In Two Minds? EMS Care of the Schizophrenic Patient

   Assessment and management of the schizophrenic patient pose additional challenges for EMS. You may need to adjust portions of your assessment to meet a patient's special needs. It is imperative that you focus on identifying, ensuring, maintaining and supporting vital functions of the patient's ABCs. Reversible causes that can result in agitation, such as infection, metabolic, endocrine, traumatic and all other medical abnormalities, should be ruled out before you attribute the patient's presenting signs and symptoms to schizophrenia.¹³ These patients will require additional communication skills, patience and compassion.

SCENE SIZE-UP

   Safety of both provider and patient is paramount. Look for hazards within the scene that may indicate suicidal or homicidal intentions. Patients may listen to and obey perceived forces that are out of their control and may be violent in nature. Identify suspected traumatic injury.

   If necessary, utilize police or additional resources to ensure a safe environment. The use of both physical and chemical restraints for patients displaying violent behavior is heavily dependent on local protocol. If restraints are required, ensure that they are used appropriately and you retain respect for the patient. Remember, patients with schizophrenia may have no indication of what is truly happening in their environment; others may be overly suspicious and falsely believe that harm will come to them if they cooperate with emergency responders.

GAINING CONSENT FOR TREATMENT

   Gaining informed consent for treatment may pose a challenge with these patients. As with all patients, a pre-existing diagnosis does not exempt them from making an informed medical decision or refusing care; however, patients with schizophrenia may require greater in-depth analysis of decisional capacity before doing so.¹³ Patients with an altered mental status should be evaluated in the emergency department. A patient suspected of being under the influence of a substance, such as alcohol, must be evaluated by a physician who can identify if he is medically stable.¹⁰ Always err on the side of the patient.

ASSESSMENT

   Assess the patient's mental status and identify his response to the environment. If the patient has a suspected head or spinal injury, apply cervical and spinal immobilization.

   Establish and maintain an open airway. If the patient is unable to provide for his own airway, utilize mechanical devices or endotracheal intubation as directed by your protocol. Have suction devices available.

   Determine if the patient is breathing adequately and if bilateral breath sounds are present. If breathing is inadequate, provide a high concentration of oxygen via positive pressure ventilation. If it is adequate, provide supplemental oxygen. Use pulse oximetry and patient presentation to identify and maintain oxygen saturation higher than 95%.

   Assess the patient's pulse and circulation, identify major bleeding and manage any life-threatening conditions. Utilize ECG monitoring and establish IV access if necessary. If the patient's condition warrants, treat for shock.

   Obtain vital signs and a glucose reading to help rule out hypoglycemia or hyperglycemia as a cause for the patient's presentation.

   Perform a complete head-to-toe assessment. Remember, you must rule out all other possible causes before concluding that the signs and symptoms are from schizophrenia. Identify and treat findings as you would for other medical or trauma patients.

   In addition to the usual assessment, note the patient's mood, affect and speech (pattern, words, tone, rate and volume), as well as any expressed or viewed impairments in judgment, impulse control or memory. Document all findings objectively.

VERBAL INTERVIEW

   For patients without life-threatening findings, the verbal interview will provide a significant amount of information that will be utilized throughout the patient's care. Conduct the interview in a quiet, non-threatening environment, reduce external noise and stimuli, and be an active listener. Speak with a calm, non-threatening voice and focus on what and how the patient describes what is happening to him. Build a good rapport with the patient. Do not argue with or agitate him, and do not give in to his delusions. Some patients understand that what they experience is not real, but they operate in both their perceived world and the real world. It may be necessary to obtain some information from family or bystanders about the patient's history, medications, behaviors or norms. Take into consideration what information is disclosed and from whom the information is received.