© 2011 National Safety Council 13-1
BEHAVIORAL EMERGENCIESLESSON 13
© 2011 National Safety Council 13-2
Behavioral Emergencies
• Process of giving emergency care may be complicated by patient’s behavior
• Many injuries and medical emergencies may cause altered mental status or emotional responses
• Patients may have emotional problems
• Patient may be a danger to self or others
© 2011 National Safety Council 13-3
Common Causes of Altered Behavior
• Situational stresses
• Illness or injury
• Psychiatric problems
• Not taking a prescribed psychiatric medication
• Low blood sugar
• Shock
• Inadequate blood flow to brain
• Head trauma
© 2011 National Safety Council 13-4
Common Causes of Altered Behavior (continued)
• Temperature extremes
• Poisoning or overdose
• Mind-altering substances, alcohol, drugs
• Seizure disorders
• Brain infection
• High fever
© 2011 National Safety Council 13-5
Assessing Behavioral Emergencies
• Perform standard assessment
• Assess mental status by observing:
- Appearance
- Actions
- Speech
- Posture and gait
- Orientation for time, person and place
- Mood, thought processes
© 2011 National Safety Council 13-6
Signs Violent Behavior May Occur
• Person holding weapon or something that can be used as weapon
• Person in threatening posture
• Person is verbally abusive, threatening
© 2011 National Safety Council 13-7
• Person agitated, uncontrollably elated, uncontrollably angry or kicking or throwing things
• Person known to be violent
• Hallucinations, paranoia
Signs Violent Behavior May Occur (continued)
© 2011 National Safety Council 13-8
Is Patient Dangerous?
• Self-destructive behavior or suicide attempts represent danger to the patient
• Threatening behavior, violence and the presence of weapons represent a danger to responders and others
© 2011 National Safety Council 13-9
Assessment for Suicide Risk
• How does the patient feel?
• Is the patient thinking about hurting or killing himself or herself or others?
• Does the patient have cultural or religious beliefs consistent with suicide or violence?
• Does the patient have a medical problem or trauma?
• Might the patient have a weapon?
• Is it safe to attempt an intervention?
© 2011 National Safety Council 13-10
Suicide Risk Factors
• Mental disorders (including depression)
• History of substance abuse
• Feelings of hopelessness
• Recent emotional crisis or painful illness
• Impulsive or aggressive tendencies
• Previous attempts
• More common in teenagers
© 2011 National Safety Council 13-11
Suicide Warning Signs
• Talking about suicide
• Comments about hopelessness or worthlessness
• Taking risks that could cause death
• Loss of interest in past activities
• Suddenly and unexpectedly seeming calm or happy after being sad
© 2011 National Safety Council 13-12
Emergency Care forBehavioral Emergencies
• Perform standard patient care
• Protect the patient and yourself
• Do not leave patient alone
• Consider need for law enforcement
• Be prepared to leave scene
• Give medications or drugs to arriving EMS
• Don’t assume patient is drug impaired
© 2011 National Safety Council 13-13
Emergency Care forBehavioral Emergencies (continued)
• Try to reduce any distressing stimuli at scene
• Always try to talk patient into cooperation
• Call for additional help if needed, including law enforcement if appropriate
• Avoid restraints unless necessary
• Calm and reassure patient
© 2011 National Safety Council 13-14
Calming a Behavioral Patient
• Approach slowly but purposefully
• Identify yourself
• Say you are there to help
• Ask patient for name, and use it
• Tell patient what you plan to do
• Treat patient with respect
© 2011 National Safety Council 13-15
Calming a Behavioral Patient (continued)
• Ask questions in calm, reassuring voice
• In cultures where acceptable, make eye contact
• Encourage patient to tell you what happened and what troubles him or her
• Show you care
• Rephrase or repeat what patient says
© 2011 National Safety Council 13-16
Calming a Behavioral Patient (continued)
• Acknowledge patient’s feelings
• Maintain a comfortable distance
• Avoid unnecessary physical contact
• Avoid any posture that may seem threatening
• Do not make quick moves
• Respond honestly to questions
• Don’t belittle, threaten, challenge or argue
• Don’t “play along” with hallucinations
• Involve family members or friends
© 2011 National Safety Council 13-17
Calming a Behavioral Patient (continued)
• Be patient, and be prepared to stay at scene for a long time
• Always remain with patient
• Call for additional help if needed
© 2011 National Safety Council 13-18
Victims of Abuse and Sexual Assault
• Child abuse, spouse abuse (domestic violence), elder abuse and sexual assault often cause injuries treated by EMRs
• These situations may also be behavioral emergencies
• Be sensitive to situation while providing medical care
• Report your observations to responding EMS personnel and in your run report
• Take special crime scene considerations
© 2011 National Safety Council 13-19
Domestic Violence
• Victim often does not report abuse to authorities
• Victim stays with abusing spouse or partner
• Signs of potential domestic violence:
- Patient seems unusually fearful
- Patient’s account of injury seems inconsistent or unlikely
- Patient is uneasy in presence of spouse or partner
- Patient’s spouse or partner aggressively blames patient
© 2011 National Safety Council 13-20
Emergency Care for Domestic Violence
• Provide emergency care as usual for injuries
• Ensure privacy for patient
• Tell responding EMS personnel in private about your suspicions
• Do not directly confront patient with suspicions, especially if spouse or partner is present
• Do not confront patient’s spouse or partner
• Try to involve a friend or family member of patient in care giving
© 2011 National Safety Council 13-21
Emergency Care for Domestic Violence (continued)
• Follow local protocol to report suspected cases to appropriate authorities
• If patient communicates information to you suggesting abuse, report this to responding EMS personnel and document it
• If appropriate, call for law enforcement personnel
• If necessary, withdraw from scene to ensure your safety
© 2011 National Safety Council 13-22
Sexual Assault and Rape
• Victim of sexual assault or rape may have other injuries
• Patient may or may not say what happened
• Be aware of likely psychological trauma
• Do not push for answers when taking patient’s history
© 2011 National Safety Council 13-23
Emergency Care forSexual Assault and Rape
• Be sensitive to patient’s psychological trauma
• Patient may be hysterical, crying, hyperventilating or in a dazed, unresponsive state
• Provide emotional support
• Ensure appropriate responders have been summoned
• Rape requires law enforcement personnel
• Ensure privacy for patient
• Try to involve a friend or family member of patient in care giving or EMS responder of same sex
© 2011 National Safety Council 13-24
Emergency Care forSexual Assault and Rape (continued)
• Ensure patient is not left alone
• Provide medical care as needed for any injury
• Preserve evidence of rape – ask patient not to urinate (unless necessary), bathe or wash before EMS personnel arrive
© 2011 National Safety Council 13-25
Restraining Patients
• If patient is danger to self or others
• Most EMRs do not restrain patients
• Restrain only if you have been trained and it is part of local protocol
• Before using restraint, have police present and work with responding EMS
© 2011 National Safety Council 13-26
Restraining Patients (continued)
• Avoid unreasonable force
- Use only as much force as needed to keep patient from injuring him or herself or others
- Use reasonable force to defend yourself
• Avoid acts or physical force that may injure patient
© 2011 National Safety Council 13-27
Reasonable Force for Restraints Depends On
• Patient’s size, strength and gender
• Patient’s abnormal behavior
• Patient’s mental state
• Method of restraint
© 2011 National Safety Council 13-28
Guidelines for Restraining
• Act only as you have been trained, following local protocol
• Ensure adequate personnel are present to help
• Plan approach you will use – then act quickly
• One responder should talk to patient throughout process
• Four responders approach together, 1 assigned to each extremity
• Extremities restrained with equipment approved by medical direction, avoiding unnecessary force
© 2011 National Safety Council 13-29
Guidelines for Restraining (continued)
• Do not restrain patient face down; maintain airway access at all times
• Assess patient’s breathing and circulation frequently
• Provide oxygen by non-rebreather mask if appropriate
• Once a patient is restrained, do not remove restraints
• Document indications and technique used
© 2011 National Safety Council 13-30
Legal Considerations in Behavioral Emergencies
• Patients may threaten or falsely accuse responders
• Document abnormal behavior factually
• Ensure others are present (witnesses)
• When possible, have same-sex responders provide care
© 2011 National Safety Council 13-31
Emotionally DisturbedPatients Resisting Treatment
• Get patient’s consent, witnessed by others
• If patient threatens self-harm or you believe this may occur, follow local protocol to provide care against patient's will if safe to do so
• Assistance of law enforcement usually required