Behavioral and Psychiatric Emergencies and Suicide

What is a behavioral emergency?

A behavioral emergency is abnormal behavior, within a given situation, that is unacceptable or intolerable to the patient, the family or the community, and it is often potentially harmful to the patient or to others. The word "abnormal" has to be read in context, because what counts as normal depends on the situation. Cultural background matters as well: a behavior that seems unusual to you may be entirely normal within the patient's culture.

Physical causes that mimic psychiatric emergencies — always rule out first

Before you conclude that a patient's behavior has a psychiatric cause, you must rule out the physical conditions that can produce the same picture. The table below lists the most important physical mimics and the signs that point to each.

Table 27.1Physical causes that mimic psychiatric emergencies — always rule out first

Ruling out a medical cause does not mean choosing between two possibilities. Medical and psychiatric conditions can coexist, and a real medical problem can also worsen the symptoms of a chronic psychiatric illness.

Acute psychosis

Acute psychosis is a severe break in the patient's ability to process reality. It is associated with schizophrenia and is defined by the presence of at least 1 of four features. The first is hallucinations; auditory hallucinations are typically psychiatric in origin, but visual hallucinations can also have a medical cause, such as drug intoxication or alcohol withdrawal. The second is delusions, which are false, fixed beliefs. The third is catatonia, in which the patient either barely interacts with the surroundings at all or moves in wildly inappropriate ways. The fourth is thought disorder.

De-escalation & assessment sequence

Your approach to the patient does much of the work of the assessment. Identify yourself and your role, speak slowly and calmly, maintain eye contact, and listen actively. Stay non-judgmental, keep your body language positive, and acknowledge the patient's feelings. Stay at least 3 feet away, and watch throughout for signs that the patient's aggression is escalating.

The assessment itself follows the usual order. The scene size-up comes first, and if the scene calls for it, the police go in before you do. Identify yourself, then perform the primary assessment, screening specifically for medical and traumatic causes of the behavior. Carry out as detailed an exam as the patient will allow, and take a thorough history, including any past psychiatric history, current medications and any missed doses, the possibility of diabetes, and substance use.

Aggressive/hostile patients — safety precautions

An aggressive or hostile patient is a danger to you before anything else, and a few rules protect you. Never isolate yourself from your partner or from other help, always maintain an escape route, and never let the patient get between you and the door. Watch for weapons, and avoid kitchens in particular, because they are a common source of them.

A calm patient can turn aggressive without warning, so do not relax because the patient seems settled. Be especially alert to sudden silence in a patient who was agitated a moment before. It may not mean the patient is calming down; it can indicate that a serious medical emergency is developing.

Reasonable force & restraint — legal note

As a general rule, an EMT cannot legally restrain, forcibly move or force care on a behavioral-emergency patient, even when the family asks you to. That authority belongs to law enforcement, and in some systems to a physician acting through medical direction. Where force is authorized, it is limited to reasonable force, which means only the force necessary to prevent the patient from harming himself or herself or others.

The rule is different when the cause is medical or traumatic. A combative hypoglycemic patient, for example, may be restrained so that treatment can be given; that is a medical necessity, not a behavioral-emergency restraint. In any case, never attempt to restrain a patient without sufficient personnel. Avoid handcuffs and plastic restraints, which cause soft tissue damage; soft restraints are preferred where local protocol authorizes them.

Excited delirium — critical danger

Excited delirium (now often called hyperactive delirium with severe agitation) is a state of extreme agitation and psychosis that most often arises from uncontrolled psychiatric illness, stimulant intoxication, or both. The patient shows bizarre and aggressive behavior, is insensitive to pain, displays unexpected strength and is hyperthermic. The critical danger comes after the struggle: these patients can suddenly stop struggling and, within minutes, develop inadequate or absent respirations and go into cardiac arrest. Constant monitoring is essential even after the patient appears to have calmed down.

Restraint procedure

When restraint is authorized and necessary, it is carried out as a planned procedure with adequate help. The steps are as follows.

1. Assemble adequate help and plan the approach. Stay beyond the patient's reach until you are ready, and once the decision is made, act quickly.
2. Assign one EMT to talk to and reassure the patient throughout. Use a minimum of 4 rescuers, one for each limb.
3. Apply restraints approved by medical direction to all 4 limbs.
4. Position the patient face-up. Never place a restrained patient prone or in any position that restricts movement of the chest wall, and never hog-tie a patient.
5. Monitor the airway constantly, and contact ALS, because chemical sedation may be needed.
6. Reassess distal circulation frequently.
7. Never remove police restraints until you are certain that the soft restraints will hold.

Positional asphyxia from improper restraint has caused patient deaths. The face-up rule is the single most important safety rule in this chapter.

Medical/legal considerations

A refusal of care from a behavioral-emergency patient carries significant risk, and the law treats it differently from other refusals. Most states allow you to transport such a patient against his or her will if the patient is a danger to self or others, which is an exception to the normal rules of consent. Whenever possible, have an EMT of the same sex as the patient attend the patient; this protects you against false accusations of misconduct. For an aggressive or violent patient, have law enforcement accompany the transport, which protects both you and the patient.