1. Silver Cross EMSS EMD CE September 2013

2.  EMDs need to give psychological support as well as emergency medical care instructions to callers  Factors contributing to behavioral changes  Medical conditions  Physical trauma  Psychiatric illnesses  Mind-altering substances  Situational stresses

3.  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.

4. 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?

5. 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

6. 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.

7.  Medical conditions  Uncontrolled diabetes  Respiratory conditions  High fevers  Infections  Inadequate blood supply to the brain  Physical trauma  Head injuries  Injuries that result in shock and an inadequate blood supply to the brain

8.  Psychiatric illnesses  Depression  Panic  Psychotic behavior  Mind-altering substances  Alcohol  A wide variety of chemical substances  Situational stresses  Death of a loved one  Serious injury to a loved one

9.  State of emotional upset or turmoil  Caused by a sudden and disruptive event  Most situational crises:  Are sudden and unexpected  Cannot be handled by the person’s usual coping mechanisms  Last only a short time  Can cause socially unacceptable, self-destructive, or dangerous behavior

10.  There are four emotional phases to each situational crisis.  High Anxiety or Emotional Shock  Denial  Anger  Remorse or Grief People may not experience every phase, but they will experience one or more.

11.  High anxiety is characterized by:  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:  Cool, clammy skin  A rapid, weak pulse  Vomiting and nausea  General inactivity and weakness

12.  Refusal to accept the fact that an event has occurred  Your response:  Allow the patient to express denial.  Do not argue with the patient.  Try to understand the emotional and psychological trauma that the patient is experiencing.

13.  Normal human response to emotional overload or frustration  May follow denial or may replace denial  People may vent angry feelings at you.  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.  Always be professional and remain calm.

14.  Acceptance of the situation may lead to remorse or grief.  People may feel guilty or apologetic about their behavior.  Be a good listener!

15.  Talk with the person.  Introduce yourself.  Ask the patient his or her name.  Ask what you can do to help.  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.

16.  Restatement  Rephrasing a person’s own words and thoughts and repeating them back  Be honest and give the patient hope, but do not give false hope.  Redirection  Helps focus a patient’s attention on the immediate situation or crisis  Use redirection to alleviate a patient’s expressed concerns.

17.  Empathy  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  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.

18.  Common occurrence in today’s society  It takes several different forms:  Elder abuse  Child abuse  Spouse and domestic partner abuse  When dispatching to a domestic call:  Maintain safety for all rescuers as well as for the patient.  Conduct effective questioning and pre-arrival instructions as needed.

19.  Physical signs and symptoms  Broken bones  Cuts  Head injuries  Bruises  Burns  Scars from old injuries  Injuries in various stages of healing  Internal injuries

20.  Emotional symptoms  Depression  Suicide attempts  Abuse of alcohol or drugs  Feelings of anxiety, distress, and hopelessness  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.

21.  Cycles of abuse  Tension phase: The abuser becomes angry and often blames the victim.  Explosive phase: The abuser becomes enraged and loses control as well as the ability to think clearly.  Make-up phase: The abuser makes promises, which are seldom kept.

22.  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  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

23.  Many patients who fail at their first attempt will try to commit suicide again.  The underlying psychiatric disease is usually treatable.  Management  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.

24.  Severe form of anxiety  People experiencing PTSD relive previous traumatic experiences.  Symptoms include:  Flashbacks  Sleep disturbances  Nightmares  Depression and guilt  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.

25.  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.  Give instructions to treat any injuries the person may have.

26.  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.

27.  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.

28. 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

29. 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.

30. AAOS Emergency Medical Responder Your First Response in Emergency Care, 5 th 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