Ch.23 Behavioralhealth Flashcards
An emergency in which abnormal behavior threatens a persons own health and safety or the health and safety of another person- for example, when a person becomes suicidal or homicidal, or has a psychotic episode
Behavioral health emergency
A delayed stress reaction to a prior incident. Often the result of one or more unresolved issues concerning the incident, and may relate to an incident that involved physical harm or threat of physical harm
Post-traumatic stress disorder
The point at which a persons reactions to events interfere with activities of daily living; this becomes a psychiatric emergency when it causes a major life interruption, such as attempted suicide
Behavioral crisis
The transmission of information to another person—verbally or through body language
Communication
How a person functions or acts in response to his or her environment
Behavior
The basic activities a person usually accomplishes during a normal day, such as eating, dressing, and bathing
Activities of daily living
A persistent mood of sadness, despair, and discouragement; may be a symptom of many different mental and physical disorders, or may be a disorder on its own
Depression
An illness with psychological or behavioral symptoms and/or impairment in functioning caused by a social, psychological, genetic, physical, chemical, or biologic disturbance
Psychiatric disorder
As an EMT, you are not responsible for diagnosing the underlying cause of a behavioral crisis or emergency. However, you should understand the two basic categories of diagnosis that a physician will use:_____ and ____
organic (physical) and functional (psychological).
____is a temporary or permanent dysfunction of the brain caused by a disturbance in the physical or physiologic functioning of brain tissue. Causes of___ include sudden illness; traumatic brain injury; seizure disorders; drug and alcohol abuse, overdose, or withdrawal; and diseases of the brain, such as Alzheimer dementia or meningitis.
Altered mental status can arise from a physiologic issue such as a hypoglycemia, hypoxia, impaired cerebral blood flow, and/or hyperthermia or hypothermia. In the absence of a physiologic cause, altered mental status may be an indicator of a psychiatric disorder such as bipolar disorder.
Organic brain syndrome
A change in the way a person thinks and behaves that may signal disease in the central nervous system or elsewhere in the body
Altered mental status
A____ is a physiologic disorder that impairs bodily function when the body seems to be structurally normal.
Something has gone wrong, but the root cause cannot be identified. Schizophrenia, anxiety conditions, and depression are good examples of____. The chemical or physical basis of these disorders does not alter the appearance of the patient.
functional disorder
A disorder in which there is no known physiologic reasons for the abnormal functioning of an organ or organ system
Functional disorder
A complex, difficult-to-identify mental disorder whose onset typically occurs during early adulthood. Symptoms typically become more prominent over time and include delusions, hallucinations, a lack of interest in pleasure, and erratic speech
Schizophrenia
______is a state of delusion in which the person is out of touch with reality. Affected people live in their own reality of ideas and feelings. To the person experiencing a psychotic episode, the line between reality and fantasy is blurred. That reality may make patients belligerent and angry toward others. Patients may become silent and withdrawn as they give all their attention to the voices and feelings within. Psychotic episodes occur for many reasons; the use of mind-altering substances is a common cause, and that experience may be limited to the duration of the substance within the body. Other causes include intense stress, delusional disorders, and, more commonly, schizophrenia. Some psychotic episodes last for brief periods; others last a lifetime.
Psychosis
______is a complex disorder that is not easily defined or easily treated. It affects how a person thinks, feels, and behaves. The typical onset occurs during early adulthood, between the ages of 16 and 30 years. Symptoms of the illness become more prominent over time. Some people in whom schizophrenia has been diagnosed display signs during early childhood; their disease may be associated with brain damage or may have other causes. Other influences thought to contribute to this disorder include genetics and psychological and social influences. Patients with schizophrenia may experience symptoms including delusions, hallucinations, paranoia, a lack of interest in pleasure, and erratic speech.
Dealing with a psychotic patient is difficult. The usual methods of reasoning with a patient are unlikely to be effective because the psychotic person has his or her own rules of logic that may be quite different from nonpsychotic thinking.
Schizophrenia
___is a condition of impairment in cognitive function that can present with disorientation, hallucinations, or delusions Agitation is a behavior characterized by restless and irregular physical activity. Although patients experiencing___ are generally not dangerous, if they exhibit agitated behavior they may strike out irrationally. One of the most important factors to consider in these cases is your personal safety.
If you think you can safely approach the patient, be calm, supportive, and empathetic. Be an active listener by nodding, indicating understanding, and by limiting your interruptions of the patient’s comments. It is extremely important to approach the patient slowly and purposefully and to respect the patient’s personal space. Limit physical contact with the patient as much as possible. It is also imperative that you do not leave the patient unattended, unless the situation becomes unsafe for you and your partner
Delirium
A temporary change in mental status characterized by disorganized thoughts, inattention, memory loss, disorientation, striking changes in personality and affect, hallucinations, delusions, or a decreased level of consciousness
Delirium
A medical emergency sometimes encountered in an EMS response is excited delirium.___ is also known as agitated delirium or exhaustive mania.
The symptoms of___ may include hyperactive irrational behavior with possible vivid hallucinations, which can create the potential for violent behavior. Common physical symptoms include hypertension, hyperthermia, tachycardia, diaphoresis, and dilated pupils. Because hallucinations are erroneous perceptions of reality, the patient may perceive you as a threat. Agitation is recognized as a biologic attempt to release nervous tension and can produce sudden, unpredictable physical actions in your patient.
Excited delirium
If the patient’s agitation continues, request ALS assistance so chemical restraint can be considered. Uncontrolled or poorly controlled patient agitation and physical violence can place the patient at risk for sudden cardiopulmonary arrest.
Physical agitation can lead to sudden death, thought to result from metabolic acidosis, though the cause of death is not clear.
Physical control measures (including TASERs) can contribute to sudden death in these patients. Also, this condition can be worsened by stimulant drugs (eg, cocaine) or alcohol withdrawal. Finally, ____occurs when a patient’s physical position restricts chest wall movements or causes airway obstruction. It can also cause sudden death. This condition can occur unintentionally when a patient is being physically restrained
positional asphyxia
Protocols should include only the use of restraint devices that have been approved by the state health department or local EMS agency. Restraint types can be soft, leather, or cloth. Soft restraints can include sheets, wide wristlets, and chest harnesses. Hard restraints can include plastic ties, handcuffs, or leather restraints. EMS protocols should avoid the use of hard restraints if possible. If hard restraints are approved, they will most likely be limited to the use of leather wrist restraints. The type of restraints used should not occlude circulation in the extremity and should allow the EMT to quickly remove them if the patient vomits or respiratory distress develops.
Restraints
Personnel must be properly trained in the use of restraints. Improperly applied restraints can result in severe and potentially life-threatening complications, such as positional asphyxia, aspiration, severe acidosis, and sudden cardiac death.
Restraints
If you restrain a person without authority in a nonemergency situation, you expose yourself to a possible lawsuit and to personal danger. Legal actions against you can involve charges of assault, battery, false imprisonment, and violation of civil rights. You may use restraints only to protect yourself or others from bodily harm or to prevent the patient from injuring himself or herself. In either case, you may use reasonable force only as necessary to control the patient, something that courts may define differently.
For this reason, follow local protocols and your company prehospital restraint policy, and consult medical control if needed.
You should always involve___ personnel if you are called to assist a patient in a severe behavioral health emergency, especially when restraining a competent individual against his or her will.____ may provide physical backup in managing the patient and serve as the necessary witnesses. A patient who is restrained by_____ personnel is in their custody.
law enforcement
Unlawfully placing a patient in fear of bodily harm
Assault
Unlawfully touching a patient or providing emergency care without consent
Battery
The confinement of a person without legal authority or the persons consent
False imprisonment
Once the decision has been made to restrain a patient, you should carry it out as quickly as is safely possible. Make sure you have adequate help to safely restrain a patient. Ideally,____ should be present to carry out the restraint, each being responsible for one extremity and the head.
five people
Use the _____that is necessary to control a patient. Avoid acts of physical force that may cause injury to the patient. The level of force will vary, depending on the following factors:
• The degree of force that is necessary to keep the patient from injuring himself or herself, and others.
• A patient’s sex, size, strength, and mental status, including the possibility of drug-induced states. Phencyclidine (PCP) use may make the patient especially difficult to restrain.
• The type of abnormal behavior the patient is exhibiting.
Other important considerations include:
• Somebody, preferably you or your partner, should talk to the patient throughout the process.
• Remember to treat the patient with dignity and respect at all times.
• Wear appropriate barrier protection during patient restraint activities.
• Never leave a restrained patient unattended.
minimum force
Physically uncooperative patients should be restrained in the___ position with one arm restrained up and one restrained down. The head can be elevated at a 30° angle, if possible, to help prevent airway compromise. Both legs and both arms should be restrained. Restraining the hips, thighs, and chest inhibits movement. Restraining the thighs just above the knees prevents kicking and is more effective than only restraining the ankles. Do not place anything over the patient’s face, head, or neck. If the patient is spitting, a surgical mask may be placed loosely over the patient’s mouth.
supine
Patients should never be transported while hobbled, hog-tied, or restrained in a prone position with hands and feet behind the back, as____ could occur.
It is impossible to adequately monitor the patient in this position, and it may inhibit the breathing of an impaired or exhausted patient. Patients should never be transported while sandwiched between backboards or mattresses. Stretcher straps should be applied during transport as the standard procedure for all patients. Sheets can be used as additional stretcher straps if necessary. Stretcher straps and sheets should never restrict the patient’s chest wall motion.
positional asphyxia
A ___technique is an option if allowed per local protocols. This technique is performed in the same way as four-point restraint, except instead of restraining all four extremities to the stationary frame of the stretcher, one arm is placed upward toward the head and the other is placed downward toward the waist
two-point restraint
When working with a potentially hostile or violent patient,____ everyone from the scene who is not needed, such as family, friends, or bystanders. This will prevent injury or the likelihood of someone agitating the patient. Conversely, if a family member has a positive influence on the patient, you may consider allowing him or her to help.
remove
Other factors to consider in____ a patient’s potential for violence include the following:
• Poor impulse control
• A history of truancy, fighting, and uncontrollable temper
• History of substance abuse
• Depression, which accounts for 20% of violent attacks
• Functional disorder (If the patient tells you voices are telling him or her to kill, believe it.)
assessing
One specific behavioral crisis that is common among teenagers is___. According to the Centers for Disease Control and Prevention,___ is the second leading cause of death for people 15 to 24 years of age. Although we sometimes tend to view a teenager’s problems as minor, problems often appear insurmountable to them. Never discount a teenager’s comments about____ as being “just an attempt to get attention.”
suicide
The single most significant factor that contributes to suicide is__. Anytime you encounter an emotionally depressed patient, you must consider the possibility of suicide.
Depression at any age, feeling trapped or purposeless
• Feelings of helplessness and hopelessness
• Previous suicide attempt (Approximately 80% of successful suicides were preceded by at least one prior attempt.)
• Current expression of wanting to commit suicide or sense of hopelessness
• Specific plan for suicide
• Family history of suicide
• People older than 40 years, particularly if single, widowed, divorced, alcoholic, or depressed (Men who are older than 55 years have an especially high risk and are often successful if they make an attempt.)
• Recent loss of spouse, significant other, family member, or support system
• Chronic debilitating illness or recent diagnosis of serious illness
• Feeling anxious, agitated, angry, reckless, or aggressive; also, dramatic mood changes such as from depression to agitation
• Financial setback, loss of job, police arrest, imprisonment, or some sort of social embarrassment
• Alcohol and substance abuse, particularly with increasing use
• Children of an alcoholic or abusive parent
• Withdrawal from family and friends or a lack of social support, resulting in isolation
• Significant anniversaries of sentinel events
• Unusual collection or acquisition of things that can cause death, such as a gun or a large volume of pills
depression
____can occur after exposure to, or injury from, a traumatic event. Such events may include sexual or physical assault, child abuse, a serious accident, a natural disaster, war, loss of a loved one, or stressful life changes. People may have experienced fear of danger, helplessness, or a severe reaction during the event. The reaction could be to trauma that occurred long ago or may be the result of multiple traumatic events over time. It is not necessarily the result of one isolated or recent event.
It is estimated that 7% to 8% of the general population will experience signs of___ at some point in their lives. For health care workers returning from a warfare environment, which could include disaster workers, threat of personal harm is considered a predictive factor in determining in whom___ will develop.
Posttraumatic stress disorder (PTSD)
Military personnel who experienced combat have a high incidence of__.___ occurred in up to 20% of veterans of
the Iraq and Afghanistan Wars, 10% of Gulf War veterans, and 30% of Vietnam War veterans. Reminders of their experiences in the military such as news coverage or gatherings of veterans can also be triggers.
PTSD
The_____ provides the fight-or-flight mechanism to help protect us in a perceived dangerous situation. It is not intended to last any longer than required to mitigate the threat. People with PTSD suffer nervous system arousal that continues and is not easily suppressed. Heart rate increases to channel blood into the heart, lungs, and brain; pupils dilate; and systolic blood pressure is increased. Senses are sharpened and mental acuity is heightened. The victim may be hypervigilant or display an exaggerated startle response to perceived danger.
sympathetic nervous system
People with PTSD can relive the traumatic event through intrusive thoughts, nightmares, or even flashbacks.___ are uncontrollable events triggered by a sound, sight, or smell. The patient may experience the same visceral response as when he or she initially encountered the stress. These episodes can last seconds or hours and can occur at any time, even years after the exposure. The person fears this inability to control a flashback and worries that it will present as irrational behavior. Recent traumatic events may also trigger old memories and create a reflex reaction of preparing for the worst. A person who has experienced flashbacks may become preoccupied with the perception of danger. Hypervigilance and trouble sleeping are not unusual.
Flashbacks
_____occurs when the person attempts to escape from constant internal distress or a particularly disturbing event. His or her altered consciousness allows him or her to continue functioning under negative conditions. Some people may undergo an out-of-body experience. Others experience delusions. Other psychological conditions such as personality disorders and increased functional impairment can develop in those with a___ subtype of PTSD.
Dissociative PTSD
Guilt, shame, paranoia, hostility, and depression are not uncommon for combat veterans. Alcohol and/or drug use is a common way to suppress the _____activity and slow down the body. This attempt at anesthesia can easily become addictive. Suicide is sometimes sought to end the pain. Veterans are much more likely to harm themselves or try to harm themselves. They also sustain a host of physical conditions, some from injuries sustained in combat, and sometimes vague, unfocused pain not associated with any specific pait of the body. This perception of physical pain may be a sign of their anguish. In particular, combat veterans may have heart disease at a younger age than expected, a higher incidence of type 2 diabetes, and a loss of brain gray matter. High cholesterol and hypertension are not uncommon and are often undiagnosed or misdiagnosed.
sympathetic nervous system
Another consideration for the combat veteran is the higher incidence of sustained from trauma secondary to explosion of an improvised explosive device (IED). In some cases, the___ may go undiagnosed due to similarities with the symptoms of PTSD or because the patient downplays the symptoms. People with___ can sustain sensory dysfunction, confusion headaches, memory loss, and general disorientation. Memory loss can include retrograde and anterograde amnesia (before and after the event). Try to eliminate excess noise. Do not touch or do anything to the veteran without an explanation.
Interestingly, diesel fumes often can be a trigger for combat veterans. Keep your diesel equipment far enough away.
TBI
Inability to remember events after an injury
Anterograde amnesia
Failure to provide the same care that a person with similar training would provide
Negligence
Unilateral termination of care by the EMT without the patients consent and without making provisions for transferring care to another medical professional with the skills and training necessary to meet the needs of the patient
Abandonment
When a patient is not mentally competent to grant consent for emergency medical care, the law assumes that there is___. For example, the consent of an unconscious patient is implied if life or health is at risk. The law refers to this as the emergency doctrine: Consent is implied because of the necessity for immediate emergency treatment. In a situation that is not immediately life threatening, emergency medical care or transportation may be delayed until the proper consent is
obtained
In cases involving behavioral health emergencies, however, the matter is not always clear. Does a life-threatening emergency exist or not? If you are not sure, contact your supervisor if available or appropriate based on local protocols, or contact medical control. Only with the concurrence of medical control can the patient be taken into custody with an emergency petition. Once the emergency petition is in place, law enforcement personnel can be used to help achieve restraint and transport.
implied consent
The principle of law that permits a health care provider to treat a patient in an emergency situation when the patient is incapable of granting consent because of an altered level of consciousness, disablilty, the effects of drugs or alcohol, or the patients age
Emergency doctrine
The general rule of law is that a____ adult has the right to refuse treatment, even if lifesaving care is involved.
However, in psychiatric cases, a court of law would probably consider your actions in providing lifesaving care to be appropriate, particularly if you have a reasonable belief that the patient would harm himself or herself, or others, without your intervention. If you decide a patient must be transported against his or her will, make sure you have the appropriate resources on scene to avoid unnecessary injury to the patient, you, or your partner. In addition, a patient who is impaired in any way, whether by mental illness, medical condition, or intoxication, may not be considered___ to refuse treatment or transportation. These situations are among the most perilous you will encounter from a legal standpoint. When in doubt, consult with your supervisor or medical control. Always maintain a high index of suspicion regarding your patient’s condition assume the worst and hope for the best. Err on the side of treatment and transport. Carefully document the patient’s statements and behavior to support your actions.
competent
