How We Deal with Emotionally Disturbed People

FD/EMS-PD

Presenters

• KentVFD EMS Lt. FF/EMT - Bill Leo• Kent PD PO - Alex Vanderwoude

The Call

An EDP shouting obscenities EMS to stage away until the scene is secured. PD Enroute

Stage Away

As EMS stages away EMS attempt to size up the scene.– What's going on is the guy violent?– Is he on meds– Is he on drugs– Is he diabetic– Is he dehydrated

PD enroute

• PD Secure the scene• Is the person under psychiatric care• Is the person violent• Does the person have weapons• What set him off

The Team

Police – EMS - Fire

EMS

EMS Role

• One role of the EMS provider is caring for emotionally disturbed patients. Most of these calls go without incident, with little more than some creative writing.

• But what about when that calm EDP decides he or she wants to rough house? What do you do? Following written guidelines can be tricky in these situations.

• What are your agency policies with emotionally disturbed patients? How do you personally handle these situations?

Signs and Symptoms

• There are many symptoms that can go along with someone being emotionally disturbed. This may happen to a child, but adults can be emotionally disturbed as well. Signs and symptoms of being emotionally disturbed, include inappropriate behavior, a general mood of depression or unhappiness, physical fears of school, or expression of personal problems. These signs can show in various ways depending on the person showing the signs. Inability to build relationships is another sign of being emotionally disturbed.

They can also be Medical or Drug induced

• Hypertension• Hypoperfusion• Diabetes• Dehydration

NYS DOH BEMS PROTOCOLAltered Mental Status

Altered Mental Status for a Non Traumatic patient

Patients must be presumed to have anunderlying medical or traumatic condition causing the alteredmental status.

Note:All suicidal or violent threats or gestures must be taken seriously.These patients should be in police custody if they pose a danger tothemselves or others.

If the patient poses a danger to themselves and/or others, summonpolice for assistance.

NYS DOH BEMS ProtocolBehavioral Emergencies

I. Determine whether the scene/situation is safe. If not, retreat to a safe location, create a safezone, and obtain additional assistance from a police agency.

II. Perform initial assessment.

III. Assure that the patient’s airway is open and that breathing and circulation are adequate.

IV. Consider other causes of abnormal behavior (hypoxia, hypoperfusion, hypoglycemia, etc.)

V. Place the patient in a position of comfort if possible.

VI. Attempt to establish a rapport with the patient.

VII. Restrain, only if necessary, using soft restraints to protect the patient and others from harm.Restraints should only be used if the patient presents a danger to themselves or others!

Behavioral continuedVIII. After application of restraints, keep the patient in the most appropriate position, whileassuring the restraints do not restrict the patient’s breathing or circulation.

IX. Transport, keeping patient warm.

X. Ongoing assessment. Obtain and record the patient’s initial vital signs, repeat enroute asoften as the situation indicates.

XI. Record all patient care information, including the patient’s medical history and all treatmentprovided, on a Prehospital Care Report (PCR).

XII. Document the reason for applying restraints to the patient as well as identifying the individual authorizing restraint of the patient

Two Sides• Los Angeles police officials say at least five officers are under investigation

following the death of Alesia Thomas.

• On July 22, LAPD officers went to Thomas' apartment building on the 9000 block of Broadway after her two children, ages 3 and 12, were found at a police station. Moses says her granddaughter left a note with her children at the police station, saying she could no longer take care of them. Family members say she has struggled with drug addiction.

• When officers went after the woman to take her into custody for suspicion of child endangerment, police say she resisted arrest, causing a violent incident. According to the Los Angeles Times, police officials say an officer kicked Thomas in the groin. When officers managed to put the woman in a patrol car, she stopped breathing and died.

Examples

• A video shot by an onlooker shows Garner telling the officers to leave him alone and refusing to be handcuffed. One responded by appearing to put him in a chokehold, which is banned under police policy. Garner is heard gasping "I can't breathe." He was later pronounced dead at the hospital. Autopsy results are pending.

Customer Service

REGARDLESS - THE EDP IS EVERYONES CUSTOMER

Body Substance Isolation

• PPE and BSI• Get creative when it comes to “the spitter”• Use a NRB

Communication

• When my mother had her heart attack a few year ago, while the EMTs were hooking up electrodes to her chest and giving her nitroglycerin, she asked the paramedics "Am I going to die?". Nobody responded to her. She grew more frantic, and asked again "Am I going to die?" Eventually after asking a couple times, one of the paramedics told her "We're all doing our best here."

• Is this standard procedure? My thoughts are you might as well tell the patient that they're not going to die, so you can at least calm them down a bit.

Communication

• Communication is key• Between PD and EDP• PD and EMS• EMS and EDP

Combative patients: Don't be the "calm down guy"

• Occasionally, patients get out of control. It isn't our preference, but it's an unavoidable fact. We are frequently called upon to provide care to individuals who neither request nor want our help. In fact, we are often charged with protecting and caring for people who wish us harm.

• Unruly patient spits blood at medics

• Whether they are confused, combative or just plain mean, sooner or later we will meet the patient who aggressively tries to escape from us, or harm us. Whole classes and workshops are devoted to the complex task of safely restraining individuals who are fighting to get away or attempting to harm us.

• one critical mistake we often make when we are in the process of restraining a combative individual. This is a mistake that we all fall victim to occasionally, regardless of experience or training. It's the mistake of becoming what I call the calm down guy.

• Who is "the calm down guy" you ask? He is anyone who gets the idea that it would be beneficial to address the patient's aggressive behavior by yelling, "Calm Down!" in their ear. The calm down guy (Yes, it's always a "guy") is the one who places themselves at the patient's head and repeatedly yells, "Calm Down!" as the patient kicks and struggles.

• You've seen the calm down guy, haven't you? Perhaps you've been the calm down guy from time to time? If so, don't feel bad. It just seems like the right thing to do. The patient obviously needs to calm down more than anything.

• If only we could just say it in a forceful enough way, surely they would understand what we need from them.

Regardless of how good your intentions are, yelling, Calm Down!" in someone's ear never, ever helps

There are four good reasons to banish the “calm down guy” forever from your scenes.

The “Calm down guy”1. It doesn't help the patient. Regardless of how good your intentions are, yelling, Calm Down!" in someone's ear never, ever helps them calm down. Try it sometime. When you are feeling frustrated and angry, ask a friend to get right up in your face. Maybe even have them grab a handful of your hair.

2. It doesn't help the calm down guy. Usually, it's the guy who needs to calm down the most who invariably ends up yelling, "calm down!" the loudest. The calm down guy often needs to take his own advice. Let the calm down guy take a step back, take a deep breath and rethink his approach.

3. It doesn't help the team. One provider yelling at the patient tends to wind everyone up. The next person who speaks will invariably speak louder, and so on, until everyone is yelling. The single provider who talks in a calm confident tone will do more to keep the team effective than a chorus of over-excited shouters.

4. It doesn't help the organization. We have to assume that we are always on film. When an Oklahoma State Trooper choked a paramedic on a remote suburban roadside, the act was caught by, not one, but two cameras. What you do on scene can be posted to the internet faster than you can put the rig in drive. In this, hyper-media environment, where everyone has the ability to instantly publish their cell phone video to a world-wide audience, the calm down guy makes everyone look bad.

What you should say instead

Stop Resisting

Another consideration is to NOT have the officer(s) screaming "stop resisting" as they are wrestling with an violent EDP, drunk, or PCP overdose victim.

CHAOS BREEDS CHAOS

More Communications

• Having one communicator can really help. Once a team member has become the voice of the team, then that should be the only voice the out of control patient hears. Also, keep your team's goal in mind at all times, the safe transport and disposition of the patent. Focus on that and keep the difficult patient in front of you.

• Remember that at the end of the day, given your professional attitude and behavior, you will win, you will always win, the patent will get where they need to be and everyone gets to go home.

Calming1. Let the calmest provider talk to the patient. You probably know who that person is already. In any situation there is usually one person who is known for their calming demeanor and unflappable attitude. Let them do the talking. Position them at the head and have them simply talk to the patient.

2. Speak softer than you think is necessary. You want to be heard, but you can talk far softer than you want to and still communicate just fine. When we want to be heard, our instinct is to talk louder. However, when we drop our voice people tend to become quiet and focus on our words more intently. Speak softly and the volume of all communication on scene will like follow suit.

3. Use the patient's name. If you know the patient's name, use it. And explain what you are doing. Bob, you need to lay still. Help us take care of you Bob. The more personal you can make it the better. Using the patient's name sends an unspoken message to the patient that their identity is important to us. It also reminds everyone involved in the encounter that there is a real human being on the opposite end of all of this conflict.

More Calming4. Use the jury test. Now that we have a calm person speaking softly and using the patients name. What should they say? Imagine that your care for this patient was called into question and a jury was allowed to watch a video of you wrestling with your patient. Their job is to decide if your care was appropriate. Imagine that the volume on the video were turned down and you were allowed to explain to the jury what you were doing and why. What would you say?

Say those things to the patient. Say, "We don't want to hurt you Bob. Please stop fighting us. We need to care for you Bob. Please don't punch us. Bob, I need you to stop kicking. I know you don't want to hurt anyone. We're very concerned about you. We're trying to be gentle with you Bob, but you're making it very hard."

The things that you would want an untrained outsider to understand about why you did the things you did are the things you should tell the patient. If that worst case scenario ever happens, you won't have to worry about turning down the volume. Your testimony will already be on the video. And all of those statements in the above paragraph are far more likely to calm an angry patient than screaming, "Calm down!" in their ear.

I recall a saying that my EMS educator friend, David Fending, was often fond of quoting. He would say, "On a cardiac arrest, the first pulse you check should be your own." Dave's joke was a valid reminder. Sometimes, we need to check our own pulse. Often, when the calm down guy shows up on scene, it's time to step back and reevaluate our strategy.

Let the calm down guy be a reminder to the team. Instead of demanding calm from the patient, double check the team's pulse. It may be time for everyone to take a deep breath and move in a new direction.

You are being watched!

NEW YORK — Four emergency workers involved in the medical response for a New York City man who died in police custody after being put in an apparent chokehold have been barred from responding to 911 calls, the Fire Department of New York said.

The two EMTs and two paramedics removed from the city's emergency response system are the latest public safety workers to face reassignment as questions mount about Thursday's death of Eric Garner. Two police officers — including the one who put his arm around Garner's neck — have been put on desk duty.

The medics' modified duty restrictions will remain in effect pending an investigation into their actions, fire department spokesman James Long said Sunday.

A video showed the responders and cops walking in circles as the man was lying on the sidewalk unresponsive .

Combative Patient Restraining

The vast majority of psychiatric or possible combative patients shouldn't need restraints. 95% of the time talking to them like an actual person, treating them with respect and attempting to verbally de-escalate the situation is more than effective.

Combative Patient Restraining• The general principle is always least invasive first, most invasive last. The gold standard for least

invasive is simply talking the patient down, and the most invasive thing we would do is chemical sedation (an antipsychotic and/or benzo, usually).

• Physical restraints should be of the soft type, and something designed for the purpose (so not tape, backboard straps, sheets, stretcher straps, etc). The idea is to make it as safe as possible for both patient and crew.

• When the decision is made to get physical, the object is to approach the patient with overwhelming force. You may win in a one on one battle with a patient, but it is going to be chaotic and someone is going to get hurt (probably you). It is always best, if possible, to slow things down and try and get help before getting physical. You should have more people than you need. Sometimes, even just the presence of overwhelming force is enough to turn a patient around. Other times not.

• If you are alone in the back of the ambulance with a patient that suddenly starts trying to hurt you, your partner needs to stop the ambulance, call for help, and then help you either contain the situation or help you escape danger (even if it means getting out of the ambulance and/or letting the patient go). The safety of the crew is the first priority, and there is no point in taking a moral stand on the "YOU NEED TO GO TO THE HOSPITAL BECAUSE YOU'RE INTOXICATED" fight. Definitely not worth it.

EMS & PD

• An officer MUST ride in the ambulance whenever a patient is handcuffed

• The EMT (Crew Chief) MUST notify the law enforcement officer in charge if any member of the ambulance crew feels uncomfortable or threatened to transport an EDP without PD

• PD can follow-behind if unable to ride aboard

Law Enforcement