Principles of assessment for ems chapter 16

Principles of Patient Assessment
in EMS

Chapter 13 – Focused History &
Physical Exam: Behavioral
Emergencies
© 2011 Bedford-Parkinson-Tolouei EMT Education Unit

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.

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.

 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.

 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.

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.”

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

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?

Common Psychiatric Disorder
Classifications
 Mental
 Emotional
 Behavioral
 Effect an estimated 20% of the U.S.
population

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

 General Appearance:
 Neglect in personal hygiene, grooming
 Inappropriate dress
 Excessive attention to details (obsessive-
compulsive)
 Unilateral neglect (brain lesion)
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

 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)

 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

 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

 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

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.

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

 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?

 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?

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

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.

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)

Mental Illness
 There are many pathologies for behavioral
and psychiatric disorders:
 Genetic
 Chemical imbalance
 Organic illness

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

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.

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 9-1-1.

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

 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 the NAEMSP policy on patient restraint
Assisting a Transportation

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.

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.

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

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

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!

Principles of assessment for ems chapter 16

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Principles of assessment for ems chapter 16