Why EMS providers need to know causes of behavioral emergencies

Understanding the underlying cause of a patient's behavioral changes is necessary to assure accurate treatment is started

Your crew responds to a 25-year-old behavioral health patient who has voiced a desire to hurt himself. Upon patient contact, he is awake, alert, and cooperative, so law enforcement is disregarded. The crew has no indication the patient will be violent so he is placed supine on the stretcher with three belts in preparation for transport to the hospital.

While in the ambulance, the patient becomes agitated. He quickly removes the belts and tries to get off the stretcher, stating "I want out ... now!"

The situation escalates rapidly and the crew feels threatened. The patient gets off the stretcher and starts yelling obscenities while the driver attempts to slow down, merging out of traffic to safely stop the ambulance.

The patient then punches the attendant in the chest, knocking him back into the captain’s chair. The EMT is incapacitated after the blow to the chest. The patient jumps from the back of ambulance while it is still rolling to a stop. With the ambulance door now open, your crew watches him run off into the darkness.

Behavioral health adverse events

The Center for Patient Safety began collecting data around behavioral health encounters in early 2015 when EMS leaders expressed an interest in learning the frequency and dynamics of certain high-risk events. The events include provider and patient safety concerns, such as the story above, involving patient elopement from an ambulance.

Since the collection of these types of events began, more than 100 have been reported to the CPS Patient Safety Organization. The data provides a small glimpse of what is occurring on a national scale in pre-hospital contact and during inter-facility transfers.

The events also highlight the community struggle with behavioral health resources. Inpatient treatment is often difficult to locate for behavioral health patients. Once a bed is found, the patient may require transportation of many miles to the closest receiving facility.

"Nursing home residents are at particular risk of behavior changes due to acute onset of illness. Understanding the underlying cause of behavioral changes is necessary to assure accurate treatment is initiated. Many times, these behavior changes are a sign of serious illness that if left untreated, could become life-threatening." Amy Vogelsmeier, PhD, RN, FAAN, Associate Professor, University of Missouri Sinclair School of Nursing, Consultant to CPS, said.

Risks to patients and providers

Behavioral health encounters present opportunities for risk not only for the patient but also the provider. Encounters that appear benign can rapidly escalate, placing the provider and patient at risk.

Many communities have made great strides in building relationships with law enforcement officials to clarify roles and support one another during these encounters. However, there are still frequent situations when law enforcement is not available or is not involved. These situations require EMS to handle the situation alone. Even with the best laid plans and protocols, these encounters can prove to be dangerous for all involved.

No encounter is the same and every patient’s needs are different. Therefore, experience, skills and training are critical for EMS providers. A variety of education and training ensures the provider can protect themselves and their patient from harm. Ask a provider who has been assaulted or had a situation deteriorate and it was often because the provider was not prepared or aware of their surroundings. The situation becomes dangerous; keep a keen eye on situational awareness and constant vigilance to protect yourself and patient. 

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