“The Psychiatric Component to Almost Every EMS Call”.

“The Psychiatric
Component to Almost
Every EMS Call”.
Mountain Lakes Initial Assessment
EMS Conference
May 20, 2016
Andrew Stern, NRP, CCEMT-P, MPA, MA
Senior Paramedic
Town of Colonie EMS
[email protected]
2
OJBECTIVES
 Describe global psychiatric issues commonly encountered
by EMS.
 Identify ways many calls can have a psychiatric component
that impacts both patient and providers.
 Discuss how these psychiatric issues can subtly creep into
a call.
 Provide examples, using case studies, of psychiatric
occurrences that can creep into EMS calls.
3
QUALIFIER
The following cases are based on numerous 911
calls that have a psychiatric component. Yet, not
one of the these cases is the psychiatric
component considered by either the caller or
dispatcher to be the primary reason for the initial
call.
What did you
say was the
problem?
4
DISCLAIMER
5
Psychiatric
Scene Safety - - 1st Priority ! ! !
 Listen
 Is there noise that indicate a problem
 Unusual speech pattern
 Look
 What does the scene look like?
 What does the patient look like?
 Behavior – Bizarre or erratic
 Dress
 Movements
 If you suspect any type of danger
 Secure force protection before encountering patient.
 Always have an exit strategy - - for your own safety.
6
Psychiatric
Psychiatric patients can be very
unpredictable.
 Stay focused.
 Never leave patient (or person with problem) alone
 Have each others back
Reminder
7
Assessment always includes:
 Scene Size-Up (Determine MOI)
 AVPU
 ABCs
 Vital Signs
 Physical Exam
 SAMPLE

BG*
 Psychiatric Evaluation
8
Psychiatric
General Issues
Emergency Care
 Be alert - - Personal safety and crew
 Treat life-threats and other significant problems
 Treat low blood glucose or call ALS
 May need to spend time talking with patient
 Encourage patient to talk
 NEVER play along with patient’s hallucinations
 Don’t lie to patient
 If it you think it might help consider involving family or friend(s)
9
Psychiatric Issues Aren’t the
Primary Reason for the Call
 Much of the time the “general” focus for an EMS call is
based on dispatch information.
 Yet, with a number of EMS calls the psychiatric
component can permeate a call to the point of
distraction.
 A few issues to consider:
 Some “psychiatric” presentations may be
intentional on the part of the patient.
 Priorities must be established.
DON’T GET DISTRACTED
10
Not Always the Patient
 From time-to-time you are called upon to
focus on someone other than the patient;
what are your objectives in these cases:
 IT IS ALL ABOUT THE PATIENT.
 Safety becomes a priority.
 Care is a close 2nd.
DON’T GET DISTRACTED
11
CASE STUDY-#1
You have been called to a residence for a 72 yo woman who has what
appears to be a medical issue of a general malaise, low grade fever, and
a cough. You suspect pneumonia. You tell the patient how important it is
to get care immediately. She says fix me here I won’t go to the hospital.
You ask why she won’t go, and she tells you she is scared, who will take
care of my dog, I will be placed on a nursing home, or I will die; because
that is what happened to her friend who went to the hospital.
 What do you do?
 What are your priorities?
12
CASE STUDY-#1a
A motor vehicle crash into a telephone pole of a restrained teenage
driver (she swears she wasn’t texting). She is out of the car when you
arrive. She is a new 16 years old driver and VERY excited; “my parents
will kill me,” “will the cut [minor] on my face leave a scare?”, “my new
jacket is ripped,”, and “what will my friends say?”.
You ask to examine her. She says no. The police officer on the scene has
talked to the father who advises her to get examined at the hospital.
Here anxiety keeps escalating.
 What do you do?
 What are your priorities?
13
Anxiety-Definition
A feeling of worry, nervousness, or
unease, typically about an imminent
event or something with an uncertain
outcome.
14
Anxiety - Signs/Symptoms
Restlessness
Being easily fatigued
Difficulty concentrating
Irritability
Muscle tension
Difficulty controlling the worry
Sleep problems
15
Anxiety
 Is the anxiety is incidental to the call?
 Was the patient anxious upon arrival?
 Did the patient become anxious after EMS
arrived?
 Is the anxiety the real reason for the call?
16









Anxiety to Panic Attack
sense of danger or doom
trembling, dizziness, weakness
shortness of breath
excessive perspiration
feeling cold or overheated
numbness or tingling in the hands
rapid heartbeat, palpitations
chest pain
hyperventilating
17
Anxiety
 With hyperventilation consider:
 Respiratory alkalosis
 pO2 = slightly elevated (80-100 mmHg)
 pCO2 = low (35-45 mmHg)
 pH = elevated (7.35-7.45)
 HCO3 = low (22 to 26 mEq/liter)
Anxiety
18
 What are the challenges?
 Mentally competent?
 Maturity?
 Danger to self or others?
 Significant medical issues?
 Liability concerns?
 _____________________?
19
CASE STUDY-#2
A 911 call, that came through an emergency alert service,
is for an 82 yo female who fell using her walker. When you
arrive you hear “I have fallen and I can’t get up.” You do a
rapid assessment and determine that this patient has no
serious injuries and you assist her to a chair in the living
room.
The patient says she feels fine and has no complaints. You
get ready to leave and the housekeeper arrives and tells you
she has dementia. You stop and wonder . . .
 Does this deserve another look?
20
Common Causes of
Behavioral Alternatives
1. Hypoglycemia( BS)
7. Hyperthermia
2. Hypoxia ( O2)
8. Hypothermia
3. Hypoperfusion
(Shock)
9.
10. Seizure Disorders
4. Head Trauma
11.
5. Mind Altering Drugs
6. Psychiatric
Meningitis
Overdose
(Toxic Substance)
12. Drug/Alcohol
Withdrawal
21
Dementia vs. Delirium
 Dementia: A chronic, generally
irreversible condition that causes a
progressive loss of cognitive abilities,
psychomotor skills, and social skills.
 Delirium: A sudden change in behavior,
consciousness, or cognitive process
generally due to a reversible physical
ailment.
22
NOTE
NOTE
Dementia vs. Delirium
Dementia
23
Evaluation (SAMPLE HX & P. Exam):
 CVA (Stroke)
 Alzheimer’s Disease

 Alcohol
 Work history (heavy metals/toxins)
 Encephalitis
24
Dementia
Associate Signs & Symptoms:
 Progress loss of cognitive function
 Short & Long Term Memory
 Decreased Attention Span
 Inability to perform daily routines
 Confusion
 Decreased ability to communicate
 Mood often angry
25
Dementia & Delirium
Problems Associated w/ Management:
 Poor historian
 Impaired judgment
 Inability to vocalize pain & symptoms
 Unable to follow commands
 Anxiety over leaving home
 Leaving spouse
 Leaving pet
 Anxiety/Fear of Treatment/Medical Problem
26
CASE STUDY-#3
A call for a cardiac patient who is 67 years old. When you enter the house she is
sitting in the couch; pale, diaphoretic, and complaining of chest pain. The 12lead ECG confirms a STEMI (anterior wall). She agrees to go to the hospital and
transport is initiated. WAIT - - THIS ISN’T A CARDIOLOGY TALK . . .
The husband who has declined to go to the hospital with his wife now looks
“sick”. Same symptoms as the wife. His 12-lead is done and he is having a
STEMI (inferior wall). A second ambulance is called, but he says he won’t go. No
reason, just refuses. You decide to try and to
convince him…still no; I WILL NOT GO!
Another provider arrives and wants to try
talking to the patient. You say no; if I can’t
change his mind it can’t be done.

What would you do?
27
HITTING THE WALL
Even when
you try hard
and do your
best you may
still hit the wall.
28
WHAT COULD YOU DO…
 How do you deal with this situation:
 Leave patient
 Call PD to invoke the mental hygiene law
 Continue to explain and “plead” with patient
 Ask for help
 Call Medical Control
 ____________________________________
29
Narcissism Definition
Narcissism is characterized by selfimportance, a craving for admiration,
and exploitative attitudes toward
others. They have unrealistically
inflated views of their talents and
accomplishments, and may become
extremely angry if they are criticized or
outshone by others.
30
Narcissism
How to deal with it . . .
 Manage your own tendencies to
overreact.
 Overcome the urge to be “right” every
time.
Cebollero, Chris, “5 tips to keep your ego in check,” EMS1.COM, 1/7/14.
31
Narcissism
 What are the challenges?
 Direct approach?
 Modelling?
 Counseling?
 Discipline?
 _____________________?
32
It’s Time. . .
33
CASE STUDY-#4
In the wee hours of the morning you are called to the residence of a 78 yo
woman complaining of stomach pain. The patient is sweet and
cooperative. She appears ill and needs to go to the hospital immediately;
she concurs.
As you are loading her onto the stretcher the outraged son comes through
the front door seemingly upset, saying: “What are you doing to Mama?”.
When the son is told he gets mad and says you can’t take Mama to
hospital.
 How would you handle the son?
(Assume no PD available.)
34
When the Problem is NOT
the Patient
 Tell the son what is going on.
 Make the situation about the patient (Mama) not the son.
 Inform him that you are obligated to do what the patient wants.
 Have Mama say something to the son.
 At what point do you use a “threat”?
 What could be the ramifications of this action?
35
Paranoia-Definition
Characterized by delusions of
persecution, unwarranted jealousy, or
exaggerated self-importance, typically
elaborated into an organized system.
36
Paranoid Behavior
 What are the challenges?
 The patient?
 Threat to patent or crew?
 Distraction from primary mission?
 Time factor?
 _____________________?
37
CASE STUDY-#5
You receive a familiar call for a possible overdose. Arriving at
an apartment you find an unconscious female patient with a
syringe next to her arm. She has respiratory depression. You
realize that Narcan is needed immediately and administer
forthwith. The patient comes around and is angry. From her
perspective you have ruined her “high”. She starts swearing
and says to leave her apartment immediately.
 How would you handle?
38
Aggressive Behavior
Definition
A form of physical or verbal
behavior leading to self-assertion.
39
Aggressive Behavior
 Characteristics:
 Self-assertion with hostile tones
 Unprovoked
 Possible explosive disorder.
 Anger
 Confusion
40
Aggressive Behavior
 What are the challenges?
 Mentally competent?
 Danger to self or others?
 Significant medical issues?
 Liability concerns?
 _____________________?
41
CASE STUDY-#6
You are called to a residence where a 12 year
old boy has fallen from a tree and has what
appears to be a “dinner fork” fracture. The
patient is in obvious pain. When you start to
assess and prepare for care the patient starts
being verbally hostile. He blames you for his
falling and the pain. The injury obviously requires
immediate care. Besides a splinting you believe
pain management is appropriate and you
consider an IV.
 How would you handle?
42
Oppositional Defiant
Disorder (ODD) Definition
A frequent and
persistent pattern of
anger, irritability,
arguing, defiance or
vindictiveness
toward you and
other authority
figures.
43
Oppositional Defiant
Disorder (ODD)
 How would you handle?
 Aggression?
 Bargaining?
 Restrain? (Physical vs. Chemical)
 _____________________?
44
Oppositional Defiant
Disorder (ODD)
 What are the challenges?
 Distraction?
 Impact to Care?
 Response from Crew? (Anger)
 Parental Interaction?
 _____________________?
45
CASE STUDY-#7
A call for a motorcycle crash that involves a 36 yo male who lost
control of his bike and set it down. The assessment identifies
only an open fracture of the right tibia. The vital signs appear
stable. The patient is in extraordinary pain, 12 on 10, and you
decide to give pain management before immobilizing the leg.
Even with the pain the patient says no needles; “I am scared of
needles they really bother me, so don’t give me a shot.” You are
worried that without medication the pain of splinting and moving
to the stretcher will be a significant problem. The patient
screams again “no needles.”
 How would you handle?
46
Phobia Definition
An overwhelming
and unreasonable
fear of an object or
situation that
poses little real
danger but
provokes anxiety
and avoidance.
47
Phobias Are Real
TO THOSE WHO HAVE THEM
48
Phobias
 How would you handle?
 Start the IV or give injection anyway?
 Discuss with the patient?
 Let him scream like a mad man?
 Whisky? (kidding)
___________________?
49
Phobias
 What are the challenges?
 Physiological response?
 Distraction to care?
 Impact on the Crew?
 _____________________?
50
CASE STUDY-#8
On a nice spring evening there is a 911 call to a private residence
for a 12 yo girl who reportedly has an upset stomach with sharp
pain. When you arrive at the patient’s home she seems in pain
(5 on 10); although intermittent. The parents look worried and the
mother says I hope the bullies at school didn’t hurt her.
The vital signs are within normal limits and the physical
examination is negative. The child is more relaxed in the
ambulance with Mom riding in the front seat.
 How would you handle?
51
Psychosomatic Illness
Definition
A physical illness
or other condition)
caused or
aggravated by a
mental factor such
as internal conflict
or stress.
52
Psychosomatic
Illness
 How would you handle?
 Medical issues only?
 Behavioral issues only?
 Suggest an RMA?
 Contact law enforcement?
 __________________?
53
Psychosomatic
Illness
 What are the challenges?
 Is there really a dire medical condition?
 Can the history be trusted?
 Do parents complicate the call?
 Making the patient feel safe?
 _____________________?
54
CASE STUDY-#9
A call received to the residence of a 34 yo female
who has severe stomach pain. When you arrive you
find a woman in extreme pain (8 on 10) who is pale
and diaphoretic. When you take vital she has a pulse
of 120 and respiration are 24. Your physical exam
finds a rigid abdomen with rebound tenderness. The
SAMPLE history identifies bright blood when going to
bathroom.
You determine this is an urgent case that needs
rapid transport for immediate care. The patient tells
you she is reluctant to go as she is scared of public
places especially emergency rooms.
 How would you handle?
55
Agoraphobia Definition
Characterized
by symptoms in
reaction to
situations where
the sufferer
perceives the
environment to be
dangerous,
uncomfortable, or
unsafe.
56
Nosocomephobia
Excessive
fear of
hospitals.
What’s in the
patient’s mind.
57
Agoraphobia
 How would you handle?
 Try to persuade the patient?
 Invoke Mental Hygiene Law?
 Contact Medical Control?
 RMA and Leave?
 _____________________?
58
Agoraphobia
 What are the challenges?
 Does the patient absolutely need to go?
 Can you overcome the patient’s fear?
 Will a rational discussion work?
 How to expedite without fear or
harm to patient?
 _____________________?
59
CASE STUDY-#10
Dispatched to an office where a worker has tripped
and hurt her ankle. The call was initiated by a coworker. When you arrive the assessment identifies a
significantly swollen and deformed ankle that is
extremely painful. The patient can’t stand; she has
already tried before you arrive. She is embarrassed
and appears mad that her office mates are looking.
When you get ready to apply a splint and the
stretcher appears she goes ballistic. She starts to
yell, “What are you doing?”, “I will see my own
doctor.”, and “Leave me alone.” You explain the
importance of getting immediate care and she
becomes more enraged.
 How would you handle?
60
Intermittent Explosive
Disorder Definition
A behavioral disorder
characterized by
explosive outbursts of
anger and violence,
often to the point of
rage, that are
disproportionate to
the situation at hand.
61
Intermittent Explosive
Disorder
 How would you handle?
 Call a LEO and invoke Mental Hygiene Law?
 Keep talking to try changing her mind?
 Ask a co-worker to transport?
 RMA and Leave?
 _____________________?
62
Intermittent Explosive
Disorder
 What are the challenges?
 Keeping the scene safe?
 Making sure patient gets appropriate care?
 Ensure event doesn’t escalate.
 Control amount of time for call?
 _____________________?
63
Summary
The cases presented today were intended to be
illustrative only. The purpose was to reinforce
psychiatric issues can become an “underlying
theme” of almost any EMS. When this occurs it
can be become a distractor that can have a
significant impact to the need to provide urgent
patient care.
64
Summary
 Scene safety is #1 priority.
 Be prepared for underlying psychiatric
issues.
 The patient is the reason for the call.
 The patient may not be the one with the
psychiatric issue.
65
Summary
 Balance is important.
 Is the Medical/Trauma Problem the priority?
 Psychiatric issue a priority?
 Remember, everyone goes
home safe at the end of a call.
66
67
68