Chapter 20 Psychiatric Emergencies. National EMS Education Standard Competencies (1 of 2) Medicine Applies fundamental knowledge to provide basic emergency

Chapter 20Chapter 20Chapter 20Chapter 20

Psychiatric Emergencies

National EMS Education National EMS Education Standard Competencies Standard Competencies (1 of 2)(1 of 2)


Medicine

Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient.



Psychiatric

Recognition of:

– Behaviors that pose a risk to the EMT, patient, or others

– Basic principles of the mental health system

– Assessment and management of:

• Acute psychosis

• Suicidal/risk

• Agitated delirium

IntroductionIntroduction

• EMTs often deal with patients undergoing psychological or behavioral crisis.

• Crisis might be the result of:– Emergency situation

– Mental illness

– Mind-altering substances

– Stress

IntroductionIntroductionIntroductionIntroduction

• Patients may present with unexpected or dangerous behavior

• May result from– Stress

– Physical trauma or illness

– Drug or alcohol abuse

– Psychiatric condition

Myth and Reality (1 of 3)Myth and Reality (1 of 3)

• We all develop some symptoms of mental illness at some point in life.– Does not mean that everyone develops mental

illness

• Do not jump to conclusions concerning:– Yourself

– Your patient


• The most common misconception is that if you are feeling “bad” or “depressed,” you must be “sick.”

• There are many justifiable reasons for feeling depressed, such as:– Divorce

– Loss of a job

– Death of a relative or friend


• Many people believe that all individuals with mental health disorders are dangerous, violent, or unmanageable.– Only a small percentage fall into this category.

– You may be exposed to a higher proportion of violent patients.

– You may be able to predict violence.

Defining a Behavioral Crisis (1 of 4)


• Behavior is what you can see of a person’s response to the environment: his or her actions.– Most of the time, people respond to the

environment in reasonable ways.

– There are times when stress is so great that the normal ways do not work.



• A behavioral crisis is any reaction to events that interferes with the activities of daily living or has become unacceptable to the patient, family, or community.– If this interruption tends to occur on a regular

basis, the behavior is also considered a mental health problem.



• Usually, if an abnormal pattern of behavior lasts for at least a month, it is a matter of concern.– Chronic depression is a persistent feeling of

sadness and despair.

– May be a symptom of a mental or physical disorder



• When a psychiatric emergency arises, the patient:– May show agitation or violence

– May become a threat to self or others

The Magnitude of Mental Health Problems (1 of 2)


• At one time or another, one in five Americans has some type of psychiatric disorder.– An illness with psychological or behavioral

symptoms that may result in impaired functioning



• The US mental health system provides many levels of assistance.– Professional counselors are available for marital

conflict and parenting issues.

– More serious issues are often handled by a psychologist.

– Severe psychological conditions require a psychiatrist.

Pathology (1 of 4)Pathology (1 of 4)

• An EMT is not responsible for diagnosing the underlying cause of a behavioral crisis or psychiatric emergency.– You should know the two basic categories of

diagnosis a physician will use: organic and functional.


• Organic– Organic brain syndrome is a temporary or

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

– Causes include sudden illness, head trauma, seizures, intoxication, and diseases of the brain


• Organic (cont’d)– Altered mental status can arise from:

• Low level of blood glucose

• Lack of oxygen

• Inadequate blood flow to brain

• Excessive heat or cold


• Functional– Abnormal operation of an organ that cannot be

traced to an obvious change in the organ itself

– Examples include schizophrenia, anxiety conditions, and depression.

– There may be a chemical or physical cause, but it is not well understood.

Psychiatric Causes of Psychiatric Causes of Behavioral EmergenciesBehavioral EmergenciesPsychiatric Causes of Psychiatric Causes of

Behavioral EmergenciesBehavioral Emergencies

• Psychiatric condition (mental disorder)– Anxiety or panic disorder

– Depression

– Bipolar disorder

– Schizophrenia

Physical Causes of Physical Causes of Behavioral EmergenciesBehavioral Emergencies

Physical Causes of Physical Causes of Behavioral EmergenciesBehavioral Emergencies

• Non-psychiatric causes of altered mental status can be life-threatening and must be considered first

Situational Stress ReactionsSituational Stress ReactionsSituational Stress ReactionsSituational Stress Reactions

• Normal reactions to stressful situations produce emotions– Fear

– Grief

– Anger

Caring for Patients Caring for Patients with Situational Stress Reactionswith Situational Stress Reactions

Caring for Patients Caring for Patients with Situational Stress Reactionswith Situational Stress Reactions

• Do not rush

• Tell patient you are there to help

• Remain calm

• Keep emotions under control

• Listen to patient

• Be honest

• Stay alert for changes in behavior

Safe Approach to a Behavioral Crisis (1 of 2)


• All regular EMT skills are used in a behavioral crisis.– However, other

management techniques come into play.



Patient AssessmentPatient Assessment

• Patient assessment steps– Scene size-up

– Primary assessment

– History taking

– Secondary assessment

– Reassessment

Scene Size-up (1 of 2)Scene Size-up (1 of 2)

• Scene safety– Is the situation unduly dangerous to you and

your partner?

– Do you need immediate law enforcement backup?

– Does the patient’s behavior seem typical or normal for the circumstances?

– Are there legal issues involved?

Scene Size-up (2 of 2)Scene Size-up (2 of 2)

• Mechanism of injury/nature of illness– Determine the MOI and/or NOI.

Primary Assessment (1 of 3)Primary Assessment (1 of 3)

• Form a general impression.– Begin your assessment from the doorway or

from a distance.

– Perform a rapid scan.

– Observe the patient closely using the AVPU scale to check for alertness.

– Establish a rapport with the patient.


• Airway and breathing– Assess the airway to make sure it is patent and

adequate.

– Evaluate the patient’s breathing.

• Circulation– Assess the pulse rate, quality, and rhythm.

– Obtain the systolic and diastolic BP.

– Evaluate skin color, temperature, condition.


• Transport decision– Unless your patient is unstable from a medical

problem or trauma, prepare to spend time at the scene with him or her.

– There may be a specific facility to which patients with mental problems are transported.

History Taking (1 of 3)History Taking (1 of 3)

• Investigate the chief complaint.– Is the patient’s central nervous system

functioning properly?

– Are hallucinogens or alcohol a factor?

– Are psychogenic circumstances involved?


• SAMPLE history– You may be able

to elicit information not available to the hospital staff.


• SAMPLE history (cont’d)– In geriatric patients, consider Alzheimer disease

and dementia.

– Your assessment has two primary goals:

• Recognizing major life threats

• Reducing the stress of the situation

– Use reflective listening.

Secondary Assessment (1 of 4)Secondary Assessment (1 of 4)

• Physical examinations– In an unconscious patient, begin with a full-body

scan.

– Avoid touching the patient without permission.

– A conscious patient may not respond at all to your questions.


• Physical examinations (cont’d)– You can tell a lot about a patient’s emotional

state from:

• Facial expressions

• Pulse rate

• Respirations


• Vital signs– Obtain vital signs when doing so will not

exacerbate the patient’s emotional distress.

– Make every effort to assess blood pressure, pulse, respirations, skin, and pupils.


• Vital signs (cont’d)– Monitoring devices may be used.

– Assess the patient’s first blood pressure with a sphygmomanometer and a stethoscope.

– A pulse oximetry device can be used to assess the patient’s perfusion status.

Reassessment (1 of 3)Reassessment (1 of 3)

• Never let your guard down.– Many patients will act spontaneously.

• If restraints are necessary, reassess and document every 5 minutes:– Respirations

– Pulse and motor and sensory function in all restrained extremities


• Interventions– There is often little you can do during the short

time you will be treating the patient.

– Diffuse and control the situation.

– Safely transport the patient to the hospital.

– Intervene only as much as it takes to accomplish these tasks.


• Communication and documentation– Try to give the receiving hospital advance

warning of the psychiatric emergency.

– Document thoroughly and carefully.

• Yours may be the only documentation about the patient’s distress.

• If restraints are used, say what types and why they were used.

Acute Psychosis (1 of 5)Acute Psychosis (1 of 5)

• Psychosis is a state of delusion in which the person is out of touch with reality.

• Causes include:– Mind-altering substances

– Intense stress

– Delusional disorders

– Schizophrenia


• Schizophrenia is a complex disorder that is not easily defined or treated.– Typical onset occurs during adulthood.

– Influences thought to contribute include:

• Brain damage

• Genetics

• Psychological and social influences


• Persons with schizophrenia experience symptoms including:– Delusions

– Hallucinations

– A lack of interest in pleasure

– Erratic speech


• Guidelines for dealing with a psychotic patient:– Determine if the situation is dangerous.

– Identify yourself clearly.

– Be calm, direct, and straightforward.

– Maintain an emotional distance.

– Do not argue.


• Guidelines (cont’d)– Explain what you would like to do.

– Involve people the patient trusts, such as family or friends, to gain patient cooperation.

Suicide (1 of 5)Suicide (1 of 5)

• Depression is the most significant factor that contributes to suicide.

• It is a common misconception that people who threaten suicide never commit it.– Suicide is a cry for help.

– Someone is in a crisis that he or she cannot handle alone.



• Be alert to these warning signs:– Does he or she have an air of tearfulness,

sadness, deep despair, or hopelessness?

– Does he or she avoid eye contact, speak slowly, and project a sense of vacancy?

– Does he or she seem unable to talk about the future?

– Is there any suggestion of suicide?

– Does he or she have any plans relating to death?


• Consider these additional risks:– Are there any unsafe objects nearby?

– Is the environment unsafe?

– Is there evidence of self-destructive behavior?

– Is there an imminent threat to the patient or others?


• Additional risks (cont’d)– Is there an underlying medical problem?

– Are there cultural or religious beliefs promoting suicide?

– Has there been any trauma?

• A suicidal patient may be homicidal as well.

Agitated Delirium (1 of 5)Agitated Delirium (1 of 5)

• Delirium is a condition of impairment in cognitive function that can present with disorientation, hallucinations, or delusions.

• Agitation is characterized by restless and irregular physical activity.– Patients may strike out irrationally.

– Your personal safety must be considered.


• Symptoms may include:– Hyperactive irrational behavior

– Inattentiveness

– Vivid hallucinations

– Hypertension

– Tachycardia

– Diaphoresis

– Dilated pupils


• Be calm, supportive, and empathetic.

• Approach the patient slowly and purposefully and respect the patient’s territory.

• Limit physical contact.

• Do not leave the patient unattended.


• Try to indirectly determine the patient’s:– Orientation

– Memory

– Concentration

– Judgment

• Pay attention to the patient’s ability to communicate, appearance, dress, and personal hygiene.


• If you determine the patient requires restraint, make sure you have adequate personnel available to help you.

• If the patient has overdosed, take all medication bottles or illegal substances to the medical facility.– Refrain from using lights and sirens.

Medicolegal Considerations (1 of 5)


• More complicated with patient undergoing behavioral crisis or psychiatric emergency

• Legal problems are reduced when the patient consents to care.– Gaining the patient’s confidence is crucial.



• You must decide whether the patient requires immediate emergency medical care.– He or she may resist your attempt to provide

care.

– Never leave the patient alone.

– Request law enforcement personnel to handle the patient.



• Consent– Implied consent is assumed with a patient who

is not mentally competent to grant consent.

– Consent matters are not always clear-cut in psychiatric emergencies.

– If you are not sure, request the assistance of law enforcement personnel.



• Limited legal authority– The EMT has limited legal authority to require a

patient to undergo emergency medical care when no life-threatening emergency exists.

– Competent adults have the right to refuse care.



• In psychiatric cases, a court of law would probably consider your actions in providing lifesaving care to be appropriate.– A patient who is in any way impaired may not

be considered competent.

– Err on the side of treatment and transport.

Restraint (1 of 5)Restraint (1 of 5)

• If you restrain a person without authority in a nonemergency situation, you expose yourself to a possible lawsuit.– Legal actions can involve charges of assault,

battery, false imprisonment, and violation of civil rights.


• You may use restraints only:– To protect yourself

or others from bodily harm

– To prevent the patient from causing injury to himself or herself


• You may use only reasonable force as necessary to control the patient.

• Always try to transport a disturbed patient without restraints if possible.

• At least four people should be present to carry out the restraint, each being responsible for one extremity.


• Level of force will vary, depending on these factors:– Degree of force that is necessary to keep the

patient from injuring himself, herself, or others

– Patient’s sex, size, strength, mental status

– Type of abnormal behavior the patient is exhibiting


• Secure the patient’s extremities with approved equipment.

• Treat the patient with dignity and respect.

• Monitor the patient for:– Vomiting

– Airway obstruction

– Cardiovascular stability

The Potentially Violent Patient (1 of 5)


• Violent patients make up only a small percentage of behavioral and psychiatric patients.

– However, the potential for violence is always an important consideration for you.



• History– Has the patient previously exhibited hostile,

overly aggressive, or violent behavior?

• Posture– How is the patient sitting or standing?

– Is the patient tense, rigid, or sitting on the edge of his or her seat?



• The scene– Is the patient holding or near potentially lethal

objects?

• Vocal activity– What kind of speech is the patient using?

– Loud, obscene, erratic, and bizarre speech patterns usually indicate emotional distress.



• Physical activity– Most telling factor of all

– A patient requiring careful watching is one who:

• Has tense muscles, clenched fists, or glaring eyes

• Is pacing

• Cannot sit still

• Is fiercely protecting personal space



• Other factors to consider:– Poor impulse control

– A history of truancy, fighting, and uncontrollable temper

– Tattoos

– Substance abuse

– Depression

– Functional disorder

Behavioral and Behavioral and Psychiatric Patient Psychiatric Patient

PresentationsPresentations

Behavioral and Behavioral and Psychiatric Patient Psychiatric Patient

PresentationsPresentations• Range of presentations

• Withdrawn, not communicating

• Talkative, agitated

• Bizarre or threatening behavior

• Wish to harm selves or others

General Rules for InteractionsGeneral Rules for InteractionsGeneral Rules for InteractionsGeneral Rules for Interactions

• Identify yourself and role

• Speak slowly and clearly

• Eye contact

• Listen

• Don’t judge

• Open, positive body language

• Don’t enter patient’s space (3 ft)

• Alert for behavior changes

AssessmentAssessmentAssessmentAssessment

• Perform careful scene size-up

• Identify yourself and your role

• Perform primary assessment

• Perform focused physical exam

• Gather thorough history

Common Patient PresentationsCommon Patient PresentationsCommon Patient PresentationsCommon Patient Presentations

• Panic or anxiety

• Unusual appearance (disordered clothing, poor hygiene)

• Agitated or unusual activity

• Unusual speech patterns

• Bizarre behavior or thought patterns

• Self-destructive behavior

• Violence or aggressive behavior

Patient CarePatient CarePatient CarePatient Care

• Treat life-threatening problems

• Consider medical or traumatic causes

• Follow general rules for positive interactions

• Encourage patient to discuss feelings

• Never play along with hallucinations

• Consider involving family or friends

SuicideSuicideSuicideSuicide

• Eighth leading cause of death

• Third leading cause in 15–24-year-olds

• Rising numbers in geriatric population

Suicide Patient AssessmentSuicide Patient AssessmentSuicide Patient AssessmentSuicide Patient Assessment

• Explore the following possibilities– Depression

– High stress levels (current or recent)

– Recent emotional trauma

– Age (15–25 and 40+ highest risk)

– Drug or alcohol abuse

– Threats of suicide

– Suicide plan

– Previous attempts or threats

– Sudden improvement from depression

Suicide Patient CareSuicide Patient CareSuicide Patient CareSuicide Patient Care

• Personal interaction is important

• Do not argue, threaten, or indicate using force1. Scene safety

2. Identify, treat life-threatening problems

3. Perform history, physical exam• Detailed exam only if safe

4. Reassess frequently

5. Notify receiving facility

Think About ItThink About ItThink About ItThink About It

• Patient is 23-year-old male. His girlfriend called 911 after a domestic dispute. He is uncooperative and refusing treatment. The girlfriend reports patient is depressed and suicidal. He owns a gun and has threatened to shoot himself.

continued

Think About ItThink About ItThink About ItThink About It

• Can you treat the patient if he did not call?

• Should you believe the girlfriend?

• Does the patient need treatment or transport?

• Can you treat and transport the patient against his will?

• What should you do?

Aggressive or Aggressive or Hostile PatientsHostile PatientsAggressive or Aggressive or

Hostile PatientsHostile Patients

• Consider clues– Dispatch information

– Information from family or bystanders

– Patient’s stance or position in room

• Ensure escape route

• Do not threaten patient

• Stay alert for weapons of any type

Aggressive or Aggressive or Hostile Patient AssessmentHostile Patient Assessment

Aggressive or Aggressive or Hostile Patient AssessmentHostile Patient Assessment

• Ensure safety

• Calm patient

• Perform a thorough assessment

• Restrain patient if necessary

Aggressive or Aggressive or Hostile Patient CareHostile Patient Care

Aggressive or Aggressive or Hostile Patient CareHostile Patient Care

• Scene size-up

• Request additional help if necessary

• Seek advice from medical control if necessary

• Watch for sudden changes in behavior

• Reassess frequently

• Consider restraint

Reasonable Reasonable Force and RestraintForce and Restraint


• Reasonable force: force necessary to keep patient from injuring self or others

• “Reasonable” determined by– Patient’s size and strength

– Type of behavior

– Mental status

– Available methods of restraint

continued



• Some systems do not allow restraint without police or medical control orders

• Never attempt restraint without proper legal authority and sufficient assistance

Restraining a PatientRestraining a PatientRestraining a PatientRestraining a Patient

• Have adequate help

• Plan actions

• Stay beyond patient’s reach until prepared

• Act quickly

• One EMT talks to and calms patient

• Requires four persons, one at each limb

• Restrain all limbs with approved leather restraints in supine position ALWAYS

continued

Restraining a PatientRestraining a PatientRestraining a PatientRestraining a Patient

• EMT is responsible for restrained patient’s airway

• Ensure patient is adequately secured throughout transport

• Apply a surgical mask to spitting patients

• Reassess frequently

• Document thoroughly

Excited DeliriumExcited DeliriumExcited DeliriumExcited Delirium

• Extremely agitated or psychotic behavior during struggle, followed by cessation of struggling, respiratory arrest, then death

• Patient is often hyperthermic and shouting incoherently

• Usually preceded by cocaine use

continued

Excited DeliriumExcited DeliriumExcited DeliriumExcited Delirium

• Often linked to improper restraint in a position where patient cannot expand chest to breathe adequately (positional asphyxia)

• Be alert for this sequence of events

Transport to Transport to Appropriate FacilityAppropriate Facility

Transport to Transport to Appropriate FacilityAppropriate Facility

• Not all hospitals are prepared to treat behavioral emergencies

• Choose correct facility based on capabilities and local protocol

Medical/Legal ConsiderationsMedical/Legal ConsiderationsMedical/Legal ConsiderationsMedical/Legal Considerations

• Consent– Refusals and restraints cause significant

medical/legal risk

– Laws typically allow providers to treat and transport patients against their will if a danger to selves or others

– Local protocol may require medical control contact and/or police presence

continued

Medical/Legal ConsiderationsMedical/Legal ConsiderationsMedical/Legal ConsiderationsMedical/Legal Considerations

• Sexual misconduct– Behavioral patients, especially those requiring

physical contact such as restraint, sometimes accuse EMS providers

– Have same-sex provider attend to patient

– Have third-party witness present at all times, on scene and during transport

Safety—Restraints VideoSafety—Restraints VideoSafety—Restraints VideoSafety—Restraints Video

Click here to view a video on the subject of proper use of soft restraints.

Back to Directory

Chapter ReviewChapter ReviewChapter ReviewChapter Review


• Ensure your own safety when caring for violent or potentially violent patients.

• Patients with behavioral problems are in crisis and need compassionate care.

• Always consider abnormal behavior to be altered mental status, with a medical or traumatic cause.

continued


• Because treatment of these patients usually requires long-term management, little medical intervention can be done in the acute situation, but how you interact with them is crucial for their continued well-being.

RememberRememberRememberRemember

• Safety is the first priority when approaching a patient with altered mental status.

• Psychiatric and behavioral emergencies are prevalent in our society. EMTs should treat them as they would any other potentially life-threatening disorder.

continued


• Assessment of altered mental status should rule out physical causes first.

• Psychiatric and behavioral emergencies can present differently, depending upon the disorder. There are best practices EMTs employ in approaching, assessing, and treating such patients.

continued


• Follow local protocols and use appropriate procedures to restrain patients when necessary.

Questions to ConsiderQuestions to ConsiderQuestions to ConsiderQuestions to Consider

• What methods help calm the patient suffering a behavioral or psychiatric emergency?

• What can you do when scene size-up reveals it is too dangerous to approach the patient?

• What factors help assess the patient’s risk for suicide?

Critical ThinkingCritical ThinkingCritical ThinkingCritical Thinking

• You respond to an intoxicated minor who is physically aggressive, threatens suicide, and whose parents permit you to treat, but not transport the patient. How would you manage this patient?

Summary Summary (1 of 6)(1 of 6)Summary Summary (1 of 6)(1 of 6)

• A behavioral crisis is any reaction to events that interferes with the activities of daily living or has become unacceptable to the patient, family, or community.


• During a psychiatric emergency, a patient may show agitation or violence or become a threat to himself or herself, or to others.


• Psychiatric disorders have many possible underlying causes including social or situational stress, psychiatric disorders, physical illnesses, chemical problems, or biologic disturbances.


• As an EMT, you are not responsible for diagnosing the underlying cause of a behavioral crisis or psychiatric emergency.

• The threat of suicide requires immediate intervention. Depression is the most significant risk factor for suicide.


• A patient in mentally unstable condition may resist your attempts to provide care. In such situations, request that law enforcement personnel handle the patient.

• Violent or dangerous people must be taken into custody by the police before emergency care can be rendered.


• Always consult medical control and contact law enforcement personnel for help before restraining a patient.

• If restraints are required, use the minimum force necessary. Assess the airway and circulation frequently while the patient is restrained.

Review (1 of 2)Review (1 of 2)

1. A behavioral crisis is MOST accurately defined as:

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

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


1. A behavioral crisis is MOST accurately defined as:

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 reaction to a stressful event that the patient feels is appropriate, but is considered inappropriate by the patient’s family or the community.

ReviewReview

Answer: B

Rationale: A behavioral crisis is any reaction to events that interferes with the patient’s 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 violent patients experiencing a psychiatric condition; these are common misconceptions. Various medical conditions can cause a behavioral crisis (eg, hypoglycemia, hypoxemia, brain tumors).


1. A behavioral crisis is MOST accurately defined as:A. a severe, acute psychiatric condition in which

the patient becomes violent and presents a safety threat to himself or herself, or to others. Rationale: This could be considered a symptom of a mental disorder.

B. any reaction to events that interferes with activities of daily living or has become unacceptable to the patient, family, or community. Rationale: Correct answer


1. A behavioral crisis is MOST accurately defined as: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. Rationale: This could be normal behavior or could progress to depression.

D. a reaction to a stressful event that the patient feels is appropriate, but is considered inappropriate by the patient’s family or the community. Rationale: This could be normal behavior.

ReviewReview

2. Depression and schizophrenia are examples of:

A. functional disorders.

B. altered mental status.

C. behavioral emergencies.

D. organic brain syndrome.

ReviewReview

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.



A. functional disorders.Rationale: Correct answer

B. altered mental status.Rationale: A common presentation in patients with a wide variety of medical problems.



C. behavioral emergencies.Rationale: Emergencies that do not have a clear physical cause and that result in aberrant behavior.

D. organic brain syndrome.Rationale: A psychiatric disorder caused by a permanent or temporary physical change in the brain.

ReviewReview

3. When assessing a patient with a behavioral crisis, your primary concern must be:A. allowing the patient to express himself to you

in his own words.B. setting your personal feelings aside and

providing needed care.C. gathering the patient’s belongings and taking

them to the hospital.D. whether the patient will cause harm to you or

your partner.

ReviewReview

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 in this question. Your primary concern, however, must be the safety of yourself and your partner.


3. When assessing a patient with a behavioral crisis, your primary concern must be:A. allowing the patient to express himself to you

in his own words.Rationale: This is a good technique used in assessment.

B. setting your personal feelings aside and providing needed care.Rationale: It is important not to allow your own prejudice to interfere with treating patients.


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

C. gathering the patient’s belongings and taking them to the hospital.Rationale: Good patient skills are utilized in the treatment of every patient.

D. whether the patient will cause harm to you or your partner.Rationale: Correct answer

ReviewReview

4. 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.

ReviewReview

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.

ReviewReview

4. General guidelines to follow when caring for a patient with a behavioral crisis include all of the following, EXCEPT:A. being honest and reassuring.

Rationale: This is part of proper treatment.

B. rapidly transporting the patient.Rationale: Correct answer

C. having a definite plan of action.Rationale: This is part of proper treatment.

D. avoiding arguing with the patient.Rationale: This is part of proper treatment.

ReviewReview

5. 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.

ReviewReview

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 insight into the patient’s situation.


5. 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. Rationale: This is considered to be clarification of a response.

B. simply listening to the patient, without speaking. Rationale: This is considered to be active listening.


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

C. asking the patient to repeat everything that you say. Rationale: Simplify and summarize the patient’s response when a patient gives confusing or disorganized responses.

D. repeating, in question form, what the patient tells you. Rationale: Correct answer

ReviewReview

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

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

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

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

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

ReviewReview

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; marital discord; death of a loved one; untreated psychiatric illness; recent acquisition of items that can cause death, such as a gun or knife; and chronic alcohol use.



A. 24-year-old woman who is successfully being treated for depressionRationale: This woman is not a high risk for suicide.

B. 29-year-old man who was recently promoted with a large pay increaseRationale: This man is not a high risk for suicide.



C. 33-year-old man who regularly consumes alcohol and purchased a gunRationale: Correct answer

D. 45-year-old woman who recently found out her cancer is in full remissionRationale: This woman is not a high risk for suicide.

ReviewReview

7. 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.

ReviewReview

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 (eg, under age, altered mental status, alcohol intoxication).


7. 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. Rationale: Do this only if the patient clearly does not have decision-making capacity (eg, under age, intoxicated).

B. leave the patient with a trusted friend or family member. Rationale: Attempt to obtain verbal consent for transport to a medical facility.


7. 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:

C. attempt to obtain consent from the patient to transport. Rationale: Correct answer

D. apply soft restraints in case the patient becomes violent. Rationale: Restraints are not often used in situations where a patient might become violent, but they are considered.

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8. 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 you.

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Answer: A

Rationale: When physically restraining a violent patient, the EMT or his or her partner should continually talk to the patient 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.



A. continually talk to the patient as he or she is being restrained.Rationale: Correct answer

B. check circulation in all extremities only if the patient is prone.Rationale: Always check the patient’s extremity circulation often when physical restraints are applied.



C. remove the restraints if the patient appears to be calming down.Rationale: Once restraints are applied, they should not be removed.

D. use additional force if the restrained patient begins to yell at you.Rationale: Only use the force necessary to initially restrain a patient.

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9. Upon arrival at the residence of a young male with an apparent emotional crisis, a police officer tells you that the man is acting bizarre. 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.

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Answer: A

Rationale: There are numerous physical problems that can cause bizarre behavior, such as hypo-glycemia, hypoxemia, and brain tumors, among others. The EMT should rule out an underlying medical cause first. The patient’s pallor, diaphoresis, and motor tremors suggest hypoglycemia. The EMT should assess the patient’s blood glucose level, if trained to do so, and consider administering oral glucose. Psychiatric illnesses, such as clinical depression and schizophrenia, cannot be ruled in or out in the field.



A. hypoglycemia.Rationale: Correct answer

B. suicidal thoughts. Rationale: This is a symptom, something that the patient tells you. It does not produce visible signs.



C. severe depression. Rationale: This cannot be ruled out in the prehospital setting.

D. schizophrenia. Rationale: Schizophrenia cannot be ruled out in the field.

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10. Which of the following signs is LEAST indicative of a patient’s potential for violence?

A. The patient appears tense and “edgy.”

B. The patient is 6'5" tall and weighs 230 lb.

C. The patient is loud and shouting obscenities.

D. The patient is facing you with clenched fists.

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Answer: B

Rationale: When assessing a patient’s 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 patient’s physical size and his or her potential for violence.



A. The patient appears tense and “edgy.”Rationale: This is a signal of possible physical aggression and anger.

B. The patient is 6'5" tall and weighs 230 lb.Rationale: Correct answer

CreditsCredits

• Background slide image: © Jones & Bartlett Learning. Courtesy of MIEMSS.



C. The patient is loud and shouting obscenities.Rationale: This is a signal of possible physical aggression and anger.

D. The patient is facing you with clenched fists.Rationale: This is a signal of possible physical aggression and anger.

Documents

Chapter 20 Psychiatric Emergencies. National EMS Education Standard Competencies (1 of 2) Medicine Applies fundamental knowledge to provide basic emergency