Chapter 59 Jay H. Reich and Aaron Stinton A psychiatric or behavioral health emergency can be defined as an acute change in conduct that results in a behavior that is intolerable for the patient, family, or society [1]. These changes range from the inability to cope with a stressful situation to agitated or violent patients who present a danger to themselves or others. Little has been written directly about behavioral health emergencies in the prehospital setting. The “standard of care” is extrapolated from emergency departments and psychiatric units. EMS professionals receive little training regarding behavioral conditions during their initial and continuing education [2,3]. The “standard” approach field personnel use may be inadequate for the assessment of behavioral health patients for multiple reasons. Providers may be unsure how to evaluate an uncooperative or dangerous patient without involving law enforcement, whose specialized training can help EMS pursue appropriate treatment options [4]. EMS may elect to contact direct medical oversight for help, but it can be equally difficult for the medical oversight physician to assess the patient remotely. Under these circumstances, it is imperative that patients who might pose a threat to themselves or others are fully evaluated. It may require the patient to be brought into the hospital against his or her will. It is important for the EMS medical director to ensure that the prehospital provider and medical oversight physician have the appropriate training and knowledge to deal with these patients before they are encountered. This may include issuing a hold order for cases where the patient lacks capacity for medical decision making. General management guidelines should be provided by protocol. Remember, as with all patients encountered by EMS, behavioral patients have legitimate health problems. Unfortunately, they are sometimes mislabeled as “uncooperative” or “difficult,” resulting in inappropriate treatment. Education should reinforce that the patient’s behavior is a manifestation of disease, and patience and compassion are essential to providing excellent, supportive care to this vulnerable population. Emergency departments and EMS are common points of entry into the health care system for the psychiatric patient [1]. Medical direction should be familiar with local psychiatric resources as well as common diagnoses including their presentations, complications, and management. These include anxiety disorders, major depression, schizophrenia, and bipolar disorder [5]. Making an accurate psychiatric diagnosis in the field is frequently impossible and generally irrelevant. Treatment protocols should describe assessment and care for clinical symptom patterns, not specific diagnoses. Policies and procedures must also be put in place to ensure safety of patient and provider [6]. The first step when confronted by a patient with a behavioral disorder is to evaluate scene safety. If not safe, EMS should withdraw and await the arrival of law enforcement before intervention is attempted. If safe, providers may carefully approach and attempt a brief medical assessment. They should determine if the behavioral changes are due to an organic etiology and/or if the patient is in imminent danger secondary to a medical emergency. There are multiple medical conditions, many reversible, which can present with behavioral changes (Box 59.1). Presentation may vary from lethargy and confusion to agitation and violence. Classic examples include the confused patient with acute hypoglycemia, the agitated patient with hypoxia, and the lethargic patient in shock. Initial evaluation must include a thorough history (medical and psychiatric) and physical examination, including measurement of blood sugar level and pulse oximetry. Mental status changes of acute onset without a previous history of psychiatric disorder are highly suggestive of an organic etiology. EMS should inquire about prescribed medications or suspected drug/alcohol abuse. Special attention should be paid during physical examination to eliciting abnormal neurological findings. If vital sign abnormalities are observed, the patient should be considered medically unstable and mental status changes a consequence of an organic problem until proven otherwise. The provider should effect appropriate interventions. Delayed stabilization or failure to transport patients with organic problems is dangerous, especially when dealing with mentally disturbed patients. Occasionally, the patient may not cooperate with the initial assessment and stabilization. In these situations, EMS personnel should try to gain the patient’s confidence by providing reassurance, explaining who they are, and describing every step before it is performed. If the patient remains non-compliant, the presence of an EMS physician, as a figure of authority, may be of assistance in obtaining the patient’s cooperation. Unfortunately, this is often not possible. Other appropriate alternatives include the indirect medical oversight physician speaking directly to the patient via radio, phone, or video phone or attempting to reach the patient’s psychiatrist or primary care physician. If the patient does not cooperate with the initial assessment, physical and/or chemical restraints may be considered. This should be done in cooperation with law enforcement. Patients with behavioral changes must receive at a minimum an appropriate prehospital assessment or be transported to the hospital. Once deemed medically stable, the next step is to determine if the patient’s mental status represents a danger to himself or herself or to others. Each case needs to be evaluated on an individual basis as not every patient with abnormal behavior will require transport. If the patient is refusing transport, he or she must meet the following criteria before the non-transport request should be honored. Many EMS systems have adopted policies permitting the use of alternative transport destinations such as psychiatric EDs and detoxification facilities. Selected patients may be more amenable to routing to these facilities rather than EDs. Strict criteria must be established in order to assure success and safety. The National Association of EMS Physicians and the American College of Emergency Physicians jointly issued a policy identifying important elements which must be in place to have a successful alternative transport destination program. Examples include EMS physician medical director oversight, medical director-led program development, implementation and quality improvement, as well as education programs at all levels. These programs may result in up to 25% of psychiatric patients being directly transported to psychiatric EDs. They have also demonstrated high sensitivity in detecting the need for medical evaluation [7,8]. It is the responsibility of the medical director to make sure that a thorough evaluation is completed before EMS personnel release a patient at the scene. Given that most adult patients presenting to the ED with new acute psychiatric symptoms will have an organic etiology [9] and the evaluation and “medical clearance” of patients in the field can be more challenging than when performed in the ED, protocols should direct providers to err on the side of caution and to transport these patients (see Box 59.1). Suicidal ideation is the existence of thoughts pertaining to ending one’s own life. Passive suicidal ideation refers to thoughts without a plan. Active suicidal ideation refers to thoughts with a plan, and thus a greater risk. A suicidal gesture is self-inflicted harm without a realistic expectation of death, whereas a suicide attempt is an act with a clear expectation of death [12]. More people die from suicide than homicide in the United States [13]. In 2010, a total of 38,364 Americans took their own lives, compared with 16,259 homicides, making suicide the 10th leading cause of death [13]. There were 12.4 suicides per 100,000, an increase from 10.7 in 2005 [13,14]. Suicide is a serious problem among young people, being the third leading cause of death for 15–24 year olds [15,16]. The most common methods include firearms, suffocation/asphyxiation, and poisonings. Suicide rates tend to increase with age and are highest among white men aged >65 [17]. Always take a suicide threat seriously. Suicidal statements indicate a crisis the individual feels he or she is unable to handle. Up to two-thirds of those who commit suicide have visited physicians or health care facilities during the preceding month [18]. It is therefore important to recognize the signs and symptoms, not just declaration of intent, with which a suicide-prone patient could present. Intervention by EMS may be the last opportunity to provide help and prevent tragedy. Initial and ongoing training coupled with comprehensive treatment protocols will help to ensure that EMS provide maximum assistance while ensuring their own safety. After arrival, EMS should perform a complete scene assessment to ensure proper situational awareness, including checking for weapons or potential weapons. Immediately remove any objects that the patient could use to inflict physical harm to him/herself or others. If guns or knives are present, the crew should withdraw to safety and await the police to remove the weapons and secure the scene. Once secured, attempts to initiate communication with the patient should be made as soon as possible. Communication with direct medical oversight, the patient’s psychiatrist, or the family physician may be beneficial in understanding the current scenario. During the negotiations, using friends or family members whom the patient trusts and respects can be effective. However, if the patient identifies an individual as being part of the crisis, that individual should be removed. Encourage the patient to discuss the situation. Most patients are relieved to be empowered just to discuss their thoughts [18]. It is important to emphasize during EMS education the need to show sympathy, empathy, and concern, and to avoid potentially frightening or agitating the patient. Providers do not have to agree or disagree with the patient, but should listen to what he or she has to say. Providers should avoid statements such as “Don’t do that!” or “You know that is not true!” The suicidal patient may consider these comments to be a challenge or that EMS are being judgmental and not supportive. If the patient perceives a negative attitude, it may worsen their already low self-esteem. The provider should offer reassurance that the crisis can be resolved and that authorities are only there to be of assistance. Promises that EMS providers are unable or unwilling to keep will make the patient more suspicious and should be avoided. Suspicion by providers of non-verbalized suicidal ideation or the presence of specific risk factors should prompt a further exploration. If the patient admits to any current or past depression, hopelessness, or despair, he should be asked directly whether he has any thoughts about self-harm. There has been no evidence to support the concern that posing such questions could actually induce suicidal thoughts and behaviors; more often, once broached directly, in a non-judgmental and sensitive manner, the patient typically welcomes the opportunity to unburden himself to caregivers. Often, such patients present with a level of anxiety and agitation that once alleviated will reduce suicidal feelings. Protocols should allow for the use of fast-acting benzodiazepines, such as lorazepam, midazolam, or diazepam, which often prove effective in low doses when titrated as necessary. If there are contraindications to benzodiazepines, such as suspicion of their abuse, another agent such as diphenhydramine or a low dose of a high-potency neuroleptic (e.g. haloperidol) may be employed [12]. Similarly, suicidal patients suffering from severe or chronic pain may become markedly less despondent after adequate analgesia. As cooperation develops, all actions and activities should be clearly explained, in advance if possible. At this point, pharmacological interventions may be considered or may be found to be unnecessary. Before initiating transport, policies should require the patient be fastened on the stretcher and not permitted to sit next to the exit door or in the front seat of the ambulance. EMS personnel should explain that these are security measures for the patient’s safety. The provider who has established the best rapport with the patient should ride along with him or her to the hospital. Additional members of the response team should then sit next to the exits. If all reasonable efforts have failed to persuade the patient to cooperate, the question of whether to commit the patient to an involuntary transport must be addressed. This is a decision in which direct medical oversight is often involved. There are several factors that correlate with a higher risk for committing suicide (Table 59.1). If it is decided that the patient is in immediate danger of committing suicide, the provider should be directed to proceed with the transport, never leaving the patient unattended. Laws pertaining to involuntary transport and admissions vary from state to state. EMS medical directors must be familiar with the specifics of their state and local statutes. When in doubt, it is always better to direct an involuntary transport and to have the patient evaluated at an ED or psychiatric institution. If, subsequent to the decision for involuntary transport, the patient becomes agitated and/or violent, the use of physical or chemical restraints may be required. This option should be addressed within protocol. Table 59.1 Factors that correlate with a higher risk for committing suicide
Behavioral health emergencies
Introduction
Evaluation of the problem
Assessment and treatment
The suicidal patient
Factors
High risk
Suicide intentions
Affirmation of suicide intention
Detailed and violent plan with poor probability for rescue and accessible resources (e.g. gun)
History of previous attempts
Psychiatric diagnosis
Schizophrenia
Bipolar disorder
Major depression
Acute psychosis
Medical problems
Diagnosis of terminal diseases (e.g. cancer, AIDS)
Diagnosis of chronic illness (e.g. diabetes)
Drug abuse
Alcohol, cocaine, other illicit drugs
Social history
Marital status –widowed or divorced
Recent significant loss – death of a loved one
Unemployment
No family support
Family history
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