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Behavioral emergency: 6 EMS success tips

Follow these methods to facilitate a safe contact with a patient experiencing hallucinations, suicidal ideations or acting violently


Few calls challenge EMS providers like emergencies in which a patient has lost control of their behaviors or emotions and poses a threat to themselves or to others. With a behavioral emergency, the patient is rarely the one who dials 911 and, therefore, our arrival in the ambulance, with flashing lights and loud sirens, can raise the patient's anxiety and paranoia. In addition, it may be difficult to get a good history on these patients; they might refuse our care and — in the worst cases — may react violently to our attempts to help.

When you’re called to help someone who is experiencing hallucinations, suicidal ideations, or is angry and combative, here are six ways to facilitate a safe and successful patient contact.

1. Be vigilant about safety
The circumstances of a call involving a violent patient or one experiencing delusions can change instantly, so you need to trust your gut on what resources you need in order to keep yourself and your crew safe. Should you search your patient for weapons before you load them into the back of the ambulance? Would another EMS provider, or police officer, in the back of the ambulance make the transport safer?

Soft arm restraints are a great way to prevent your patient from removing their seatbelts, taking a swing at you, or pulling out that necessary IV. A spit hood or nonrebreather mask flowing oxygen is effective at preventing an exposure from a spitting patient. Be proactive in requesting or implementing these safeguards, instead of waiting for the situation to go south. The back of the ambulance becomes very cramped, claustrophobic and dangerous when a combative patient is on the loose. 

2. Search for a medical complaint behind the behavior
A patient who is hypoxic, who has a head injury or brain bleed often presents quite similarly to someone suffering a behavioral emergency. The patient might be anxious, irritable, angry or combative. Before you immediately decide your patient is suffering from a mental illness or having an acute psychotic episode, work hard to obtain a full history of the present illness, a full set of vital signs and do a detailed physical exam to rule out trauma, hypoglycemia, alcohol or drug withdrawal, or dementia.

"You prove what your patient is suffering from by proving everything it’s not," my paramedic preceptor instructed as a way of always being thorough in my assessments, and I’ve followed his advice ever since.  

3. Relax the patient's environment
Environmental factors often contribute to an acute behavioral emergency. When you arrive on scene, ask yourself how you can remove stimuli the area to help de-escalate the situation. Can you remove family members or other bystanders who might be triggering a negative emotion in your patient? Is it possible to soften the lighting, turn down music and limit background noise to calm the patient's auditory and visual hallucinations? 

Maybe you shouldn’t immediately bring in all your equipment off the ambulance, such as the gurney, cardiac monitor, airway bag and medications bag, because the patient may view it as a threat. By creating a relaxed external environment, you help facilitate your patient’s internal world. 

4. Stay calm in the midst of a storm
In the blur of a behavioral emergency, it is important to attempt to reorient and refocus the patient. If you are afraid and uneasy, it will likely worsen the patient’s agitation and panic.

Instead, speak to your patient directly, maintain eye contact, and remind them who you are and that you’re there to help. Sometimes giving the patient a small task such as writing down their name and address can help shift their mind away from their present distress. Avoid any sudden movements that may trigger the patient’s paranoia. Always keep a safe distance between you and the patient and never let them stand between you and the exit. 

5. Be an active listener and speak the truth
A person suffering a behavioral emergency is likely experiencing one of the worst days of their lives. Therefore it is imperative to listen mindfully, with compassion, and always be honest. Don’t pretend to see any hallucinations your patient is experiencing. Maintain a supportive tone and avoid any comments that may be received as accusatory or belittling.

Try to ask questions that help your patient move beyond their present stress. Speak with the patient to help find out what they ultimately want or need.

If your patient is suicidal, work hard to find something about which they can have hope. Never underestimate the healing power that the presence of a compassionate EMT or paramedic can have.

6. Debrief with your team after the incident
Dealing with a patient experiencing a behavioral emergency is difficult and stressful, so it’s important to debrief after the incident to determine what worked; what didn’t, and how you can improve on the next call. Like treating a pediatric patient, responding to a behavioral emergency is rare and, therefore, many EMS providers are apprehensive about these calls. But with practice and patience, it is possible to lose this fear and to become effective at helping resolve a behavioral emergency. 

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