Beyond the Basics: Behavioral Emergencies

CEU Review Form Behavioral Emergencies (PDF)Valid until December 6, 2006

A "psych emergency" call comes in for a patient who is talking to himself on a main street in town. You respond cautiously, and, although the police are on the scene, you scan it carefully for hazards. The patient is sitting on the steps of a family grocery talking with the police. The police officer sees you coming and smiles. "Ladies and gentlemen," he says, "I'd like you to meet the Lord."

     Before you can even formulate a response, the patient tells you, "It's OK. He doesn't believe me. But quite frankly, I have been taking persecution for years, and it continues to this very day."

     Anyone who has been in EMS for any amount of time has seen patients with delusional thoughts. Psychiatric emergencies are common calls for EMS providers. Some estimate that more than 20 million people in the United States are being treated for depression. To put this in perspective, a similar number of people experience asthma. Zoloft and Lexapro (antidepressants) and alprazolam (Xanax, for anxiety) were included in the top 20 most prescribed medications in 2005.

Altered Mental Status
     EMS providers should consider all behavioral emergencies altered mental status until proven otherwise. The stories of diabetic patients acting like they're drunk or experiencing behavioral emergencies are many-and costly, if this basic concept is overlooked.

     Even patients who have a history of psychiatric conditions can experience medical problems like diabetes. Medications taken for psychiatric conditions are powerful. Misuse-either intentional or accidental-can cause alterations in the patient's mental status and serious acute medical conditions.

     The mnemonic AEIOU-TIPS is commonly used to identify conditions in the differential diagnosis for altered mental status (Table I). Note that there are many versions of this mnemonic.

Pathophysiology of Psychiatric Disorders
     Articles much more extensive than this have been written about the causes of psychiatric conditions. While brain chemistry is the focus of pharmacologic treatment, some of the causes of psychiatric conditions remain less than clear.

     It is widely held that changes in levels of neurotransmitters in the central nervous system are responsible for conditions like depression. What makes listing an exact pathophysiology challenging is the fact that many people are not clinically depressed until a particular event or series of events occur in their life. This means that their neurotransmitters were either in a normal or subclinical range until some sort of emotional trauma caused changes in these important substances. Furthermore, in some cases, patients may be successfully treated without medications (behavioral and cognitive therapies) to improve conditions such as depression, anxiety and obsessive-compulsive disorders without altering neurotransmitter levels pharmacologically.

     Neurotransmitters send impulses through the synaptic cleft, commonly called synapse, or space, between two nerve cells. The neurotransmitter is released from the presynaptic neuron and crosses the synaptic cleft to the postsynaptic neuron. When the neurotransmitter binds to the receptor on the postsynaptic neuron, the cell depolarizes and propagates the impulse through the nervous system.

     The neurotransmitter is then broken down by an enzyme and undergoes a process of reabsorption or reuptake. This process occurs in milliseconds and is repeated continuously in the central nervous system. As mentioned previously, it is believed that a reduced level of neurotransmitters is responsible for conditions like depression.

Medications
     While medications are commonly discussed in the treatment category, in fact, there are few field medications for the patient with a behavioral emergency. Since many medications are designed to alter the level of neurotransmitters in the brain, this section logically follows here. Antidepressants will be used as an example, due to their prevalence in relation to other medications.

     Early antidepressant medications were the tricyclics. Named for their chemical structure, tricyclic antidepressants targeted the neurotransmitters norepinephrine and serotonin. In about the same time period, another class of drugs, the monoamine oxidase (MAO) inhibitors, were introduced. In addition to targeting reuptake of norepinephrine and serotonin, MAO inhibitors also targeted dopamine.

     While effective for treating depression, the side effects of tricyclics and MAO inhibitors and strict dietary requirements of the MAO inhibitors were often prohibitive.

     A newer class of drugs, serotonin-selective reuptake inhibitors (SSRIs), was introduced with fewer side effects and without dietary restrictions. This class of antidepressant is in widespread use today.

     A class of drugs called serotonin-norepinephrine reuptake inhibitors (SNRI) has been introduced that affect levels of serotonin and norepinephrine (as the older tricyclics did), but without the side effects of tricyclics and without some of the potential sexual side effects of SSRIs.

     Other medications, sometimes called atypical antidepressants, are also in use. One of these is Wellbutrin (buproprion), which acts on serotonin, norepinephrine and dopamine, with concentration on dopamine.

     Medications like lithium may also be used when conventional medications do not provide therapeutic effects. Lithium is a mood elevator often used in bipolar disorder and to elevate the mood of depressed patients.

     Medications in the antidepressant class are frequently used for other conditions, such as anxiety disorder and obsessive/compulsive disorder. Common medications, listed by class, are shown in Table II.

Behavioral Emergencies
     In the EMS world, we like definites, although we aren't always allowed to have them. We know that bradycardia is a heart rate below 60 and tachycardia is a rate greater than 100. If only behavioral emergencies were that easy. In fact, we sometimes try to base our clinical decisions in the field on a "normal baseline." Even this can be challenging, since "normal" is a very subjective word. Rather than being a baseline, "normal" is a wide, gray area that borders mental illness. Further confounding definitions of mental illness are the varied beliefs and norms of the culturally diverse society we live in.

     What is the difference between depression and clinical (or serious) depression? When does behavior tip the scale to be considered actual depression? When a loved one dies, isn't depression "normal?" When is behavior outrageous enough to be considered psychosis?

     The simple, field impression is based on whether the patient is a harm to him/herself or others. This is often the barometer for when we transport a patient for further care.

     Clinically, mental illness is diagnosed using a set of criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Currently in version IV-TR (text revision), the DSM is published by the American Psychiatric Association and lists specific diagnostic criteria for conditions that otherwise may seem less than objective.

     In addition to whether the patient is a harm to him/herself or others (a difficult determination in many cases), the DSM relies on other factors including:

  • The patient's clinical presentation (as determined in a mental status examination)
  • How long the condition has persisted
  • How the condition has affected the patient's life including:
    • Relationships
    • Employment
    • Living conditions
    • Appetite and nutrition (weight gain or loss).

     Examples of diagnostic guidelines for depression are listed in Table III. Note the specific criteria for diagnosis. Partial criteria for schizophrenia are listed in Table IV as an example of another common condition.

Mental Status Examination
     The patient who is experiencing a behavioral emergency should receive the same history and physical exam as any other patient, with an eye toward the differential diagnoses of the altered mental status patient (AEIOU-TIPS).

     Once the sample history and physical exam are completed, and you believe that you are in fact dealing with a patient experiencing a behavioral emergency, move to the mental status examination. This examination, performed routinely in both out- and in-patient facilities, will allow you to obtain pertinent psychiatric findings not present in the SAMPLE history, as well as accurately and intelligently document the patient's psychiatric signs and symptoms.

     Components of the mental status examination include:

  • Appearance and General Impression
         How does the patient appear to you? How is he acting in general? Note the patient's attire and level of hygiene.

  • Affect
         What is the patient's affect (often defined as the outward projection of the patient's mood or behavior)? It may range from excited to flat (absent).

  • Thought processes
         This step looks at thought content and processes. Does the patient's thinking make sense? Is it in keeping with his environment? Is there a consistent association between his thoughts? Is there evidence of hallucination (auditory, visual, tactile, olfactory)? Does the patient feel he has any special ability or powers, or believe he is someone he isn't? Does the patient feel as if he is being watched or controlled by an outside force? These are called delusions (see Table V).

  • Speech
         Observe the patient's speech as an indicator of thoughts (above), as well as a sign in itself. Does the patient speak? Does the speech appear pressured (as though words are forced out when the mouth is opened)? Is speech slow or monotone?

  • Judgment and Insight
         How does the patient feel he is doing right now? Does he feel he needs help? Has the patient done or suggested anything (taking off clothes in public or cold temperatures, running in traffic) that indicates judgment that is questionable or harmful? Has the patient mentioned or attempted suicide?

     Use these components of the mental status examination as a guide to observation and history-taking. The categories and descriptions contained within also pose a suitable framework for documentation of your exam. It is often difficult to describe someone who is acting in an usual manner. Use of the word "abnormal" should be avoided. Instead, detail the patient's affect, thoughts, speech and judgment descriptively and with examples.

Care for the Behavioral Emergency Patient
     Just as the assessment of a patient experiencing a behavioral emergency may seem subjective, the lack of steadfast rules in caring for the behavioral emergency continues the challenge for EMS providers. Following are a few concrete guidelines for patient care:

  1. Ensure safety during the scene size-up and throughout the call. While not all behavioral emergency patients will be out to hurt themselves-or you-caution is always warranted. Seek law enforcement assistance early in the call.
  2. Observe for and maintain an open airway.
  3. Consider all patients experiencing unusual behavior as having altered mental status until proven otherwise. This tenet of care has saved many providers from a lawsuit when assuming a diabetic, stroke or disabled patient was really a "psych." Remember that medications taken for psychiatric conditions are extremely dangerous if taken in excess.
  4. Treat all medical and traumatic conditions.
  5. If restraint is required, never restrain the patient face down (see restraint later in this article).

     Much of the care we give is interpersonal, not clinical. After ensuring safety and ruling out treatable medical conditions, our interpersonal dealings with the patient form the bulk of our care. We can't dictate in this article what to say or when. This must come from you, using the following guidelines:

  1. Be calm and direct. Don't hesitate to talk to the patient about his/her condition. In fact, it is often better to be direct and respectful rather than tentative and uncomfortable. If you can't talk about a patient's condition with him, he won't talk to you.
  2. Use appropriate body language. Show interest and openness while maintaining a safe position and distance. Avoid looking disinterested or using closed body language.
  3. Have a plan. Patients are surprisingly receptive to a plan expressed confidently. Conversely, patients will detect hesitance in your voice. Explain slowly and clearly what you are going to do. Patients who feel they are losing control may respond positively to this. "I am going to take you to the hospital. The police are going to help us get to the ambulance, and then I'll put you on the stretcher for the trip. We're going to take good care of you." Asking whether the patient wants to go to the hospital when there really is no choice is counterproductive.
  4. Never play into delusions. Don't agree with or further a patient's delusions. It is unprofessional and counterproductive to the patient's care. Many times, a part of the patient is clinging to reality and he will sense patronizing behavior.

Restraint
     In some cases, restraint will be required to ensure the safety of the patient and crew during transport to the hospital. Restraint must be done in accordance with local laws and protocol. In most states, it is the police who have the ability to authorize transportation of a patient against his will.

     Restraint may be accomplished by a number of methods, which will vary depending on the number of persons attempting restraint and the equipment available. While, in theory, law enforcement should do the restraining, it is common practice for EMS to perform restraint alongside law enforcement personnel. Concepts of effective restraint include:

  1. Have enough people to perform restraint effectively-generally four or five people, when possible. This allows one person for each extremity and another for the head, or to assist another provider. When working around the patient's head, use caution to avoid a bite wound.
  2. Use soft, humane restraints. Avoid handcuffs or flex-ties.
  3. Restrain the patient in a face-up position. Although spitting and derogatory remarks about your mother may tempt you to restrain in the prone position, don't.
  4. When restraining, position the patient so he can't use major muscle groups (e.g., biceps) to pull against your restraints.
  5. Monitor the patient continuously. Be especially aware of patients who have been struggling and agitated but suddenly become quiet and calm. In some patients, this may be an indication of unresponsiveness and apnea.

Conclusion
     Behavioral emergencies lack some of the objective clinical signs and symptoms we have become accustomed to in other medical emergencies. In this article, we have presented some of the criteria used to diagnose these conditions, as well as some of the terminology, assessment and treatment considerations that will make the care of your next behavioral emergency patient more effective.

CEU Review Form Behavioral Emergencies (PDF)Valid until December 6, 2006

Bibliography
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association, 2000.

Daniel D. Limmer, AS, EMT-P, is a paramedic with Kennebunk Fire-Rescue in Kennebunk, Maine, and a faculty member at Southern Maine Community College. He is the author of several EMS textbooks and a nationally recognized lecturer.

Joseph J. Mistovich, MEd, NREMT-P, is a professor and the chair of the Department of Health Professions at Youngstown (OH) State University, author of several EMS textbooks and a nationally recognized lecturer.

William S. Krost, BSAS, NREMT-P, is an operations manager and flight paramedic with the St. Vincent/Medical University of Ohio/St. Rita's Critical Care Transport Network (Life Flight) in Toledo, Ohio, and a nationally recognized lecturer.

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