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CHAPTER 24 Behavioral Emergencies

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KEY TERMS
Abnormal behavior
Behavior exhibited by a person that is outside the norm for the situation and is socially unacceptable;
this behavior may result in harm to the person or to others.

Behavioral emergency
A situation in which a person exhibits abnormal behavior that is unacceptable or intolerable to the
person, family members, or the community.

Domestic dispute
A form of violence that results from a family argument and may result in abuse of the spouse or
children.

Psychotic
Behavior exhibited by a person who has lost touch with reality.

Reasonable force
The force required to prevent a person from injuring himself or herself or others.

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CHAPTER 24 Behavioral Emergencies

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IN THE FIELD
Sara and Sean are dispatched to the home of a 45-year-old woman. Her neighbors have requested that
EMS and the police check on the woman because they haven't seen her in 3 days. She was recently
widowed, and her neighbors report that she has been very depressed.
Sara and Sean recognize that a depressed patient may become a behavioral emergency. They wait for law
enforcement officers to arrive before they approach the scene. After Sara and Sean ring the doorbell
several times, the woman answers the door. She clearly has not been taking care of herself; her clothes are
dirty, and her hair and face are unwashed. Sara begins to ask the woman questions about how she has been
feeling lately. The woman admits to feeling depressed since her husband's death and to feeling that she
can't take care of herself. Although the woman is calm and quiet, Sara and Sean recognize the potential for
violence in this situation; as with all patients, they treat the woman carefully and with respect, and they
also make sure to speak to her very gently and calmly. She agrees to be transported to a hospital where she
can be evaluated and can receive help in dealing with her feelings.

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EMTs respond to many situations involving behavioral emergencies, from stress reactions to severe altered
mental status resulting from illness or injury. Some behavioral emergencies result from mental illness or the
use of mind-altering substances, such as alcohol, illegal drugs, or prescription medications. Being aware of
behavioral emergencies and their causes will help you handle these situations and understand the options
available to you as a caregiver. Sometimes EMTs approach an apparently safe scene, such as a medical call,
but then discover a danger present. For this reason, it is acceptable for EMS providers to contact law
enforcement officers prior to entering any situation.

BEHAVIOR
Behavior is the manner in which a person acts or performs. All physical and mental activities are part of a
person's behavior. A great many factors can influence behavior, including cultural norms, stress levels, and
psychological makeup.
A behavioral emergency results when a person exhibits abnormal behavior in a situation that results in
potential harm to himself or herself or to others (Fig. 24-1). An abnormal behavior is one that is
unacceptable or intolerable to the person, family members, or the community. It might be the result of
extreme emotion and could lead to violence. It can also be caused by traumatic injuries or acute illness, such
as lack of oxygen or low blood sugar.

BEHAVIORAL CHANGES
Many situational stresses, medical illnesses, and legal or illegal drugs, including alcohol, can alter a
person's behavior. For example, diabetic individuals may show a change in behavior, such as
aggressiveness, restlessness, or anxiety, if the level of sugar in their blood drops. In such cases not enough
energy is reaching the cells, and the brain suffers from the lack of nutrients, resulting in an altered mental
status. Lack of oxygen and inadequate blood flow to the brain are other causes of an altered mental status,
resulting in similar behavior. These conditions may result from head injuries or other trauma with loss of
blood.
Other possible causes of behavioral changes are the use of mind-altering substances and extremes of body
temperature. Many medications can affect a person's mood and behavior. When considering the potential
that medications are affecting a patient's behavior, assess for prescription, over the counter, and illicit drug
use. Extreme changes in body temperature can also affect a person's behavior. Excessive cold as well as
excessive heat can cause a person to act irrationally.

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Fig. 24-1 A self-inflicted knife wound in the throat.

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Be aware of the environment in which you find the patient, and document any findings such as
temperature, lack of food, lack of proper ventilation, cleanliness, and so on. These findings may be
important for you and the receiving facility to treat the patient properly.

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PSYCHOLOGICAL CRISES
Other changes in behavior may result from mental illness and may produce psychotic thinking or
depression. A person experiencing a psychological crisis may panic easily as a result of very little stress or
may become agitated with no apparent or obvious provocation. These patients may be a danger to
themselves or to others. They can be provoked to violent behavior, and their behavior can change quickly
and unpredictably. Patients experiencing certain psychoses think and behave differently. A patient with
paranoia may be convinced that people are plotting against him or her. A manic patient may be very
agitated, moving and speaking rapidly without producing clear or complete sentences. A depressed patient
may not want to move or answer any questions. Treat these patients gently, and avoid making sudden
movements or actions so as not to scare or agitate them.

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SUICIDAL GESTURES
When you examine a patient who may be experiencing an abnormal behavior, determine whether the
patient may be at risk of harming himself or herself or others. A person who is notably depressed may be
expressing thoughts of death or suicide and may seem very sad in expression and behavior. It is important
to recognize signs of depression and suicidal gestures before the patient behaves self-destructively. Box
24-1 lists some risk factors that may help you determine whether a person is at risk for suicidal behavior.

BOX 24-1 Risk Factors for Suicide

Patients over 40 years of age, widowed or divorced, alcoholic, or depressed

Patients who have spoken of taking their own lives

Patients with a previous history of self-destructive behavior

Patients with recently diagnosed serious illness

Patients in an environment in which there is an unusual gathering of destructive items (e.g.,


guns or large amounts of pills)

Patients who have recently lost a loved one

Patients who recently were arrested or imprisoned

Patients who have lost their job

The fact that patients do not have any risk factors for suicide, however, does not mean that they are not at
risk, and patients who have some risk factors may not be considering suicide. Find out from family
members and friends if the patient has been depressed recently. Patients may seem cheerful when you are
present, but previous indications of risk factors are extremely important. Depressed patients may be too
exhausted to commit suicide but may be at risk thereafter.

REVIEW QUESTIONS
BEHAVIOR
1. Define the word behavior.
2. Which of the following are considered risk factors for suicide?
a. Divorce
b. Beginning a new job
c. Recovery from recent illness

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d. Previous destructive behavior
e. Recently widowed
3. A behavioral emergency exists when the person acts in a(n)_____________ manner that may
be a threat to himself or herself or others.

ASSESSMENT AND EMERGENCY CARE


SCENE SIZE-UP
The first action EMTs should take in the emergency medical care of a patient with a suspected behavioral
emergency is the scene size-up. Be careful when examining the patient's environment. The environment
may be unsafe, or the patient may have an unsafe object that presents a risk. The patient may be seated in a
defensive position or may have the fists clenched. Note whether the patient is calm or standing and
yelling, and observe how the patient is moving. Try to determine whether the patient is under the influence
of alcohol or other drugs. If you believe the scene is unsafe, do not enter. Contact law enforcement
personnel as needed.
Gather information from family members or bystanders about the patient's behavior prior to your arrival.
Do not let the patient get between you and the nearest exit route (Fig. 24-2). Stay near doors or exits if
possible. If the scene becomes unsafe and cannot be secured after you have entered and begun care, exit as
quickly as possible. See Chapter 9 for more detailed information regarding safety.

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Fig. 24-2 Do not allow any participant in a dispute to position himself or


herself between you and the door or exit route.

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ALERT!
Stay near doors and exits. Never let the patient position himself or herself between you and the door,
blocking your route of escape.
You may need to remove the patient from the surroundings and bystanders in order to perform the
assessment. For example, an adolescent with peers present may not answer questions correctly for fear of
embarrassment or may not want to admit a problem in front of friends.

BOX 24-2 Signs of Potential Patient Violence

Sitting on the edge of the seat as if ready to move

Clenched fists

Yelling and using profanity

Standing or moving toward the EMT

Throwing things

Holding onto a potentially dangerous object

Any behavior that makes the EMT uneasy

If the patient was or is displaying destructive behavior toward himself or herself or others or if you feel
threatened or sense that the situation may get out of control and you require additional assistance, first
leave the scene and then contact law enforcement officers. Box 24-2 lists some signs of potential violence.
As you enter a situation, approach the patient from the head (if supine) rather than from the side or the foot
in case the person has a weapon. Don't forget that violent patients can also use items EMTs bring into the
situation (e.g., flashlights, clipboards, and scissors) as weapons.

ALERT!
Use caution! Any item near the patient may become a dangerous object if the patient intends to do
harm.
Often violence erupts in a domestic dispute. Scenes involving interpersonal violence are highly charged
emotionally for both the patient and the abuser, and it is essential to have law enforcement personnel on
scene if violence is suspected. Interview and treat the patient separately if possible. If you suspect abuse to
a spouse, child, or elder, request law enforcement assistance.

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COMMUNICATION AND EMERGENCY MEDICAL CARE
After determining that the scene is safe, introduce yourself and explain to the patient why emergency
medical services personnel are there (if the patient is not the one who called EMS). Then assess the patient
for injury or illness. If there is a medical problem, perform the appropriate interventions while explaining
everything to the patient. Assess how the patient feels and whether he or she is experiencing suicidal
tendencies.
Ask questions to determine whether the unusual behavior has a medical or psychological cause, although
too much prying may provoke aggressive behavior in some individuals. Ask basic questions to assess the
patient, such as, What is your name, the date, and your address? How do you feel? Would you like
some help with your problem? Do you have a history of diabetes or heart disease? Usually the answers
to simple questions such as these can help you determine the patient's psychological status.
Observe the patient's appearance, activity, speech, and orientation for time, person, and place. If you
suspect a drug overdose, take any drugs or medications found at the scene to the medical facility with the
patient. Always treat the patient with respect and dignity.

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In cases of interpersonal violence in which you may suspect abuse of a spouse, child, or elder, request
assistance from the police. Document any abuse observed or your reasons for suspecting abuse and report
that information to the receiving medical facility. Medical providers are generally required to report
suspected abuse, so know the laws in your state regarding the documentation and reporting of suspected
abuse.

CALMING THE PATIENT


Try to calm the patient if he or she is upset, and do not leave the patient alone unless you are in danger.
Ask all questions in a calm, reassuring manner without judging the patient. Repeat the patient's answers to
show that you are listening. Always acknowledge how the patient feels, and do not challenge or argue with
the individual. During questioning, remain a comfortable distance from the patient, use good eye contact,
and do not make sudden movements. It is imperative to remain calm. Question family members and
friends to obtain a detailed history of the patient, including medical and psychiatric illnesses. Perform an
initial assessment of the patient, including an evaluation of mental status and the potential for violence or
suicide.

RESTRAINTS
In some situations you will be unable to calm the patient sufficiently to approach and provide care safely.
Family members often insist that the patient be taken to a medical treatment facility or that the person be
treated for his or her own safety or well-being. Patients who cannot be calmed and who are showing
destructive behavior toward themselves or others may need to be restrained before treatment and transport
(Principle 24-1).

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Follow your local protocols and laws regarding restraints. In many areas restraints cannot be used without
the cooperation of law enforcement officers or without consultation with medical direction. Some EMS
providers may be prohibited from restraining patients under any circumstances.
Use of restraints can be dangerous to the patient. Suffocation, poor circulation distal to the restraints, poor
access to the airway or an injury, and poor access to the patient are medical problems that can arise from
improper use of restraints. Never turn patients face down on the stretcher to restrain them. Numerous cases
of suffocation have been documented in patients who were restrained in this position, in which it also is
impossible to monitor the airway adequately or treat any changes in the patient's condition.

PRINCIPLE 24-1 Restraining a Patient


1. Have adequate help, including police assistance if possible.
2. Have a plan of action.
3. Use only necessary force.
4. Stay beyond the patient's range of motion.
5. Act quickly.
6. Talk to the patient.
7. Work with another EMT or other personnel; decide in advance how each of you will restrain a
limb, and approach together.
8. Secure the limbs with approved equipment, such as soft restraints.
9. You may cover the patient's mouth with a surgical mask or an oxygen mask if the person is
spitting or biting.
10. Reassess the situation frequently, including the patient's vital signs and physical status.
11. Document all your actions and the patient's actions.

ALERT!
Never restrain a patient face down on the stretcher.

Fig. 24-3 Examples of soft restraints.

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You must document the patient's condition before and after applying restraints and perform several
assessments after application. Patients experiencing a behavioral emergency may later claim injury
because of the restraints. Once again, documentation is extremely important. Use soft leather or padded
cloth restraints, not metal handcuffs, to avoid soft tissue damage (Fig. 24-3). If applying a mask to a
patient, use one that will not obstruct the airway or reduce oxygen flow, such as a surgical mask or an
oxygen mask. Once restraints have been applied, do not remove them; restraints should be removed by the
receiving facility or law enforcement officers. If the restraints are too tight when you reevaluate them, they
should be loosened, not removed. Technique 24-1 describes one way to restrain a patient.

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TECHNIQUE 24-1 Restraining a Patient


1. Four EMTs approach the patient; each EMT restrains one extremity.

2. Place the patient supine and secure the extremities with soft restraints.

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See Chapter 3 for more information on legal issues regarding the use of restraints and law enforcement
concerns.

ASSESSMENT AND EMERGENCY CARE


1. The first assessment the EMT should perform is the_________.
2. Patients should be restrained in the __________ position.
3. What should you do if you suspect abuse?

MEDICAL AND LEGAL CONSIDERATIONS


CONSENT
Patients generally have the right to choose whether to be treated for their medical problem and/or
transported to a treatment facility. Patients with behavioral emergencies represent a unique challenge in
that they may not be competent to make decisions about their own care, particularly if they are a threat to
themselves or others. If an emotionally disturbed patient consents to treatment and transport, the decisions
are more easily made and the legal problems are avoided or greatly reduced.

RESISTANCE TO TREATMENT
Unfortunately, emotionally disturbed patients often resist treatment or transport. The patient may threaten
to harm you or others if approached. Once again, follow local protocols regarding the care of patients who
refuse treatment. In general, you must decide whether the patient is mentally able to make an informed
decision. Consider the patient's psychological status, level of consciousness, age, vital signs, and injury (if
present). A competent adult may choose to refuse treatment even after being informed of the
consequences. See Chapter 3 for more information on consent.
Adults showing abnormal behavior or an altered mental status may refuse treatment after being informed
of the consequences because they do not understand the seriousness of the illness or injury. Such patients
may be transported without consent after you contact medical supervisors. To treat or transport a patient
without consent often requires the assistance of law enforcement officers to restrain a patient. If you are
unsure of the mental capabilities of the patient, you should choose to treat and transport.

USE OF FORCE
The use of force in behavioral emergencies should be limited to reasonable force, which is the force
necessary to keep patients from injuring themselves or others, including yourself or other personnel. Law
enforcement officers usually are needed if force is necessary, although sometimes you also may be
involved in the process.

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Use only enough force to keep the patient from injuring himself or herself or others, and avoid physical
force that may injure the patient. Be aware that after a period of combativeness and aggression, some calm
patients unknowingly may be provoked to cause unexpected and sudden injury to themselves and others.

ALERT!
Reasonable force depends on:
1. The patient's size and strength
2. The type of abnormal behavior exhibited by the patient
3. The patient's mental status
4. The method of restraint used

DOCUMENTATION
EMTs cannot be too cautious when dealing with an emotionally unstable patient. Documentation of all
abnormal behavior exhibited by the patient is extremely important (Box 24-3). Because patients may
accuse EMTs of sexual misconduct, have a witness present for treatment and transport. If same-sex
attendants are available, let them provide or assist you with care. You or your partner should never be
alone with psychologically unstable patients.

BOX 24-3 Important Documentation for Behavioral Emergencies

The position in which the patient was found

Any aggressive or abnormal action by the patient

Anything unusual the patient says, documented in direct quotations if possible

Assessment findings in detail

Restraining procedures used and assessment findings before and after their use

Persons assisting or witnessing the treatment and transport of the patient

REVIEW QUESTIONS
MEDICAL AND LEGAL CONSIDERATIONS
1. When is it acceptable to use force to restrain a patient?
___________________________________
2. What is the definition of reasonable force?

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__________________________________
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CHAPTER SUMMARY
BEHAVIOR
EMTs must be aware that any call can involve a behavioral emergency. Even if the scene size-up does not
indicate an immediate danger, the situation may later become dangerous. A behavior is the manner in
which a person acts or performs, including all physical and mental activity. A behavioral emergency is a
situation in which a person exhibits abnormal or unacceptable behavior that is intolerable to the person,
family, or community. A change in behavior may result from mental illness, situational stress, alcohol,
drugs, medical illness, or a traumatic injury.

ASSESSMENT AND EMERGENCY CARE


Be aware of the danger that can arise when dealing with a behavioral emergency. Always be concerned for
your own safety and the safety of others. Under no circumstances should you risk injury to yourself or
others.
Determine whether the patient is a danger to himself or herself or others and consider the need for law
enforcement officers and restraints. Patients may have certain risk factors that predispose them to suicidal
thoughts and tendencies.
Perform the scene size-up first. Observe the patient's environment, attitude, and behavior. Do not let the
patient get between you and the nearest door or exit route. Talk to family members, friends, and
bystanders when obtaining the patient's history. If the patient cannot be managed and is a threat to himself
or herself or others, consider the use of restraints. Follow local protocol to get approval from medical
direction or seek the assistance of law enforcement officers before using restraints. Use only reasonable
force when restraining a patient. Perform several assessments after applying restraints to ensure the
patient's safety.

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Be very cautious when dealing with a behavioral emergency. Emotionally disturbed patients often refuse
treatment or transport. You may treat a patient without consent if you believe that the patient will harm
himself or herself or others. Document all patient behaviors and witnesses for later verification if needed.

MEDICAL AND LEGAL CONSIDERATIONS


It is essential that you know the local protocols and laws regarding the treatment and transport of patients
who refuse care. In general, patients who are mentally competent can elect to refuse care. Determine
whether the patient is mentally competent to make an informed refusal. If you are unsure, elect to treat and
transport. Seek medical direction and assistance from law enforcement officers in difficult situations.
Document all events in the situation so that you can legally defend any actions you took or did not take in
the treatment of the patient.

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United States Department of Transportation National Highway Traffic Safety


Administration EMT-Basic Objectives
Check your knowledge. The National Registry of EMTs and many state EMS agencies use the
objectives below to develop EMT-Basic certification examinations. Can you meet them?

Cognitive
1. Define behavioral emergencies.
2. Discuss the general factors that may cause an alteration in a patient's behavior.
3. State the various reasons for psychologic crises.
4. Discuss characteristics of an individual's behavior that suggest the patient is at risk for suicide.
5. Discuss special medical and legal considerations for managing behavioral emergencies.
6. Discuss the special considerations for assessing a patient with behavioral problems.
7. Discuss the general principles of an individual's behavior that suggest the person is at risk for
violence.
8. Discuss methods to calm patients with a behavioral emergency.

Affective
1. Explain the rationale for learning how to modify your behavior toward the patient with a
behavioral emergency.

Psychomotor
1. Demonstrate the assessment and emergency medical care of the patient experiencing a
behavioral emergency.
2. Demonstrate various techniques for safely restraining a patient with a behavioral problem.
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Review Questions Answer Key


BEHAVIOR
1. The manner in which a person acts or performs
2. A, D, E
3. Abnormal

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ASSESSMENT AND EMERGENCY CARE
1. Scene size-up
2. Supine
3. Separate the patient from the potential abuser and report your suspicions.

MEDICAL AND LEGAL CONSIDERATIONS


1. When the patient is a threat to himself or herself or others
2. The force necessary to prevent a patient from harming himself or herself or others

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