This document provides information on behavioral emergencies and geriatric considerations for emergency medical responders. It discusses therapeutic communication skills, psychiatric competencies, medical legal issues, and Virginia EMS protocols for behavioral emergencies. Specific conditions like post-traumatic stress disorder, depression, and schizophrenia are explained. Verbal de-escalation techniques, reflective listening, talking to patients and families, and conversational hypnosis are covered. Risk and resilience factors for suicide are outlined. The document also addresses communicating with older adults, impact of aging on psychiatric emergencies, depression, suicide, and elder abuse.

1. Behavioral
Emergencies
Justin R. Steele, MA, CHt
Christopher Sutton, MA

2. BLS Competencies
Therapeutic Communication
 Principles of communicating with patients in a manner that
achieves a positive relationship
 Adjusting communication strategies for age, stage of
development, patients with special needs, and differing cultures
 Interviewing techniques
 Verbal defusing strategies
 Family presence issues
(Virginia EMS Education Standards, 1F)

3. BLS Competencies
Psychiatric
 Behaviors that pose a risk to the EMR, patient or others
 Basic principles of the mental health system
 Assessment and management of:
 acute psychosis
 suicidal/risk
 agitated delirium
(Virginia EMS Education Standards, 10G)

4. BLS Competencies
Medical/Legal and Ethics
 Consent/refusal of care
 Confidentiality
 Advance Directives
 Tort and criminal actions
 Evidence preservation
 Statutory responsibilities
 Mandatory reporting
 Ethical principles/moral obligations
 End-of-life issues
(Virginia EMS Education Standards, 1G)

5. Behavioral Emergencies
11th edition Protocols
 General Information:
 Contact police if there is any questions of scene safety
 Assure physical safety of patient and personnel
 Capacity to refuse issues are complex. If a patient is intoxicated, has had a
head injury, has a history of overdose or is thought to be of any danger to self
or others, he/she is most likely not capable to refuse treatment.Contact police
and Medical Control to aid in making the decision
 No transport does not mean no PCR is necessary
 Documentation should be complete including patient’s mental state and your
rationale for the no transport decision
 Warnings/Alerts:
 Behavioral emergency calls can rapidly deteriorate
 Failure to appropriately address behavioral emergencies for patients with
questionable capacity may lead to negative outcomes
(Tidewater Emergency Medical Services Council, Inc., 2013)

6. Behavioral Emergencies
11th edition Protocols
Treatment per the
Airway/Oxygenation/Ventilation
Protocol
Scene Safety
No transport.
Document findings
Yes
Patient consents to
treatment?
Consider alternative causes for
an altered mental status such as
hypoglycemia, stroke,
overdose, head injury, etc.
Patient has
capacity to refuse?
YesYes
NoNo No
Transport to closest
appropriate
Emergency
Department unless
otherwise directed.
Exit to Combative Patient Protocol
Is patient
combative?
Transport to closest appropriate
Emergency Department unless
otherwise directed. (Tidewater Emergency Medical Services Council, Inc., 2013)

7. What we are going to cover
 Mental Health System
 Psychopathology
 Reflective Listening Skills
 Emotional Support for Patients
 Talking to Families
 Conversational HypnosisTechniques
 Risk Factors for Suicide
 Resilience Factors
 Legal Decision-Making

8. Basic Principles of the
Mental Health System
2. Mental Health Symptoms
1. Biopsychosocialspiritual Factors
4. Ambulance Ride
3/7. Supportive Psychotherapy
6. Inpatient Care/Medication
4/8. Patient Feels Better (not always cured)
3. Someone Calls 9-1-1
5. ERAssessment and Evaluation

9. Psychopathology
 Posttraumatic Stress Disorder (PTSD)
 Depression
 Schizophrenia
 Other disorders?

10. Posttraumatic Stress Disorder
Re-experiencing theTrauma
Avoidance
Hyperarousal
(American PsychiatricAssociation, 2000)

11. Posttraumatic Stress Disorder
 Re-experiencing theTrauma
 Recurrent recollections of the event
 Distressing dreams
 Flashbacks
 Distress when exposed to similar events
(American PsychiatricAssociation, 2000)

12. Posttraumatic Stress Disorder
 Avoidance
 Efforts to avoid thoughts and places similar to event
 Inability to recall
 Loss of interest or pleasure
 Detachment from others
 Restricted emotion
 Sense of a shortened future
(American PsychiatricAssociation, 2000)

13. Posttraumatic Stress Disorder
 Hyperarousal
 Difficulty falling or staying asleep
 Irritability or anger
 Difficulty concentrating
 Hypervigilance
 Exaggerated startle response
(American PsychiatricAssociation, 2000)

15. Depression
 Depressed mood
 Decreased interest or
pleasure
 Losing or gaining weight
 Sleeping too much or
too little
 Hyperactivity
 Fatigue
 Feelings of
worthlessness or
inappropriate guilt
 Difficulty concentrating
 Indecisiveness
 Recurrent thoughts of
death
(American PsychiatricAssociation, 2000)

16. Schizophrenia
 Delusions
 Hallucinations
 Disorganized speech
 Disorganized behavior
 Catatonic behavior
 Flat emotion
 Missing content in speech
 Lack of drive/motivation
(American PsychiatricAssociation, 2000)

17. 10-minute break

18. Verbal De-escalation
11th edition Protocols
 Verbal De-escalation Guidelines
 Make every attempt not to aggravate or
worsen pre-existing injuries or medical
conditions
 Attempt to control the patient with verbal
counseling
 Verbal De-escalation Procedure
 Remain calm and friendly, be aware of
your emotions
 Be mindful of your body language
 Breathe slowly and deeply
 Maintain a safe distance and refrain
from touching
 Utilize contact and cover principles
 Position yourself between the patient and
your exit.
 Verbal De-escalation Procedure (Con’t)
 Keep your hands in front of your body (Non-
threatening manner)
 Only one provider should communicate with
the patient
 Maintain a soothing tone of voice
 Listen to patient’s concerns
 Empathize. Use positive feedback
 Be reassuring. Outline the patient’s choices
 Be willing to slow down and disengage if
appropriate
 Calmly set boundaries of acceptable behavior
(Tidewater Emergency Medical Services Council, Inc., 2013)

19. Reflective Listening Skills
 Reflection of Content
 Reflection of Emotion
 Open Questions about Content
 Open Questions about Emotion
(Ivey, Ivey, & Zalaquett, 2003)

20. Demonstration
Reflective Listening

21. Role-play
Option One
You are talking to your friend after they
have just had a terrible day at work.
Reflectively listen to them as they
elaborate on the pressures of their
occupation.
Selina Kyle has just lost her husband
after a 25 year marriage. She is
distressed about all the memories
they had together.You are tasked
with speaking to Mrs. Kyle while the
other responders address the
medical needs of the scene.
OptionTwo
You are talking to your friend after they
have just gotten back from a very
disappointing vacation. Reflectively
listen to them as they elaborate on
the distress of a not-so-relaxing
vacation.
BruceWayne just witnessed his friend
being shot. Mr.Wayne’s friend was a
bystander accidentally shot during a
drive by shooting. You are tasked
with speaking to Mr.Wayne while the
other medical providers treat his
friend.

22.  Just keep talking!
 Keep your voice cheerful and confident
 Make sure the patient understands what you are doing
 If they are confused, talk about what is happening
 If they seem quiet, talk to them about their lives
 Do they have children?
 What are their children’s names?
 Do they have any pets?
 If you can discover a hobby, ask them about it
 Make sure the patient keeps their mind on something else
Emotional Support for Patients

23. CPR is going on in the next room…

24. The CPR Talk
 Be confident!
 Have an open and inviting posture
 Use confident phrases
 There are several highly-trained medical professionals in there doing their best
 We’re doing our best to make sure she receives the best care possible
 Do not reference yourself (ex: how this is your first arrest, etc.)
 Be present with them and remember your reflective listening skills
 Monitor your own behavior and expressions

25. Talking to Families
 It’s more about what NOT to say than what to say
 Do not reference your own distress
 Do not minimize their distress
 Do not tell them facts, ideas, or conclusions
 Silence is better than saying something inappropriate
 Be present with them and remember your reflective listening skills
 Be empathetic
 Monitor your own behavior and expressions
(Corey & Corey, 2003)

26. Role-play
Scenario One
Peter Parker’s uncle Ben had a heart
attack and paramedics are in the
other room conducting CPR.
Attend to Mr. Parker’s emotional
responses.
ScenarioTwo
 Mary Jane is currently trapped
underneath a car and is being
extracted by the SquadTruck
Team. Attend to Ms. Jane’s family
as the SquadTruckTeam assist’s
Mary Jane.

27. Conversational Hypnosis
(Fiske, 2010; Ivey, Ivey, & Zalaquett, 2010)
 Try to keep the same individual talking with the patient
 Increased exposure increases likeability
 Initial trust and rapport can be very important
 Maintain appropriate eye contact whenever possible
 Eye contact alone can increase attraction
 Mirroring behavior
 Empathy helps patients to know that you care
 Modeling appropriate breathing helps patients to calm down
 Mirroring a patients breathing, body language, and verbiage communicates
understanding
 Some level of control can even be established here

28. Demonstration
Conversational Hypnosis

29. Role-play
Scenario One
Clark Kent just safely walked away from
a major motor vehicle accident. He is
medically fine, but he is
hyperventilating and in emotional
shock from the incident.
ScenarioTwo
Lois Lane was just mugged by a stranger
on the street. She is medically fine,
but she is hypervigilant, physically
agitated, and is having trouble
speaking.

30. Debrief Role-plays
Reflective Listening
Talking to Families
Conversational Hypnosis

31. 10-minute break

32. Risk Factors for Suicide
 Depressive feelings
 “I feel empty”
 “I feel worthless”
 Depression symptoms
 I have been sleeping a lot lately
 Irritability
 Drug abuse
 Prior suicide attempts
 Suicide around the individual
 Suicidal ideation
 Self-harm
 cutting
 Being bullied
 In-person
 Cyber bullying
 Gun ownership
 Psychological disorders
 Family violence/discord
 Parents fighting
 Impulsivity
(Jashinsky et al., 2014)

33. Resilience Factors
 Resilience Factors
 Strong relationships with others
 Organizational and community supports
 Supportive relationships
 Personal control (executive functioning)
 Older age
 Intelligence
 How can resilience be increased in your own life?
 Supportive friendships (Rescue Partner)
 Becoming a part of a community organization (VBEMS)
 Others?
(Diehl & Hay, 2010; Masten, 2009)

34. Legal Decision-Making
 Consent and Refusal of Care
 What indications are there that a patient is refusing care?
 What indications are there that a patient is not refusing care?
 Confidentiality
 What is confidential?
 What is not?
 Why is this important?

35. ???Questions???
Panel Discussion

36. References
 American PsychiatricAssociation. (2000). Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition,Text Revision.Washington, DC:
American Psychiatric Association.
 Corey, M. S. & Corey, G. (2003). Becoming a Helper (4th ed.). PacificGrove,
CA: Brooks/ColeThomson Learning.
 Diehl, M. & Hay, E. L. (2010). Risk and Resilience Factors in CopingWith
Daily Stress inAdulthood:The Role of Age, Self-Concept Incoherence, and
PersonalControl. Developmental Psychology, 46(5), 1132-1146. doi:
10.1037/a0019937
 Fiske, S.T. (2010). Social Beings: Core Motives in Social Psychology (2nd ed.).
Danvers, MA: JohnWiley & Sons, Inc.
 Ivey, A. E., Ivey, M. B., & Zalaquett, C. P. (2010). Intentional Interviewing &
Counseling: FacilitatingClient Development in a Multicultural Society (7th
ed.). Belmont, CA: Brooks/Cole Cengage Learning.

37. References
 Jashinsky, J., Burton, S. H., Hanson,C. L.,West, J., Giraud-Carrier,C.,
Barnes, M. D., &Argyle,T. (2014).Tracking Suicide Risk FactorsThrough
Twitter in the US. Crisis, 35(1), 51-59. doi:10.1027/0227-5910/a000234
 Masten,A. S. (2009).Ordinary Magic: Lessons from Research on Resilience
in Human Development. EducationCanada, 49(3), 28-32. Retrieved from
www.cea-ace.ca/sites/cea-ace.ca/files/EdCan-2009-v49-n3-Masten.pdf
 Tidewater Emergency Medical Services Council, Inc. (2013). Regional
Medical Protocols (11th ed.).Tidewater Emergency Medical Services Council,
Inc.

38. Geriatric Emergencies
Addendum

39. Communication and the Older Adult
 Older people may be insulted if you use their first name
 “Sir” or “Ma’am”
 Ask only one question at a time
 Explain what you are going to do before you do it
 Do not assume that all older patients are hard of hearing
 Do not talk about the patient in front of him or her
 Be patient
 As for patients of any age, older patients have more difficulty
communicating clearly when they are stressed by an emergency or
personal crisis
(Pollak, Gulli, Chatelain, & Stratford, 2005)

40. Impact of Aging on
Psychiatric Emergencies
 Fulfillment, satisfaction, and a lifetime
of accomplishments for the majority
 Depression
 Physical pain
 Psychological distress
 Doubts about the significance of
life’s accomplishments
 Financial concerns
 Loss of loved ones
 Dissatisfaction with living conditions
 Seemingly unbearable disability
 Some contributing factors to depression
 Substance abuse
 Isolation
 Prescription medication use
 Chronic medical conditions
 Suicide
 Older men more likely
 Older individuals chose more lethal
means and have less recuperative
ability
 Only a small percentage will seek
treatment
(Pollak, Gulli, Chatelain, & Stratford, 2005)

41. Elder Abuse
 Elder abuse is a problem that has been largely
hidden from society
 The definitions of abuse and neglect among the
geriatric population vary
 Victims of elder abuse are often hesitant to
report the problem to law enforcement agencies
or human and social welfare personnel
 They may feel the abuser will try to get back at
them
 Injuries to the genitals or rectum with no
reported trauma may be considered abuse in any
patient
 Abuse may be:
 Physical (assault, neglect, diet, poor
maintenance of home, poor personal
hygiene, etc.)
 Psychological (neglect, verbal, treating the
person as an infant, deprivation of sensory
stimulation, etc.)
 Financial (theft of valuables, embezzlement,
etc.)
 Information that may be important in assessing
possible abuse includes the following:
 Repeated visits to the ER
 A history of being accident-prone
 Soft-tissue injuries
 Unbelievable or vague explanations of
injuries
 Psychosomatic complaints
 Chronic pain
 Self-destructive behavior
 Eating and sleep disorders
 Depression or a lack of energy
 Substance and/or sexual abuse
(Pollak, Gulli, Chatelain, & Stratford, 2005)

42. References
 Pollak,A. N., Gulli, B., Chatelain, L., & Stratford, C. (Eds.). (2005).
Emergency: Care andTransportation of the Sick and Injured (9th ed.).
Sudbury, MA: Jones and Bartlett Publishers.