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FCA 0911 - Psych

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Redwood Memorial Hospital
EMS Field Care Audit Lecture

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FCA 0911 - Psych

  1. 1. Crazy for You Veronica Bonales, M.D.CEP America Emergency Medicine RMH Paramedic Coordinator
  2. 2. ObjectivesWhat is considered “normal” behavior?Some “abnormal” behaviorsBehavioral emergencies & how to deal with them
  3. 3. What is “Normal?”
  4. 4. “Normal” BehaviorDisagreement over what is “normal”No clear definition or ideal modelIdeas of normal vary by culture/ethnic groupSociety accepts it
  5. 5. Ab-”Normal?”Maladaptive behavior is a more useful termDeviates from society’s norms and expectationsInterferes with well-being and ability to functionHarmful to the individual or group
  6. 6. Specific Behavioral Disorders
  7. 7. Common MisconceptionsAbnormal behavior is always bizarreAll patients with mental illness are unstable and dangerousMental disorders are incurableHaving a mental disorder is cause for embarrassment andshame
  8. 8. TerminologyAffect FearAnger Mental statusAnxiety Open-endedConfusion questionsDepression Posture
  9. 9. Cognitive DisordersMay have an organic etiology or be a result ofphysical or chemical injury Result in a disturbance of cognitive functioning May manifest as delirium or dementia
  10. 10. DeliriumAbrupt disorientation of time & place Illusions and hallucinations Symptoms vary according to personality, environment, and severity of illness Treatment - fix the underlying problem
  11. 11. DementiaClinical state characterized by loss of function in cognitivedomains Slow, progressive loss of awareness for time and place Usually have inability to learn new things or remember recent events Many different causes Progressive, treatments may slow the progress
  12. 12. SchizophreniaGroup of disordersCharacterized by recurrent episodes of psychotic behavior May include abnormalities of: Thought process Though content (delusions) Perception (auditory hallucinations common) Judgement
  13. 13. Anxiety DisordersPatients display a persistent, fearful feeling that cannot beconsciously related to realitySevere anxiety disorders may manifest in a panic disorder(panic attack) May mimic many medical emergencies, including AMI
  14. 14. PhobiaType of anxiety disorderPatients transfer anxiety to a situation or object as anirrational intense fear Patients know their fear is unreasonable but cannot prevent the phobiaTreated by medication and desensitization therapy
  15. 15. PTSDAnxiety reaction to severe psychological event Usually life-threatening; associated with repetitive intrusive memories Manifestations include: depression, sleep disturbances, nightmares, survivor guilt Frequently complicated by substance abuse
  16. 16. Mood DisordersDescribes the illnesses of depression and bipolardisorderBoth are associated with an increased risk for suicide
  17. 17. DepressionAn impairment of normal functioningOne of the most prevalent major psychiatric conditionsHigh risk of suicideTreatment includes counseling and medication, trials withEST and vagus nerve stimulators
  18. 18. Bipolar DisorderA biphasic emotionaldisorder in which depressiveand manic episodes alternatePatients may go withoutsleeping for days and arehyperactiveManagement is throughmedications
  19. 19. Suicide & Suicide ThreatsThreat is an indication that a patient has a serious crisisthat requires immediate interventionRequires counseling and treatment of underlying problem
  20. 20. Suicide RisksMale, single, older than 65Depression and other mental disorders, or a substance-abuse disorder (often incombination with other mental disorders)Prior suicide attemptFamily history of mental disorder or substance abuseFamily history of suicideFamily violence, including physical or sexual abuseFirearms in the homeIncarcerationExposure to the suicidal behavior of others, such as family members, peers, ormedia figures
  21. 21. Substance-related Disorders Psychiatric illness and behavioral problems are often a result of drug dependence, drug abuse, and intoxication Narcotics, opiates, sedative-hypnotics, stimulants, PCP, hallucinogens, TCAs, EtOH
  22. 22. Somatoform DisordersGroup of conditions in which there are physical symptomsfor which no physical cause can be found & for which thereis definite or strong evidence that the underlying cause ispsychologicalie: 20 y.o. patient with chest pain
  23. 23. Somatoform DisordersMost common disorders in this group Somatization disorder (chest pain) Conversion disorder (hysterical blindness)Both are associated with anxiety, depression, and threats ofsuicideTreatment often requires psychotherapy
  24. 24. Factitious DisordersSymptoms mimic a true illness but have been invented &are under the control of the patient to receive attention Munchausen’s syndrome Munchausen’s by Proxy - cause illness to someone else to receive attention
  25. 25. Dissociative DisordersGroup of psychological illnesses in which a particular mentalfunction is separated (dissociated from the mind as a whole) Dissociative amnesia Dissociative fugue Dissociative identity disorder Depersonalization disorder
  26. 26. Eating DisordersTwo most common Anorexia nervosa & bulimiaBoth result in starvation and can be fatal Managed with supervision and regulation of eating habits, psychotherapy, antidepressants Patients will require hospitalization
  27. 27. Impulsive Control Disorders Group of psychiatric disorders characterized by the inability to resist an impulse or a temptation to do some act that is unlawful, socially unacceptable or self-harmful
  28. 28. Obsessive Cumpulsive Disorders Patient feels stress or anxiety about thoughts or rituals over which they have little control Need to repeat actions or have rituals that must perform Treatment with medications &therapy
  29. 29. Personality DisordersGroup of conditions characterized by a general failure tolearn from experience or adapt appropriately to changesresulting in personal distress & impairment of socialfunctioning Symptoms recognized in adolescence and continue through life
  30. 30. Personality DisordersAntisocial Narcissistic No guilt or remorse Self-centeredAvoidant Obsessive-compulsive Avoids contact Hoarding, strict detailsBorderline Paranoid Impulsive & dramatic Socially isolatedDependent Schizoid Passive, can’t be alone Avoids emotions and intimacyHistrionic Schizotypal Need approval Odd beliefs, fantasies, speech
  31. 31. Behavioral Emergencies
  32. 32. Behavioral EmergenciesUnanticipated behavioral episodeBehavior that is threatening to the patient or othersRequires immediate intervention by emergencyresponders
  33. 33. Behavioral EmergenciesMay range from: Disordered and disturbed patients who are dangerous to themselves and others to Less intense situations in which the patient has a transient inability to cope with stress or anxietyMost behavioral emergencies result from: Biological/organic causes Psychosocial causes Sociocultural causes
  34. 34. EMS PsychPrehospital care for most behavioral emergencies is primarilysupportive and includes: Protecting the patient and others from harm (including the possible use of restraints) Assessing and managing coexisting emergency medical problems Transporting the patient for physician evaluation
  35. 35. AssessmentSurvey the scene for evidence of: Violence Substance abuse Suicide attemptGather information from: Patient Family Bystanders First responders
  36. 36. AssessmentEvaluate the scene for possible danger If a dangerous situation is suspected, do not approach the patient until police are present and the potential for danger is controlledFour general principles must be remembered when dealing withbehavioral emergencies Ensure scene safety Contain the crisis Render appropriate emergency medical care Transport the patient to an appropriate health care facility
  37. 37. EMS PsychWhen possible, remain at a safe distance from the patientDo not allow the patient to block your exitKeep large furniture between you and the patientDo not allow a single paramedic to remain alone with thepatientAvoid threatening statementsUse folded blankets or cushions to absorb the impact ofthrown objects
  38. 38. AssessmentLimit the number of people around the patient (or isolatethe patient if necessary) Stay alert to signs of possible danger (e.g., patient rage or hostility)
  39. 39. AssessmentDuring the patient assessment, attempt to gather the following data: Patients mental state (alertness, orientation, and ability to communicate) Patients name and age Significant past medical history Medications that have been taken Past psychiatric problems Precipitating situation or problem
  40. 40. AssessmentActive listeningBeing supportive and empatheticLimiting interruptionsRespecting the patient’s personal space by limiting physicaltouch
  41. 41. AssessmentAssessment findings that are important to note during the interview Physical/somatic complaints Intellectual functioning (orientation, memory, concentration, judgment) Thought content (disordered thoughts, delusions, hallucinations, unusual worries/fears) Language (speech pattern and content) Mood (anxiety, depression, elation, agitation, alertness, distractability) Appearance (personal hygiene, dress) Psychomotor activity
  42. 42. The Challenging PatientIf the patient refuses to be interviewed:Speak to the patient in a quiet voiceAvoid questions that may be interpreted by the patient as an “interrogation”Allow extra time for the patient to respondPatients who are too talkative:Will need to be focused on the interviewCall out their nameRaise your hand to get their attention
  43. 43. The Challenging PatientA patient who is confrontational: May require additional manpower at the scene to ensure scene safety Will sometimes require restraint
  44. 44. AssessmentAfter the initial assessment and history, the remainder ofthe examination is determined by: The patients overall condition The nature of the psychiatric problem
  45. 45. ParanoiaClearly identify yourself and express your intent to provide helpExhibit an attitude that is friendly, yet somewhat distant andneutralNever respond to the patients angerDo not speak with family members or bystanders in hushed orsecretive tonesUse tact and firmness in persuading the patient to be transported tothe hospitalRemember that paranoid reactions can lead to violent behavior
  46. 46. Violent Patient AssessmentFactors that may help determine the potential for a violent episode Past history – Has the patient exhibited hostile, aggressive, or violent behavior? Posture – Is the patient sitting or standing? Does the patient appear to be tense or rigid? Vocal activity – Is the patient’s speech loud, obscene, or erratic, indicating emotional distress? Physical activity – Is the patient pacing or agitated or displaying protection of physical boundaries?
  47. 47. When Things Go BadSeverely disturbed patients who pose a threat to themselves orothers may need to be restrained, transported, and hospitalizedagainst their will Each state has a statute covering the criteria for involuntary commitment Be familiar with all applicable lawsThe premise on which most state laws are based suggests thatone person may restrain another to protect life or prevent injury
  48. 48. When Things Go BadIf violent behavior must be contained, “reasonable force” torestrain the patient should be used as humanely as possible In most cases, the restraint duty (if necessary) should be given to law enforcement personnel
  49. 49. Practicing RestraintIf the patient is homicidal, do not attempt restraint withoutlaw enforcement assistanceIf the patient is armed: Move everyone out of range Retreat from the scene Wait for law enforcement personnel Do not attempt restraint without law enforcement assistance
  50. 50. Practicing RestraintIf the patient is armed: Move everyone out of range Retreat from the scene Wait for law enforcement personnel
  51. 51. Practicing RestraintRemember that the patient may not be responsible for his orher actionsPlan your restraining action to include a back-up plan incase the initial action failsBe sure that adequate help is available
  52. 52. Practicing RestraintBegin with a gentle, nonthreatening, low-profile approach and progress to moredirect intervention as neededAlways explain the options of physical restraint to the patient before applyingforce If the patient is still unwilling to cooperate, he or she should be advised that restraint is necessary to protect against injury and to ensure the safety of othersBefore approaching the violent patient, be aware of the patients surroundings
  53. 53. Practicing RestraintDo not attempt to enter the patients physical space until theother members involved in the restraint action are ready toproceedBe familiar with the restraint devices available and improviseif the need arisesSequence of restraint actions
  54. 54. Practicing Restraint
  55. 55. Practicing RestraintControl Position - Rescuersface same direction, inside legsin front of patient, outsidehands hold patient’s wrists,inside hands form a C onpatient’s shoulders
  56. 56. Child PsychGain the child’s trust and try to convince the child that youare a friend who can helpMake it clear that you are strong enough to be in control,but that you will not hurt him or herKeep the interview questions brief The child’s attention span may be extremely short
  57. 57. Child PsychNever lie; be honestUse all available resources to communicate (e.g., drawingpictures, telling stories)Involve parents or caregivers in the interview or examination(if appropriate)Take any threat of violence seriously
  58. 58. Questions..?? Thank you!

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