West Coast EMT Chapter 23

Behavioral Crisis

The point at which a person's reactions to events interfere with activities of daily living; this becomes a psychiatric emergency when it causes a major life interruption, such as attempted suicide.

Behavioral Health Emergency

An emergency in which abnormal behavior threatens a person's own health and safety or the health and safety of another person - for example, when a person becomes suicidal or homicidal, or has a psychotic episode

Depression

A persistent mood of sadness, despair, and discouragement; may be a symptom of many different mental and physical disorders, or it may be a disorder on its own.

Excited Delirium

A serious behavioral condition in which a person exhibits agitated behavior combined with disorientation, hallucinations, or delusions; also called agitated delirium or exhaustive mania.

Functional Disorder

A disorder in which there is no known physiologic reason for the abnormal functioning of an organ or organ system.

Organic Brain Syndrome

Temporary or permanent dysfunction of the brain, caused by a disturbance in the physical or physiologic functioning of brain tissue.

Positional Asphyxia

Restriction of chest wall movements and/or airway obstruction; can rapidly lead to sudden death.

Posttraumatic Stress Disorder (PTSD)

A delayed stress reaction to a prior incident. Often the result of one or more unresolved issues concerning the incident, and may relate to an incident that involved physical harm or the threat of physical harm.

Psychiatric Disorder

An illness with psychological or behavioral symptoms and/or impairment in functioning caused by a social, psychological, genetic, physical, chemical, or biologic disturbance.

Psychosis

A mental disorder characterized by the loss of contact with reality.

Schizophrenia

A complex, difficult-to-identify mental disorder whose onset typically occurs during early adulthood. Symptoms typically become more prominent over time and include delusions, hallucinations, a lack of interest in pleasure, and erratic speech.

Organic Disorders

Organic brain syndrome is a temporary or permanent dysfunction of the brain caused by a disturbance in the physical or physiological functioning of the brain tissue.

Causes: sudden illness, traumatic brain injury(TBI), seizure disorders, drug and alcohol abuse, overdose, or withdrawal, and diseases of the brain

Functional disorders

Physiologic disorder that impair bodily functions when the body seems to be structurally normal

Examples: schizophrenia, anxiety conditions, and depression

Symptoms of Schizophrenia

Delusions

Hallucinations

A lack of interest in pleasure

Erratic speech

Symptoms of Delirium

Hyperactive irrational behavior

Vivid hallucinations

Hypertension

Tachycardia

Diaphoresis

Dilated pupils

When caring for a patient with Excited Delirium:

Be calm, supportive, and empathetic

Approach the patient slowly and respect the patients personal space

Limit physical contact

Do not leave the patient unattended

Symptoms of PTSD

Helplessness

Anxiety

Anger

Fear

Example events: Natural disasters, War, Loss of a loved one, Stressful life changes

PTSD occurs after ?

Exposure to, or injury from, a traumatic event

Example events: Sexual and Physical assault, Child Abuse, Serious Accidents

Warning signs of suicide:

Air of tearfulness, sadness, deep despair, or hopelessness

Avoiding eyes contact, speaking slowly, and projecting a sense of vacancy

Unable to talk about the future

Suggestion of suicide

Having any plans related to death

Signs of a potentially violent patient:

Has tense muscles, clenched fists, or glaring eyes

Is pacing

Cannot sit still

Is fiercely protecting personal space

Other factors include: Poor impulse control, A history of truancy, fighting, and uncontrollable temper, History of substance abuse, Depression, and Functional disorder

You may only use restraints when ?

To protect yourself or others from bodily harm

To prevent the patient from injuring himself or herself

When using Restraints, monitor the patient for ?

Vomiting

Airway obstruction

Respiratory status

Circulatory status (blood pressure)

Changes in level of consciousness

A behavioral crisis is MOST accurately defined as:

A. A severe, acute behavioral condition in which the patient becomes violent and presents a safety threat to self or to others

B. Any reaction to events that interferes with activities of daily living or has become unacceptable to the patient m, family, or community

C. A normal response of a patient to a situation that causes an overwhelming amount of stress, such as the loss of a job or marital problems

D. A ready on to a stressful event

Answer B

Rationale: a behavioral crisis is any reaction to event that interferes with the patients activities of daily living or has become acceptable to the patient, his or her family, or the community. Not all patients with an emotional crisis are "psychotic", nor are all the violent patients experiencing a behavioral condition; these are common misconceptions. Various medical conditions can cause a behavioral crisis EX. Hypoglycemia,hypoxemia,brain tumors

Depression and schizophrenia are examples of:

A. Functional disorders

B. Altered mental status

C. Behavioral emergencies

D. Organic brain syndrome

Answer A

Rationale: Unlike an organic disorder, a functional disorder cannot be linked to any physical dysfunction or failure of an organ. Depression, schizophrenia, obsessive-compulsive disorder (OCD), and bipolar disorder are examples of functional disorders. They are usually caused by a chemical imbalance in the brain-not a structural or physical abnormality

When assessing a patient with a behavioral crisis, your primary concern must be:

A. Allowing the patient to express himself or herself to you in his or her own words

B. Setting your personal feelings aside and providing needed care

C. Gathering the patients belongings and taking them to the hospital

D. Whether the patient will cause harm to you or your partner

Answer D

Rationale: There are many things that you should be concerned with when assessing a patient with a behavioral crisis, including all of the items listed as answers to this question. Your primary concern, however, must be the safety or yourself and your partner

General guidelines to follow when caring for a patient with a behavioral crisis include all of the following EXCEPT:

A. Being honest and reassuring

B. Rapidly transporting the patient

C. Having a definite plan of action

D. Avoiding arguing with the patient

Answer B

Rationale: When caring for a patient with a behavioral crisis, the EMT must be prepared to spend extra time with the patient. It may take longer to assess and listen to the patient prior to transport

Reflective listening, an assessment technique used when caring for patients with an emotional crisis, involves:

A. Asking the patient to repeat his or her statements

B. Simply listening to the patient, without speaking

C. Asking the patient to repeat everything that you say

D. Repeating, in question form, what the patient tells you

Answer D

Rationale: Reflective listening-a technique in which you repeat, in question form, what the patient tells you- allows the patient to further expand on his or her thoughts; it also helps the EMT gain inside into the patients situation

Which of the following patients is at HIGHEST risk for suicide ?

A. A 24-year-old woman who is successfully being treated for depression

B. A 29-year-old man who was recently promoted with a large pay increase

C. A 33-year-old man who regularly consumes alcohol and purchased a gun

D. A 45-year-old woman who recently found out her cancer is in full remission

Answer C

Rationale: Situations or indications that place a patient at high risk for suicide include, but are not limited to, recent diagnosis of a serious illness; financial setback; death of a loved one; specific plan for suicide; recent acquisition of items that can cause death, such as a gun or large volume of pills; and chronic alcohol use

When caring for a patient with an emotional crisis who is calm and not in need of immediate emergency care, your BEST course of action is to:

A. Advise the patient that he or she cannot refuse treatment

B. Leave the patient with a trusted friend or family member

C. Attempt to obtain consent from the patient to transport

D. Apply soft restraints in case the patient becomes violent

Answer C

Rationale: Just because a patient is experiencing an emotional crisis does not mean that he or she is "mentally incompetent" and cannot refuse EMS treatment and/or transport. You should attempt to obtain consent from any conscious patient unless he or she clearly does not have decision-making capacity. EX: underage,altered mental status, alcohol intoxication

When physically restraining a violent patient, the EMT should:

A. Continually talk to the patient as he or she is being restrained

B. Check circulation in all extremities only if the patient is prone

C. Remove the restraints if the patient appears to be calming down

D. Use additional force if the restrained patient begins to yell at the providers

Answer A

Rationale: When physically restraining a violent patient, the EMT or his or her partner should continually talk to the patron throughout the process. Treat the patient with dignity and respect- regardless of the situation. Once restraints are placed, they should not be removed, even if the patient appears to be calm. Circulation in all extremities should be monitored, regardless of the position in which the patient is restrained

Upon arrival at the residence of a young male with an apparent emotional crisis, a police officer tells you that the man is acting bizarrely. You find him sitting on his couch; he is conscious but confused. He takes medications but cannot remember why. His skin is pale and diaphoretic, and he has noticeable tremors to his hands. You should FIRST rule out:

A. Hypoglycemia

B. Suicidal thoughts

C. Severe depression

D. Schizophrenia

Answer A

Rationale: There are numerous physical problems that can cause bizarre behavior, such as hypoglycemia, hypoxemia, and brain tumors, among others. The EMT should rule out an underlying medical cause first. The patients pallor, diaphoresis, and motor tremors suggested hypoglycemia. The EMT should assess the patients blood glucose level, if trained to do so, and consider administering oral glucose. Behavioral health disorders, such as clinal depression and schizophrenia, cannot be ruled in or out in the field

Which of the following signs is LEAST indicative of a patients potential for violence ?

A. The patient appears tense and "edgy"

B. The patient is 6'5" tall and weighs

230 lb

C. The patent is loud and shouting obscenities

D. The patient is facing you with clenched fists

Answer B

Rationale: When assessing a patients potential for violence, you should observe for suggestive physical activity, such as clenching of the fists; glaring eyes; shouting obscenities; and rapid, disorganized speech. There is no correlation between a patients physical size and his or her potential for violence

Assessment In Action Scenario: Page #1

It is July 10th and you are called for a 57-year-old man who is "acting strangely. An ALS fire engine has been called and you have been cleared to enter. Police and several bystanders are present I. The area. The man is cowering against a wall in an alley. He is wearing a woman and dirty military uniform and boots that seem out of place in this hot weather. His head is bleeding. The patient watches your approach with skepticism and fear In his eyes.

Assessment in Action Scenario: Page #2

Police tell you some kids were blowing up 4th of July fireworks nearby. According to bystanders, the patient started running around and yelling about an IED. He stared fighting the police when they encountered him, but they confirmed he does not have any weapons. The patient pulled away from them and cowered against the wall. A woman comes forward to tell you the patients name is Charlie and he got back from Afghanistan about 6 months ago. He was in the army but was medically discharged m. He was having problems with civilian life, and his wife said he has had frequent angry outbursts. She threw him out of the house a few weeks ago. You ask if she is aware of any medical conditions. She states he takes medications for a few conditions but she is not sure what. Charlie allows you to approach but still feels very afraid. You ask him if you can look at the wound on his head and ask him how it happened. He tells you it was from shrapnel from the IED. You ask him if he has any

Assessment in action: Page #3

medical problems, takes medication, or has any allergies. He tells you his is allergic to sulfa and has high blood pressure and diabetes, but he has had no medication available. He complains of headache. You ask him what happened today. He tells you the IED scared him and killed his friend, Nate. You ask him where he is and he tells you "Afghanistan".

Assessment in action Question #1:

Which of the following points given by the neighbor is the most important to your care ?

A. He got back from Afghanistan about 6 months go

B. He was in the Army but was medically discharged

C. His wife said he has had contacts angry outbursts

D. She threw him out of the house a few weeks ago

Answer C

Assessment in action Question #2

What is the significant concern in his story about the IED ?

A. His friend died

B. It was in Afghanistan

C. The IED explosion scared him

D. He believes it was an IED rather than fireworks

Answer D

Assessment in action Question #3

What is the most likely psychological condition ?

A. Alzheimer disease

B. Depression

C. Anxiety and possible psychotic illness

D. Hypertension

Answer C

Assessment in action Question #4

Which of the following statements may help you provide care for Charlie?

A. I know how you feel

B. I'm sorry about your loss

C. Come with me, and let's go to a place where they can help you

D. It wasn't an IED, it was just fireworks

C

Assessment in action Question #5

Which of the following treatments would be appropriate for Charlie?

A. Sedative medication

B. Oxygen by mask

C. Glucose, if ALS confirms that the level is low

D. High blood pressure medication

Answer C

Assessment in action Question #6

Would it be wise to restrain this patient to the stretcher?

A. Yes, he is potentially violent

B. Yes, it is best to retrain psychiatric patients

C. No, restraint is unethical

D. No, it may simply aggravate the situation

Answer D

Assessment in action Question #7

Which of the following statements is true regarding the returning veteran?

A. A persons altered consciousness call allow them to continue functioning under negative conditions

B. Guilt, shame, paranoia, and hostility are rare with combat veterans

C. Alcohol and/or drug use is a common way to activate the sympathetic nervous system

D. Suicide is rare in these patients

Answer A

JBL Question #1

___________ is what you can see if a persons response to the environment

A. Affect

B. Psychosis

C. Behavior

D. Neurosis

Answer C

JBL Question #2

A physiologic disorder that impairs bodily function when the body seems to be structurally normal is called a:

A. Functional disorder

B. Traumatic brain injury

C. Drug and alcohol abuse

D. Seizure

Answer A

JBL Question #3

A technique used to gain insight into a patients thinking, which involves repeating in question form what the patient has said, is called:

A. Reflective listening

B. Active listening

C. Passive listening

D. Intuitive listening

Answer A

JBL Question#4

After ensuring his or her own safety, the EMT's next priority when caring for a patient with a behavioral emergency is to:

A. Determine the underlying cause of the problem and offer advice

B. Diagnose the patients problem and provide definitive treatment

C. Transport the patient directly to a specialized psychiatric facility

D. Assess the patients response to his or her environment

Answer D

JBL Question #5

Common causes of acute psychotic behavior include all of the following, EXCEPT:

A. Intense stress

B. Alzheimer's disease

C. Schizophrenia

D. Mind-altering substance use

Answer B

JBL Question#6

General guidelines for managing a patient with a behavioral emergency include:

A. Firmly identifying yourself as an EMS provider

B. Placing the patient between yourself and an exit

C. Allowing the patient to be a lone if he or she wishes

D. Being prepared to spend extra time with the patient

Answer D

JBL Question #7

Immediately after physically restraining a violent patient, the EMT should:

A. Reassess the patients airway and breathing

B. Document the time the restraints were applied

C. Advise the patient why restraint was needed

D. Inform medical control of the situation

Answer A

JBL Question #8

In which position should you restrain a physically uncooperative patient ?

A. Prone

B. With arms and legs bound

C. With hands tied behind the back

D. Supine

Answer D

JBL Question #9

Organ brain syndrome is defined as:

A. Bizarre behavior secondary to a chemical imbalance or disturbance in the brain

B. A dysfunction of the brain caused by abnormal physical or psychological function

C. A change in behavior or mental status secondary to decreased cerebral blood flow

D. A disorder that cannot be traced to the abnormal structure or function of an organ

Answer B

JBL Question #10

People at risk for suicide include all of the following, EXCEPT:

A. Those with a recent diagnosis of a serious illness

B. Married males older than 30 years

C. Substance abusers

D. Children with parents addicted to alcohol

Answer B

JBL Question #11

Post traumatic stress disorder can happen after:

A. Exposure to or injury form a traumatic occurrence

B. Alcohol withdrawal

C. Extended periods of hyperthermia or hypothermia

D. A bout with depression

Answer A

JBL Question #12

Signs of excited delirium include:

A. Subdued behavior, crying, and suicidal thoughts

B. Diaphoresis, tachycardia, and hallucinations

C. Slurred speech, bradycardia, and a high fever

D. Pallor, hypotension, and constricted pupils

Answer B

JBL Question #13

The first step in accessing a patient with a behavioral emergency is to:

A. Restrain the patient

B. Ensure your safety

C. Take vital signs

D. Obtain proper consent

Answer B

JBL Question #14

The single most significant factor that contributes to suicide is:

A. Depression

B. Drug abuse

C. Advanced age

D. A chronic illness

Answer A

JBL Question #15

The term "behavioral crisis" is MOST accurately defined as:

A. A sudden, violent outburst of an otherwise mentally stable person toward a family member

B. A period of severe depression that lasts longer than 2 weeks and cannot be controlled with medications

C. A medical illness with psychological symptoms that may lead to limited motor functioning

D. A situation in which a patient of any age exhibits agitated, violent, or uncooperative behavior

Answer D

JBL Question #16

When assessing a patient with a behavioral crisis, you should:

A. Spend as little time with the patient is possible

B. Ask the police to handcuff the patient for safety

C. Frisk the patient for the presence of weapons

D. Be direct and clearly state your intentions

Answer D

JBL Question #17

Which of the following conditions or situations would MOST likely make excited delirium worse ?

A. Dimly lit environment

B. Elevated blood glucose

C. Limited physical contact

D. Alcohol withdrawal

Answer D

JBL Question #18

Which of the following is an example of functional behavioral disorder ?

A. Drug addiction

B. Alzheimer's disease

C. Schizophrenia

D. Head trauma

Answer C

JBL Question #19

Which of the following statements regarding the physical examination of a patient with a behavioral problem is correct ?

A. The physical examination of a patient with behavioral problem often yields crucial information and should always be performed, even if the patient is violent

B. It is only appropriate to perform a physical examination on a patient with behavioral problem if he or she is unconscious or is being physically restrained

C. Although the physical exam can

Answer C

JBL Question #20

You may not be able to determine whether a person has a mental illness, but you can predict the person's likelihood of becoming:

A. Diabetic

B. Psychotic

C. Violent

D. Suicidal

Answer C