Psych 1
Behavioral vs Psychiatric Emergencies
Emergency definition: a situation that is very concerning and requires urgent assessment and response; not all behavioral issues are emergencies, but when behavior interferes with safety or health, it is an emergency.
Behavioral emergencies: disorders of mood, thought, or behavior that interfere with Activities of Daily Living (ADLs).
ADLs examples: eating, bathing, dressing, transferring, toileting, walking, moving around.
If a patient has a depressive episode and is not eating for days, this can be a behavioral emergency because it interferes with ADLs.
Psychiatric emergencies: behavior that threatens the health or safety of the patient or others.
Examples include hostility toward police or responders, violent behavior, or highly unsafe actions.
Overlap: many cases have both behavioral and psychiatric elements; assessment must consider both.
Patient-centered definition of emergency: patients define what is an emergency for themselves; responders should respect that perspective and provide support.
Scene safety is paramount: dangerous bystanders, weapons, and volatile behavior require safety planning, potential police involvement, and protective PPE.
Causes and Differential Diagnosis of Abnormal Behavior
Abnormal behavior is not limited to psychiatric disorders; it can be driven by a range of biological, environmental, and substance-related factors.
Biological/medical causes to consider (AEIOU framework):
A: Alcohol or other substances
E: Epilepsy or other neurological conditions
I: Insulin-related issues (e.g., hypoglycemia)
O: Overdose or other toxicologic processes
U: Unknown etiology
Other medical causes to consider: hypoxia, stroke, tumors, traumatic brain injury, renal failure, infections, metabolic disturbances.
Environmental and social factors: abuse, neglect, social stressors, housing instability.
Substance-related etiologies: intoxication or withdrawal (e.g., opioids, alcohol, stimulants).
Agitated patients: literature suggests a sizable mix of etiologies among agitated patients:
40\%\text{ to }50\% are primarily psychiatric issues
30\%\text{ to }40\% are substance-related
10\%\text{ to }15\% remain undetermined or mixed
Practical implication: always maintain a broad differential and rule out medical causes first.
Common patterns to recognize: manic episodes (e.g., euphoria with risky behavior), psychosis, dementia-related delirium, acute intoxication, withdrawal syndromes, acute neurologic events.
Recognizing and Assessing Agitated Patients
Agitation is a spectrum:
Directable: patient can be guided and cooperative (safe to move forward with explanation and consent).
Agitated/Disruptive without danger: patient is upset or disruptive but not immediately dangerous; may require verbal de-escalation and sometimes short-acting sedatives.
Dangerous/Excited delirium: patient poses danger to self or others and cannot be directed; requires higher-level restraints and emergency management.
Important safety concepts:
Always assess scene safety and have an exit plan; maintain PPE as appropriate.
Trust your gut; if a patient says they will harm you, take the threat seriously and step back to ensure safety.
Be prepared for longer on-scene times when dealing with mental health crises; plans should account for potential extended engagement and transport delays.
Observational cues to consider (from the classroom discussion):
Verbal and nonverbal signs: aggressive language, hyperarousal, panic, paranoia, hallucinations, flight of ideas, rapid or slowed speech, disorganized thinking.
Physical signs: agitation level, motor restlessness, tremors, perspiration, cyanosis (as in the case where lips appeared cyanotic and oxygen was needed).
Responsiveness: ability to follow commands, respond to questions, engage in open-ended dialogue.
Medical re-evaluation is essential: even if a patient seems psych-related, rule out life-threatening medical conditions first.
De-Escalation, Communication, and De-essment Techniques
Core de-escalation approach:
Actively listen and show empathy; open with a calm introduction and explain your role and purpose.
Use open-ended questions to obtain information: instead of asking yes/no questions, ask things like: "What is bothering you today?" rather than "Are you okay?" or "Do you see things?".
Reflect and validate feelings: e.g., "I can hear anger and fear in your voice and I can see that upsets you."; reflect statements to show understanding.
Do not argue or validate delusions: avoid saying, for example, that the hallucination is real; acknowledge the emotion and offer help instead.
Be honest about what you can and cannot do: avoid false assurances and clearly explain procedures before performing them.
Obtain consent for interventions and explain each step before performing it (e.g., blood pressure checks, positioning, or transport plans).
Use simple language; expect that understanding may take time during crises.
Maintain safe distance and avoid crowding; keep exits and safety routes clear.
Avoid overreacting or escalating the situation with force; aim to reduce agitation through calm presence and respectful language.
Communication techniques exemplified in practice:
Open-ended prompts to gather information and assess safety.
Reflective statements to acknowledge feelings and build rapport.
Do not acknowledge or dismiss delusions; use phrases like, "I believe you see it, and I understand you're scared; we want to get you help." instead of arguing.
When there are other responders, coordinate roles and maintain a calm, unified approach.
Non-technical de-escalation tools:
Stay with the patient and provide a sense of presence and support.
Encourage movement that is safe and purposeful (e.g., dressing, sitting up, moving to a safer space) to reduce restlessness.
Avoid provocative actions; no threats or coercive tactics.
Recognize signs of calming and adjust the approach accordingly.
On-scene de-escalation training resources referenced in the session:
A crisis de-escalation video emphasizing active listening, rapport-building, and safe execution of care.
Emphasis on using a calm demeanor, clear explanations, and patient consent to improve safety for all.
Medical vs Psychiatric Considerations and the “Rule-Out Medical” Principle
Important principle: even when a patient presents with psychiatric symptoms, you must rule out medical etiologies first because medical problems can present as psychiatric symptoms.
Practical checklist related to AEIOU and beyond:
Screen for hypoxia, hypoglycemia, drug intoxication/withdrawal, infection, stroke, head injury, renal/hepatic failure, metabolic disturbances.
Consider environmental and social contributors to agitation and behavior.
Emergency evaluation nuances:
In some settings, agitated patients may be labeled as psychiatric or agitated; this is a starting point for triage, not a final diagnosis.
Distinguish agitation due to intoxication from true primary psychiatric illness, while remaining mindful of overlapping features.
System Resources, Legal Frameworks, and On-Scene Options
Crisis response resources to augment EMS response:
988 crisis line: a nationwide crisis hotline that can connect callers to crisis teams for on-scene support; can help bring mental health specialists to the scene.
On-scene crisis teams in some areas (e.g., Georgia crisis teams, metro-area units, or county programs) that can assist with assessment and, in some cases, involuntary holds.
Time and training considerations:
General paramedic training may include limited psych training (e.g., ~2 hours); real-world expertise often relies on collaboration with mental health professionals.
10:13 involuntary hold process:
10:13 is a legal mechanism to involuntarily detain a person for psychiatric evaluation; it requires proper authorization by a physician or licensed mental health professional on scene.
It is not permissible to order a 10:13 from hospital staff remotely; the involved Licensed professional must be on the scene to sign the involuntary hold.
Some crisis teams can execute a 10:13; others coordinate with physicians to arrange the hold, depending on jurisdiction and licensing.
On-scene collaboration and limits:
Crisis teams can be called in to consult, accompany, or take over care on scene; in some regions, dispatch can contact them directly (e.g., via 988).
In practice, response models vary: some teams stay with the patient on-scene; in others, responders may need to wait for the crisis team or transport the patient to safety while maintaining supervision.
Real-world considerations and experiences:
Some responders report positive experiences with crisis teams; others report challenges with timeliness or on-scene coordination.
The role of law enforcement differs by region; safety planning often involves police when there is risk of violent behavior, weapon threats, or elopement risk.
Practical takeaway:
Use available resources (988, crisis teams) when appropriate to enhance safety and ensure proper legal processes are followed for holds.
Maintain scene safety, stay with the patient as needed, and document all actions and rationales for decisions.
Practical Scenarios, Ethical Considerations, and Takeaways
Scenarios highlighted in the session included:
A patient with PEA in the context of uncertain downtime and resuscitation decisions; the need to balance organized rhythm (PEA or V-fib) against obvious death signs.
A suicide attempt with a handgun; the patient’s presentation and potential for rapid deterioration.
A patient with apparent hypoxia or respiratory distress identified during agitation; the importance of oxygen and non-invasive interventions before aggressive sedation.
A patient who briefly appeared dead but later recovered (false negative in a time-of-death call); the need for cautious reassessment and humility in calling death prematurely.
The challenge of managing agitated psychiatric patients; emphasize safety, de-escalation, and appropriate use of chemical restraints when necessary, with consideration of medical causes.
Safety and longevity in EMS practice:
Long-term safety requires situational awareness, de-escalation skills, and proper use of restraints only when necessary and justified.
Stories of real-world incidents illustrate risks of escalation, the potential consequences of misinterpretation, and the necessity of staying calm and patient-centered.
Ethical considerations:
Respect patient autonomy and dignity while ensuring safety for patient and responders.
Do not coerce or humiliate; use compassionate communication and provide clear options for the patient to choose from.
Avoid over-reliance on sedatives; prioritize oxygenation, basic life-sustaining care, and appropriate involvement of mental health professionals when possible.
Key practical takeaways for exam preparation:
Be able to distinguish behavioral vs psychiatric emergencies and articulate the overlap.
Recognize the AEIOU framework and the breadth of medical and environmental causes of abnormal behavior.
Understand the escalation ladder for agitation: directable, agitated without danger, dangerous/excited delirium, and corresponding management strategies.
Master the core communication techniques: open-ended questions, reflective listening, empathy, consent, and non-arguing.
Know the legal mechanisms (e.g., 10:13) and the role of crisis teams and 988 in on-scene management.
Prioritize safety: scene assessment, PPE, exit routes, and a plan for escalating to law enforcement or crisis teams when needed.
ext{ADLs}=ig\u2206 ext{(eating, bathing, dressing, transferring, toileting, walking)}ig
Key reminders from the transcript:
Even with psychiatric symptoms, medical causes must be ruled out first.
Open-ended questions and empathetic listening are central to de-escalation.
The patient’s perception of emergency matters; responders should validate and respond with care.
Crisis resources (988, on-scene crisis teams) can improve safety and facilitate appropriate care decisions.