IACP 2022 preview: Management of the acutely agitated behavioral health emergency
Response to these medical emergencies should focus on intervention and treatment of the patient
Faroukh M. Mehkri is an assistant professor of emergency medicine at the University of Texas SW Medical Center, as well as a SWAT physician with the Dallas Police Department. At IACP 2022, he will present a session on “Management of the Acutely Agitated Behavioral Health Emergency: A Patrol Nightmare.”
As a former EMT, a patrol police officer, and a doctor and SWAT physician, Mehkri offers three unique perspectives. His lecture is the result of a 15-month deep dive into behavioral health emergency patients, their outcomes, and the situations surrounding the call and both police and EMS interventions.
Mehkri’s session will cover the high-stress nature of responses to acutely agitated behavioral health emergency patients, as well as collaborative care with EMS, fire and other first responders. This article recaps his major points and key takeaways.
At the core of the session is the idea that the person at the center of the 911 call is in fact a patient – not a subject, criminal, perpetrator, or suspect, but a patient. If everyone approaches the call and response with the mindset that the individual is someone in a mental health crisis or behavioral health emergency, the situation may not escalate on both sides as fast, if at all.
The inevitable outcome, even though PD arrived first and must deal ahead of any other responder, ends with an EMS and hospital outcome. In simple terms, this is a police response to a medical emergency and the mentality should be one of intervention and treatment of the patient.
Things a cop should know (or try to determine) when approaching a patient in crisis
Presenting condition and history
The dispatch/communication center should, if possible, ascertain if there is a history of violence or a signal of previous crisis or behavioral health responses during the incoming 911 call and pass this on as vital information.
For the responding patrol officers, is it vital to find out if the person has a known psychiatric condition. Information can be gathered from family members or friends regarding whether the person has a condition such as schizophrenia, bipolar disorder, suicidal ideations, or depression.
If the person has a known history or appears to be under the influence of any drugs, particularly stimulating drugs such as cocaine or methamphetamine, Mehkri advises this is a “big red flag.” It is reasonable to assume that the person is already going to be in a different physiologic state of mind where their body is ramped up, hyperactive and potentially aggressive.
Mehkri equates this to a person who has just run a marathon and the officer is stopping them dead in their tracks when they wish to keep running.
Abnormal vital signs such as an extremely fast heart rate or breathing, or extremely high blood pressure, are bad signs. While the average patrol officer does not have a blood pressure cuff, medical equipment, or detailed clinical knowledge, note signs such as a sweaty pallor or fast speech to indicate that the person is acutely agitated.
Altered mental status
As officers learn early in their law enforcement careers, compliance techniques, whether they be physical presentation, verbal commands or even physical restraint depend on a person having a clear capacity to communicate. If the person is in an altered state they not may be to understand to obey commands and instructions given. This may lead to further escalation of the subject.
Dr. Mehkri acknowledges that if a situation deteriorates rapidly, physical restraint is inevitable. He advises that, “When you have a person in front of you who is already identified as a being on the edge of the scale (the scale being from calm to agitated and fighting), there is no magic or secret, they are going to need to be physically restrained and anything else is not realistic as they are a danger, not only to themselves but to others and could potentially have a weapon.”
Physical restraint of the patient should be for the minimum amount of time necessary and in a coordinated fashion with EMS arriving on scene or already on scene.
As Mehkri notes, “physical restraint and body weight on the chest is dangerous and can kill people.”
Mehkri believes that in the ideal situation, at least five officers should respond to these incidents, including a supervisor who controls the scene and crowd. The key element however is to restrain, detain, sit up and then treat via EMS.
Dr. Mehkri identifies that EMS treatment may well consist of chemical sedation, but this is the absolute decision of the medic on scene. In light of recent litigation and legislation across the country following the in-custody death of Elijah McClain, many EMS providers are afraid to use medication for management of patients in an acute behavioral crisis, but Mehkri passionately believes that chemical sedation saves lives. Mehkri stresses that there is no such thing as “chemical restraint” – that the clinical procedure administered is in fact “chemical sedation” and he suggests that calling it restraint in documentation opens all up to a considerable amount of liability.
As already stressed, Dr. Mehkri maintains that in speech and in writing your words matter. How you describe these individuals is important. First off, they are patients. Terms that are not based in evidence-based science should not be used. The bottom line Mehkri offers consists of five points and should be noted by all:
1. Words matter, in your documentation and on your body camera
2. Physical restraint kills – so we must minimize this activity.
3. Chemical sedation for medication management saves lives.
4. Monitor, monitor, monitor.
5. The person is the patient!