chapter 32 abnormal behavior. © 2005 by thomson delmar learning,a part of the thomson corporation....

Chapter 32Abnormal Behavior

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© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved

Overview

Behavioral Emergency Psychiatric Disorders

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Any situation where patient exhibits unacceptable, dangerous, or intolerable behavior to himself, family, or community

Often brought to authorities’ attention because behavior is violent

Behavioral Emergency

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Violent behavior is not always present Person may simply “not act right”

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Organic disorders– Any disease or physical condition causing brain

to malfunction • Malfunction in brain causes abnormal behavior• Suspect a medical, not psychiatric, cause

– Don’t dismiss abnormal behavior as “just plain crazy”

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Organic disorders– First safeguard patient’s life– Evaluate and treat any serious medical conditions

that could create abnormal behavior– Use AEIOU-TIPS to understand possible organic

causes of altered mental states

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Mental disorders– Any disorder that impairs the brain’s function, the

way the brain thinks, without a firm physical (organic) cause

– Outward evidence of mental illness is bizarre or irrational behavior

– Some examples of common mental illnesses are depression and psychosis

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Scene size-up– Be alert for potential violence on scene

• Initial dispatch information• Radio reports of “shots fired,” “suicide attempted”• Call history and previous EMS calls to street address

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Scene size-up– Never enter an unsafe scene

• Place or stage ambulance at safe distance• Turn off warning lights that might alert of your presence• Stay in vehicle until police declared the scene safe

– Perform a visual sweep of the scene upon approach

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Scene size-up: Safety measures– Never enter alone – use “buddy system”– Always have a police officer clear the scene first– Always think about escape

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Scene size-up: Safety measures– Carry gear over one shoulder only or in

one hand by straps– Have portable radio immediately available

for emergency use– Only first EMT should hold a flashlight, to

decrease target profile– Study the crowd carefully

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Scene size-up: Safety measures– Stand to side of door and knock loudly

• Call out loudly, using terms like “ambulance” or “rescue squad”

– Leave door open and path to the door clear– Stand a safe distance from patient

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Assessment– General approach to assessing a potentially

violent patient is to “stop, look, and listen”• Observe patient carefully • Look into patient’s eyes and maintain good eye contact• Do initial assessment at a safe distance

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History and focused physical examination– If patient is unwilling or unable to provide a history

of present illness and SAMPLE history, obtain them from family members

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History and focused physical examination– Limit focused physical examination for safety

reasons, but try to assess patient from head to toe for signs of obvious injury

– Measure vital signs when safe to do so, and repeat as often as necessary

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Management– Maintain a calm and professional manner – Have only one EMT talk to patient

• Develop EMT-patient relationship

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Management– Identify yourself clearly and tell patient

your intentions – Direct conversation to patient– Keep good eye contact with patient

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Management: Verbal persuasion– Good, effective communication

• Speak slowly and clearly• State your name and purpose• Repeat message until patient understands • Ask patient about his concerns

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Management: Verbal persuasion– Good, effective communication

• Answer patient honestly when he asks a question • Reassure patient you are there to help and protect him• Seek patient’s cooperation, encourage him to “speak up,”

and listen to him• Firmly reject his refusal to transport for medical attention

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Management: Physical restraint – May need to restrain patient for his own protection

• When verbal persuasion is ineffective and patient displays signs of excited delirium or is a clear danger to himself or others

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Physical restraint: Medical necessity– Patient may be restrained against his will when he

is a danger to himself or others• Legitimate medical necessity

– Ordered by a doctor and done only for safety of patient and others

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Physical restraint: Medical necessity– This treatment cannot be refused by the patient – Use only reasonable force to restrain a patient

• If excessive force is used, legal actions may be taken against the EMT

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Physical restraint: Restraint procedure– Takedown procedure

• A planned orderly restraint of a patient for medical purpose

• Preplanning helps ensure safety of all involved and patient

• Usually involves obtaining and keeping control of extremities

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Physical restraint: Restraint procedure– Takedown procedure

• Safe strategy– Ensure adequate number of crew members

(usually four) – Assign team leader and a specific role for each

crew member – Last effort to get patient to accept care by a

show of force– Have the stretcher conveniently near

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Physical restraint: Total body restraint – Totally encapsulate patient

• Prevents him from moving, but allows him to be carried

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Physical restraint: Extremity restraint– Lift patient by all four extremities and place

him face up on the stretcher • Prevents respiratory compromise • Allows EMT to monitor patient’s ABCs

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Physical restraint: Extremity restraint– Secure arms in opposing directions: dominant

above head, nondominant down at side – Place straps under the armpits, above knees,

and if necessary, restrain ankles

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Physical restraint– Restraint devices

• Cravats, triangular bandages• Strong roller gauze• Leather restraint device• Chest harness

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Physical restraint– Safety

• If safety is compromised, team should withdraw• In those cases, encourage police to restrain the patient• Replace police restraint with medical restraint at

earliest convenience• If police restraints are not replaced, police officer should

accompany patient to hospital

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Transport– Transport patient to closest appropriate hospital– Be familiar with capabilities of each nearby institution

• Some hospitals have separate psychiatric facilities

– Always follow local protocols regarding transport of the psychiatric patient

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Ongoing assessment– Restrained patient cannot care for himself and

thus completely depends on EMT for safety – Check pulses, movement, and sensation in the

extremities at least every 10 minutes – Patient’s ABCs should be reassessed at least

every 5 minutes

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Documentation– Patient’s condition– Efforts made to avoid using the restraint– Contact of the medical control that gave

orders to restrain

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Documentation– Police officer’s name, badge number, and

agency if officer ordered the restraint – Method of restraint– Ongoing assessment of the patient

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Stop and Review

Describe several concerns an EMT should have about scene safety on the scene of a behavioral emergency.

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Psychiatric Disorders

Patient may completely lose touch with reality or have distorted perceptions of reality

Patient may no longer be able to interact appropriately with the environment and does not see the world as others do

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Depression– Sadness and despair predominate moods– Feelings can become overwhelming and lead to

neglect of family, friends, and self– Clinical depression occurs in about one-third of the

U.S. population at least once in their lives

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Depression: Signs and symptoms– Mental apathy– Melancholy– Changes in appetite– Weight gain or loss– Sleeping difficulties– Illness

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Depression: Assessment– Take note of surroundings– Look for evidence of drug use– Look for evidence of overdose

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Depression: Management– Be supportive– Be there to offer medical help

• A hand to hold will be appreciated

– Patients with severe depression may have difficulty making decisions• Be supportive

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Suicide– Patient who has voluntarily taken his own life– A national health problem– Know the suicide risk factors

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Suicide– Increased incidence around

• Holidays• Anniversaries • Birthdays

– Any suicide attempt is a cry for help– Every suicide attempt should be taken seriously

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Suicide: Signs and symptoms– Self-inflicted injury – Illness secondary to poisoning or overdose– Specific signs and symptoms present will be

related to method of attempted suicide

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Suicide: Management– Clear questioning– Does patient intend to harm himself or not?– Transport patient to the ED if he is a potential

danger to himself– Treat whatever injuries are found in a focused

physical exam

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Bipolar disorder– Manic-depressive disorder– A type of mental illness characterized by extremes

of emotion ranging from total elation to total depression

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Bipolar disorder: Signs and symptoms– Some days, patient may feel all-powerful,

euphoric, and full of energy • Patient can become extremely agitated and irritable

– On other days, patient is depressed and withdrawn, and feels worthless

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Bipolar disorder: Management– Prescription: lithium– If out of touch with reality or in any danger of

causing harm to himself or others, patient must be transported safely to the ED

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Schizophrenia– A poorly understood mental disease that may be

due to a neurochemical imbalance– Signs and symptoms

• Out of touch with reality• Hallucinations

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Schizophrenia– Management

• Ask, “Are you hearing voices?” • Reassure patient

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Anxiety disorder– Anxiety is a normal response to stress.– Anxiety becomes abnormal when response is

exaggerated or inappropriate to the situation– Anxiety disorders collectively represent the largest

group of mental illnesses in the United States

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Psychiatric Disorders Anxiety disorder: Signs and symptoms

– Anxiety– Palpitations– Shortness of breath– Sweatiness– Fear– Tremulousness– Tachycardia– Hyperventilation– Diaphoresis– Dilated pupils

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Substance abuse– Misuse of a drug or other substance in order to

alter the person’s perception or mood – A significant health problem in the United States

• Includes alcohol abuse

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Substance abuse– Can lead to a number of chronic

debilitating diseases • Costs Americans almost a trillion dollars a

year in health care and related costs

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Substance abuse, including drug abuse, can lead to behavioral emergencies.

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Substance abuse– People use illicit drugs in order to get high – Most illicit drugs are impure– Repeated consumption of certain drugs causes

the body to need that drug – Not all drugs are physically addicting

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Substance abuse: Overdose– Toxic: when too much of a substance is ingested,

inhaled, or injected into the body,– A toxin, or poison, interferes with body’s

metabolism– Too much of a toxin eventually kills the patient– Any intoxication is an overdose of the drug

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Drug withdrawal– Alcohol withdrawal

• Alcoholic patients are both psychologically dependent and physically addicted to alcohol

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• Chronic alcoholism causes damage to every organ system, especially the liver and heart– Heart disease– Hypertension– Cirrhosis– Pancreatitis– Gastrointestinal problems

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• Signs and symptoms– Marked tremors (shaking)– Weakness– Nausea– Vomiting– Diarrhea– Tachycardia– Hypertension– Delirium tremens


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• Management– Oxygen administration– ABCs– Quiet transport to the hospital


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Stop and Review

What are some mental illnesses that can result in a behavioral emergency?

List several signs and symptoms of severe or clinical depression.

chapter 32 abnormal behavior. © 2005 by thomson delmar learning,a part of the thomson corporation....

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