© 2011 National Safety Council 13-1 BEHAVIORAL EMERGENCIES LESSON 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 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 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 Emergency Care for Behavioral 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 Emergency Care for Behavioral 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 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 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 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 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 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 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 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 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 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 Emergency Care for Sexual 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 Emergency Care for Sexual 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 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 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 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 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 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 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 Emotionally Disturbed Patients 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