EH

Behavioral Health Emergencies: Comprehensive Notes

General Factors Causing Behavioral Alterations

  • Behavioral health emergencies can stem from various factors:
    • Acute medical situations
    • Mental illness
    • Mind-altering substances
    • Stress
    • Numerous other causes

Behavioral Crisis Defined

  • A behavioral crisis involves a temporary or permanent disturbance in a person's emotional state, behavior, or cognitive function.
  • Almost everyone will experience an emotional crisis at some point, but not everyone develops a long-term mental illness as a result.
  • Acute, one-time crises can be detrimental without leading to chronic mental health disorders.

Temporary Mental Health Disorders

  • Otherwise healthy individuals can experience acute or temporary mental health disorders.
  • Seasonal depression is common, especially during winter months due to:
    • Lack of vitamin D
    • Reduced outdoor activities
    • Less exposure to sunlight and nature

Normal Responses vs. Mental Illness

  • Avoid jumping to conclusions about mental illness based solely on an acute crisis.
  • Crises can be triggered by:
    • Divorce
    • Job loss
    • Death of a relative or friend
    • Terminal illness diagnoses in loved ones
  • Experiencing depression or crises can be a normal response to highly stressful situations.

Violence and Mental Health

  • Most individuals experiencing mental health disorders are not dangerous, violent, or unmanageable.
  • Healthcare providers may encounter a higher proportion of violent patients due to the nature of emergency calls.
  • Thorough and peaceful communication is crucial for de-escalation.

Communication Techniques

  • Building trust through honesty and respectful communication can de-escalate situations.
  • Treating patients with dignity and empathy can improve cooperation.

Understanding Behavior

  • Behavior is defined as observable responses to the environment or actions.
  • People develop coping mechanisms over time to adapt to situations, including stress.
  • Coping mechanisms can be healthy or unhealthy.
  • Overwhelming circumstances can lead to sudden crises.

Perspective and Approach

  • Emergency responders are often called by observers, not the patient.
  • Approaching a patient in crisis with understanding and peaceful communication is essential.
  • Avoid escalating the situation with uniforms, lights, and sirens.

Indicators of Long-Term Mental Health Issues

  • Abnormal or disturbing behavior lasting a month or more may indicate a need for long-term treatment.
  • Patients in behavioral health emergencies may exhibit agitation or violence, posing a threat to themselves or others.

Prevalence of Mental Health Disorders

  • Mental health disorders are common in the United States, affecting tens of millions annually (according to the National Institute of Mental Health).
  • A psychiatric disorder is an illness with psychological or behavioral symptoms that impair functioning.

Common Anxiety Disorders

  • Anxiety disorders are the most common type of mental health disorder. Categories include:
    • Generalized anxiety disorder
    • Panic disorder
    • Social anxiety disorder
    • Post-traumatic stress disorder (PTSD)
    • Obsessive-compulsive disorder (OCD)
    • And others

Evolution of Mental Health Attitudes

  • Historically, stigma surrounded mental health, leading to shame and reluctance to seek help.
  • Younger generations are more open about mental health and seek help more readily.
  • This shift represents a positive evolution in behavioral health and medicine.

Mental Health Support Systems

  • Professional counselors are available for marital and parenting issues.
  • Counselors are integrated into school systems and communities.
  • More serious issues like clinical depression are referred to psychologists or psychiatrists.

Roles of Psychologists and Psychiatrists

  • Psychologists provide therapy and counseling.
  • Psychiatrists prescribe medication.
  • Severe disorders like schizophrenia and bipolar disorder often require psychiatry and medication.

Levels of Care

  • Most psychological disorders can be managed with outpatient visits.
  • Inpatient hospitalization may be necessary for constant surveillance and medication titration.

Changing Perceptions of Inpatient Care

  • The stigma around inpatient mental health facilities has decreased.
  • Inpatient stays are now viewed as a necessary part of treatment rather than a sign of severe instability.

Underlying Causes of Behavioral Health Disorders

  • Social and situational stress
  • Individual stressors (e.g., dislike of Walmart environments)
  • Diseases such as schizophrenia or bipolar disorder
  • Physical illnesses and endocrine emergencies (e.g., diabetic emergencies)
  • Chemical problems, including alcohol or drug use and withdrawal
  • Biological disturbances

Diagnosing Behavioral Health Disorders

  • Two basic diagnostic categories:
    • Organic disorders
    • Functional disorders

Scope of Practice

  • Diagnosing underlying causes may be outside the scope of practice for some healthcare providers.
  • However, diagnosing and treating conditions like hypoglycemia is within the scope.

Organic Disorders

  • Also known as organic brain syndrome.
  • Temporary or permanent brain dysfunction caused by disturbances in brain tissue.
  • Can result from:
    • Sudden illness
    • Traumatic brain injuries
    • Seizure disorders
    • Alcohol or drug abuse, overdose, or withdrawal
    • Brain diseases such as Alzheimer's and dementia
    • Meningitis
  • Altered mental status can arise from:
    • Hypoglycemia
    • Hypoxia
    • Impaired cerebral blood flow or stroke
    • Hyperthermia or hypothermia

Functional Disorders

  • Physiological disorders that impair bodily functions without structural abnormalities.
  • Examples include schizophrenia, anxiety, and depression.

Approach to Behavioral Crisis

  • Use regular interpersonal skills.
  • Maintain eye level with the patient.
  • Appear open and welcoming (avoid standoffish postures).
  • Be aware of positioning to allow for quick movements if needed.

Scene Safety and Assessment

  • Prioritize safety at the scene.
  • Request law enforcement assistance early.
  • Questions to consider:
    • Is the situation potentially dangerous?
    • Is law enforcement needed?
    • Should we stage until law enforcement arrives?
    • Is the patient's behavior typical for the circumstances?
    • Are there legal issues involved (crime scene, assault, consent issues, refusal)?
  • Take standard precautions.
  • Call for additional resources early.

Patient Interaction

  • Unless the patient is unstable due to a medical problem or trauma, spend time with the patient to reassure them.
  • Investigate the chief complaint and gather a sample history.
  • Key questions:
    • Is the central nervous system functioning appropriately?
    • Are hallucinogens, drugs, or alcohol a factor?
    • Have there been significant life changes?
    • Are there symptoms or illnesses involved?
    • Is there a history of behavioral health disorders?
  • Gather information from people around the patient when possible.

Geriatric Considerations

  • Consider Alzheimer's and dementia as causes of abnormal behavior in geriatric patients.
  • Never assume elderly patients have dementia or Alzheimer's, but consider it if symptoms fit.

Listening Techniques

  • Use reflective listening.
    • Allow time for the patient to answer questions.
    • Repeat back what they said to ensure understanding.
    • Rephrase their statements to confirm comprehension.
    • Show patients you are actively listening.
  • Often, patients in behavioral health crises need someone to listen.

Questions for Mental Health Assessment

  • Does the patient appropriately answer questions?
  • Does their behavior seem appropriate?
  • Do they seem to understand?
  • Are they withdrawn or detached?
  • Are they hostile or friendly?
  • Are they happy or depressed?
  • Is their vocabulary and expression appropriate for the circumstances?
  • Do they seem aggressive or dangerous?
  • Is their memory intact?
  • Check orientation to person, place, time, and event.
  • Do they express disordered thoughts, delusions, or hallucinations?

Physical Exam Considerations

  • Even with an unconscious patient, perform a head-to-toe exam.
  • Remember that medical and trauma issues can overlap.
  • Prioritize C-spine precautions.
  • A conscious patient may be disoriented or too agitated to answer questions.

Indicators of Emotional State

  • Observe facial expressions, pulse rate, and respirations.
  • Rapid breathing and pulse may indicate distress.
  • Facial expressions (anger, tears, sweating, blushing) can indicate state of mind.
  • A blank gaze or rapidly moving eyes may indicate central nervous system dysfunction.

Transport Considerations

  • Transport with additional personnel when available (firefighter, law enforcement).
  • There may be specific facilities for behavioral health emergencies.
  • In Maryland, psychiatric patients are generally not transported across state lines.
  • Transport by ground rather than air unless there is a coexisting medical necessity.
  • Keep the patient as calm and comfortable as possible.
  • Never let your guard down.

Restraints

  • If restraints are necessary, reassess and document every five minutes.
  • Assess pulse, motor, and sensory function.
  • Assess ABCs (airway, breathing, circulation).
  • In Maryland, BLS providers need orders and additional providers to restrain patients.
    • An alternative is to call ALS for assistance.
  • Typically, five providers are needed: one for each extremity and one for the head.

De-escalation Techniques

  • Diffuse and control the situation without trying to control the patient
  • Create a controlled environment.
  • The best treatment is often being a good listener.
  • Intervene only as much as necessary.
  • If pharmacological restraint is needed, call ALS early.

Communication with Hospital

  • Give the receiving hospital advanced notification.
  • Inform them of a violent patient so they have security on standby.
  • Document thoroughly and carefully:
    • Types of restraints used
    • Why restraints were used
    • Number of providers involved
    • Whether orders were obtained

Acute Psychosis

  • Psychosis: a state of delusion in which the person is out of touch with reality.
  • Can be caused by:
    • Mind-altering substances
    • High stress levels
    • Delusional psychiatric disorders such as schizophrenia

Schizophrenia

  • A complex disorder that is not easily defined or treated.
  • Onset typically occurs during young adulthood.
  • Contributing factors: brain damage, genetics, and psychological and social influences.
  • Symptoms:
    • Delusions
    • Hallucinations
    • Lack of interest and pleasure
    • Erratic speech

Guidelines for Psychotic Patients

  • Determine if the situation is dangerous.
  • Clearly identify yourself
  • Be calm, direct, and straightforward.
  • Maintain an emotional distance.
  • Do not argue with the patient.
  • Explain what you want to do before you do it.
  • Involve people the patient trusts (family, friends) to gain cooperation.

Excited Delirium (Agitated Delirium)

  • Textbook definitions may not acknowledge it as official diagnosis.
  • Delirium: impairment in cognitive function with disorientation, hallucinations, or delusions.
  • Agitation: restless or irregular physical activity.
  • Signs and symptoms:
    • Hyperactive, irrational behavior
    • Vivid hallucinations
    • Inability to distinguish between hallucinations and reality
    • Hypertension, tachycardia, diaphoresis, and dilated pupils

Approach to Excited Delirium

  • If it's safe to approach proceed calmly, supportively, and empathetically.
  • Approach the patient slowly, respecting personal space.
  • Limit physical contact.
  • Do not leave the patient unattended.
  • Careful interviewing to assess cognitive functions
  • Observe appearance, dress, and personal hygiene.

Additional Considerations for Excited Delirium

  • If overdose is suspected, take medication bottles or illegal substances to the medical facility.
  • Refrain from using lights and sirens during transport.
  • If agitation continues, request ALS for chemical restraints.

Risks of Excited Delirium

  • Can lead to sudden death.
  • Causes:
    • Cardiopulmonary arrest
    • Metabolic acidosis due to extreme physical agitation
    • Stimulant use
    • Positional asphyxiation (never leave patients prone)

Physical Restraint Protocols

  • As BLS providers, orders are required in Maryland to restrain patients.
  • Restraining a patient without authority in a non-emergency situation is illegal.
  • The National Association of Emergency Medical Services Physicians (NAEMSP) recommends every pre-hospital transport have a restraint protocol in place.

Risks of Restraint

  • Associated risks can be life-threatening:
    • Positional asphyxia
    • Aspiration
    • Severe acidosis
    • Cardiac arrest

Legal Charges for Improper Restraint

  • Potential charges:
    • Assault
    • Battery
    • False imprisonment
    • Violation of civil rights
  • Can result in loss of license.
  • Restraints are to protect self and others from bodily harm.

Law Enforcement Involvement

  • Involve law enforcement when possible.
  • They may take action before EMS arrives.

Restraint Process

  • Five people needed: one for each extremity plus head.
  • Team movement needs quick, coordinated action.
  • Team leader directs the process and plans the actions
  • Use minimum force necessary.
  • Consider patient's sex, size, strength, mental status, and abnormal behavior.

Communication and Dignity

  • If possible, talk the patient through the process.
  • Treat the patient with dignity and respect.
  • Whenever possible, a provider of the same gender should attend patient.
  • Wear appropriate barrier protection.
  • Avoid direct eye contact and respect personal space.

Monitoring Restrained Patients

  • Never leave a restrained patient unattended.
  • Four-point restraints (both arms, both legs) are preferred with one arm above and one below the head.
  • Monitor for:
    • Vomiting (suction if needed)
    • Airway obstruction
    • Respiratory status
    • Circulatory status and blood pressure
    • Changes in level of consciousness

Violent Patients

  • Violent patients account for a small percentage of those in behavioral crisis.
  • EMS may see higher ratios of these patients due to call types received.

Assessing Violence Potential

  • History with violence:
    • Previous hostile or aggressive behavior, especially to uniformed personnel.
    • Known prior altercations
  • Posture:
    • Tense, rigid, or sitting on the edge of seat
  • Scene awareness/peripheral vision monitoring.
  • Vocal activity:
    • Yelling, loud, obscene, erratic, bizarre speech.
  • Tense muscles, clenched fists, glaring eyes, pacing/agitation
  • Fiercely protecting their personal space

Other Risk Factors for Potential

  • Poor impulse control
  • History of truancy, fighting, uncontrollable temper.
  • History of substance abuse/functional disorder/schizophrenia.
  • Statements indicating voices commanding them to act.

Depression and Suicide

  • Depression is the single most significant factor in suicide.
  • Threatening suicide is an indication someone needs help.
  • Immediate intervention is necessary.

Suicide Warning Signs

  • Feelings of sadness, despair, hopelessness.
  • Avoid eye contact, speak slowly, or in vacant manner.
  • Inability to talk about future
  • Suggests suicide or has a plan

Risk Assessment and Safety

  • Look for unsafe objects nearby, environmental dangers, etc.
  • Evidence of self-destructive behavior.
  • Imminent threat to the patient or to others.
  • Underlying medical problems.
  • Cultural or religious beliefs promoting suicide - assess any potentially causal factors and any other signs of mental health concern.

PTSD (Post-Traumatic Stress Disorder)

  • Occurs after exposure to or injury from a traumatic event.
  • Examples: physical/sexual assault, child abuse, serious accidents, natural disasters, loss of a loved one, and war.
  • Can stem from jumble of things that have happened over time.
  • 7-8% of the general population may experience signs of PTSD.
  • Military veterans and EMS are highest risk professions.

Signs and Symptoms of PTSD

  • Feelings of hopelessness, anxiety, anger, and fear.
  • Avoiding things that remind them of the trauma (loud noises, certain smells).
  • Constant nervous system arousal that is not easily suppressed (elevated HR, dilated pupils).
  • Reliving the traumatic events via thoughts, nightmares, or flashbacks.
  • Dissociative PTSD: attempting to escape from constant internal distress.
  • Alcohol and drug abuse are common.

Long Term Risks Associated with PTSD

  • Increased risk of suicide
  • Proneness to early heart disease
  • Higher incidence of type 2 diabetes
  • Loss of gray matter
  • Higher incident of TBI

Veteran-Specific Approach

  • Refrain from touching/doing anything to the veteran without explaining them first.
  • Keep equipment at arm's length.
  • Remove loud noises, sirens, lights
  • Use calm, firm voice and be in charge.
  • Respect their personal space.
  • Limit the number of people involved:
  • Ask about suicide intentions/plans
  • Ensure there’s nothing the patient can use as a weapon on themselves/others.

Legal Considerations

  • Legal problems are reduced when a patient consents to care.
  • A patient with reduced mental capacity cannot refuse care.
  • A patient in unstable mental condition may resist care.
  • Do not leave the patient alone, and always ask for law enforcement as needed.

Types of Consent

  • Implied consent is assumed when a patient is not mentally competent.
  • Consent matters are not clear cut, medical control is available as a ready recourse.
    *

Guidelines

  • Competent adults have the right to refuse life-sustaining treatment.
  • In psychiatric cases, court law considers providing life-sustaining care appropriate.
  • Maintain high index of suspicion, assume the worst, and document everything including patient statements.