Transcript 5. Any drugs or alcohol involved? PRE

Silver Cross EMSS
EMD CE
September 2013
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EMDs need to give psychological support as
well as emergency medical care instructions to
callers
Factors contributing to behavioral changes
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Medical conditions
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Physical trauma
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Psychiatric illnesses
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Mind-altering substances
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Situational stresses
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Use your All Caller Interrogation
and Key Questioning to make sure
that the scene is safe and gather
information about the patient’s
mental status, ABC’s and history.
Relay any pertinent information to
responders and determine if police
are needed.
PSYCHIATRIC/BEHAVIORAL PROBLEMS
KEY QUESTIONS
1. Is the patient violent or threatening others?
2. Is the patient suicidal? YES? Go to SUICIDE
Protocol being careful not to agitate patient
3. Does the patient have a history of mental
problems?
4. If under a doctor’s care, does patient take any
regular medications? Are they current and
compliant?
5. Any drugs or alcohol involved?
PRE-ARRIVAL INSTRUCTIONS
1. Send law enforcement to secure the scene
2. If caller is not patient, tell caller to maintain a safe
distance
3. If caller is also patient, attempt to maintain phone
contact and build rapport
4. Call back if condition worsens prior to the arrival
of emergency personnel
Behavioral emergencies are
situations in which persons exhibit
abnormal, unacceptable behavior
that cannot be tolerated by the
patients themselves or by family,
friends, or the community.
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Medical conditions
Uncontrolled diabetes
 Respiratory conditions
 High fevers
 Infections
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Inadequate blood supply to the brain
Physical trauma
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Head injuries
Injuries that result in shock and an inadequate
blood supply to the brain
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Psychiatric illnesses
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Depression
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Panic
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Psychotic behavior
Mind-altering substances
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Alcohol
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A wide variety of chemical substances
Situational stresses
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Death of a loved one
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Serious injury to a loved one
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State of emotional upset or turmoil
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Caused by a sudden and disruptive event
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Most situational crises:
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Are sudden and unexpected
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Cannot be handled by the person’s usual coping
mechanisms
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Last only a short time

Can cause socially unacceptable, self-destructive, or
dangerous behavior
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There are four emotional phases to each
situational crisis.
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High Anxiety or Emotional Shock
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Denial
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Anger
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Remorse or Grief
People may not experience every phase, but they
will experience one or more.
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High anxiety is characterized by:
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Flushed (red) face
Rapid breathing
Rapid speech
Increased activity
Loud or screaming voice
General agitation
Emotional shock is often the result of a sudden illness, accident,
or sudden death of a loved one.
Emotional shock is characterized by:
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Cool, clammy skin
A rapid, weak pulse
Vomiting and nausea
General inactivity and weakness
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Refusal to accept the fact that an event has
occurred
Your response:
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Allow the patient to express denial.
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Do not argue with the patient.
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Try to understand the emotional and psychological
trauma that the patient is experiencing.
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Normal human response to emotional
overload or frustration
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May follow denial or may replace denial
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People may vent angry feelings at you.
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Do not take the person’s anger personally. Be alert
for violent actions towards responders.
Frustration and a sense of helplessness can
often build to anger.
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Always be professional and remain calm.
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Acceptance of the
situation may lead
to remorse or grief.
People may feel
guilty or
apologetic about
their behavior.
Be a good listener!
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Talk with the person.
Introduce yourself.
 Ask the patient his or her
name.
 Ask what you can do to help.
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Be honest, warm, caring,
and empathetic.
Use a calm, steady voice
and provide honest
reassurance.
Try not to let negative
personal feelings interfere
with your attempt to
provide assistance.
Simple acts of kindness can
provide comfort and
reassurance.
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Restatement
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Rephrasing a person’s own words and thoughts
and repeating them back
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Be honest and give the patient hope, but do not give
false hope.
Redirection
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Helps focus a patient’s attention on the immediate
situation or crisis
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Use redirection to alleviate a patient’s expressed
concerns.
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Empathy
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Imagining yourself in another person’s situation and sharing his or her
feelings or ideas
Empathy is one of the most helpful concepts you can use.
Use a calm and caring approach.
Communication skills
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Identify yourself and let the patient know you are there to help.
Inform the patient of what you are doing. (i.e. dispatching units, etc.)
Ask questions in a calm, reassuring voice.
Allow the patient to tell you what happened—do not be judgmental.
Show you are listening by using restatement and redirection.
Acknowledge the patient’s feelings.
Assess the patient’s mental status.
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Common occurrence in today’s society
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It takes several different forms:
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Elder abuse
Child abuse
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Spouse and domestic partner abuse
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When dispatching to a domestic call:
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Maintain safety for all rescuers as well as for the
patient.
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Conduct effective questioning and pre-arrival
instructions as needed.
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Physical signs and symptoms
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Broken bones
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Cuts
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Head injuries
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Bruises
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Burns
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Scars from old injuries
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Injuries in various stages of healing
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Internal injuries
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Emotional symptoms
Depression
 Suicide attempts
 Abuse of alcohol or drugs
 Feelings of anxiety, distress, and hopelessness
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Abusers may be paranoid, overly sensitive,
obsessive, or threatening.
If you suspect abuse, your responsibility is to
maintain safety for the patient and responders.
Try to separate the patient from the abuser.
 Try to keep from judging the patient.
 Send law enforcement to secure the scene.
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Cycles of abuse
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Tension phase: The abuser becomes angry and
often blames the victim.
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Explosive phase: The abuser becomes enraged and
loses control as well as the ability to think clearly.
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Make-up phase: The abuser makes promises, which
are seldom kept.
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Immediately attempt to
establish verbal contact
with the patient.
Check with the caller about
the patient’s past history of
violence.
Signs of potential violence
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History of violence
Yelling or verbal threatening
Loud, obscene, or bizarre
speech
Pacing, inability to sit still,
and protection of personal
space
Abuse of drugs or alcohol
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Many patients who fail at their first attempt will try to
commit suicide again.
The underlying psychiatric disease is usually
treatable.
Management
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Obtain a complete history of the incident.
Determine whether the patient still has a weapon or drugs on
him or her.
Support the patient’s ABCs.
Provide pre-arrival instructions for the injuries or conditions
the caller reports.
Do not judge the patient.
Provide emotional support.
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Severe form of anxiety
People experiencing PTSD relive previous
traumatic experiences.
Symptoms include:
Flashbacks
 Sleep disturbances
 Nightmares
 Depression and guilt
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As an EMD, your job is to:
Speak with the patient in a positive and supportive way.
 Arrange for the patient to be transported to an
appropriate medical facility.
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The psychological aspects of treatment are
important.
You may have to delay all but the most
essential treatment until a responder of the
same sex as the patient arrives.
Your first priority is the medical well-being of
the patient.
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Give instructions to treat any injuries the person
may have.
This controversial subject has become a hot topic in the
law enforcement and EMS community in recent years.
 In 2009, the American College of Emergency
Physicians released a White Paper report which
recognized this condition but organizations like the
American Medical Association, World Health
Organization and the American Psychiatric
Association do not. Link to full article here:
http://www.academia.edu/1131068/ACEP_Excited_Deli
rium_White_Paper__Contribution_via_CA_Hall_MD_FRCPC
 The following slides contain general information about
this condition.
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This disorder is usually drug-related (cocaine
or "crack", PCP or "angel dust",
methamphetamine, amphetamine), but can
occur in non-drug users as well.
The presentation of excited delirium occurs
with a sudden onset, with symptoms of bizarre
and/or aggressive behavior, shouting,
paranoia, panic, violence toward others,
unexpected physical strength, and
hyperthermia.
Excited Delirium Mnemonic
N: Patient is naked and sweating from hyperthermia
O: Patient exhibits violence against objects, especially glass
T: Patient is tough and unstoppable, with superhuman
strength and insensitivity to pain
A: Onset is acute (e.g., witness say the patient “just
snapped!”)
C: Patient is confused regarding time, place, purpose and
perception
R: Patient is resistant and won’t follow commands to desist
I: Patient’s speech is incoherent, often with loud shouting
and bizarre content
M: Patient exhibits mental health conditions or makes you
feel uncomfortable
E: EMS should request early backup and rapid transport to
the ED
It has been cited as a cause of sudden death in
situations where individuals have been restrained
or Tased after exhibiting bizarre and erratic
behavior. Dopamine (important brain and CNS
chemical) disturbances, drugs and/or underlying
medical conditions may be contributing factors as
well.
Recommended management includes: safety for
responders, calming techniques, monitoring of
vital signs, possible sedation (at medical control
discretion) and rapid transport to the closest
Emergency Department. Treat other signs and
symptoms or injuries as needed.
AAOS Emergency Medical Responder
Your First Response in Emergency Care,
5th Edition
Will County 9-1-1 EMDPRS
www.ExcitedDelirium.org
Journal of Emergency Medical Services,
www.JEMS.com
American College of Emergency Physicians
White Paper report