Behavioral EmergenciesBehavioral Emergencies

PARAMEDIC PROGRAMPARAMEDIC PROGRAM

Summer 08Summer 08

A 28-year old male was brought into the ER after an attempted suicide. The

man had swallowed several nitroglycerin pills and a fifth of vodka.

When asked about the bruises about his head and chest, he said that they were from him ramming himself into

the wall in an attempt to make the nitroglycerin explode.

Strange But TrueStrange But True

What’s this all about?What’s this all about? Is it normal or abnormal?Is it normal or abnormal? Prevalence?Prevalence? Pathophysiology of behavioral and Pathophysiology of behavioral and

psychiatric disorderspsychiatric disorders Factors that alter behavior or Factors that alter behavior or

emotional statusemotional status Medical legal considerationsMedical legal considerations Overt behaviors associated with Overt behaviors associated with

behavioral and psychiatric disordersbehavioral and psychiatric disorders

Verbal techniques useful in mgmt of Verbal techniques useful in mgmt of the emotionally disturbed pt.the emotionally disturbed pt.

Appropriate safety measuresAppropriate safety measures When should family, etc be removed When should family, etc be removed

from premises?from premises? Techniques for physical assessmentTechniques for physical assessment When are you expected to transport When are you expected to transport

a patient against his/her will?a patient against his/her will? To restrain or not?To restrain or not?

TermsTerms AffectAffect AngerAnger AnxietyAnxiety ConfusionConfusion DepressionDepression FearFear Mental statusMental status Open-ended questionsOpen-ended questions PosturePosture Post-traumatic stress Post-traumatic stress

syndromesyndrome Psychogenic amnesiaPsychogenic amnesia Schizophrenia Schizophrenia

BereavementBereavement Biological/organicBiological/organic Bipolar disorderBipolar disorder CatatoniaCatatonia DeliriumDelirium DelusionsDelusions Dementia Dementia Flat affectFlat affect ManicManic Multiple personality Multiple personality

disorderdisorder PhobiaPhobia Positional asphyxiaPositional asphyxia

Behavioral and Psychiatric Behavioral and Psychiatric EmergenciesEmergencies

Not clear cutNot clear cut They require a complete history, They require a complete history,

exam, and careful/skilled approachexam, and careful/skilled approach Most of what you do will depend on Most of what you do will depend on

your people skillsyour people skills Behavioral emergencyBehavioral emergency

Behavior is so unusual, bizarre, Behavior is so unusual, bizarre, threatening or dangerous – possibly life-threatening or dangerous – possibly life-threatening to self or othersthreatening to self or others

What is normal, anyway???What is normal, anyway??? Determined byDetermined by

Culture Culture Ethnic groupsEthnic groups Socioeconomic classSocioeconomic class Personal interpretation, opinionPersonal interpretation, opinion

Does itDoes it Interfere with core life functions?Interfere with core life functions? Pose a threat to the life or well-being of the Pose a threat to the life or well-being of the

patient or others?patient or others? Significantly deviate from society’s Significantly deviate from society’s

expectations?expectations?

Normal ? Behavior that is readily Normal ? Behavior that is readily acceptable in a society!acceptable in a society!

PathophysiologyPathophysiology ~ 20% of population has some type ~ 20% of population has some type

of mental health problemof mental health problem 1 in 7 will require treatment1 in 7 will require treatment

AnxietyAnxiety DepressionDepression Eating disordersEating disorders Mild personality disordersMild personality disorders

Behavioral and psychiatric disorders Behavioral and psychiatric disorders incapacitate more people than all incapacitate more people than all other health problems combined!other health problems combined!

True/not true?True/not true?

All mental patients are unstable and All mental patients are unstable and

dangerous dangerous

Their conditions are incurableTheir conditions are incurable

Biological causesBiological causes

AlcoholAlcohol

Drugs (including OTC, Rx)Drugs (including OTC, Rx)

InfectionInfection

TumorsTumors

Potential Organic CausesPotential Organic Causes

Frontal atrophy from Alzheimer’s disease

Brain neoplasm

Psychosocial Psychosocial

Personality stylePersonality style Dynamics of unresolved conflictDynamics of unresolved conflict Crisis management methodsCrisis management methods EnvironmentEnvironment

Traumatic childhood incidentsTraumatic childhood incidents

Sociocultural Sociocultural

SituationalSituational RelationshipsRelationships Support systemsSupport systems Social isolationSocial isolation Rape/assaultRape/assault Witnessing acts of violenceWitnessing acts of violence Loss of a jobLoss of a job Ongoing prejudice or discriminationOngoing prejudice or discrimination

Assessment of behavioral Assessment of behavioral patientspatients

The same as for all other The same as for all other

patientspatients Scene size-up – look for Scene size-up – look for

hazardshazards Initial assessment – watch Initial assessment – watch

posture & body languageposture & body language Focused history Focused history Physical examinationPhysical examination

You begin your care at You begin your care at

the same time – good the same time – good

interpersonal skills!interpersonal skills!

More about the H & EMore about the H & E Listen – open-ended questionsListen – open-ended questions

Pay attentionPay attention Spend timeSpend time Be assuredBe assured Do not threatenDo not threaten Let there be silenceLet there be silence Place yourself at their levelPlace yourself at their level Keep a safe & proper distanceKeep a safe & proper distance Appear comfortableAppear comfortable Don’t judgeDon’t judge Never lieNever lie

Mental status examinationMental status examination General appearanceGeneral appearance Behavioral observations – verbal and non-verbalBehavioral observations – verbal and non-verbal Orientation Orientation MemoryMemory Sensorium – is pt. focused, paying attention?Sensorium – is pt. focused, paying attention? Perceptual processes – thought patterns Perceptual processes – thought patterns

ordered?ordered? Mood and affectMood and affect IntelligenceIntelligence Thought processesThought processes InsightInsight JudgmentJudgment PsychomotorPsychomotor

Form a general impressionForm a general impression

DementiaDementia 25 – 50% over 85 y/o have dementia 25 – 50% over 85 y/o have dementia

Alzheimer’s most commonAlzheimer’s most common Mini-strokesMini-strokes

Affected person sometimes recognizes Affected person sometimes recognizes first signsfirst signs Keys?Keys? Lost while driving, etcLost while driving, etc Common tasksCommon tasks Difficulty with wordsDifficulty with words

Time between first symptoms & death – 7 Time between first symptoms & death – 7 – 10 years– 10 years

DementiaDementia Gradual impairment of Gradual impairment of

memory and cognitive memory and cognitive functionsfunctions ForgetfulnessForgetfulness Failure to recognize Failure to recognize

objects or stimuliobjects or stimuli OrientationOrientation

Excellent recall of past Excellent recall of past historyhistory

May not remember May not remember current eventscurrent events

AffectAffect Normal or flat, Normal or flat,

depending on stage of depending on stage of conditioncondition

AphasiaAphasia Impaired Impaired

communicationcommunication ApraxiaApraxia

Impaired motor Impaired motor activitiesactivities

AgnosiaAgnosia Failure to recognize Failure to recognize

objectsobjects Disturbance in Disturbance in

executive functioningexecutive functioning Impaired ability to plan, Impaired ability to plan,

organize or sequenceorganize or sequence

DementiaDementia

Causes:Causes: Alzheimer’s diseaseAlzheimer’s disease AIDSAIDS Parkinson’s diseaseParkinson’s disease Vascular diseaseVascular disease Head traumaHead trauma Substance abuseSubstance abuse

Dementia and Dementia and DeliriumDelirium

Delirium may occur in dementia patientsDelirium may occur in dementia patients Delirium PresentationDelirium Presentation

Rapid onset (hours or days)Rapid onset (hours or days) Inattention, disorientation, memory Inattention, disorientation, memory

impairment and visual hallucinationsimpairment and visual hallucinations Causes of delirium are usually reversibleCauses of delirium are usually reversible

Rule out acute medical problems, medication Rule out acute medical problems, medication changeschanges

Treatment Treatment

SupportiveSupportive MedsMeds

AriceptAricept CognexCognex

SchizophreniaSchizophrenia

Gross distortions of realityGross distortions of reality Preoccupation with inner Preoccupation with inner

fantasiesfantasies Withdrawal from social Withdrawal from social

interactioninteraction Disorganization of thoughts, Disorganization of thoughts,

perceptions, and emotionsperceptions, and emotions Behavior linked with Behavior linked with

medication noncompliancemedication noncompliance Chronic substance abuse in Chronic substance abuse in

teenage years linked to teenage years linked to development of the diseasedevelopment of the disease

Schizophrenia SymptomsSchizophrenia Symptoms

Disorganized behavior/dressDisorganized behavior/dress Flat affectFlat affect Disorganized speechDisorganized speech

Incoherent or frequently veers off trackIncoherent or frequently veers off track

DelusionsDelusions HallucinationsHallucinations

Often auditory; sometimes visualOften auditory; sometimes visual

Motor MovementsMotor Movements May act upon hallucinationsMay act upon hallucinations

Profiles of Profiles of Schizophrenic Schizophrenic

BehaviorBehavior Delusional:Delusional:

A man who wraps his house in tin A man who wraps his house in tin foil to divert the rays from FBI foil to divert the rays from FBI satellites.satellites.

Paranoid:Paranoid: The man introduces himself as The man introduces himself as

Jesus Christ and tells you that the Jesus Christ and tells you that the city council is out to crucify him.city council is out to crucify him.

Profiles of Schizophrenic Profiles of Schizophrenic BehaviorBehavior

Disorganized (interview with a Disorganized (interview with a

physician):physician):

““S____t on you all who rip into my internals! S____t on you all who rip into my internals!

The grudgerometer will take care of you all! The grudgerometer will take care of you all!

I am the Queen, see my magic, I shall turn I am the Queen, see my magic, I shall turn

you all into sidgelings forever!”you all into sidgelings forever!”

Profiles of Schizophrenic Profiles of Schizophrenic BehaviorBehavior

Undifferentiated:Undifferentiated:

Magical thinkingMagical thinking

Creates new words or cryptic languageCreates new words or cryptic language

Cannot reason abstractlyCannot reason abstractly

Diagnosis of SchizophreniaDiagnosis of Schizophrenia

Two or more symptoms must each Two or more symptoms must each be present for a significant portion of be present for a significant portion of each month over the course of 6 each month over the course of 6 months. months.

Sx must cause a social or Sx must cause a social or occupational dysfunction occupational dysfunction

Most schizophrenics are diagnosed in Most schizophrenics are diagnosed in early adulthoodearly adulthood

Approach To A Approach To A SchizophrenicSchizophrenic

Be supportiveBe supportive Be nonjudgmentalBe nonjudgmental Don’t reinforce the patient’s Don’t reinforce the patient’s

hallucinations – but know that he hallucinations – but know that he considers them realconsiders them real

Speak openly and honestlySpeak openly and honestly Be encouraging and realisticBe encouraging and realistic Be alert for aggressive behaviorBe alert for aggressive behavior Restrain patient if necessaryRestrain patient if necessary

Anxiety DisordersAnxiety Disorders

Panic AttacksPanic Attacks Acute, unprovoked episodesAcute, unprovoked episodes Last approximately 1 hourLast approximately 1 hour Symptoms: Symptoms:

Cardiac chest pain, nauseaCardiac chest pain, nausea Dyspnea or a sense of feeling “smothered”Dyspnea or a sense of feeling “smothered” Fear of going crazyFear of going crazy Paresthesia, dizzinessParesthesia, dizziness Trembling, shakingTrembling, shaking

Mood Disorders: ManiaMood Disorders: Mania

Sudden onset with rapid Sudden onset with rapid progression of symptoms (days)progression of symptoms (days)

Presentation:Presentation: Progressive inflation of self-esteemProgressive inflation of self-esteem Distracted, racing thoughtsDistracted, racing thoughts

Delusions may occurDelusions may occur Very talkative with rapid speechVery talkative with rapid speech Excessive involvement in high Excessive involvement in high

pleasure/high risk activitiespleasure/high risk activities

Management for anxiety Management for anxiety disorderdisorder

Simple, supportiveSimple, supportive Be empatheticBe empathetic Assess medical complaints & tx prnAssess medical complaints & tx prn Consider sedativeConsider sedative

ValiumValium VersedVersed AtivanAtivan Benadryl Benadryl

Bipolar disorderBipolar disorder

One or more manic episodes with or One or more manic episodes with or without depression, lasting at least without depression, lasting at least one weekone week

Not commonNot common Episodes often begin suddenly and Episodes often begin suddenly and

escalate rapidlyescalate rapidly Disorder usually develops in Disorder usually develops in

adolescence or early adulthoodadolescence or early adulthood

The Stages of ManiaThe Stages of Mania MildMild

““On top of the world”On top of the world” EgocentricEgocentric Decreased need for sleepDecreased need for sleep

Severe elationSevere elation Rapid speechRapid speech Illogical associationsIllogical associations Delusions of grandeurDelusions of grandeur Excessive involvement in Excessive involvement in

pleasurable activities with high pleasurable activities with high potential for consequencespotential for consequences

Mood Disorders: Mood Disorders: DepressionDepression

Situational vs. persistentSituational vs. persistent Lack of interest in daily Lack of interest in daily

activitiesactivities Altered mood impairs daily Altered mood impairs daily

functioningfunctioning May be present with other May be present with other

disorders disorders Bipolar diseaseBipolar disease Substance abuseSubstance abuse

Presentation of DepressionPresentation of Depression

Bizarre behavior usually not seen in Bizarre behavior usually not seen in depressiondepression

Inability to see beyond the person’s Inability to see beyond the person’s immediate situationimmediate situation

Lethargy, slow thought process and Lethargy, slow thought process and speechspeech

Stooped postureStooped posture Poor appearancePoor appearance

General Management General Management ConsiderationsConsiderations

Behavioral crisis development and Behavioral crisis development and management are viewed as a management are viewed as a “spectrum”“spectrum” Patients do not suddenly develop anger or Patients do not suddenly develop anger or

passivitypassivity Use the scene dynamics wisely to Use the scene dynamics wisely to

effect patient cooperationeffect patient cooperation Never leave depressed or suicidal Never leave depressed or suicidal

patient alonepatient alone

Management Management (cont.)(cont.)

Assess situationAssess situation Protect self and othersProtect self and others Summon law enforcement if necessarySummon law enforcement if necessary If no evidence of immediate danger, If no evidence of immediate danger,

then one EMT responsible for then one EMT responsible for assessing, treating and assessing, treating and communicating with patientcommunicating with patient

Transport with consent (when Transport with consent (when possible) without sirens possible) without sirens

The SpectrumThe Spectrum

When is it time for patient When is it time for patient restraint?restraint?

RestraintsRestraints

Use only when necessary Use only when necessary Patient is a danger to themselves or othersPatient is a danger to themselves or others

Look for all possible causes for the behaviorLook for all possible causes for the behavior

Restraints must allow for adequate Restraints must allow for adequate

monitoring of vital signsmonitoring of vital signs

Restraints applied by law enforcement must Restraints applied by law enforcement must

allow sufficient “slack”allow sufficient “slack”

RestraintsRestraints

Patient must be able to straighten the Patient must be able to straighten the

abdomen and chest and take full breathsabdomen and chest and take full breaths The officer must accompany the patient in The officer must accompany the patient in

the ambulancethe ambulance Approved equipment for prehospital Approved equipment for prehospital

personnelpersonnel Padded leatherPadded leather Soft restraints (posey, velcro, seatbelts)Soft restraints (posey, velcro, seatbelts)

Unapproved Methods Of Unapproved Methods Of Restraint For Prehospital Restraint For Prehospital

PersonnelPersonnel Hard plastic ties or device that requires a Hard plastic ties or device that requires a

key to removekey to remove Backboard, scoop, or flat used to sandwich Backboard, scoop, or flat used to sandwich

the patientthe patient “ “Hog - tied” (hands and feet behind the Hog - tied” (hands and feet behind the

patient)patient) Methods or material that could cause Methods or material that could cause

neurovascular compromise neurovascular compromise Evaluate and document the condition of the Evaluate and document the condition of the

restrained extremity (neurovascular check) restrained extremity (neurovascular check) every 15 minutes.every 15 minutes.

Documentation of Restraint Documentation of Restraint ApplicationApplication

Reason the restraints were needed      Reason the restraints were needed      Which agency applied the Which agency applied the

restraints        restraints        Information and data regarding the Information and data regarding the

monitoring of circulation to the monitoring of circulation to the restrained extremityrestrained extremity

Information and data regarding the Information and data regarding the monitoring of respiratory status while monitoring of respiratory status while restrainedrestrained

Somatoform disordersSomatoform disorders

Somatization disorderSomatization disorder Pt is preoccupied with physical symptomsPt is preoccupied with physical symptoms

Conversion disorderConversion disorder Loss of function (blindness, paralysis)Loss of function (blindness, paralysis)

HypochondriasisHypochondriasis Exaggerated interpretation of physical Exaggerated interpretation of physical

symptomssymptoms

NeurotransmitterNeurotransmitters and Behaviors and Behavior

Neurotransmitters: NorepiNeurotransmitters: Norepi

Promotes awakening and enhances Promotes awakening and enhances dreamsdreams

Elevates moodElevates mood CNS locations: cortex, medulla, CNS locations: cortex, medulla,

hypothalamus, limbic system, cerebellumhypothalamus, limbic system, cerebellum NorEpi locations outside the CNSNorEpi locations outside the CNS Mania and delusions with overstimulationMania and delusions with overstimulation Depression with low levelsDepression with low levels

Neurotransmitters: Neurotransmitters: DopamineDopamine

Stimulates emotional responses Stimulates emotional responses Controls subconscious skeletal Controls subconscious skeletal

movementmovement CNS locations: cerebral cortex, CNS locations: cerebral cortex,

hypothalamus and limbic systemhypothalamus and limbic system Schizophrenia and schizoid symptoms Schizophrenia and schizoid symptoms

from amphetaminesfrom amphetamines

Neurotransmitters: Neurotransmitters: SerotoninSerotonin

Controls sleep, sensory perception, mood Controls sleep, sensory perception, mood

controlcontrol Thermal regulationThermal regulation CNS locations: hypothalamus, limbic CNS locations: hypothalamus, limbic

system and cerebellumsystem and cerebellum Hallucinations with LSD and Hallucinations with LSD and

overstimulationoverstimulation Depression and anxiety with low levelsDepression and anxiety with low levels

Neurotransmitters: GABANeurotransmitters: GABA

Gamma aminobutyric acidGamma aminobutyric acid

Depresses mood and emotionDepresses mood and emotion

CNS locations: everywhere!CNS locations: everywhere!

Enhanced by benzodiazepinesEnhanced by benzodiazepines

Anxiety from low levels of GABAAnxiety from low levels of GABA

Neurotransmitters and Neurotransmitters and Drug TherapyDrug Therapy

Top prescribed Rx for Top prescribed Rx for 20042004 & & 20072007

#6, #6, 1313 – Zoloft – Zoloft (SSRI)(SSRI)

#9, #9, 9898 – Zyprexa – Zyprexa (Antipsychotic)(Antipsychotic)

#13, #13, 1515 – Effexor XR – Effexor XR (SSRI)(SSRI)

#18, #18, 8585 – Risperdal – Risperdal (Antipsychotic)(Antipsychotic)

#19, #19, 3131 – Seroquel – Seroquel (Antipsychotic)(Antipsychotic)

#23, #23, 1616 – Ambien – Ambien

#47, #47, 1919 – Welbutrin – Welbutrin (SSRI)(SSRI)

#53, #53, 8686 – Ablify – Ablify (Antipsychotic)(Antipsychotic)

#58, #58, 11 – Paxil – Paxil ((SSRI)SSRI)

#69, #69, 3434 – Adderall – Adderall

(Amphetamine)(Amphetamine)

Additional Top Rx - 2003Additional Top Rx - 2003

AlprazolamAlprazolam LorazepamLorazepam ClonazepamClonazepam ProzacProzac AmitryptilineAmitryptiline

TrazadoneTrazadone DiazepamDiazepam TemazepamTemazepam Remeron Remeron (Serotonin (Serotonin

stimulant)stimulant) Concerta Concerta (amphetamine)(amphetamine)

Drug Therapies: Drug Therapies: AntipsychoticsAntipsychotics

Phenothiazines and their derivativesPhenothiazines and their derivatives Mellaril, Navane, risperidone, thorazine, Mellaril, Navane, risperidone, thorazine,

stelazine, Prolixinstelazine, Prolixin Dopamine blockadeDopamine blockade

Will produce a flatter affectWill produce a flatter affect Suppress hallucinations and delusionsSuppress hallucinations and delusions Side effects: hypotension, dystonic Side effects: hypotension, dystonic

reactionsreactions

Drug Therapies: LithiumDrug Therapies: Lithium

Metallic compoundMetallic compound Slows the elevated use of serotonin, Slows the elevated use of serotonin,

norepi and dopamine in the synapsenorepi and dopamine in the synapse Slows sodium transport into the cell and Slows sodium transport into the cell and

reduces nerve transmissionreduces nerve transmission Effective for chronic control of maniaEffective for chronic control of mania

In mania, sodium transport occurs 200% In mania, sodium transport occurs 200% more than normal!more than normal!

Drug Therapies: TCA, MAOIDrug Therapies: TCA, MAOI

Both work to keep norepinephrine in the Both work to keep norepinephrine in the synapse longersynapse longer Elevates activity and mood in depressionElevates activity and mood in depression

Anticholinergic effectsAnticholinergic effects OverdoseOverdose

Initially, massive amounts of norepi released Initially, massive amounts of norepi released Lack of reabsorption drops functional norepi Lack of reabsorption drops functional norepi

levels dramaticallylevels dramatically Systemic effects!Systemic effects!

Drug Therapies: SSRIDrug Therapies: SSRI

Keeps serotonin in the synapseKeeps serotonin in the synapse

Prozac, Paxil, ZoloftProzac, Paxil, Zoloft

Overdose symptoms typically limitedOverdose symptoms typically limited

Serotonin SyndromeSerotonin Syndrome

Medications that work in similar Medications that work in similar areas as SSRIsareas as SSRIs TCAs and MAOIsTCAs and MAOIs Tramadol (narcotic)Tramadol (narcotic) Meprobamate (Sedative-hypnotic)Meprobamate (Sedative-hypnotic) PromethazinePromethazine

Intense potentiation of SSRI effectsIntense potentiation of SSRI effects

Medical Causes Of Medical Causes Of Behavioral CrisesBehavioral Crises

Clues Suggestive Of A Clues Suggestive Of A Potential Medical Cause Of Potential Medical Cause Of

The BehaviorThe Behavior Abnormal vital signsAbnormal vital signs Depressed level of consciousnessDepressed level of consciousness

ObtundedObtunded Evidence of drug or toxin ingestionEvidence of drug or toxin ingestion Very sudden onset of symptomsVery sudden onset of symptoms Focal neurological signsFocal neurological signs No previous psychiatric historyNo previous psychiatric history Presence of specific physical symptoms Presence of specific physical symptoms

A 24 year-old female was seen for

manic-type symptoms. She had

irritability, rapid speech and distracted

conversation. These symptoms had

progressed over a 1-week period.

She had no history of mental illness or

drug intoxication.

Lab tests revealed a markedly high T4

level and she was diagnosed with

thyrotoxicosis.

A 28 year-old female with a history of

bipolar disorder was experiencing

significant withdrawal and

depression. She was apathetic with a

flat affect and did not seem to

interact with things around her. An

hour after admission, she was

lethargic, nonresponsive and

hypotensive.

Lab tests revealed lithium toxicity.

A 20 year-old was talking incoherently, picking at her clothes and staring into space. After she was admitted to the hospital, her level of consciousness rapidly deteriorated, becoming disoriented and less responsive. She had no history of psychiatric disease or drug use. Her only history was that of herpes zoster.

After an EEG and lumbar puncture, she was diagnosed with encephalopathy.

Suicide Suicide

99thth leading cause of death overall leading cause of death overall

33rdrd leading cause of death in 15-24 leading cause of death in 15-24

age groupage group

Women attempt suicide more often, Women attempt suicide more often,

but – men are more often successfulbut – men are more often successful

Assessing Potentially Assessing Potentially Suicidal PatientsSuicidal Patients

Perform appropriate H & EPerform appropriate H & E

Provide appropriate psychological Provide appropriate psychological

carecare

Document observations, especially Document observations, especially

any detailed plansany detailed plans

Risk factors for suicideRisk factors for suicide Previous attemptsPrevious attempts DepressionDepression Age (15-24, & >40)Age (15-24, & >40) Alcohol or drug abuseAlcohol or drug abuse Divorced or widowedDivorced or widowed Giving away personal belongingsGiving away personal belongings Living alone/increased isolationLiving alone/increased isolation Psychosis with depressionPsychosis with depression Major separation traumaMajor separation trauma Major physical stressesMajor physical stresses

Risk factors, Risk factors, cont.cont.

Loss of independenceLoss of independence Lack of goals & plans for futureLack of goals & plans for future Suicide of same-sexed parentSuicide of same-sexed parent Expression of a plan for suicideExpression of a plan for suicide Possession of mechanism for suicide Possession of mechanism for suicide

(gun, rope, pills)(gun, rope, pills)

Age-related conditionsAge-related conditions GeriatricsGeriatrics

You may mistake depression for dementiaYou may mistake depression for dementia Assess their ability to communicateAssess their ability to communicate Provide reassuranceProvide reassurance Compensate for vision, hearing lossCompensate for vision, hearing loss Treat with respectTreat with respect Avoid administering medication if possibleAvoid administering medication if possible Take your timeTake your time Allow family & friends to be with patientAllow family & friends to be with patient

Pediatrics Pediatrics Avoid separating young child from parentAvoid separating young child from parent Make all explanations brief and simple; Make all explanations brief and simple;

repeat oftenrepeat often Be calm, speak slowlyBe calm, speak slowly Identify yourselfIdentify yourself Be truthfulBe truthful Encourage child to help with his careEncourage child to help with his care Don’t discourage child from crying, Don’t discourage child from crying,

showing emotionshowing emotion Allow child to keep favorite blanket or toyAllow child to keep favorite blanket or toy

Peds, cont.Peds, cont. Don’t leave child alone, even for short Don’t leave child alone, even for short

periodperiod If you must be separated from child, If you must be separated from child,

introduce care giver who will take overintroduce care giver who will take over

Management of Sudden Death Management of Sudden Death SituationsSituations

Resuscitate patient unless obviously Resuscitate patient unless obviously deaddead

Keep family informed         Keep family informed         Be truthful         Be truthful         Avoid trite phrases        Avoid trite phrases        Do not offer false hope        Do not offer false hope        Empathize/sympathize          Empathize/sympathize          Allow emotional response   Allow emotional response   Maintain professionalismMaintain professionalism

Management of terminally Management of terminally illill

Do not isolate the familyDo not isolate the family

Allow feelings to be expressedAllow feelings to be expressed

Provide for patients physical comfortProvide for patients physical comfort

Allow for patients dignity in dying Allow for patients dignity in dying

processprocess

Resuscitate according to local protocol Resuscitate according to local protocol

regardless of a living will regardless of a living will

GriefGrief

Many different reactionsMany different reactions Cultural differencesCultural differences

DenialDenial AngerAnger BargainingBargaining DepressionDepression AcceptanceAcceptance

How you doin’?How you doin’?

Helplessness/GuiltHelplessness/Guilt Anger/FrustrationAnger/Frustration AvoidanceAvoidance NightmaresNightmares Gallows humorGallows humor Physiological responsePhysiological response

Can you cope?Can you cope? RestRest ExerciseExercise HumorHumor HobbiesHobbies Have a life outside of EMSHave a life outside of EMS Talk!Talk! Others?Others?