Transcript Chap23- Behavioral 417KB Jan 14 2015 08:21:52 AM

Chapter 23
Behavioral Emergencies
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 1
Case History
You arrive at the scene of a disturbance. You
find a 30-year-old male throwing articles out
the window of the house. He is screaming that
everyone is out to get him and he tells you that
he will not let anyone touch him.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 2
Behavioral Emergency
Definition:
An occurrence in which the patient exhibits
abnormal behavior within a given situation
that is unacceptable or intolerable to the
patient, family, or community
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 3
Scope of the Problem
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Depression is often underemphasized in EMS.
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Depression is present in at least 11% of population in
U.S.
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20% of adults experience at least one episode of
clinical depression.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 4
Depression and Suicide
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Symptoms of depression
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Loss of sleep, appetite, sex drive
Sad, tearful
Guilt
Hopelessness
Thoughts of death or taking one’s life
Physical symptoms
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 5
Suicide –
Scope of the Problem
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28,000 suicides each year
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Men >65 y/o have three times higher suicide rate.

Young person attempts suicide every 90 seconds.
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Successful suicide every 90 minutes
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 6
Suicide –
Assessment of Risk Factors
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Male
Individuals over 40
Single, widowed, or divorced
Socially isolated
Alcoholic, drug abuse
Recent diagnosis of serious illness
Recent loss of significant loved one
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 7
Suicide –
Assessment of Risk Factors
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Previous history of self-destructive behavior
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Arrest, imprisonment, loss of job
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Lethal plan of action that has been verbalized
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Gathering of articles that can cause death
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Gun
Large volumes of pills
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 8
Suicide –
Assessment Findings
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Patient in an unsafe environment?
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With unsafe objects in hands?
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Displaying self-destructive behavior?
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 9
Suicide – Important Questions
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How does the patient feel?
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Suicidal tendencies in the past?
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If so, what interventions have occurred?
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Is patient a threat to self or others?
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Is there a medical problem?
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10
Emergency Medical Care
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Perform scene size-up.
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Personal safety is a priority.
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Conduct patient assessment.
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Calm the patient.
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Do not leave patient alone.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11
Emergency Medical Care
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Restrain, if necessary.
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Consider need for law
enforcement.
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Transport.
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If overdose, bring
medications or drugs.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12
Behavioral Change
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General factors that may alter a patient's behavior
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Situational stresses
Medical illnesses
Psychiatric problems
Alcohol or drugs
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13
Common Factors
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Low blood sugar
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Lack of oxygen
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Inadequate blood
flow to the brain
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Head trauma
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14
Common Factors
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Mind-altering substances
Psychogenic – resulting in psychotic thinking,
depression, or panic
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Excessive cold
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Excessive heat
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15
Situational Reactions
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Panic
Agitation
Anger
Anxiety
Paranoia
Denial
Withdrawal
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16
Personality Disorders
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Definition: Character traits that interfere with a
person’s ability to function successfully in work or
personal relationships
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Patient can be manipulative and self-focused.
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Avoid getting angry with the patient.
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Be positive but establish limits.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17
Psychosis
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Disordered thoughts
Disordered perceptions of reality
Hallucinations
Inappropriate responses to environment
Possible communication difficulty
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Speaks incoherently
Out of control
May need to obtain history from others
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18
Organic Brain Syndrome
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Medically caused brain syndrome
Disordered thoughts
Disorientation
Delirium
Hallucinations
Numerous causes
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Tumor
Trauma
Infection
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19
Scene Size-up
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Most important aspect of assessment
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Can present a serious threat to EMT safety
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Try to identify potential causes of presenting problem.
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Aggressive or bizarre behavior
Open bottles of medications, syringes, track marks
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20
Scene Safety
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Be aware of potential dangers
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If notified of a violent patient, wait for police before
entering scene.
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First priority is prevention of further injuries.
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Environmental dangers may exist.
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Gas exhaust
Carbon monoxide
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21
Violent Behavior
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Recognizing impending violence is vital.
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Do not put yourself in jeopardy.
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Assess what can be done to avoid outburst.
Leave yourself an escape route.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 22
Signs of a
Potentially Violent Patient
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Angry voice
Pressured speech
Pacing
Expressions of violence
Psychiatric history of emotional disturbance
Drug intoxication
Situational frustration
Threatening posture or movements
Presence of heavy or threatening objects
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 23
Principles for Assessing
Behavioral Emergency
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Identify yourself.
Let the person know you are there to help.
Inform the patient of what you are doing.
Ask questions in a calm, reassuring voice .
Allow the patient to tell what happened.
Do not be judgmental.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 24
Principles of Assessing
Behavioral Emergency
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Rephrase or repeat to confirm communication.
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Acknowledge the patient’s feelings.
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Assess the patient's mental status.
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Appearance
Activity
Speech
Orientation for time, person, and place
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 25
Assessment of
Potential Violence
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Scene size-up
History
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Check with family and bystanders.
Known history of aggression or combativeness?
Posture
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Stands or sits in a position which threatens self or others
Fists clinched or lethal objects in hands
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 26
Assessment of
Potential Violence
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Vocal activity
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Yells or verbally threatens harm to self or others
Physical activity
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Moves toward caregiver
Carries heavy or threatening objects
Has quick, irregular movements
Tenses muscles
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 27
Methods to Calm Behavioral
Emergency Patients
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Acknowledge that the person seems upset.
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Restate that you are there to help.
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Inform the patient of what you are doing.
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Ask questions in a calm, reassuring voice.
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Maintain a comfortable distance.
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Encourage the patient to state what is troubling him.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 28
Methods to Calm Behavioral
Emergency Patients
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Do not make quick moves.
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Respond honestly to patient's questions.
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Do not threaten, challenge, or argue.
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Tell the truth.
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Do not “play along” with visual or auditory disturbances.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 29
Methods to Calm Behavioral
Emergency Patients
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Involve trusted family members or friends.
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Be prepared to stay at scene for a long time.
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Always remain with the patient.
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Avoid unnecessary physical contact.
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Call additional help, if needed.
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Maintain good eye contact.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 30
Medicolegal Considerations
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Management of emotionally or mentally disturbed patient presents
high legal risk.
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When emotionally disturbed patients consent to care, legal problems
are greatly reduced.
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Patient will often resist treatment.
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Patient may threaten EMT-Basics and others.
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To provide care against patient's will, you must show a reasonable
belief patient would harm self or others.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 31
If Patient Resists Treatment
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If a threat to self or others, may
be transported without consent.
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Contact medical direction.
Law enforcement is usually
required.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 32
Reasonable Force
Definition:
Action necessary to keep
patient from injuring self
or others
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 33
Determining
Reasonable Force
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Patient’s size and strength
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Type of abnormal behavior
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Sex of patient
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Mental state of patient
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Method of restraint
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 34
Using Force
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Calm patients may cause unexpected and sudden
injury to self and others.
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EMS personnel may use reasonable force to defend
against an attack.
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Avoid acts or physical force that may cause injury to
the patient.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 35
Police and Medical Direction
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Seek medical direction when
considering restraining a
patient.
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Ask for police assistance, if
during scene size-up the
patient appears or acts
aggressive or combative.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 36
Accusations
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Protection against false accusations
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Documentation of abnormal behavior important
Witnesses in attendance, especially during transport
Accusations of sexual misconduct are common.
 Same-sex attendants and third-party witnesses
can prove beneficial.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 37
Restraining Patients
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Avoid restraints, if possible.
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Use only when patient is a danger to self or others.
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Have police present.
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Get approval from medical direction.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 38
Restraining Patients
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Be sure to have adequate help.
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Plan your activities.
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Use only the force necessary for restraint.
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Estimate range of motion of patient’s arms and legs.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 39
Restraint Technique
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Act quickly.
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Have one EMT-Basic talk to
patient.
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Approach with four persons.
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One assigned to each limb, all
at the same time
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 40
Restraint Technique

Secure limbs together
with equipment
approved by medical
direction.
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Turn patient face up on
stretcher.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 41
Restraint Technique
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Secure patient to
stretcher with multiple
straps.
Cover patient’s face
with surgical mask if
spitting.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 42
Restraining Technique
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Reassess circulation
frequently.
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Document indication for
restraining patient and
technique of restraint.

Avoid unnecessary force.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 43
Other Behavioral Problems –
General Principles
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Always try to talk patient into cooperating.
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Do not belittle or threaten patients.
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Be calm and tolerant in your attitude.
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Do not agree with disturbed thinking.
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Be reassuring.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 44
Other Behavioral Problems –
General Principles
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Avoid arguing with irrational patients.
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Suggest appropriate steps to take.
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Lower distressing stimuli.
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Avoid restraints unless necessary.
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Treat with respect.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 45