Psychiatric emergencies
can be one of the most dangerous and challenging emergencies that prehospital
providers can encounter. Our training in these situations is scant at best and
these patients present a myriad of challenges. If you are presented with a
patient in the midst of psychiatric emergency emotions will be at an all-time
high for the patient, as well as, you and your crew. If you follow these
four simple guidelines you will increase your confidence and improve the
patient's outcome in these very challenging emergencies.
1) They are having a medical emergency until proven otherwise.
This
is extremely important as there are several medical conditions that can affect
a patient's behavior: hypoglycemia, thyroid disorders, toxins, and stroke to
just name a few. In the prehospital setting we can rarely rule out all the
causes of behavioral changes so never pigeon hole a patient as a coo
coo bird. This is a classic mistake and will only lead to poor treatment
decisions and a horrible experience for the patient and their family who has
summoned you to save them from a seemingly impossible situation.
2) Safety first: The safety of the patient
and the emergency responders is paramount. One of the first
determinations you need to make is whether the patient is dangerous to
themselves or others. Always include law enforcement and never allow the
patient to be alone at any time once you have made contact. Truly
suicidal patients who are being cornered will make any excuse to get away from
you and finish the task. It is not unusual for a patient to simply ask to
go to the bathroom and then jump off of their balcony. Remember, once you
make contact don't let them out of your sight and make sure you always have
enough help to fully restrain and immobilize them in case the situation
warrants immediate control.
3) Simple assessment questions: Ascertain the patient’s suicide
scale and homicide scale. On a scale of 0-10 where zero is no
thoughts whatsoever and 10 means they want to commit suicide right now; what
number would they give themselves? If they give you any number above zero for
the suicide scale the next question you want to ask is do they have a plan? A
truly suicidal patient spends 24/7 thinking about and planning on how they are
going to get the job done. If they give you a plan then add a few points to the
scale because they are serious. If they give you any number above
zero for the homicide scale the next question you should ask is to whom their
aggression is directed. If they are having feelings of anger and aggression you
need to know who the target is. Is it one person or a group of people? Is the
person in the room? Are you the person? These are all very important pieces
of information that will assist you in diffusing the situation. Ask
the patient if they hear voices. If they say yes then you want to know what
they are saying. If the voices are telling them to kill the paramedic then that
is a very important piece of information. Ask if they are seeing things and
what they are. If you ask every suspected psychiatric patient these
few questions it will give you a very good snapshot of their mental stability.
So remember to ask these questions:
- Suicide Scale
- Homicide Scale
- Voices
- Hallucinations
4) Diffuse the situation: The next step in mitigating these types of
emergencies is to diffuse the situation and transport the patient to the
nearest hospital with psychiatric facilities. If their suicide scale
is anything above a zero then they warrant an emergency custody order and
immediate transport regardless of their feelings about the situation. Consult
your state laws regarding ECPs and TDOs. Never humor their delusions or lie to
them about anything that is happening or going to happen. The best road to
successfully diffusing the situation is honesty and professionalism. Remain
tactical and aware of scene safety. Psychiatric scenes are very dynamic and can
change rapidly from a pleasant conversation to a life threatening MAYDAY in a
matter of seconds.
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