Management of Behavioral Emergencies in the Wilderness
Laura McGladrey
Catherine Campisi
INTRODUCTION
Few areas of emergency response are as challenging and rewarding as managing an emotional or behavior crisis in the remote setting: the climber in the grip of a panic attack clinging to a cliff face 45 m (150 ft) above the ground; the isolated Antarctic researcher, plagued by suicidal thoughts; or the relief worker, in the throes of psychosis, screaming that snakes are crawling on her skin. Environmental stressors, prolonged evacuation times, and lack of available psychiatric resources add a layer of complexity to already difficult presentations, calling on providers to demonstrate innovation and resourcefulness.
No two behavioral health emergencies are alike, and rarely can providers rely on clear-cut treatment protocols. Compounding this, training often focuses on a few extreme mental health presentations, such as psychosis or violence. This often results in reluctance on the part of the provider to engage in mental health issues that feel complicated, or “out of their scope.” Avoiding mental health presentations is not an option in the remote setting, when the patient with acute mental health concerns may be far from meaningful treatment. This situation creates a real threat to not only the patient, but the expedition and the rescue operation as well.
The aim of this chapter is to increase the comfort and confidence of the remote provider by providing examples of potential presentations and interventions with mental illness in the remote setting. While this chapter cannot provide comprehensive skills for complete psychiatric care in the remote setting, it will offer tangible tools for evaluating and caring for individuals in this unique setting. This chapter will review the most common and most extreme mental health concerns. For each mental health problem, information on the assessment of the patient’s presentation, practical tools for management, and information regarding evacuation in mental health emergencies will be described. As in other areas of mental health treatment, the mainstays of interventions are basic, but important skills of communication, validation, calm presence and often, the use of firm boundaries.
Providers should keep in mind that feeling comfortable with treatment of behavioral crisis in remote settings, ideally starts in the urban context. Providers should challenge themselves to engage with difficult patients in their everyday practice settings. This challenge includes engaging with individuals they ordinarily would avoid. Gaining experience and confidence treating a range of mental health concerns in the urban context is important preparation for treating such concerns in the more challenging context of a remote setting. Avoiding these experiences not only adds to the responder’s anxiety, but prevents the responder from developing the assessment and interventions skills needed to safely resolve individuals in crisis in the wilderness.
Definitions
Although diagnosis of the patient with mental health issues is outside of the scope of most wilderness providers, it is helpful to have a framework to understand the constellation of symptoms that may accompany certain behaviors. A mental disorder is a syndrome that affects thinking, behavior, or mood in ways that cause significant functional impairment in daily life. Mental health practitioners rely on The Diagnostic and Statistical Manual of Mental Disorders, now in its Fifth Edition (DSM-5),1
an important text that classifies and defines mental disorders. It provides diagnostic criteria, definitions, and explanation of symptoms for mental illness, and creates a common and consistent language to characterize and treat mental health presentations. Table 23.1 lists the most common conditions in DSM-5.1
an important text that classifies and defines mental disorders. It provides diagnostic criteria, definitions, and explanation of symptoms for mental illness, and creates a common and consistent language to characterize and treat mental health presentations. Table 23.1 lists the most common conditions in DSM-5.1
The cause of mental illness is complex, takes many forms, and is thought to derive from multiple factors. Biologic factors, such as genetics (inherited conditions), medical illness, and abnormalities in brain function may contribute to mental illness. Socioeconomic ecology, current environment stressors, and exposure to stressors early in life can all play an equally important role in the potential development of mental illness. For example, an individual may develop symptoms such as severe depression, anxiety, or psychosis as a result of genetic predisposition, alterations in neurotransmitter function in the brain, life circumstances (eg, child abuse or neglect), or stressful life events. Medical conditions and exposure to drugs (both illicit and prescribed) may also increase susceptibility to detrimental changes in emotional and behavioral functioning.
Symptoms of mental illness are best viewed as part of a spectrum or range of symptoms. Severity, persistence, and impairment to daily function are critical criteria for the clinical diagnosis of a mental illness. For instance, depression and anxiety are among the most common mental health concerns. An individual may experience depressive symptoms after the death of a loved one, but may not meet the criteria for a major depressive disorder—a clinical diagnosis of mental illness. Similarly, an individual in a wilderness setting may experience fear and anxiety when engaging in high-risk activities (such as rock climbing), seeing a bear, or being far from home. These symptoms may resolve completely upon arrival at home and would be considered part of the adaptive, normal response to anxiety-producing situations.
Table 23.1 Common Categories of Diagnostic and Statistical Manual of Mental Health Disorders and Their Key Features | ||||||||||||||||||||
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Individuals with preexisting mental illness may be more at risk when they find themselves in a stressful environment, like a remote setting. Stressors such as extremes in temperature, physical exertion, unexpected obstacles (getting lost, bad weather), interpersonal dynamics in group settings (a fellow participant may be irritating), interrupted sleep patterns due to altitude or temperature, and lack of normally available coping skills, may worsen symptoms. For example, someone who has a diagnosis of bipolar disorder may be more vulnerable to developing hypomania or manic symptoms when sleep patterns change, a common occurrence at altitude. A person suffering from a generalized anxiety disorder or panic disorder may find himself/herself overwhelmed with debilitating anxiety, when separated from important loved ones in remote settings. An individual with obsessive-compulsive disorder, with a fear of germs, may find themselves affected by extreme anxiety from the lack of frequent opportunities for handwashing.
The understanding of neurobiology and function of the brain related to mental illness directs medication treatment choices. For example, psychotropic medications (medications capable of affecting the mind, body, and behaviors) generally target neurotransmitters (chemicals that transfer information to other nerves, muscles, etc.) such as serotonin, norepinephrine, and dopamine in the brain. These chemical “messengers” drive changes in mood and cognition (thoughts, understanding, reasoning, etc.). Medications increase messenger availability, block their reuptake or increase the amount of individual receptor sites. For example, one theory of the development of major depressive
disorder describes how deficits in the neurotransmitter serotonin result in depressed mood, poor sleep patterns, and changes in appetite. Psychotic disorders are thought to be the result of excess dopamine in particular areas of the brain. Medications used to manage the symptoms of these disorders target serotonin and dopamine respectively.
disorder describes how deficits in the neurotransmitter serotonin result in depressed mood, poor sleep patterns, and changes in appetite. Psychotic disorders are thought to be the result of excess dopamine in particular areas of the brain. Medications used to manage the symptoms of these disorders target serotonin and dopamine respectively.
In addition, the wilderness provider must consider the impact of psychotropic medications on the patient, as hydration levels, maintenance of core body temperatures, appropriate sweating and cooling, and the body’s propensity to develop a fever may all be impacted by psychotropic drugs a person may be taking. For instance, sun exposure and dehydration may impact levels of drugs such as lithium and antipsychotics, and excess exposure and dehydration may lead to toxicity. Some drugs, such as antidepressants, may cause hyperthermia when overdosed or taken in excess. The wilderness provider must consider environmental conditions that may precipitate adverse drug reactions.
CLINICAL MANAGEMENT
Behavioral and emotional emergencies in remote settings pose unique challenges to the safety and continuation of an expedition or activity. Anxiety, depression, or agitation requires enormous amounts of time and resources to manage. The provider will often be in a position to determine whether the expedition can continue, or how an individual can safely be evacuated when they present as dangerous to themselves or others. As in medical rescue scenarios, safety of the provider, fellow rescuers, and other expedition members must be prioritized over diagnosis or treatment.
Once safety has been established, the second priority in the remote setting is stabilization and treatment of the presenting symptoms. Finding the underlying cause of the symptom can be key to stabilizing and treating it, when the symptom is caused or exacerbated by an environmental stressor that is reversible (eg, dehydration, heat stroke, altitude illness, medication side effect, etc.). However, the cause of a symptom may not be clear in the moment. Psychosis in a humanitarian aid worker, for example, might be related to underlying bipolar disorder, infection, or a side effect of taking the antimalarial medication called mefloquine (Lariam). Indeed, even in an acute care setting, it could take hours or days for a skilled clinician to determine the cause of such a symptom. Thus, priority should remain with stabilization of the symptom and exploration of the underlying cause with a thorough evaluation.
Anxiety
Epidemiology and Causes
Anxiety disorders tend to develop early in life, and wax and wane throughout the life span. Anxiety disorders are often related to developmental transitions, such as starting kindergarten or leaving for college, or life stressors such as moving, losing a job, financial stressors, or divorce. One in four persons in the United States meets diagnostic criteria for at least one anxiety disorder.2 Statistically, women tend to be more vulnerable to anxiety than men, with a 30% lifetime prevalence rate for women compared to a 19% lifetime prevalence rate for men.2
The causes of anxiety presentation are often multifaceted. Abnormalities in neurotransmitters, such as gamma-aminobutyric acid, norepinephrine, and serotonin, as well as increases in stress hormones and heightened activity of the autonomic nervous system, all may underlie the development of anxiety disorders. Genetic vulnerability is believed to play a role in one-third of those experiencing anxiety disorders.1 Additionally, there are many medical conditions known to cause symptoms of anxiety (Table 23.2).
In the remote setting, the stress of unknown environments, sleep disturbance, separation from loved ones, as well as engaging in perceived risky activities such as climbing, can all induce anxious responses in those already at risk. Ongoing studies into anxiety may show a relationship between the onset of acute anxiety and ascending to high altitude.3,4 Recent studies also suggest that withdrawal from technology may be a significant contributor to anxiety states in adolescent populations. These study results may be possible to extrapolate to adult populations.5,6 It should be noted that medications used to treat anxiety, when stopped abruptly, may cause distressing withdrawal symptoms that include rebound anxiety. Immediate withdrawal of benzodiazepines can be life-threatening.
Clinical Features
Everyone experiences anxiety. It is considered a highly adaptive process that initiates action in times of danger, and is the cornerstone of our survival mechanism. Like depression, anxiety becomes problematic only when it interferes with the capacity to complete necessary daily activities and enjoy life. Presentations of anxiety vary widely. For those with more generalized anxiety,
symptoms include constant worry about a myriad of issues, restlessness or irritability, difficulty concentrating, and sleep disturbance. Anxiety can also be very specific, focused on isolated fears such as separation from family, social situations, phobias or obsessive-compulsive thoughts and behaviors. These symptoms may be worsened or emerge unexpectedly in remote settings, when patients are separated from loved ones, feel far from help, or are overwhelmed by their environment. Encounter-specific phobia triggers in the wilderness, such as heights or enclosed spaces, can also initiate anxiety or panic attacks.
symptoms include constant worry about a myriad of issues, restlessness or irritability, difficulty concentrating, and sleep disturbance. Anxiety can also be very specific, focused on isolated fears such as separation from family, social situations, phobias or obsessive-compulsive thoughts and behaviors. These symptoms may be worsened or emerge unexpectedly in remote settings, when patients are separated from loved ones, feel far from help, or are overwhelmed by their environment. Encounter-specific phobia triggers in the wilderness, such as heights or enclosed spaces, can also initiate anxiety or panic attacks.
Table 23.2 Medical Causes of Anxiety | ||||||||||||||
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Anxiety can be experienced as highly physical, and in fact can be mistaken for other medical diagnoses such as cardiac or neurologic events. Physical symptoms of anxiety can include fatigue, increased heart rate (HR), dizziness, trembling, chest pain, muscle tension, and upset stomach. Panic attacks are characterized by these symptoms to the extreme and can be associated with fear of dying or losing control. They generally last between 20 and 30 minutes and rarely more than an hour.
In the remote setting, those paralyzed by anxiety may present a risk to the rescuers, because their reactions may be erratic or unpredictable. Individuals may demonstrate compromised problem-solving and decision-making skills, resulting in the inability to respond to directions, or participate in self-rescue. Anxiety that is well controlled in familiar environments may produce out-of-proportion or incapacitating symptoms in remote settings. Overwhelming environmental stimuli or lack of available coping mechanisms, such as social supports and electronic devices, may contribute to this.
Assessment
The remote provider should be prepared to address the physical symptoms first and use the assessment to both calm the patient and build rapport. Patients who are experiencing high levels of anxiety feel with certainty that something is physically wrong with them. Because of this, even if the provider suspects the presentation is solely due to anxiety, addressing and validating physical complaints serves to calm the patient and decrease anxiety. For instance, providers may choose to listen to lung sounds, intentionally asking the patient to take deep breaths, as a means to slow the patient’s breathing. This serves to demonstrate concern, while at the same time, evaluating the patient for any underlying medical conditions, and physiologically calming the patient. It should be noted that providers sometimes err by assuming that a presentation is related to anxiety, when the patient is actually experiencing a medical emergency, such as supraventricular tachycardia, myocardial infarction, or pulmonary emboli (Table 23.3). These techniques form a key component of “psychological first aid”, a technique discussed more fully in Chapter 10.
The most common medications used to address underlying anxiety states include selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), serotonin norepinephrine inhibitors (SNRIs) such as venlafaxine (Effexor), and short- and long-acting benzodiazepines such as alprazolam (Xanax) and clonazepam (Klonopin) (see Table 23.4). These medications are often relevant in wilderness settings, as 10% of Americans over the age of 12 take an SSRI.7 Abrupt discontinuation of SSRIs and SNRIs can cause symptoms of anxiety, flu-like illness, insomnia, sensory disturbances, and hyperarousal. Benzodiazepines are also commonly prescribed for anxiety disorders. When used on a daily basis and then stopped abruptly, they can have serious and life-threatening withdrawal symptoms, such as seizures. Taking a robust medical history is protective against missing less obvious causes of anxiety such as medication withdrawal.
Table 23.3 Common Medications in Wilderness Medical Kits That Can Cause Anxiety | |||||
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Treatment
ALL LEVELS—CRISIS MANAGEMENT, NON-PHARMACOLOGIC TREATMENT
Responding to the anxious, panicking, or terrified individual in the remote setting can paradoxically result in anxiety for the rescuer as well. The remote provider may feel that the lack of their usual selection of tools and medications renders them powerless to treat the patient and assist them in resolving troubling symptoms. Crucial to the provider’s response is understanding that the emotional state of the rescuer will greatly impact the response of the individual patient. Providers who understand this, and take necessary steps to calm themselves and enter the scene in an emotionally regulated state, have already engaged the primary and most powerful remote treatment tool: calming themselves in order to help calm their patient. The transmission of calm from the provider to patient is transformational, but is often overlooked because of its simplicity. Although other tangible tools for remote management will be discussed, the calm state of the rescuer remains the primary treatment approach, and will be the treatment modality most likely to have the greatest impact on the patient’s response and well-being. It should be considered the foundation of management for the patient with anxiety. For more in-depth discussion and additional tools for supporting patients in distress, see Chapter 10, Psychological First Aid and Stress Injuries.
The principles of anxiety management include:
1. Calm oneself and build on-scene relationship with patient.
2. Complete patient assessment to rule out underlying medical causes for anxiety.
Table 23.4 Mental Health Medications and Withdrawal | ||||||||||||
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3. Reflect to the patient tangible evidence of safety, when available.
4. Use appropriate calming techniques.
Calming Techniques
a. Reassurance– Normalize reactions of shaking, crying, anxiety, and fear, which are normal responses to overwhelming situations. If possible, reflect to the patient true and encouraging facts about the current situation. Stating the positive without unneeded details can achieve this. This would include statements like “it has been confirmed that everyone survived,” or “a helicopter has been deployed to our location.” Reflecting on evidence of safety is a powerful tool to alleviate further stress response from the individual.
b. Validation– “This is a normal response to an abnormal situation” can be a very helpful statement to normalize the reaction of the patient. Patients often feel ashamed of their reactions and hearing that others might experience similar feelings can be very helpful.
c. Breathing– Deep breathing does not have to be complex. It may be as simple as asking the patient to repeat slow, deep breaths, while the provider listens to lung sounds. Reflect back on the evidence that breath sounds are present, saying “you’re doing good, keep taking a few more deep breaths” can be comforting to the individual. Demonstrating slow, deep breaths, often elicits the same breathing pattern from the anxious patient. Pausing to take a deep breath, and perhaps exaggerating this for the patient will have the effect of encouraging the patient to breathe deeply.
d. Problem-solving and returning to the present moment-Those who experience severe anxiety often perseverate on things that could happen (this is often called catastrophizing). Returning the patient’s thoughts to the present moment can be helpful. Assigning individuals a task or engaging in problem-solving activities helps redirect and focus on solutions, providing escape from disturbing thoughts.
e. Explore preexisting coping skills– Many individuals often have well-established coping skills. Exploring with each person what they usually do when they feel anxious or what has worked in the past to relax or calm down is useful. Patients may forget (until reminded) that they already have many skills needed to care for themselves.
f. Grounding techniques- Examples of this include asking a patient to put their feet on the floor and take in a deep, slow breath. The patient might then be asked to describe three nonthreatening things they can hear around them (eg, birds chirping, rescuers talking, wind in the trees). Taking a deep breath and counting to four before a slow exhale also connects an individual to their body.
ADVANCED LIFE SUPPORT AND CLINICIAN PROVIDERS
Advanced life support (ALS) and clinician providers should implement all the interventions discussed above for first aid and basic life support providers. At the advanced level, providers with access to medication must weigh the risks and benefits of medication use for severe anxiety (Table 23.4). SSRI and SNRI medications require 4 to 6 weeks to take effect, and are not used acutely. Restarting an SSRI or SRNI if anxiety is due to abrupt discontinuation of the medication is the simplest way of alleviating symptoms.
For the provider preparing for anxiety in the remote setting, hydroxyzine (Vistaril) is an antihistamine indicated and frequently used for anxiety. It is also used off-label for insomnia. This medication is well tolerated with minimal side effects. Hydroxyzine at doses of 50 mg may be given up to four times a day for acute anxiety in adults. The onset of action for oral formulation is 15 to 20 minutes. Side effects include dry mouth,
sedation, and tremor. In addition, the side effect (as noted above, sometimes used as a primary effect for insomnia) of sleepiness may contraindicate this medication for wilderness operational activities requiring alertness for safety.
sedation, and tremor. In addition, the side effect (as noted above, sometimes used as a primary effect for insomnia) of sleepiness may contraindicate this medication for wilderness operational activities requiring alertness for safety.
Benzodiazepines may be considered for use in acute anxiety/panic symptoms that are extreme and impairing. Lorazepam (Ativan) is a benzodiazepine of choice for acute symptoms, given its relatively quick onset of action (15 to 30 minutes) and duration of action (4 to 6 hours). Lorazepam 0.5 to 1.0 mg may be repeated every 2 to 4 hours. Side effects of lorazepam include sedation, fatigue, dizziness, ataxia, slurred speech, weakness, forgetfulness, and confusion. Respiratory depression, which can be life-threatening, can occur with an overdose or in combination with other sedating agents such as alcohol. Avoid short-acting agents such as alprazolam (Xanax) due to rebound anxiety symptoms. Benzodiazepines are not the medication of choice for anxiety related to acute stress responses/posttraumatic stress disorder (PTSD) unless there is the presence of agitation. Acute stress responses, PTSD, and the reasons why benzodiazepines are less ideal for them are discussed more fully in Chapter 10. In addition, benzodiazepines have their effect on cognitive function and an individual’s reaction time, which could make wilderness travel and self-care hazardous in some settings. The Wilderness Medical Society Practice Guidelines8 also recommend oral haloperidol (Haldol) 5 to 10 mg in cases of anxiety with severe agitation. This would typically be reserved for the most severe cases, where agitation may have dangerous consequences to the individual or rescuers and other means of reducing anxiety have failed.
Evacuation
Many anxiety states can be managed in the remote setting. Some presentations of anxiety will be outside the provider’s comfort level or ability to manage. In these instances, the patient must be evacuated. The following situations related to anxiety can be used to indicate a probable need for evacuation.
1. Severe or recurrent anxiety reactions or panic symptoms disruptive to the group.
2. Symptoms that interfere with the patient’s ability to care for themselves, or keep themselves safe.
3. Anxiety presentations that are beyond the provider’s ability to manage.
4. Anxiety states that render the patient, rescuer, or group unsafe.
Depression
Epidemiology and Etiology
Like anxiety, depression is common, with depressive disorders in the United States affecting approximately 7.6% of the population over the age of 12.7 Gender plays a role as well, with females experiencing 1.5- to threefold higher rates of depression than males, beginning in early adolescence.1 Like anxiety states, a variety of issues can contribute to depressive disorders, including genetic vulnerability, early childhood trauma, current life stressors, and belief structures. Deficits in neurotransmitters such as serotonin, norepinephrine, and dopamine are also thought to contribute to the development of depression.
Clinical Presentation
Depression can manifest itself in a variety of ways, ranging from subtle changes in motivation and energy, to complete disruption of one’s ability to perform daily tasks, to loss of desire to live. Although there exist “classic” symptoms of depression, such as sadness, hopelessness, and decreased energy, each individual will be unique in how they manifest their symptoms making depression, at times, difficult to detect. This is in part due to the fact that many depressive states are accompanied by shame, self-blame, social isolation, and a barrage of negative self-thoughts, that result in the inability (or lack of desire) to share how truly painful the experience is. Many individuals endure symptoms of depression without sharing them for weeks, months, or even years. Often it is the objective physical findings (eg, weight loss, weight gain, decrease in energy, or sleep disturbance) that draw the attention of medical personnel. Self-harm, suicidal thoughts or attempts, and, rarely, psychosis account for the majority of emergency department (ED) visits related to depression.
While the essential feature of depression is sadness or depressed mood, hopelessness, self-blame, negative thoughts, and loss of interest or joy can all present in most who suffer from depression. Sleeping too much or not enough, overeating or loss of appetite, isolation, fatigue, and decreased ability to concentrate, complete tasks, or make decisions, can all be found in depression. Rumination (repetitive and worrisome thoughts), worry, and anxiety can also accompany depression.
Likely the most distressing and dangerous of symptoms of depression are repetitive thoughts about death or dying, suicidal thoughts, or plans to commit suicide. Risk of suicide is ever present among those experiencing depression. Especially concerning are patients with a history of previous suicide attempts, history of family members who have completed suicide, and individuals with highly lethal and available plans already formed. Prominent feelings of hopelessness, substance abuse, and borderline personality disorder significantly increase the risk of suicide attempts. Older males, single or living alone, are also particularly at risk.1
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