Tips for assessing an adolescent psychiatric patient

You were asked to respond to the nurse’s office at the high school for a patient with lacerations up both forearms; did you make the right decision?


Whenever you respond to a patient with a potential behavioral or psychiatric complaint safety needs to be a chief concern for all responders involved with the call. Your safety and that of your crew, patient and bystanders must continue to be a point of focus even as the call progresses. Situations can escalate quickly and there have been reports recently of EMS providers being attacked on scene of calls.

On this particular call, you were asked to respond for a teenager with a "controlled hemorrhage." Obviously there are many calls which fit this criteria and your first response when hearing such vague dispatch information should be, "Why was she hemorrhaging in the first place?" In many EMS systems around the country, radio traffic is not secure and can be monitored by the public with relatively inexpensive and easily obtained equipment. In this case, the dispatcher may be intentionally vague to keep from overtly announcing a suicide attempt at a local school over the radio. When it seems like dispatch is using intentionally vague language considering calling them on the phone for more specific information.

When arriving on scene and establishing that you and your colleagues are relatively safe, turn your attention to the patient and determine if she represents a danger to herself. In cases like this scenario, determining if the patient attempted to take her own life (as the school resource officer suspects) can change your assessment and treatment, as well as the transport destination for the patient. Often, determining whether or not a suicide attempt has taken place requires much more than simply asking the right questions; it takes the patient trusting responders so that genuine answers are given to your questions.

Building a rapport
Webster’s Dictionary defines rapport as a "relation marked by harmony, conformity, accord or affinity." Having a good rapport with a patient means that there is a level of trust between him/her and the medical provider.

EMS providers are often placed in situations where they are required to ask a variety of sensitive or personal questions of their patients. Taking care with how such questions are asked and even where they are asked (in front of bystanders vs. in the privacy of the ambulance) can go a long way toward establishing trust and building a good rapport.

Behavioral emergency patients, particularly adolescents, often respond well to providers who express genuine concern for their situation and ask appropriate, respectful questions in an environment which respects their privacy. All patients have a story to tell but these patients in particular should be allowed to tell their story at their own pace rather than have EMS providers assume the intent behind the patient’s actions.

Self-injury vs. suicidal gesture
While any episode of self-harm is concerning, not every self-harm act is a suicide attempt. While the exact definition of Non-Suicidal Self-Injury (NSSI) is somewhat debated, the main difference from a suicidal attempt or gesture is the intent behind the action [1]. NSSI is an action not intended to end the life of the patient whereas a suicide attempt is driven by such an intent.

EMS providers may find themselves called to scene where bystanders have already assumed that an episode of self-harm is a suicide attempt, but that assumption may not be correct. Providers should take care to let the patient tell their own story before determining whether or not intent may have existed. In most cases, these patients will be transported for treatment and evaluation by mental health professionals, but EMS providers can assist in the initial assessment and history taking.

It is important to note that while a particular episode of NSSI may not be a suicidal gesture, such episodes are statistically linked to suicide and an episode of NSSI (particularly cutting-type behavior) may accidentally result in a more serious outcome or even be fatal [1].

There is not much data currently available regarding the prevalence of NSSI in the general population [2]. This is because most of the data is derived from patient populations already under the care of a mental health professional so they cannot easily be applied to more broad populations. Even so, a 2011 study looked at rates of NSSI among college students and found that among more than 14,000 participants, female respondents were more likely than males to act when upset or in hopes that "someone would notice" whereas males were more likely to act when angry or intoxicated. The average rate of NSSI was 15.3 percent while only 8.9 percent reported having disclosed an episode to a mental health provider [3].

Know your community resources
Once an EMS provider has a sense of the intent behind the action taken by their patient knowledge of resources available in the community (and applicable protocols) becomes the chief guiding principal in deciding the next steps for the patient. Some EMS systems may allow providers to medically clear a patient and then transport the patient to a specific psychiatric receiving facility. Other systems may have a specific emergency department designated to receive behavioral and psychiatric patients of particular ages. Also, determine if your city or county has crisis services available that you may be able to provide the patient with access to. A good place to start when compiling lists of resources is the social work department of your local hospital.

Conclusion
After determining that the school counselor has a good rapport with Alicia you ask the other members of your crew to step out of the office while you and the counselor remain behind. Since you have determined that Alicia’s injuries are not life threatening you begin to ask questions about what her intent was when she cut her arms. Alicia states that she was upset about her parents’ imminent divorce and that cutting helps her feel some temporary relief and distraction from her stress and anger. You ask if she intended to kill herself and she says no. Based on the protocols in your system, the local pediatric emergency department is the preferred destination for all behavioral and psychiatric patients Alicia’s age. You encourage her to be open with the medical and social work staff at the hospital and the school counselor provides her with contact information for counseling resources within the community. When the transport unit arrives you step out of the office to provide a report before introducing the crew to Alicia. She is transported to the ER without incident.

References

  1. Whitlock, J. (2010). Self-Injurious Behavior in Adolescents. PLoS Medicine7(5), e1000240.
  2. Laye-Gindhu, A., & Kimberly Schonert-Reichl. (2005). Nonsuicidal Self-Harm Among Community Adolescents: Understanding the “Whats” and “Whys” of Self-Harm.Journal of Youth and Adolescence,34(5), 447–457.
  3. Whitlock, J., & et al. (2011). Nonsuicidal self-injury in a college population: general trends and sex differences. Journal of American College Health59(8), 691–698.

About the author

An EMS practitioner for nearly 15 years, Patrick Lickiss is currently located in Grand Rapids, MI. He is interested in education and research and hopes to further the expansion of evidence-based practice in EMS. He is also an avid homebrewer and runner.

  1. Tags
  2. Mental Health
  3. Patient Assessment
  4. Pediatric Care
  5. Scenario

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