An EMS Approach to Psychiatric Emergencies

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An EMS Approach to Psychiatric Emergencies

By Thomas J. Doyle, MD, & Robert J. Vissers, MD, FACEP, FRCPC

Psychiatric patients often present a challenge to the EMS provider. They are usually considered difficult patients and can elicit negative reactions from their care providers. These patients may display disruptive behavior, suffer from chronic conditions, and their disposition can be difficult and time-consuming.

General approaches to the psychiatric patient by EMS should incorporate the following goals:

Begin to develop a rapport with the patient. Assess your own safety and that of your patient, and try to establish a therapeutic alliance.
Make a medical evaluation of the patient, including vital signs, and attempt to ascertain medical problems as well as psychiatric ones.
Complete a psychiatric assessment to evaluate the patient's mental status, the risk to himself or others, and any collateral information.
Disposition: Does this patient need to be transported? What if he doesn't want to?

With these goals in mind, read the following case scenario, focusing on the areas of patient competency and dealing with the unpredictable and/or violent patient.

Case Study

You respond on a 9-1-1 call to the home of a 56-year-old woman. The call came in from a friend who hasn't been able to contact the patient and is concerned. He had received a call from her several hours ago complaining that she couldn't sleep. The patient had apparently been drinking today and told the friend she felt tired and hopeless. He reports that she has been drinking a lot more than usual and has been increasingly withdrawn and tearful. The friend has not spoken with her in three weeks until today's call, since she stopped coming to an evening class they both attend. He is concerned that she may hurt herself if left alone. The friend states she is " seeing a therapist" and takes " something for her nerves."

You arrive with the police and find the door to her house unlocked. After banging several times on the door and identifying yourself as police and EMS, you go inside. You find an older woman lying on the couch in her living room. On examination, she appears intoxicated. Her speech is slurred, and vitals are: pulse 134, BP 150/100, RR 20. The physical exam is otherwise unremarkable and the neurological exam is non-focal, but the patient seems unusually restless. Her attention is poor, and she is only oriented to person.

When you attempt to obtain additional information and a medical history, the patient becomes uncooperative. She raises one trembling arm, points it in the general direction of the door and says, "Leave me alone and get the hell out!" Your partner, after a quick scouting expedition, returns with several bottles of pills, some half full, some empty. After examination, you determine that the patient is taking fluoxetine (a serotonin reuptake inhibitor), some Xanax (a benzodiazepine) and a tricyclic antidepressant. Your partner asks the patient if she took all of these pills today and is met with a stream of profanity.

The police officer, who has been standing in the doorway, shakes his head and says, "Let's get out of here. There's no way in hell she's gonna want to go with you guys. Just let her sleep it off and her friend can check on her in the morning." Since you are the senior medic, your partner looks at you and says, "What do you want to do?"

You decide that this patient needs to be transported to the hospital. You attempt to establish a rapport with her by explaining that you are concerned for her safety, and you think she should come to the hospital. She responds, "Why should you care! Nobody cares!" and rolls over. You gently touch her shoulder, and she lashes out with her arm, pushes you away and yells, "I @#$%^&* told you to leave me alone! If you touch me again, I'll kick your ass!" You decide to contact medical control.

The online physician agrees with your assessment and says the patient needs to come to the hospital, in restraints if necessary. He wants you to notify law enforcement as well, and you tell him they are already on scene.

Since you have sufficient law-enforcement backup, you approach the patient once more to explain that you will be transporting her to a hospital for evaluation and give her another opportunity to agree. She responds by throwing a vodka bottle at you and screaming, "Don't come near me!" Using a team approach and following your protocols, you restrain the patient and secure her to the stretcher. As you wheel her outside, you notice that a crowd of neighbors has gathered. The patient struggles against the restraints and shouts loudly with slurred speech, "You can't do this to me! I have rights! I'm gonna sue!" Your partner looks at you and asks, "Are we going to get into trouble?"

Discussion

You have responded to a 9-1-1 call because a friend was concerned about this patient. The woman apparently has a history of depression, for which she has been in treatment, and she is taking several different psychiatric medications, but you have no idea how much she has taken today because she won't cooperate. She also has been drinking. According to your own mental status exam, the patient is alert and oriented times one. There are two questions to ask:

What is the potential emergency here?
Can the patient refuse treatment at this time?

The potential emergency is that this is a suicide attempt. This patient is on multiple medications, and it is unclear how much she has taken. In particular, an overdose of tricylics can result in life-threatening arrhythmias. Furthermore, the patient has been consuming alcohol in addition to these medications. This patient is a threat to herself until proven otherwise. She needs evaluation in an emergency department to rule out an overdose and a psychiatric evaluation to rule out suicidal ideation.

This patient is not competent to refuse care at this time. She is only alert and oriented times one on mental status exam, she is intoxicated, and she has taken a potentially life-threatening overdose.

Competency

In order for patients to refuse care or transport, they must demonstrate that they are capable of making an informed decision about the risks involved in refusing care. Patients should also be alert and oriented to person, place and time, respond appropriately to questions and not be a threat to themselves or others. Thus, the patient in this case does not meet any criteria as indicated above.

Suicide

Epidemiology
Suicide is the eighth leading cause of death in the United States and second in persons under age 24. There are approximately 30,000 suicides a year--about 1.2 per 10,000 Americans. The ratio of attempted to completed suicides is 40:1. Two percent of Americans have thought about it, and 1% have attempted suicide.

Risk factors and predictors
Factors suggestive of high risk include:

· Demographics. The high-risk patient is often male, younger than 45 years of age, unmarried and unemployed.

· Medical. The patient often has a chronic illness and/or suffers from alcoholism or drug abuse.

· Psychiatric. The patient may present with severe depression, panic disorder, psychosis, hopelessness, self blame.

· Suicide attempt. The attempt often occurs after frequent and prolonged suicidal thoughts. A patient who has a history of multiple attempts and has a concrete plan is at very high risk.

· Patient resources. The suicidal patient often suffers from isolation, poor insight (self-awareness) and has an unconcerned family. (See Table I for the SAD PERSONS Scale.1)

Table I: Modified
SAD PERSONS Scale1

<TBODY>S / Sex - male
A / Age - <19 or >45
1
D / Depression/hopelessness
2
P / Past attempts or psych care
1
E / Excessive alcohol/drug use
1
R / Rational thinking loss/psychosis
12
S / Separated/widowed/divorced
1
O / Organized or serious attempt
2
N / No social supports
1
S / Stated future intent
2</TBODY>

A score of 6 or greater requires psychiatric evaluation and probable hospitalization.

Two large, prospective studies followed 4,880 and 1,906 patients for several years. Both concluded that suicide is not currently predictable at the individual level. The difference in the male to female ratio (3:1) may be mainly attributed to alcohol or drug abuse and gun ownership, not gender.

Patient Restraint

For EMS purposes, physical restraints are commonly used. Restraints should be considered when the patient is a danger to self or others by virtue of a medical or psychiatric condition. Their purpose is to prevent harm and allow for examination of the violent patient.

Principles of patient restraint

Restraints should be individualized and afford as much dignity as possible.
Restraints should be humanely and professionally administered.
Protocols to ensure patient safety should be developed and followed.
Personnel should carefully document reasons for and means of restraint and perform periodic assessment.
Restraints should be as least restrictive as is necessary.
Restraints should conform to applicable laws, rules, regulations and accreditation standards.

Guidelines for use of restraints

· At least 4-5 people should be involved in applying restraints--don't try it alone!

· Use any available personnel, and call for backup or law enforcement if necessary. Leather restraints are the safest and surest.

· Explain to the patient why you're using restraints, but do not negotiate. Allow the patient an opportunity to cooperate.

· Emphasize the therapeutic reasons for the restraints; they are not to be used punitively or as a threat.

· Start with a four-point restraint, one arm above and one below. Never leave only one limb in restraint.

· Undress the patient and remove all personal objects.

· Clearly document indications and perform frequent patient rechecks.

· EMS providers should contact medical control before initiating restraints.

Chemical restraints
Chemical restraints are the preferred method of restraint by physicians, since they are considered least restrictive and potentially therapeutic. However, they may be considered a greater infringement of rights than physical restraints because of alterations in a person's thoughts, expressions and motor activity, and the potential for long-term effects. They serve a dual purpose of control and therapeutic intervention.

Medications: Rapid tranquilization
The most commonly used medications are neuroleptic agents, benzodiazepines or a combination of both. The drugs are given every 30 minutes until the desired effect is reached. The drugs most often used are Haldol (haloperidol) or droperidol 5 mg IV or IM. Droperidol is more rapid in onset and has a shorter half-life. Anyone using medication for chemical restraint must be aware of the potential side-effects, particularly dystonic reactions. Rarely, neuroleptic malignant syndrome can develop. Personnel may wish to consider adding Benadryl to prevent dystonic reactions. Obviously, the use of chemical restraints will depend on individual EMS protocols and input from medical control.

Legal Considerations

Involuntary commitment
Involuntary commitment is still the subject of legal and ethical debate, because it deprives patients of their constitutional right to liberty. Physical restraint under other conditions would constitute assault and battery, false imprisonment and an infringement of constitutional rights. All 50 states, however, have statutes requiring physicians to involuntarily detain a patient who is determined to be dangerous to self or others.

A 1982 Supreme Court decision stated that "restraints are justified to protect others or self in the judgment of the health professional." However, the healthcare provider must ensure that restraint is not negligently performed. There have been several in-patient deaths or suicides when patients were restrained in an unsafe manner or left unsupervised.

The legal conundrum
The legal conundrum is the conflict between protection of personal freedoms and societal need to protect from harm. There have been several malpractice cases where a patient left or escaped the ED and died by suicide or impaired judgment. Although the conflict was recognized by the courts, if there was evidence of possible mental incompetence and threat to self or others, the cases often went against the physician. There have also been suits against physicians for violation of personal freedoms, although less frequently. There are far more cases for negligent disposition of a harmful patient (i.e. not treating) than false imprisonment or assault and battery. In general, the cases were judged on the reasonableness of the physician's actions and upheld the need for involuntary commitment.

Summary

Psychiatric patients present challenges not only to EMS, but in the emergency department as well. As we have tried to indicate in the case report, the presentation is not always clear-cut. There may not be a definite solution, and each case can be different.

As an EMT or paramedic, how should you approach these issues? First, always make sure the scene is safe for you and your team. If you have doubts, contact law enforcement. With regard to patient care, err on the side of safety and what is in the best interest of the patient (which may include restraints). Follow established procedures and guidelines, and always document well. If you have any questions on scene, always contact medical control, and document doing so. If there is a question, let the physician decide on competency issues.

Adapted from a presentation to the 1998 ACEP Scientific Assembly by Robert J. Vissers, MD, FACEP, FRCPC, Oct 15, 1998.

References

1. Hockberger RS, Rothstein RJ. Assessment of suicidal intention by nonpsychiatrists using the SAD PERSONS score. J Emerg Med 99:6, 1988.

2. Use of patient restraint. ACEP policy statement, approved January, 1996.

Bibliography

Gardner W, Lidz CW, Mulvey EP, Shaw EC. Clinical versus actuarial predictions of violence in patients with mental illnesses. J Cons Clin Psychiatry 64:602-609, 1996.

Goldstein RB, Black DW, Nasrallah MA, et al. The prediction of suicide. Arch Gen Psychiatry 48:418-422, 1991.

Gutheil TG. Suicide and suit: Liability after self destruction. In: Jacobs D, ed. Suicide and Clinical Practice. Washington, DC: American Psychiatric Press; 1992.

Hughes DH. Can the clinician predict suicide? Psychiatric Services 46:449-451, 1995.

Hoffman DB, Dubovsky SL. Depression and suicide assessment. Emerg Med Clin North Am 9:107-121, 1991.