

Much more likely to harm themselves or try to harm themselves.

List physical conditions more common in combat veterans

Heart disease at a younger age; higher incidence of type 2 diabetes; loss of gray matter in the brain; unfocused pain not tied to a specific body part.

List tips for interacting with a combat veteran in crisis

Eliminate excess noise; don't touch or act without explaining first; keep diesel equipment/fumes away (possible trigger); ask "How do you want me to help you?" or "What is it you need right now?"

Define dementia

A slow, progressive decline in cognitive function that impairs memory and leads to behavior change; common cause of abnormal behavior in older adults.

What hostile behaviors can develop in Alzheimer disease patients?

Kicking, yelling, pinching, and hitting.

How should restraint be handled with a dementia patient?

Gently, if restraint is necessary.

Define delirium

An acute state of confusion that occurs suddenly and may fluctuate over short periods; may present with disorientation, hallucinations, delusions, or agitation.

Is delirium a disease itself?

No — delirium is not a disease itself, but rather a sign of an underlying problem.

How should a new case of delirium be treated, given its onset?

As a true emergency, because of its sudden, rapid onset.

What is "excited delirium" and is the term still used?

An older term for patients with extreme agitation; it is no longer used clinically. Current practice emphasizes identifying/treating the underlying condition (substance use, psychiatric disorder, or medical emergency).

Define substance use disorder (SUD)

A chronic, treatable medical condition characterized by uncontrolled use of substances (alcohol, opioids, stimulants, other drugs) despite harmful consequences.

List medical emergencies related to SUDs

Overdoses, withdrawal symptoms, respiratory depression, and altered mental status.

What does treatment of SUD-related emergencies include?

Stabilizing the patient, administering appropriate interventions, and connecting patients to long-term care resources.

Define psychosis

A disruption to a person's thoughts and perceptions that makes it difficult for them to recognize what is real and what is not.

Is psychosis a symptom or an illness?

A symptom, not an illness.

List 8 possible causes of a psychotic episode

Mind-altering substances or certain medications; genetics; intense stress; sleep deprivation; infection; traumatic brain injury; dementia; mental health conditions (schizophrenia, bipolar, depression).

Define hallucinations

False perceptions involving the senses of sight, sound, taste, smell, or touch.

Define delusions

False beliefs that persist despite incontrovertible evidence to the contrary.

Are most patients with mental illness or a behavioral health crisis dangerous?

No — most are not dangerous.

List 4 situations with increased potential for violence

Drug or alcohol intoxication; acute psychosis; involuntary treatment/transport situations; a behavioral crisis severe enough that someone called 9-1-1.

What should you do if signs of danger become apparent on scene?

Move to a safe location immediately and wait for law enforcement to intervene.

Is fleeing an unsafe scene considered patient abandonment?

No — fleeing an unsafe scene is not patient abandonment.

What are the first things to consider during scene size-up for a behavioral emergency?

Scene safety and the patient's response to the environment.

What should you note regarding medications/substances during scene size-up?

Any medications or substances that may have contributed to the patient's mental status or were prescribed for a relevant condition.

How should you begin your primary assessment approach with a behavioral patient?

From a distance/doorway; introduce yourself and explain you are there to help; maintain a safe distance at a 45° angle with a clear exit path until the situation is assessed.

What is the APVU scale used for?

Checking for alertness (Alert, Verbal, Painful, Unresponsive).

How can you determine if a patient's current behavior is normal for them?

Ask someone who knows the patient (family/friend).

What history-taking method should you use, and what should you ask about?

SAMPLE history; ask about previous episodes, treatments, hospitalizations, and medications related to behavioral problems.

Why is determining a patient's baseline mental status important?

It guides treatment/transport decisions and helps hospital personnel.

Define reflective listening

A technique of repeating, in question form, what the patient tells you, used to gain insight into the patient's thinking.

What vital signs/values should you pay special attention to in a behavioral patient?

Blood glucose level, oxygen saturation level, pupil size and reactivity — signs of conditions explaining altered mental status.

How can you assess a patient's emotional state if they don't respond to questions?

Observe facial expressions, pulse rate, and respirations.

What does a blank gaze or rapidly moving eyes suggest?

Possible central nervous system dysfunction.

How should a behavioral health patient be positioned for transport?

Comfortable but secured on the stretcher with all straps; Fowler or high Fowler position helps prevent aspiration and reduces exertion by relaxing abdominal muscles.

During reassessment/transport, should you ever let your guard down?

No — it is not possible to predict if a patient may become violent during transport; be prepared to intervene quickly with a plan in place with your partner.

What should you tell the receiving hospital in advance?

That a patient with a behavioral health emergency is coming in, and whether restraints will be required.

Why is thorough documentation critical in behavioral health emergencies?

There are serious legal concerns involving involuntary transport and restraint; documentation helps determine if involuntary admission is warranted and provides insight if the case is reviewed for medicolegal reasons. Document factually, note who reported suicidal statements, and use direct quotes when possible.

What should be attempted before physical restraint?

Verbal de-escalation techniques (consider asking family to help calm/reason with the patient).

List 5 effective de-escalation techniques

Showing empathy; practicing active listening; using open body language; controlling the volume/tone of your voice; validating the patient's feelings.

What are the two classifications of restraints?

Soft restraints and hard restraints.

Describe soft restraints

Constructed from nylon, neoprene, or other soft material; can be cut with relative ease (e.g., trauma shears).

Describe hard restraints and give examples

Cannot be removed easily, often require a key; examples include handcuffs, leather restraints, and flex cuffs (plastic ties); more likely to cause patient injury and generally avoided.

Why are locking restraint devices discouraged?

If the key is not immediately available during an emergency, the patient's safety could be jeopardized.

How many rescuers are ideally needed to restrain a patient, and how are roles assigned?

Five — each responsible for one extremity, plus one for the head; a team leader directs the process and one person secures the restraints.

What should never happen when applying restraints (body areas)?

No weight should ever be placed on the patient's chest, face, neck, or groin, and joints should not be manipulated beyond normal range of motion.

What is the role of the team member at the patient's head during restraint?

Grasp the sides of the patient's head and speak calmly to the patient throughout the process.

How should the patient's wrists be secured?

One wrist secured above the patient's head, the other secured downward along the patient's side.

Where should restraints be anchored on the stretcher?

To the "T-joints" along the stretcher's upper frame.