Self Explanatory.

1. Barry Kidd 2010 1
Focused History & Physical Exam:
Behavioral Emergencies

2. Barry Kidd 2010 2
Objectives
 Describe the elements that lead up to a
behavioral emergency.
 Describe the EMS provider’s role in
controlling the setting in a behavioral
emergency.
 List eleven classifications of psychiatric
disorders and provide an example of each.

3. Barry Kidd 2010 3
Objectives (continued)
 Provide examples of specific behaviors
manifested by persons with emotional and
psychiatric disorders.
 List a major misconception concerning
behavioral emergencies.
 Describe examples of nonverbal
communication.

4. Barry Kidd 2010 4
 Describe specific risk factors the EMS
provider should screen for during the
focused history of a patient experiencing a
behavioral emergency.
 Describe the components of the mental
status examination.
 List the most common behavioral
emergencies the EMS provider is called for.
Objectives (continued)

5. Barry Kidd 2010 5
 List medical conditions that mimic
behavioral disorders.
 List the possible signs and symptoms of
ineffective or failing coping mechanisms of
stress that may be seen in EMS providers.
Objectives (continued)

6. Barry Kidd 2010 6
Introduction
 Every type of illness/injury will come with
some type of emotional or psychological
element.
 Behavioral emergencies occur when a
person with/without a psychiatric hx
becomes stressed & overwhelmed or feels
they are “loosing control.”

7. Barry Kidd 2010 7
Introduction (continued)
 A crisis occurs when a person’s perception
of an acute distressing event results in an
abnormal behavioral response.
 Crisis is an internal response that can
create reactions such as:
 Severe anxiety
 Panic
 Paranoia
 Other psychotic events

8. Barry Kidd 2010 8
The EMS Provider’s Role
 You must be able to take an active role in
controlling the situation without being
threatening:
 Upon arrival make a clear, short and calm statement
of who you are and why you are there.
 Determine the problem and how many people are
involved.
 Get a description of any unusual activities, risk
factors, prior episodes.
 Remember scene safety! Is this a crime scene?

9. Barry Kidd 2010 9
Common Psychiatric Disorder
Classifications
 Mental
 Emotional
 Behavioral
 Effect in Canada an estimated:
 6% to 9% of the population has a personality disorder.
 Onset usually occurs during adolescence or in early
adulthood.
 Anti-social personality disorder is frequently found
among prisoners (up to 50%).
 Of hospitalizations for personality disorders in general
hospitals, 78% are among young adults between 15 and
44 years of age.

10. Barry Kidd 2010 10
Psychological Disorders
 Features:
 Observe the patient’s body language and
verbal responses for clues
 Various disorders have distinctive
characteristics

11. Barry Kidd 2010 11
Psychological Disorders
 Effect in Canada an estimated:
 6% to 9% of the population has a personality
disorder.
 Onset usually occurs during adolescence or in
early adulthood.
 Anti-social personality disorder is frequently
found among prisoners (up to 50%).
 Of hospitalizations for personality disorders in
general hospitals, 78% are among young adults
between 15 and 44 years of age.

12. Barry Kidd 2010 12
 General Appearance:
 Neglect in personal hygiene, grooming
 Inappropriate dress
 Excessive attention to details (obsessive-
compulsive)
 Unilateral neglect (brain lesion)
Psychological Disorders (continued)

13. Barry Kidd 2010 13
Psychological Disorders (continued)
 Intellectual Function:
 Assess memory, concentration, judgment and
orientation
 Psychiatric disorders may affect short, long
and recall memory
 Assessment is done in the patient interview

14. Barry Kidd 2010 14
 Thought Content:
 Thought content and perceptions should be
logical, consistent and connected with the
current situation
 Delusions – a false personal belief or idea is
portrayed as true
 Hallucination – a perception of something that
is not present
Psychological Disorders
(continued)

15. Barry Kidd 2010 15
Psychological Disorders (continued)
 Physical Complaints:
 Often vague – headache, muscle ache, weight
loss, lack of energy
 Consider medical causes first
 Motor Activity:
 Tense, restlessness, pacing, crying, fidgeting
or slow moving
 Consider drug intoxication, pain, abnormal
blood sugar or hypoxia first

16. Barry Kidd 2010 16
Psychological Disorders (continued)
 Speech & Language:
 Consider word choice, quality, pace and
articulation of speech and language
 Consider other causes for alterations such as
stroke, tumors or trauma.
 Body Language:
 Body language is the expression of thoughts
or emotions by means of posture or gestures
 Stay alert to non-verbal cues for potential
violence

17. Barry Kidd 2010 17
Psychological Disorders (continued)
 Mood:
 Assess mood and affect through facial
expressions, body language and responses to
questions
 Should be appropriate for the current
situation and transitions according with topics
in conversation

18. Barry Kidd 2010 18
Assessment
 Scene Safety:
 A major misconception “all mental patients
are unstable and dangerous”
 Many behavioral emergencies begin as
medical calls. ALWAYS assess scene safety in
every call.
 Respect a patient’s personal space.
 Limit the number of people and avoid
overwhelming the patient.

19. Barry Kidd 2010 19
Assessment (continued)
 Focused History:
 Obtaining a history may be difficult, these
patients are often unreliable, poor historians
or uncooperative
 Family or caretakers may not be available or
may distort the information
 Assess predisposing risk factors such as
depression or major life event

20. Barry Kidd 2010 20
Assessment (continued)
 S – What type of crisis is the patient
having? Any associated symptoms?
 A – Are there any allergies to meds?
 M – What meds and any recent changes
to medication schedule?
 P – What is the patient’s behavioral
history? Any substance abuse?
 L – meds, meals, alcohol?
 E – new stress, changes in social status?

21. Barry Kidd 2010 21
Assessment (continued)
 O – Where, when and how did the event begin?
 P – What is the problem today? Did the patient
intend on harming him/herself?
 Q – What type of crisis is the patient
experiencing?
 R – Are there any concomitant medical factors?
 S – Is this event similar to previous episodes?
 T – How long has this been going on?

22. Barry Kidd 2010 22
Mental Status Exam
 Obtain baseline assessment and verify
finding with family/caretaker, MD
 Appearance – note physical position and
posture, personal hygiene, appropriate
dress, age and gender
 Affect – what feelings is the patient
exhibiting

23. Barry Kidd 2010 23
Mental Status Exam (continued)
 Behavior – what is the patient doing?
 Cognitive function – assess level of
consciousness, memory, mood and affect.
 Speech – assess word choice, content,
intonation, clarity and pace.
 Thought process – assess if judgment is
reasonable for the current situation.

24. Barry Kidd 2010 24
Behavioral Emergencies
 Depression is a common reaction to major
life stress:
 Feelings of sadness, discouragement, and
hopelessness
 Reduced activity levels, inability to function,
and sleep disturbances
 Severe depression is a risk factor for suicide
 May present as symptoms of disease (organic
illness, cardiac or respiratory conditions)

25. Barry Kidd 2010 25
Mental Illness
 There are many pathologies for behavioral
and psychiatric disorders:
 Genetic
 Chemical imbalance
 Organic illness

26. Barry Kidd 2010 26
Substance Abuse
 Dependence, abuse and intoxication.
 True addiction is both psychological and
physical.
 Alcoholism is particularly insidious among
the elderly.

27. Barry Kidd 2010 27
Suicide Attempts
 Occur when a patient has a true desire to
die.
 Gestures are pleas for help.
 Whether “attempt” or “gesture” do not
discount the patient’s emotional state in
any way.
 Be direct and ask:
 “Where you trying to kill yourself?”
 “Do you want to die?”
 Clearly report and document your findings.

28. Barry Kidd 2010 28
Attention/Pleas for Help
 Some behavior calls are related to a patient’s cry
for attention:
 Suicide gesture
 Hypochondriac
 Lonely person calling repeatedly for no apparent
medical reason
 Safest approach is to assume something is
seriously wrong until proven otherwise.
 Often people who want help are unaware of
available resources and they call the HC or
9-1-1.

29. Barry Kidd 2010 29
Assisting a Transportation
 Mental health evaluation order.
 The police should have an order and be on
the scene
 Inmates feigning illness.
 Complete a thorough assessment

30. Barry Kidd 2010 30
 Patients who are a danger to themselves
or another.
 Major concern is safety for EMS providers and
the patient
 Do not use excessive force and be aware of
the dangers of restraint
 Never restrain a patient in a prone position!
 Review your policy and procedure on patient
restraint
Assisting a Transportation

31. Barry Kidd 2010 31
Medical Conditions that Mimic
Behavioral Disorders
 Stroke, tumors, or trauma can affect
speech.
 Medications, severe infections, hypoxia,
hypo or hyperglycemia can cause altered
mental status, depression or psychosis.
 Psychotropic meds can have powerful side
effects and severe interactions with other
medications.

32. Barry Kidd 2010 32
Stress and the EMS Provider
 Emergency responders are routinely
subjected to both positive and negative
stress.
 Stress disorders may be acute or develop
into chronic conditions if not recognized
and managed.
 Be watchful and recognize
signs/symptoms of stress in yourself and
coworkers.

33. Barry Kidd 2010 33
Stress and EMS Providers
(continued)
 Signs and symptoms of ineffective or failing
coping mechanisms include:
 Increased absenteeism
 Withdrawal
 Depression
 Hyperactivity
 Irritability
 Increased smoking or alcohol use
 Sleep disturbances
 Headaches
 Poor concentration and decision making

34. Barry Kidd 2010 34
Conclusion
 Response to crisis varies by person.
 Inability to cope or failing mechanisms can
cause impaired functionality.
 Some become withdrawn/depressed,
others overactive/violent.

35. Barry Kidd 2010 35
Conclusion (continued)
 Many factors can alter a patient’s behavior
(regardless of any mental health history).
 Personal safety comes first! Take an
active role in controlling the situation and
supporting the patient’s emotional and
physical needs.
 Whenever possible obtain a complete
history!

36. Barry Kidd 2010 36
Questions
 1: The best way to gain the confidence
of, and effectively communicate with, a
frightened patient is to:
A: shout at the patient.
B: use medical terminology.
C: let the patient have some time alone.
D: make and keep eye contact with the
patient

37. Barry Kidd 2010 37
Answer
 1: The best way to gain the confidence of, and
effectively communicate with, a frightened
patient is to:
D: make and keep eye contact with the patient.
Reason: The best way to communicate with a
frightened patient is to make and keep eye
contact in order to help the patient keep calm.

38. Barry Kidd 2010 38
Question
 2: A woman is lethargic and moving around
slowly. She is speaking coherently but does not
show any expression when speaking. These
signs and symptoms suggest:
A: mania.
B: paranoia.
C: depression.
D: a potential suicide attempt

39. Barry Kidd 2010 39
Answer
 2: A woman is lethargic and moving around
slowly. She is speaking coherently but does not
show any expression when speaking. These
signs and symptoms suggest:
C: depression.
Reason: Extreme lethargy, slow movement, and
very little facial expression while talking are
signs of possible depression.

40. Barry Kidd 2010 40
Question
 .3: Your primary responsibility in the initial
management of a disruptive patient is to:
A: make a specific diagnosis.
B: lecture the patient about the dangers of
substance abuse.
C: take charge of the situation but protect
yourself if necessary.
D: play along with the patient if he or she sees
or hears things that are not real.

41. Barry Kidd 2010 41
Answer
 3: Your primary responsibility in the initial
management of a disruptive patient is to:
C: take charge of the situation but protect
yourself if necessary.
Reason: Your primary responsibility in the initial
management of a disruptive patient is to take
charge of the situation and to be mindful of your
personal safety.

42. Barry Kidd 2010 42
Question
 4: Your patient is displaying disruptive
behavior and needs to be restrained. You
should:
A: threaten the patient.
B: use handcuffs if available.
C: ask law enforcement to handle it.
D: use whatever means are available.

43. Barry Kidd 2010 43
Answer
 4: Your patient is displaying disruptive behavior
and needs to be restrained. You should:
C: ask law enforcement to handle it.
Reason: Whenever a patient who is displaying
disruptive behavior needs to be restrained, you
should ask law enforcement to handle the
situation.

44. Barry Kidd 2010 44
Question
 5: The driver in a one-car crash has no
apparent injuries but is acting unruly. A half-full
whiskey bottle is lying on the passenger seat.
The appropriate course of action would be to:
A: assume that the driver is drunk.
B: ask bystanders to help you restrain the driver.
C: let law enforcement officials handle the
matter.
D: assess the situation to determine why the
driver is acting unruly.

45. Barry Kidd 2010 45
Answer
 5: The driver in a one-car crash has no apparent
injuries but is acting unruly. A half-full whiskey bottle is
lying on the passenger seat. The appropriate course of
action would be to:
 D: assess the situation to determine why the driver is
acting unruly

Reason: The appropriate course of action in this
situation would be to assess the scene to determine why
the driver is being disruptive. Do not "write" off the
unruly or abusive patient as "just another drunk."

46. Barry Kidd 2010 46
Question
 6: A patient with organic brain syndrome
who is exhibiting disruptive behavior will
most likely be:
A: elderly.
B: paralyzed.
C: terminally ill.
D: unable to speak

47. Barry Kidd 2010 47
Answer
 6: A patient with organic brain syndrome
who is exhibiting disruptive behavior will
most likely be:
A: elderly.
Reason: Most patients with organic brain
syndrome are elderly.

48. Barry Kidd 2010 48
Question
 7: Which of the following statements about restraining a
patient is FALSE?
A: Soft, wide leather or cloth restraints should be used.
B: You should talk to the patient throughout the
process.
C: There should be two law enforcement officers
present.
D: Use the minimum force necessary to restrain the
patient.

49. Barry Kidd 2010 49
Answer
 7: Which of the following statements about
restraining a patient is FALSE?
C: There should be two law enforcement officers
present.
Reason: To safely restrain a patient, there
should be at least four officers present. Each
should be responsible for one extremity.

50. Barry Kidd 2010 50
Question
 8: A suicidal act can be described as a state in
which the patient might:
A: believe that people are plotting to harm or kill
him or her.
B: not want to do anything and might not
cooperate or answer questions.
C: be threatening to kill himself or herself or
might already have made an attempt.
D: be severely agitated, speaking rapidly, and
usually not finishing a sentence or a complete
thought.

51. Barry Kidd 2010 51
Answer
 8: A suicidal act can be described as a
state in which the patient might:
C: be threatening to kill himself or herself
or might already have made an attempt.
Reason: A suicidal act is a situation in
which a patient may be threatening to kill
himself or herself or may have already
made an attempt.

52. Barry Kidd 2010 52
Question
 9: When caring for a patient with a behavioral
emergency, if the patient is sitting on the edge
of his or her seat, tense, rigid, and speaking
loudly and making obscene comments, the EMR
should consider that:
A: the patient might become violent.
B: the patient is only nervous.
C: standing close to the patient will help to
reassure him or her.
D: all of the above.

53. Barry Kidd 2010 53
Answer
 9: When caring for a patient with a behavioral
emergency, if the patient is sitting on the edge
of his or her seat, tense, rigid, and speaking
loudly and making obscene comments, the EMR
should consider that:
A: the patient might become violent.
Reason: A patient who is sitting on the edge of
his or her seat, appears tense or rigid, speaks
loudly, and makes obscene comments has the
potential to become violent.

54. Barry Kidd 2010 54
Question
 10: A behavioral crisis can be defined as:
A: any emergency in which the patient is
mentally crazy.
B: any reaction that is psychological in nature.
C: any situation in which the patient cannot act
appropriately.
D: any reaction to events that interferes with the
activities of daily living.

55. Barry Kidd 2010 55
Answer
 10: A behavioral crisis can be defined as:
D: any reaction to events that interferes with the
activities of daily living.
Reason: A behavioral crisis is any reaction to
events that interferes with the activities of daily
living or has become unacceptable to the
patient, family, or community.