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Behavioral EmergenciesBehavioral EmergenciesChapter 23Chapter 23


Case HistoryCase History

You arrive at the scene of a disturbance. You You arrive at the scene of a disturbance. You find a 30-year-old male throwing articles out find a 30-year-old male throwing articles out the window of the house. He is screaming that the window of the house. He is screaming that everyone is out to get him and he tells you that everyone is out to get him and he tells you that he will not let anyone touch him.he will not let anyone touch him.


Behavioral EmergencyBehavioral Emergency

Definition:Definition: An occurrence in which the patient exhibits An occurrence in which the patient exhibits

abnormal behavior within a given situation abnormal behavior within a given situation that is unacceptable or intolerable to the that is unacceptable or intolerable to the patient, family, or communitypatient, family, or community


Scope of the ProblemScope of the Problem Depression is often underemphasized in EMS.Depression is often underemphasized in EMS.

Depression is present in at least 11% of population in Depression is present in at least 11% of population in U.S.U.S.

20% of adults experience at least one episode of 20% of adults experience at least one episode of clinical depression.clinical depression.


Depression and SuicideDepression and Suicide Symptoms of depressionSymptoms of depression

Loss of sleep, appetite, sex driveLoss of sleep, appetite, sex drive Sad, tearfulSad, tearful Guilt Guilt HopelessnessHopelessness Thoughts of death or taking one’s lifeThoughts of death or taking one’s life Physical symptomsPhysical symptoms


Suicide – Suicide – Scope of the ProblemScope of the Problem

28,000 suicides each year28,000 suicides each year

Men >65 y/o have three times higher suicide rate.Men >65 y/o have three times higher suicide rate.

Young person attempts suicide every 90 seconds.Young person attempts suicide every 90 seconds.

Successful suicide every 90 minutesSuccessful suicide every 90 minutes


Suicide –Suicide –Assessment of Risk FactorsAssessment of Risk Factors

MaleMale Individuals over 40Individuals over 40 Single, widowed, or divorcedSingle, widowed, or divorced Socially isolatedSocially isolated Alcoholic, drug abuseAlcoholic, drug abuse Recent diagnosis of serious illnessRecent diagnosis of serious illness Recent loss of significant loved oneRecent loss of significant loved one


Suicide – Suicide – Assessment of Risk FactorsAssessment of Risk Factors

Previous history of self-destructive behaviorPrevious history of self-destructive behavior

Arrest, imprisonment, loss of jobArrest, imprisonment, loss of job

Lethal plan of action that has been verbalizedLethal plan of action that has been verbalized

Gathering of articles that can cause death Gathering of articles that can cause death GunGun Large volumes of pillsLarge volumes of pills


Suicide – Suicide – Assessment FindingsAssessment Findings

Patient in an unsafe environment?Patient in an unsafe environment?

With unsafe objects in hands?With unsafe objects in hands?

Displaying self-destructive behavior?Displaying self-destructive behavior?


Suicide – Important QuestionsSuicide – Important Questions How does the patient feel?How does the patient feel?

Suicidal tendencies in the past?Suicidal tendencies in the past? If so, what interventions have occurred?If so, what interventions have occurred?

Is patient a threat to self or others?Is patient a threat to self or others?

Is there a medical problem?Is there a medical problem?


Emergency Medical CareEmergency Medical Care

Perform scene size-up.Perform scene size-up.

Personal safety is a priority.Personal safety is a priority.

Conduct patient assessment.Conduct patient assessment.

Calm the patient.Calm the patient.

Do not leave patient alone.Do not leave patient alone.


Emergency Medical CareEmergency Medical Care

Restrain, if necessary.Restrain, if necessary.

Consider need for law Consider need for law enforcement.enforcement.

Transport.Transport.

If overdose, bring If overdose, bring medications or drugs.medications or drugs.


Behavioral Change Behavioral Change General factors that may alter a patient's behaviorGeneral factors that may alter a patient's behavior

Situational stressesSituational stresses Medical illnessesMedical illnesses Psychiatric problemsPsychiatric problems Alcohol or drugsAlcohol or drugs


Common FactorsCommon Factors

Low blood sugarLow blood sugar

Lack of oxygenLack of oxygen

Inadequate blood Inadequate blood flow to the brainflow to the brain

Head traumaHead trauma


Common FactorsCommon Factors Mind-altering substancesMind-altering substances

Psychogenic – resulting in psychotic thinking, Psychogenic – resulting in psychotic thinking, depression, or panicdepression, or panic

Excessive coldExcessive cold

Excessive heatExcessive heat


Situational ReactionsSituational Reactions PanicPanic AgitationAgitation AngerAnger AnxietyAnxiety ParanoiaParanoia Denial Denial WithdrawalWithdrawal


Personality DisordersPersonality Disorders Definition: Character traits that interfere with a Definition: Character traits that interfere with a

person’s ability to function successfully in work or person’s ability to function successfully in work or personal relationshipspersonal relationships

Patient can be manipulative and self-focused.Patient can be manipulative and self-focused.

Avoid getting angry with the patient.Avoid getting angry with the patient.

Be positive but establish limits.Be positive but establish limits.


PsychosisPsychosis Disordered thoughtsDisordered thoughts Disordered perceptions of realityDisordered perceptions of reality HallucinationsHallucinations Inappropriate responses to environmentInappropriate responses to environment Possible communication difficultyPossible communication difficulty

Speaks incoherentlySpeaks incoherently Out of controlOut of control May need to obtain history from othersMay need to obtain history from others


Organic Brain SyndromeOrganic Brain Syndrome Medically caused brain syndromeMedically caused brain syndrome Disordered thoughtsDisordered thoughts DisorientationDisorientation DeliriumDelirium HallucinationsHallucinations Numerous causesNumerous causes

TumorTumor TraumaTrauma InfectionInfection


Scene Size-upScene Size-up Most important aspect of assessmentMost important aspect of assessment

Can present a serious threat to EMT safetyCan present a serious threat to EMT safety

Try to identify potential causes of presenting problem.Try to identify potential causes of presenting problem. Aggressive or bizarre behaviorAggressive or bizarre behavior Open bottles of medications, syringes, track marksOpen bottles of medications, syringes, track marks


Scene SafetyScene Safety Be aware of potential dangersBe aware of potential dangers

If notified of a violent patient, wait for police before If notified of a violent patient, wait for police before entering scene.entering scene.

First priority is prevention of further injuries.First priority is prevention of further injuries.

Environmental dangers may exist.Environmental dangers may exist. Gas exhaustGas exhaust Carbon monoxideCarbon monoxide


Violent BehaviorViolent Behavior Recognizing impending violence is vital.Recognizing impending violence is vital.

Do notDo not put yourself in jeopardy. put yourself in jeopardy. Assess what can be done to avoid outburst.Assess what can be done to avoid outburst. Leave yourself an escape route.Leave yourself an escape route.


Signs of a Signs of a Potentially Violent PatientPotentially Violent Patient

Angry voiceAngry voice Pressured speechPressured speech PacingPacing Expressions of violenceExpressions of violence Psychiatric history of emotional disturbancePsychiatric history of emotional disturbance Drug intoxicationDrug intoxication Situational frustrationSituational frustration Threatening posture or movementsThreatening posture or movements Presence of heavy or threatening objectsPresence of heavy or threatening objects


Principles for Assessing Principles for Assessing Behavioral EmergencyBehavioral Emergency

Identify yourself.Identify yourself. Let the person know you are there to help.Let the person know you are there to help. Inform the patient of what you are doing.Inform the patient of what you are doing. Ask questions in a calm, reassuring voice .Ask questions in a calm, reassuring voice . Allow the patient to tell what happened.Allow the patient to tell what happened. Do not be judgmental.Do not be judgmental.


Principles of Assessing Principles of Assessing Behavioral EmergencyBehavioral Emergency

Rephrase or repeat to confirm communication. Rephrase or repeat to confirm communication.

Acknowledge the patient’s feelings.Acknowledge the patient’s feelings.

Assess the patient's mental status. Assess the patient's mental status. AppearanceAppearance ActivityActivity SpeechSpeech Orientation for time, person, and placeOrientation for time, person, and place


Assessment of Assessment of Potential Violence Potential Violence

Scene size-upScene size-up HistoryHistory

Check with family and bystanders.Check with family and bystanders. Known history of aggression or combativeness? Known history of aggression or combativeness?

PosturePosture Stands or sits in a position which threatens self or othersStands or sits in a position which threatens self or others Fists clinched or lethal objects in hands Fists clinched or lethal objects in hands


Assessment of Assessment of Potential Violence Potential Violence

Vocal activityVocal activity Yells or verbally threatens harm to self or others Yells or verbally threatens harm to self or others

Physical activityPhysical activity Moves toward caregiverMoves toward caregiver Carries heavy or threatening objectsCarries heavy or threatening objects Has quick, irregular movementsHas quick, irregular movements Tenses musclesTenses muscles


Methods to Calm Behavioral Methods to Calm Behavioral Emergency PatientsEmergency Patients

Acknowledge that the person seems upset.Acknowledge that the person seems upset.

Restate that you are there to help.Restate that you are there to help.

Inform the patient of what you are doing.Inform the patient of what you are doing.

Ask questions in a calm, reassuring voice. Ask questions in a calm, reassuring voice.

Maintain a comfortable distance.Maintain a comfortable distance.

Encourage the patient to state what is troubling him.Encourage the patient to state what is troubling him.



Do not make quick moves.Do not make quick moves.

Respond honestly to patient's questions.Respond honestly to patient's questions.

Do not threaten, challenge, or argue.Do not threaten, challenge, or argue.

Tell the truth.Tell the truth.

Do not “play along” with visual or auditory disturbances.Do not “play along” with visual or auditory disturbances.



Involve trusted family members or friends. Involve trusted family members or friends.

Be prepared to stay at scene for a long time.Be prepared to stay at scene for a long time.

Always remain with the patient.Always remain with the patient.

Avoid unnecessary physical contact.Avoid unnecessary physical contact.

Call additional help, if needed. Call additional help, if needed.

Maintain good eye contact.Maintain good eye contact.


Medicolegal Considerations Medicolegal Considerations Management of emotionally or mentally disturbed patient presents Management of emotionally or mentally disturbed patient presents

high legal risk.high legal risk.

When emotionally disturbed patients consent to care, legal problems When emotionally disturbed patients consent to care, legal problems are greatly reduced.are greatly reduced.

Patient will often resist treatment.Patient will often resist treatment.

Patient may threaten EMT-Basics and others.Patient may threaten EMT-Basics and others.

To provide care against patient's will, you must show a reasonable To provide care against patient's will, you must show a reasonable belief patient would harm self or others.belief patient would harm self or others.


If Patient Resists TreatmentIf Patient Resists Treatment

If a threat to self or others, may If a threat to self or others, may be transported without consent.be transported without consent. Contact medical direction.Contact medical direction.

Law enforcement is usually Law enforcement is usually required.required.


Reasonable Force Reasonable Force

Definition:Definition: Action necessary to keep Action necessary to keep

patient from injuring self patient from injuring self or othersor others


Determining Determining Reasonable ForceReasonable Force

Patient’s size and strengthPatient’s size and strength

Type of abnormal behaviorType of abnormal behavior

Sex of patientSex of patient

Mental state of patientMental state of patient

Method of restraintMethod of restraint


Using ForceUsing Force Calm patients may cause unexpected and sudden Calm patients may cause unexpected and sudden

injury to self and others.injury to self and others.

EMS personnel may use reasonable force to defend EMS personnel may use reasonable force to defend against an attack.against an attack.

Avoid acts or physical force that may cause injury to Avoid acts or physical force that may cause injury to the patient.the patient.


Police and Medical DirectionPolice and Medical Direction

Seek medical direction when Seek medical direction when considering restraining a considering restraining a patient.patient.

Ask for police assistance, if Ask for police assistance, if during scene size-up the during scene size-up the patient appears or acts patient appears or acts aggressive or combative.aggressive or combative.


AccusationsAccusations Protection against false accusationsProtection against false accusations

Documentation of abnormal behavior importantDocumentation of abnormal behavior important Witnesses in attendance, especially during transportWitnesses in attendance, especially during transport

Accusations of sexual misconduct are common.Accusations of sexual misconduct are common. Same-sex attendants and third-party witnesses Same-sex attendants and third-party witnesses

can prove beneficial.can prove beneficial.


Restraining PatientsRestraining Patients Avoid restraints, if possible.Avoid restraints, if possible.

Use only when patient is a danger to self or others.Use only when patient is a danger to self or others.

Have police present.Have police present.

Get approval from medical direction.Get approval from medical direction.


Restraining PatientsRestraining Patients

Be sure to have adequate help.Be sure to have adequate help.

Plan your activities.Plan your activities.

Use only the force necessary for restraint.Use only the force necessary for restraint.

Estimate range of motion of patient’s arms and legs.Estimate range of motion of patient’s arms and legs.


Restraint TechniqueRestraint Technique

Act quickly.Act quickly.

Have one EMT-Basic talk to Have one EMT-Basic talk to patient.patient.

Approach with four persons.Approach with four persons. One assigned to each limb, all One assigned to each limb, all

at the same time at the same time


Restraint TechniqueRestraint Technique Secure limbs together Secure limbs together

with equipment with equipment approved by medical approved by medical direction. direction.

Turn patient face up on Turn patient face up on stretcherstretcher..


Restraint TechniqueRestraint Technique Secure patient to Secure patient to

stretcher with multiple stretcher with multiple straps.straps.

Cover patient’s face Cover patient’s face with surgical mask if with surgical mask if spitting. spitting.


Restraining TechniqueRestraining Technique Reassess circulation Reassess circulation

frequently.frequently.

Document indication for Document indication for restraining patient and restraining patient and technique of restraint. technique of restraint.

Avoid unnecessary force. Avoid unnecessary force.


Other Behavioral Problems –Other Behavioral Problems –General PrinciplesGeneral Principles

Always try to talk patient into cooperating. Always try to talk patient into cooperating.

Do not belittle or threaten patients.Do not belittle or threaten patients.

Be calm and tolerant in your attitude.Be calm and tolerant in your attitude.

Do not agree with disturbed thinking.Do not agree with disturbed thinking.

Be reassuring.Be reassuring.


Other Behavioral Problems –Other Behavioral Problems –General PrinciplesGeneral Principles

Avoid arguing with irrational patients.Avoid arguing with irrational patients.

Suggest appropriate steps to take. Suggest appropriate steps to take.

Lower distressing stimuli.Lower distressing stimuli.

Avoid restraints unless necessary. Avoid restraints unless necessary.

Treat with respect.Treat with respect.