Principles of Patient Assessment in EMS. Focused History & Physical Exam: Behavioral Emergencies.

Principles of Patient Principles of Patient Assessment in EMS Assessment in EMS

Focused History & Physical Focused History & Physical Exam: Behavioral Exam: Behavioral

Emergencies Emergencies

IntroductionIntroduction Every type of illness/injury will come Every type of illness/injury will come

with some type of emotional or with some type of emotional or psychological element.psychological element.

Behavioral emergencies occur when Behavioral emergencies occur when a person with/without a psychiatric a person with/without a psychiatric hx becomes stressed & overwhelmed hx becomes stressed & overwhelmed or feels they are “loosing control.”or feels they are “loosing control.”

Introduction Introduction (continued)(continued) A crisis occurs when a person’s A crisis occurs when a person’s

perception of an acute distressing event perception of an acute distressing event results in an abnormal behavioral results in an abnormal behavioral response. response.

Crisis is an internal response that can Crisis is an internal response that can create reactions such as:create reactions such as: Severe anxietySevere anxiety PanicPanic ParanoiaParanoia Other psychotic eventsOther psychotic events

The EMS Provider’s RoleThe EMS Provider’s Role You must be able to take an active You must be able to take an active

role in controlling the situation role in controlling the situation without being threatening:without being threatening: Upon arrival make a clear, short and calm Upon arrival make a clear, short and calm

statement of who you are and why you are statement of who you are and why you are there.there.

Determine the problem and how many people Determine the problem and how many people are involved.are involved.

Get a description of any unusual activities, risk Get a description of any unusual activities, risk factors, prior episodes.factors, prior episodes.

Remember scene safety! Is this a crime scene?Remember scene safety! Is this a crime scene?

Common Psychiatric Disorder Common Psychiatric Disorder ClassificationsClassifications

MentalMental EmotionalEmotional BehavioralBehavioral Effect an estimated 20% of the U.S. Effect an estimated 20% of the U.S.

population population

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Psychological DisordersPsychological Disorders Features:Features:

Observe the patient’s body language Observe the patient’s body language and verbal responses for cluesand verbal responses for clues

Various disorders have distinctive Various disorders have distinctive characteristicscharacteristics


General Appearance:General Appearance: Neglect in personal hygiene, groomingNeglect in personal hygiene, grooming Inappropriate dressInappropriate dress Excessive attention to details Excessive attention to details

(obsessive-compulsive)(obsessive-compulsive) Unilateral neglect (brain lesion)Unilateral neglect (brain lesion)

Psychological Disorders Psychological Disorders (continued)(continued)



Intellectual Function:Intellectual Function: Assess memory, concentration, Assess memory, concentration,

judgment and orientationjudgment and orientation Psychiatric disorders may affect short, Psychiatric disorders may affect short,

long and recall memorylong and recall memory Assessment is done in the patient Assessment is done in the patient

interviewinterview


Thought Content:Thought Content: Thought content and perceptions should Thought content and perceptions should

be logical, consistent and connected be logical, consistent and connected with the current situationwith the current situation

Delusions – a false personal belief or Delusions – a false personal belief or idea is portrayed as trueidea is portrayed as true

Hallucination – a perception of Hallucination – a perception of something that is not presentsomething that is not present




Physical Complaints:Physical Complaints: Often vague – headache, muscle ache, Often vague – headache, muscle ache,

weight loss, lack of energyweight loss, lack of energy Consider medical causes firstConsider medical causes first

Motor Activity:Motor Activity: Tense, restlessness, pacing, crying, Tense, restlessness, pacing, crying,

fidgeting or slow movingfidgeting or slow moving Consider drug intoxication, pain, Consider drug intoxication, pain,

abnormal blood sugar or hypoxia firstabnormal blood sugar or hypoxia first



Speech & Language:Speech & Language: Consider word choice, quality, pace and Consider word choice, quality, pace and

articulation of speech and languagearticulation of speech and language Consider other causes for alterations such Consider other causes for alterations such

as stroke, tumors or trauma.as stroke, tumors or trauma. Body Language:Body Language:

Body language is the expression of Body language is the expression of thoughts or emotions by means of posture thoughts or emotions by means of posture or gesturesor gestures

Stay alert to non-verbal cues for potential Stay alert to non-verbal cues for potential violenceviolence



Mood:Mood: Assess mood and affect through facial Assess mood and affect through facial

expressions, body language and expressions, body language and responses to questionsresponses to questions

Should be appropriate for the current Should be appropriate for the current situation and transitions according with situation and transitions according with topics in conversationtopics in conversation


AssessmentAssessment Scene Safety:Scene Safety:

A major misconception “all mental A major misconception “all mental patients are unstable and dangerous”patients are unstable and dangerous”

Many behavioral emergencies begin as Many behavioral emergencies begin as medical calls. ALWAYS assess scene medical calls. ALWAYS assess scene safety in every call.safety in every call.

Respect a patient’s personal space.Respect a patient’s personal space. Limit the number of people and avoid Limit the number of people and avoid

overwhelming the patient.overwhelming the patient.


Assessment Assessment (continued)(continued) Focused History:Focused History:

Obtaining a history may be difficult, Obtaining a history may be difficult, these patients are often unreliable, poor these patients are often unreliable, poor historians or uncooperativehistorians or uncooperative

Family or caretakers may not be Family or caretakers may not be available or may distort the informationavailable or may distort the information

Assess predisposing risk factors such as Assess predisposing risk factors such as depression or major life eventdepression or major life event


Assessment Assessment (continued)(continued) O – Where, when and how did the event O – Where, when and how did the event

begin?begin? P – What is the problem today? Did the P – What is the problem today? Did the

patient intend on harming him/herself?patient intend on harming him/herself? Q – What type of crisis is the patient Q – What type of crisis is the patient

experiencing?experiencing? R – Are there any concomitant medical R – Are there any concomitant medical

factors?factors? S – Is this event similar to previous S – Is this event similar to previous

episodes?episodes? T – How long has this been going on?T – How long has this been going on?© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Assessment Assessment (continued)(continued) S – What type of crisis is the patient S – What type of crisis is the patient

having? Any associated symptoms?having? Any associated symptoms? A – Are there any allergies to meds?A – Are there any allergies to meds? M – What meds and any recent M – What meds and any recent

changes to medication schedule?changes to medication schedule? P – What is the patient’s behavioral P – What is the patient’s behavioral

history? Any substance abuse?history? Any substance abuse? L – meds, meals, alcohol?L – meds, meals, alcohol? E – new stress, changes in social E – new stress, changes in social

status?status?© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Mental Status ExamMental Status Exam

Obtain baseline assessment and Obtain baseline assessment and verify finding with family/caretaker, verify finding with family/caretaker, MDMD

Appearance – note physical position Appearance – note physical position and posture, personal hygiene, and posture, personal hygiene, appropriate dress, age and genderappropriate dress, age and gender

Affect – what feelings is the patient Affect – what feelings is the patient exhibitingexhibiting


Mental Status Exam Mental Status Exam (continued)(continued)

Behavior – what is the patient doing?Behavior – what is the patient doing? Cognitive function – assess level of Cognitive function – assess level of

consciousness, memory, mood and consciousness, memory, mood and affect.affect.

Speech – assess word choice, Speech – assess word choice, content, intonation, clarity and pace.content, intonation, clarity and pace.

Thought process – assess if judgment Thought process – assess if judgment is reasonable for the current is reasonable for the current situation.situation.


Behavioral EmergenciesBehavioral Emergencies

Depression is a common reaction to Depression is a common reaction to major life stress:major life stress: Feelings of sadness, discouragement, and Feelings of sadness, discouragement, and

hopelessnesshopelessness Reduced activity levels, inability to Reduced activity levels, inability to

function, and sleep disturbancesfunction, and sleep disturbances Severe depression is a risk factor for Severe depression is a risk factor for

suicidesuicide May present as symptoms of disease May present as symptoms of disease

(organic illness, cardiac or respiratory (organic illness, cardiac or respiratory conditions)conditions)© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Mental IllnessMental Illness

There are many pathologies for There are many pathologies for behavioral and psychiatric disorders:behavioral and psychiatric disorders: GeneticGenetic Chemical imbalanceChemical imbalance Organic illnessOrganic illness


Substance AbuseSubstance Abuse

Dependence, abuse and intoxication.Dependence, abuse and intoxication. True addiction is both psychological True addiction is both psychological

and physical.and physical. Alcoholism is particularly insidious Alcoholism is particularly insidious

among the elderly.among the elderly.


Suicide AttemptsSuicide Attempts Occur when a patient has a true desire Occur when a patient has a true desire

to die.to die. Gestures are pleas for help.Gestures are pleas for help. Whether “attempt” or “gesture” do not Whether “attempt” or “gesture” do not

discount the patient’s emotional state discount the patient’s emotional state in any way.in any way.

Be direct and ask:Be direct and ask: ““Where you trying to kill yourself?”Where you trying to kill yourself?” ““Do you want to die?”Do you want to die?”

Clearly report and document your Clearly report and document your findings.findings.


Attention/Pleas for HelpAttention/Pleas for Help Some behavior calls are related to a Some behavior calls are related to a

patient’s cry for attention:patient’s cry for attention: Suicide gestureSuicide gesture HypochondriacHypochondriac Lonely person calling repeatedly for no Lonely person calling repeatedly for no

apparent medical reasonapparent medical reason Safest approach is to assume something Safest approach is to assume something

is seriously wrong until proven is seriously wrong until proven otherwise.otherwise.

Often people who want help are unaware Often people who want help are unaware of available resources and they call 9-1-of available resources and they call 9-1-1. 1.


Assisting a TransportationAssisting a Transportation Mental health evaluation order.Mental health evaluation order.

The police should have an order and be The police should have an order and be on the sceneon the scene

Inmates feigning illness.Inmates feigning illness. Complete a thorough assessmentComplete a thorough assessment


Patients who are a danger to Patients who are a danger to themselves or another.themselves or another. Major concern is safety for EMS providers Major concern is safety for EMS providers

and the patientand the patient Do not use excessive force and be aware of Do not use excessive force and be aware of

the dangers of restraintthe dangers of restraint Never restrain a patient in a prone position!Never restrain a patient in a prone position! Review the NAEMSP policy on patient Review the NAEMSP policy on patient

restraintrestraint

Assisting a TransportationAssisting a Transportation


Medical Conditions that Mimic Medical Conditions that Mimic Behavioral DisordersBehavioral Disorders

Stroke, tumors, or trauma can affect Stroke, tumors, or trauma can affect speech.speech.

Medications, severe infections, Medications, severe infections, hypoxia, hypo or hyperglycemia can hypoxia, hypo or hyperglycemia can cause altered mental status, cause altered mental status, depression or psychosis.depression or psychosis.

Psychotropic meds can have Psychotropic meds can have powerful side effects and severe powerful side effects and severe interactions with other medications. interactions with other medications.


Stress and the EMS ProviderStress and the EMS Provider

Emergency responders are routinely Emergency responders are routinely subjected to both positive and subjected to both positive and negative stress.negative stress.

Stress disorders may be acute or Stress disorders may be acute or develop into chronic conditions if not develop into chronic conditions if not recognized and managed.recognized and managed.

Be watchful and recognize Be watchful and recognize signs/symptoms of stress in yourself signs/symptoms of stress in yourself and coworkers.and coworkers.


Stress and EMS Providers Stress and EMS Providers (continued)(continued)

Signs and symptoms of ineffective or Signs and symptoms of ineffective or failing coping mechanisms include:failing coping mechanisms include: Increased absenteeismIncreased absenteeism WithdrawalWithdrawal DepressionDepression HyperactivityHyperactivity IrritabilityIrritability Increased smoking or alcohol useIncreased smoking or alcohol use Sleep disturbancesSleep disturbances HeadachesHeadaches Poor concentration and decision makingPoor concentration and decision making


ConclusionConclusion

Response to crisis varies by person.Response to crisis varies by person. Inability to cope or failing Inability to cope or failing

mechanisms can cause impaired mechanisms can cause impaired functionality.functionality.

Some become withdrawn/depressed, Some become withdrawn/depressed, others overactive/violent. others overactive/violent.


Conclusion Conclusion (continued)(continued)

Many factors can alter a patient’s Many factors can alter a patient’s behavior (regardless of any mental behavior (regardless of any mental health history).health history).

Personal safety comes first! Take an Personal safety comes first! Take an active role in controlling the situation active role in controlling the situation and supporting the patient’s and supporting the patient’s emotional and physical needs.emotional and physical needs.

Whenever possible obtain a complete Whenever possible obtain a complete history! history!

Principles of Patient Assessment in EMS. Focused History & Physical Exam: Behavioral Emergencies.

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Transcript of Principles of Patient Assessment in EMS. Focused History & Physical Exam: Behavioral Emergencies.