# Psych Hold - How do you assess?



## Aprz (Jan 9, 2012)

First I am gonna share with you guys the story about this call I did that prompted me to ask this question. You guys might think I'm really bad (or hopefully not) for saying these things to a patient, but I hope to learn from you guys, and not repeat this mistake.

Today I did a transport, and the hospital was very unhappy with the questions I asked the patient. I thought these were good questions to ask, but they told my partner (not me) that they were inappropriate questions and somebody needs to stop me. My partner wasn't in the room when I asked the question, and he listed off a couple of the things I said that was consistent with what I asked that bothered them, but he said there was more, and that he couldn't remember.

When I walked into the room, I introduced myself, verified she was the right patient by asking her name and checking her name tag/bracelet, and asked the patient how come they where here. We do interfacility transport, and this was dispatched as a 5150 (72 hour psychiatric hold in California) so I already knew. They didn't like that I asked why were they there.

The patient was a minor so I asked if the parents were present. They were also mad that I asked this. My partner said there was something about child protective service, or something, so maybe that's why. I still thought it was a reasonable question.

Here are questions I figured may have bugged them, but these are questions I started asking based off what the facility I transport to them ask. I asked if she had any intention to hurting herself or others, did she have a plan, and if she did, how she planned to do it. When I asked, she said she really didn't mean it, it was the heat of the moment, no plan. She just told somebody that she wanted to die. She is stressed out about school. I asked what grade she was in, and then asked if finals were going on and if that's why she's stressing? This was while the nurse was going in and out of the room, and the security gaurd sitting in front of the entrance of the room the entire time.

By then my partner said "I need to speak with you right now." and signal me to come over. He told me that the nurse and security (security sits in front of the room to make sure 5150s don't try to escape, hurt themselves, or others) said that I was asking "inappropriate questions", and that I need to be stop, I am not a psychologist, and it's not my place to ask these questions.

I think the nurse was trying to get me out of the room the entire time because she said "I'll give you a report outside of the room in just a moment", and I told her "Oh, my partner will actually take your report. He's hunting for you right now." She didn't like my choice of wording "hunting" either he said (like I said, they clearly complained cause he wasn't in the room when I asked these questions).

The reason I was asking these questions instead of him was because usually the EMTs here do an assessment by asking "Do you have any headache, dizziness, nausea, vomiting, shortness of breath, pain, chest pain?", they'll check vitals, lung sounds, and CSM in all extremities, and to me, that's not even really an assessment. If my partner is not present and paperwork is not ready, I'll try to do an assessment, and then I'll give a report to my partner before we start transporting (by the way, they trained us to report to our partner, but usually only AO questions, the list I told you with headache, dizziness, etc...., and if we see anything obvious like a g-tube).

I was pretty bummed because not only was one person mad, but two people where mad (the RN and security guard). To my partner, they made it sound like I was out of control. Neither of them spoke to me or stopped me (maybe cause they are too polite), and talked very negatively to my partner about me as if I was his problem, like a pet almost (that's how I felt), and they smiled at me the entire time. He didn't tell me it was the security guard too either until after the call ended, cause when I stopped, I just waited by the patient on the gurney while waiting for my partner, and the security guard and I talked too, and he was really friendly with me, and I just felt like he was being a phony to me instead (well, really being professional by still smiling and stuff at me).

I was really bummed with this call afterwards. I felt like I really screwed up. How bad am I really am if I couldn't even tell I was doing a bad job during the call? Had nobody told me, I would've continued to think I was doing the right thing.

Perhaps my partner felt I over stepped his role too

He was also telling me about the previous call, he didn't like that I told the parents about HIPAA either. We require a signature so they know their information is suppose to be kept a secret, but that their signature is giving us permission to tell that information to their insurance company so we can bill them rather than sending the bill to the family directly. If they don't sign, a bill will be sent directly to their address instead. He said that I need to be a people person, and just tell them that it's for keeping their info a secret (only tell them half of it, whether they sign or not, I am gonna keep the info secret).

*TL;DR Anyhow, in short, tell me how bad I did. What I could've done to improve. If you work IFT, what kind of questions do you ask a psychiatric hold patient. What's involved in your assessment? Does it change for pediatric patients?*


----------



## JPINFV (Jan 9, 2012)

Oh noes, the security guard was upset. How about the security guard stay focused on security and not medical care, mmkay? 

On the HIPAA note, you don't need permission to bill, it's a "permitted use" under the "treatment, billing, and healthcare operations" heading.

As far as the questions. Where they necessary? Probably not. The patient is already on a hold and deemed a danger to herself, thus the hold. With the exception of deciding if restraints are needed, I don't see how the questions would change treatment. Where they inappropriate in the sense of "You aren't a psychologist"? Absolutely not. If you're ever on a scene call for a patient with an acute psychiatric disorder, then you need to be able to ask those questions to determine the patients legal status (implied consent vs informed consent, the need for a hold vs no hold, etc).


----------



## CBentz12 (Jan 9, 2012)

Thats BS I have been through some Psych calls and as far as what you did I would have done the same. If your going to be transporting this PT you have to know how serious they are and what kind of person they are so you can either A) Prepare yourself for the worst 10-15 minutes or B) Focus on filling out the report while en route whil enot having to worry about the PT taking the straps off and jumping out. I have seen many Psych PTs un strap themselves and try to stand up in the ambulance and I knew they would just by the way they were talking to me during my PT assessment. 

There are some really *****y RN's out there you just have to learn how they are for next time but you can't just go pick a PT up and not say a damn word to them. Especially a minor who feels more comfortable most of the time when you try to get and know them better. You do what you do but I would have asked the same questions and I have before.


----------



## Sasha (Jan 9, 2012)

I've asked similar questions during txp. It's making conversation.


----------



## DesertMedic66 (Jan 9, 2012)

I just do a medical assessment. Any pain, medical history, etc. the way I see it is they are on a hold already so there is no need to asking if they feel like hurting themselves or others. As long as they are on the hold they get restraints regardless. 

It's pretty much "hi my name is EMT John. I work for XYZ company and we are here to transport you to XYZ facility. I already got all your paperwork and all your belongings." then I go thru my sample history and ask the patient if they have any injuries. Then tell them to hop on the gurney and explain the restraints. And then we are off.


----------



## Handsome Robb (Jan 9, 2012)

firefite said:


> It's pretty much "hi my name is EMT John. I work for XYZ company and we are here to transport you to XYZ facility. I already got all your paperwork and all your belongings." then I go thru my sample history and ask the patient if they have any injuries. Then tell them to hop on the gurney and explain the restraints. And then we are off.



This.

You can get all the info you asked from the transfer packet. These people are pissed off already, then they've been stuck in a hospital for who knows how long. The last thing they want is repeat questioning. 

Don't beat yourself up dude, it's not the end of the world. The questions were appropriate questions but like I said before most if not all of the answers will be in the transfer packet. 

Don't let the nurse or security douche get under your skin. They have a hospital with lots of backup. You have your partner who has to stop the ambulance, get out, run around to the door then get in to come and help you if you get into a bind with this patient so it's your right and job to know what's going on. With this said, see what I said before about transfer packets. 

Just look at it as a learning experience.


----------



## JPINFV (Jan 9, 2012)

NVRob said:


> This.
> 
> You can get all the info you asked from the transfer packet. These people are pissed off already, then they've been stuck in a hospital for who knows how long. The last thing they want is repeat questioning.


Maybe I just got lucky, maybe I just have selective memory, but the vast majority of the patients I've transported who were already on a hold weren't pissed off. Resigned? Sure.  Upset? Not many.


----------



## tacitblue (Jan 9, 2012)

JPINFV said:


> Oh noes, the security guard was upset. How about the security guard stay focused on security and not medical care, mmkay?
> 
> On the HIPAA note, you don't need permission to bill, it's a "permitted use" under the "treatment, billing, and healthcare operations" heading.
> 
> As far as the questions. Where they necessary? Probably not. The patient is already on a hold and deemed a danger to herself, thus the hold. With the exception of deciding if restraints are needed, I don't see how the questions would change treatment. Where they inappropriate in the sense of "You aren't a psychologist"? Absolutely not. If you're ever on a scene call for a patient with an acute psychiatric disorder, then you need to be able to ask those questions to determine the patients legal status (implied consent vs informed consent, the need for a hold vs no hold, etc).


This

First off, the security guards opinion on your history taking is a non-issue. The reasons for this are obvious. Also, when I have my patients or their parents sign the HIPPA and Assignment of Benefits section of the PCR, I inform them it is for permission to bill their insurance and for notifying them of their privacy rights. Your partner suggesting you explain any less than this, he is advocating dishonesty.


----------



## Handsome Robb (Jan 9, 2012)

JPINFV said:


> Maybe I just got lucky, maybe I just have selective memory, but the vast majority of the patients I've transported who were already on a hold weren't pissed off. Resigned? Sure.  Upset? Not many.



Agreed. Most are calm. I have run into a few very, very angry ones.


----------



## Epi-do (Jan 9, 2012)

I have asked similar questions, so I don't see a problem with it.  However, I work 911, and not IFT.  Therefore, those answers haven't necessarily been established yet.

Like others have said, don't give a second thought to the security guard.  His job is to provide security, not patient care.  And, when it comes to the signature, I always explain what they are signing, as well as give them an opportunity to read the abbreviated blurb on the form, if they chose to do so.


----------



## Sasha (Jan 9, 2012)

"do you want to hurt yourself or others" is important. I'd like a heads up if they're going to jump out the back or stab me with a pen.


----------



## DesertMedic66 (Jan 9, 2012)

Sasha said:


> "do you want to hurt yourself or others" is important. I'd like a heads up if they're going to jump out the back or stab me with a pen.



It all depends on your system. It's not an important question for my system because:
1) all 5150 patients get 5 seatbelts and 4 point soft limb restraints (company policy). 
2) you should always pay attention to your patient. So you will notice if they are trying to get out of the restraints. 
3) once again watch your patient when you are letting them out of the restraints. And never be the only one there. For our system we have the RN, the monitor tech, a security guard, and then the EMS crew all there for 5150 holds.


----------



## Sasha (Jan 9, 2012)

For mine we only restrain with Dr order. 

The only one in the back is the tech. 

And we have had patients who snap in a second.


----------



## Anjel (Jan 9, 2012)

I disagree with "everyone gets restrained" but whatev.

I think you were asking too many questions . Do you want to hurt yourself or others is important.

But its a kid. I wouldnt be saying "did you try and kill yourself? How were you going to do it? Was it because of school?" I think thats where you crossed the line.

Not to be mean, but you seem to have very little faith in yourself from what I can tell on here. Everything you do you need reassurance and a pat on the head.telling you that you will be ok.

Toughen up a little bit. So when you do get *****y nurses or crazy patients it wont effect you so much, and cause you to loose sleep over it.


----------



## Tigger (Jan 9, 2012)

JPINFV said:


> Maybe I just got lucky, maybe I just have selective memory, but the vast majority of the patients I've transported who were already on a hold weren't pissed off. Resigned? Sure.  Upset? Not many.



I get the idea that most of the holds I transport don't really understand what the hold actually entails and many expect to be released from the destination facility as soon as we arrive. I would never intentionally lie to my patients, but if that's what they want to believe I am not going to potentially upset them by setting them straight. I'm happy to be honest and answer their questions to the best of my ability, but I am not about to go into detail about the hold process or their illness for that matter. Most of the time the angry patients are just angry that they are languishing in an ER and are happy and ready to cooperate to get on the road. Perhaps this is why I've never applied restraints to anyone. I'll bring them in with me, but unless the patient is actively fighting the staff, I'm not going to use them, and even then I doubt I'd even choose to transport until a way to calm the patient down (Hadol) is established.


----------



## Handsome Robb (Jan 9, 2012)

Sasha said:


> For mine we only restrain with Dr order.
> 
> The only one in the back is the tech.
> 
> And we have had patients who snap in a second.



Legal 2000s, Nevada's version of a 5150, are pretty much the only IFTs we run, the rest is 911.

We decide if we want to restrain the pt or the doctor can order it. I have yet to restrain one on an IFT. 9/10 times the Intermediate is attending and the medic is driving. 

5 point seat belts and 4 point soft restraints seems excessive. Not judging, just my 0.02


----------



## JPINFV (Jan 9, 2012)

NVRob said:


> Legal 2000s, Nevada's version of a 5150, are pretty much the only IFTs we run, the rest is 911.
> 
> We decide if we want to restrain the pt or the doctor can order it. I have yet to restrain one on an IFT. 9/10 times the Intermediate is attending and the medic is driving.
> 
> 5 point seat belts and 4 point soft restraints seems excessive. Not judging, just my 0.02



I agree that mandatory limb restraints is bat poop stupid, but if that's the way the county protocol is written, then so be it. Of course I'm the sort of tool that would hand every patient the contact info for the county LEMSA under the concept of play stupid games, win stupid prizes. 

I'm having a hard time figuring out 5 point seatbelts. A chest belt and a leg belt is 4 points. Shoulder straps add another 2 points. A waste belt would add another 2 points.


----------



## DesertMedic66 (Jan 9, 2012)

NVRob said:


> Legal 2000s, Nevada's version of a 5150, are pretty much the only IFTs we run, the rest is 911.
> 
> We decide if we want to restrain the pt or the doctor can order it. I have yet to restrain one on an IFT. 9/10 times the Intermediate is attending and the medic is driving.
> 
> 5 point seat belts and 4 point soft restraints seems excessive. Not judging, just my 0.02



On most patients it is really excessive. And I don't like the fact that we have to restrain all 5150 patients but it's what the company wants, and I like my job lol. I've had to restrain 4 year old patients and 92 year old patients.


----------



## Tigger (Jan 9, 2012)

JPINFV said:


> I agree that mandatory limb restraints is bat poop stupid, but if that's the way the county protocol is written, then so be it. Of course I'm the sort of tool that would hand every patient the contact info for the county LEMSA under the concept of play stupid games, win stupid prizes.
> 
> I'm having a hard time figuring out 5 point seatbelts. A chest belt and a leg belt is 4 points. Shoulder straps add another 2 points. A waste belt would add another 2 points.



There's five buckles? If you count the attachments on the shoulder belts that go through the chest buckle that is.


----------



## exodus (Jan 9, 2012)

JPINFV said:


> I agree that mandatory limb restraints is bat poop stupid, but if that's the way the county protocol is written, then so be it. Of course I'm the sort of tool that would hand every patient the contact info for the county LEMSA under the concept of play stupid games, win stupid prizes.
> 
> I'm having a hard time figuring out 5 point seatbelts. A chest belt and a leg belt is 4 points. Shoulder straps add another 2 points. A waste belt would add another 2 points.



Lap belt, waist belt, chest bealt, shoulder belt x2. Total of 5.


----------



## JPINFV (Jan 9, 2012)

The concept of "point" is "points of attachment." For example, the classic 5 point restraint system for pilots is 2 points for the lap belt (one on the right, one on the left), 1 point for the crotch strap between the legs, and 1 point for each of the shoulder straps.

Lap+waist+chest+shoulder belt would be 8 points of attachment.


----------



## exodus (Jan 9, 2012)

So 12 points counting the soft restraints... Man, we're ballin in points


----------



## DesertMedic66 (Jan 9, 2012)

JPINFV said:


> The concept of "point" is "points of attachment." For example, the classic 5 point restraint system for pilots is 2 points for the lap belt (one on the right, one on the left), 1 point for the crotch strap between the legs, and 1 point for each of the shoulder straps.
> 
> Lap+waist+chest+shoulder belt would be 8 points of attachment.



Are you really getting this technical over seatbelts? :huh:


----------



## JPINFV (Jan 9, 2012)

firefite said:


> Are you really getting this technical over seatbelts? :huh:



If RON PAUL is "Dr. No," someday I'm going to be "Dr. Technical."


----------



## EMS123 (Jan 9, 2012)

*Restraints*

Correct me if I am wrong....

Being strapped to a stretcher can feel restrictive enough with an altered mental status (AMS)/ Psych hold restraints could distress the pt even further.

Granted I feel restraints should be at the discretion of the provider/doctors orders they shouldn’t be used on every psych patient.


----------



## JPINFV (Jan 9, 2012)

Logic and EMS in Southern California doesn't go together.


----------



## MMiz (Jan 9, 2012)

I'm not sure that much more than a SAMPLE history is needed for a psych transport/transfer.  The patient is already diagnosed, and it should all be in the charts.  You're truly a glorified taxi at this point.


----------



## CBentz12 (Jan 9, 2012)

Wouldn't you want to get to know your PT before you ride with them? I mean I have heard some crazy stories about Psych PTs and to me I want to get to know their thoughts or how crazy they might be. There are some who just run on tough times who just need someone to vent too who isnt a doctor and you got the other Pysch PTs who truly want to harm themselves or others. I guess its just all personal prefrence.


----------



## Sasha (Jan 9, 2012)

Off topic but what are the opinions on "playing into delusions"? I know the books say not to but sometimes its easier just to pet an imaginary cat then to deal with the agitated patient when you tell them there is no cat.


----------



## Anjel (Jan 9, 2012)

Sasha said:


> Off topic but what are the opinions on "playing into delusions"? I know the books say not to but sometimes its easier just to pet an imaginary cat then to deal with the agitated patient when you tell them there is no cat.



Ill play into them. If I have to squash some imaginary spiders to get the pt to stop screaming, then let me get my rolled up paper and start swatting.


----------



## Meursault (Jan 9, 2012)

Anjel1030 said:


> But its a kid. I wouldnt be saying "did you try and kill yourself? How were you going to do it? Was it because of school?" I think thats where you crossed the line.


That's what I thought, too. For psych/behavioral patients in the field, I do try to do a review of symptoms for depression, mania, SI/HI, delusions/hallucinations, drug abuse, and anxiety/panic attacks, but I try to avoid delving deeply into their history. Sometimes they'll volunteer info, which is convenient. 
For transfer patients, everything should be in the packet or in the stellar report I always get. I'll usually ask how they're feeling and if I see something like HI with no further info, I'll ask about that, but they've already had a proper interview. 




Sasha said:


> Off topic but what are the opinions on "playing into delusions"? I know the books say not to but sometimes its easier just to pet an imaginary cat then to deal with the agitated patient when you tell them there is no cat.



I have yet to have a patient with innocuous delusions/hallucinations. For my patients with delusions of persecution or the like that don't involve me, I try to appear sympathetic without expressing any definite beliefs or agreeing with them. A perceived friendly ear seems to go a long way. 

When the delusions do involve me or other providers (we're here to drug you and drag you off to an air force base to take you back to Mars for secret government work) I try to gently and persistently counter them with concrete evidence.


----------



## JPINFV (Jan 9, 2012)

"How are you going to do it" is an important question before they're on a hold. However, once they're on a hold it's a good indication that either the patient admitted to a plan or that whoever wrote the hold doesn't believe that the patient doesn't have a plan.


----------



## Meursault (Jan 9, 2012)

JPINFV said:


> "How are you going to do it" is an important question before they're on a hold. However, once they're on a hold it's a good indication that either the patient admitted to a plan or that whoever wrote the hold doesn't believe that the patient doesn't have a plan.



Or isn't confident enough to d/c them regardless. Or hands out psych holds like candy as a precautionary measure in case the patient changes their mind about signing themselves in. Or has been pressured to write one by idiot EMTs.


----------



## JPINFV (Jan 9, 2012)

Oh, and since we're on the topic, I think I should repeat this message. For all that is good and holy, don't take a patient on a hold to the hospital he or she works at for medical clearance unless there's no other choice (like an hour long transport).


----------



## Aprz (Jan 9, 2012)

Some don't have a plan, and a lot of them I personally don't think they should be 5150. Yesterday I had one who was put on a 5150 as a percaution only. She stated she had no plan, no intention of hurting herslef or others, and she only grieving because the previous day someone important to her died. She was also a minor so I think the parents were concern and that's how she ended up on it/ I'm not sure.


----------



## Tigger (Jan 10, 2012)

CBentz12 said:


> Wouldn't you want to get to know your PT before you ride with them? I mean I have heard some crazy stories about Psych PTs and to me I want to get to know their thoughts or how crazy they might be. There are some who just run on tough times who just need someone to vent too who isnt a doctor and you got the other Pysch PTs who truly want to harm themselves or others. I guess its just all personal prefrence.



No, I do not want to get know my psych patients. I want to know if they are going to be a threat to me or themselves, and that they are otherwise medically well. That's it. The very vast majority of psych transports are glorified taxi rides, as MMiz noted. I know that in class it sounds like every hold transport starts with you arriving at the sending facility to find a 300 pound monster trashing the place and holding the entire staff at bay. This just doesn't happen. It's not like you have to take the patient either, if you think the patient is too agitated to transport, don't accept care. Ask an RN nicely enough and you might be able to ensure that the patient is given some medication to "calm him down before transport" if you anticipate problems. Asking doesn't make you a weaker provider.

As a personal rule, I don't wish to apply restraints. Even on the street when we're taking someone for a hold, if the person is so agitated and doesn't want to go, I am calling for PD assistance. I have no interest in my partner and I duking it with a violent, mentally ill person in an unfamiliar environment. Half the time the cops presence will get them to comply peacefully anyway.


----------



## DrParasite (Jan 10, 2012)

When I do a psych transfer, there are 3 questions I always ask the nurse: why is the patient here, are they violent, and are they going to jump out of the back of my ambulance (flight risk).  everything else I will get from the chart or from the patient.





Aprz said:


> they told my partner (not me) that they were inappropriate questions and somebody needs to stop me. My partner wasn't in the room when I asked the question, and he listed off a couple of the things I said that was consistent with what I asked that bothered them, but he said there was more, and that he couldn't remember.


without knowing your experience or your partner's, I would say you should ask your partner if he thought the questions were wrong.





Aprz said:


> When I walked into the room, I introduced myself, verified she was the right patient by asking her name and checking her name tag/bracelet, and asked the patient how come they where here.


all very valid questions to ask.  you might know what the hospital is telling you, but it doesn't hurt to ask the patient.


Aprz said:


> The patient was a minor so I asked if the parents were present. They were also mad that I asked this. My partner said there was something about child protective service, or something, so maybe that's why. I still thought it was a reasonable question.


excellent question, but it should have probably been asked of the nurse first.  that can be a trigger for a problem.  but if the nurse doesn't know, and the patient is a minor, someone needs to sign consent, so the question is valid (if the nurse doesn't have a good answer).





Aprz said:


> I asked if she had any intention to hurting herself or others, did she have a plan, and if she did, how she planned to do it. When I asked, she said she really didn't mean it, it was the heat of the moment, no plan. She just told somebody that she wanted to die.


all legit questions.  it's called getting a history of present illness and events leading up to the incident.  I would have asked the same.





Aprz said:


> She is stressed out about school. I asked what grade she was in, and then asked if finals were going on and if that's why she's stressing?


ehhhh, that's a little personal (asking about how her finals were), but it's simple conversation.  would I have asked it?  no.  would I have dragged you out of the room for asking?  no.





Aprz said:


> This was while the nurse was going in and out of the room, and the security guard sitting in front of the entrance of the room the entire time.


so they witnessed the whole thing, and didn't think it warranted an immediate chat with you either in or outside of the room.  or they did think it warranted an immediate intervention, yet didn't do anything about it directly.  me thinks the former.





Aprz said:


> By then my partner said "I need to speak with you right now." and signal me to come over. He told me that the nurse and security (security sits in front of the room to make sure 5150s don't try to escape, hurt themselves, or others) said that I was asking "inappropriate questions", and that I need to be stop, I am not a psychologist, and it's not my place to ask these questions.


sounds like your partner was a jerk.  My old partner and I had an unspoken rule: we back each other up against anyone else, provided we didn't do something completely against the rules.  we might disagree in private (and frequently did, only once where we needed the supervisor to intervene), we defended each other when someone else said we screwed up.  Sounds like you and your partner weren't like that.





Aprz said:


> I think the nurse was trying to get me out of the room the entire time because she said "I'll give you a report outside of the room in just a moment", and I told her "Oh, my partner will actually take your report. He's hunting for you right now." She didn't like my choice of wording "hunting" either he said (like I said, they clearly complained cause he wasn't in the room when I asked these questions).


get the information from the nurse before you make patient contact.  you might gain some important information about the patient, which is useful to know.  even better. have her give you the report, than your partner can receive a more thorough report.





Aprz said:


> The reason I was asking these questions instead of him was because usually the EMTs here do an assessment by asking "Do you have any headache, dizziness, nausea, vomiting, shortness of breath, pain, chest pain?", they'll check vitals, lung sounds, and CSM in all extremities, and to me, that's not even really an assessment. If my partner is not present and paperwork is not ready, I'll try to do an assessment, and then I'll give a report to my partner before we start transporting (by the way, they trained us to report to our partner, but usually only AO questions, the list I told you with headache, dizziness, etc...., and if we see anything obvious like a g-tube).


wow, you do a more thorough exam on a psych transfer than I used to.  not a bad thing mind you, just a statement.





Aprz said:


> I was pretty bummed because not only was one person mad, but two people where mad (the RN and security guard). To my partner, they made it sound like I was out of control. Neither of them spoke to me or stopped me (maybe cause they are too polite), and talked very negatively to my partner about me as if I was his problem, like a pet almost (that's how I felt), and they smiled at me the entire time. He didn't tell me it was the security guard too either until after the call ended, cause when I stopped, I just waited by the patient on the gurney while waiting for my partner, and the security guard and I talked too, and he was really friendly with me, and I just felt like he was being a phony to me instead (well, really being professional by still smiling and stuff at me).


  The security guard doesn't count.  who cares if they are mad at you?  if you were mad at the actions of security, do you think they would care?  the RN is a little different, but definitely not something to be bummed about.





Aprz said:


> I was really bummed with this call afterwards. I felt like I really screwed up. How bad am I really am if I couldn't even tell I was doing a bad job during the call? Had nobody told me, I would've continued to think I was doing the right thing.


if that's the worst thing you do, be great full.  wait until you kill someone.


Aprz said:


> Perhaps my partner felt I over stepped his role too


ehhhh





Aprz said:


> He was also telling me about the previous call, he didn't like that I told the parents about HIPAA either. We require a signature so they know their information is suppose to be kept a secret, but that their signature is giving us permission to tell that information to their insurance company so we can bill them rather than sending the bill to the family directly. If they don't sign, a bill will be sent directly to their address instead. He said that I need to be a people person, and just tell them that it's for keeping their info a secret (only tell them half of it, whether they sign or not, I am gonna keep the info secret).


 do some research on what HIPPA really is.  it's probably one of the most misunderstood and erroneously quoted laws in healthcare.





Aprz said:


> *TL;DR Anyhow, in short, tell me how bad I did. What I could've done to improve. If you work IFT, what kind of questions do you ask a psychiatric hold patient. What's involved in your assessment? Does it change for pediatric patients?*


I've done worse, you will be fine.  

the only thing I would have gotten is a quick report from the nurse.  sometimes they can give you information that can prevent you from pressing a hot button issue.   but other than that, you did fine, don't let it get to you.


----------



## firetender (Jan 10, 2012)

Aprz said:


> *  asked the patient how come they where here.
> 
> * The patient was a minor so I asked if the parents were present.
> 
> ...


 
Every one of these are valid questions or comments. None of them are unprofessional.

That is, of course, if you're human who happens to be a professional with human concern and curiosity.

You treated the girl as if she were a real human being. And she was...just a human being under stress. That is important for you to know. 

HOW you work with her could make the difference between her having an uneventful transfer and her getting far more traumatized enroute. Is that not part of your job as well as packaging?

I think you followed your instincts and I think they were good. Everyone else was practicing cookbook medicine, and in my book, not medicine at all.

I hear a lot of what sounds like you should treat her like a loaf of bread and just be sure you don't dent her with restraints. That is not patient care.

The parents deserve the information you gave them. You were not interpreting the law.

Too many Flesh Mechanic's eyes looking over you in my book. They're the ones who need help.

Thank you for being your patient's advocate.


----------



## Ewok Jerky (Jan 10, 2012)

*dont get butthurt*

what you did was not inappropriate.  5150s are people too, and medical patients so they deserve whatever assessment you feel is necessary.  you can also talk to them just like you would any other Pt.  

I usually try to get a report from the nurse first.  and I generally save most of my assessment and chit chat for once we are in the rig.  around here, nurses are too busy to "care" about the 5150s, they are just taking up a bed until they get transported (I dont agree thats just how it is).  the 5150s that arent psychotic see this as being ignored and not cared about. half the time no one has told them where they are going or why.  being a Pt advocate I try to let these people know what is going.  now, if a Pt is not interested in talking or they dont care, or they are psychotic, i tend to keep quiet.

one Pt comes to mind.  ATF "suicidal" teenage M in hospital in 4-points.  while waiting for a nurse to give a report i ask him why he is restrained, he tells me he ran away from the ED and the cops had to bring him back.  I ask if he will do it again he says no, i ask if he will jump out of my ambulance he says no, i ask if im cool with him will he be cool with me he says no. i say ok, well im going to put these on you but im not going to tie you down, but i will if you test me.

get him in the rig and he tells me he is not suicidal, he wanted to get high and took his dogs phenobarb.  got sleepy and dizzy and his girlfriend called 911. well, no one had told this kid that phenobarb is a barbituate and too much will make you "so sleepy" that you stop breathing. he says are you serious? you see, this kid wasnt suicidal, just stupid.  

i ask why do you want to get high? he says the psych meds hes on dont work. did you tell your dr? he says no. you should tell him and they can try different meds... 

anyways, when i dropped him off he was smiling, unrestrained, understood why he was on a hold, understood why what he did was stupid and everyone was making a big deal about it, and as I was leaving the room he said "hey Beano, thankyou".  

this isnt to toot my own horn, but APRZ, you need to do what you think is best for your Pt and screw everyone else cause its not their Pt.


----------



## AlphaButch (Jan 10, 2012)

Other than the HIPAA explanation (which just needs refining), I see nothing wrong with your actions.

I would recommend that you look over the transfer paperwork and get a report from the nurse before meeting the patient. As stated, this can clue you into any hot buttons, prior behavior, and may have the answers to all of your questions prior to pt. contact.

As for the question;

"Do you have any intention to hurting herself or others, do you have a plan to do so?"

It is a very appropriate and relevant question to ask, and is often not asked by new providers (EMS, nurses and even physicians) because they're "afraid" of asking. If I don't see it in my packet, I ask. Yes, it should have been asked before a 5150 was issued, but I never assume that someone has done a proper interview. We also teach this and are taught this in every behavioral emergency course I've participated in.


----------



## Nervegas (Jan 10, 2012)

Of all the non-voluntary psych transfers I've done, I always get an officer to ride, always. As medics, we cannot enforce the protective custody orders, they specifically state remanded to a peace officer, not paramedic. If they say they want to hurt themselves, then we can restrain them, but I prefer to just let LE deal with it. 

Voluntary psych transfers are where it gets fun, because if they suddenly decided enroute that they no longer want to go, unless they say they want to hurt themselves, and are oriented and answering questions appropriately, we have to let them go.

As far as assessments, I try to ascertain where they are mentally before they go in the back of the box, I always get a full Hx and will ask many of those exact questions, they are my patient at that point and if they are in the back, then I'm going to do what I need for my charting and pt care/personal safety. I take everything the RN's tell me with a grain of salt until otherwise proven. I cant go to court and point at my chart and say the RN told me his blood pressure was stable, when in fact it wasn't and my own assessment would have revealed that fact, extrapolate that to anything involved in the assessment and you catch my drift.

PS: Just ignore the security guard, he is there for safety, not medical assessment.


----------



## adamjh3 (Jan 10, 2012)

Nervegas said:


> Of all the non-voluntary psych transfers I've done, I always get an officer to ride, always.



On the IFT side this is often impossible, and more often than not unnecessary. In more than a year and a half where 60-80% of my calls were psych IFTs I can count on my hands the number of times PD was on scene prior to my transport (the majority came out of EDs or psych hospitals as I believe is the case with the OPs patient). Once and only once did PD follow us to the hospital. And that was more to act as a witness for myself and my partner, as right when we made contact with our profoundly inebriated, minor, female patient she started screaming that we were going to sexually assault her. Of course she yelled these accusations in the ER and I am very appreciative that the officer was there to back us up.


----------



## Fish (Jan 11, 2012)

Aprz said:


> First I am gonna share with you guys the story about this call I did that prompted me to ask this question. You guys might think I'm really bad (or hopefully not) for saying these things to a patient, but I hope to learn from you guys, and not repeat this mistake.
> 
> Today I did a transport, and the hospital was very unhappy with the questions I asked the patient. I thought these were good questions to ask, but they told my partner (not me) that they were inappropriate questions and somebody needs to stop me. My partner wasn't in the room when I asked the question, and he listed off a couple of the things I said that was consistent with what I asked that bothered them, but he said there was more, and that he couldn't remember.
> 
> ...



These are the same questions I ask on a 911 call that turns out to be Pysch related, you need to do a full assesment even if it is just an "IFT" and an Eval has already been done. You have to watch over and take care of this patient for the length of Transport and you have to write a detailed report at the end of the call, going over History of present illness(why did the patient come to be in your Ambulance) Chief Complaint, etc... To the nurse and security guard, tough. Should you have gotten a report from her first before you walked in and started questioning the patient? Maybe, since you don't know the fragility of the situation yet.


----------



## Nervegas (Jan 11, 2012)

adamjh3 said:


> On the IFT side this is often impossible, and more often than not unnecessary. In more than a year and a half where 60-80% of my calls were psych IFTs I can count on my hands the number of times PD was on scene prior to my transport (the majority came out of EDs or psych hospitals as I believe is the case with the OPs patient). Once and only once did PD follow us to the hospital. And that was more to act as a witness for myself and my partner, as right when we made contact with our profoundly inebriated, minor, female patient she started screaming that we were going to sexually assault her. Of course she yelled these accusations in the ER and I am very appreciative that the officer was there to back us up.



Idk about other states, but in TX an officer is the only person who can enforce a court order of protective custody, without them, I could potentially be accused of kidnapping the patient, unless they meet the criteria for not being of sound mind.


----------



## Handsome Robb (Jan 11, 2012)

Nervegas said:


> Idk about other states, but in TX an officer is the only person who can enforce a court order of protective custody, without them, I could potentially be accused of kidnapping the patient, unless they meet the criteria for not being of sound mind.



Even if you have the original documentation? I'd check with a lawyer about that one my friend because what you said doesn't make any sense. 

Not trying to throw stones, of course. 

In Nevada only a Psychiatrist, LEO or Physician can invoke a 72-hour "Legal 2000". however once the paperwork is finished any medical professional of the appropriate level of care can enforce the hold provided the original documentation is present.


----------



## JPINFV (Jan 11, 2012)

NVRob said:


> In Nevada only a Psychiatrist, LEO or Physician can invoke a 72-hour "Legal 2000". however once the paperwork is finished any medical professional of the appropriate level of care can enforce the hold provided the original documentation is present.



Psychiatrist or psychologist?

/Psychiatrists are physicians.


----------



## Handsome Robb (Jan 11, 2012)

JPINFV said:


> Psychiatrist or psychologist?
> 
> /Psychiatrists are physicians.



Psychologists. Brain fart. 3 hours of sleep doesn't work too well.


----------



## Nervegas (Jan 11, 2012)

NVRob said:


> Even if you have the original documentation? I'd check with a lawyer about that one my friend because what you said doesn't make any sense.
> 
> Not trying to throw stones, of course.
> 
> In Nevada only a Psychiatrist, LEO or Physician can invoke a 72-hour "Legal 2000". however once the paperwork is finished any medical professional of the appropriate level of care can enforce the hold provided the original documentation is present.




From the Texas Health Code:

(a) The court may authorize the transportation of a committed patient or a patient detained under Section 573.022 or 574.023 to the designated mental health facility by:

(1) a relative or other responsible person who has a proper interest in the patient's welfare and who receives no remuneration, except for actual and necessary expenses;

(2) the facility administrator of the designated mental health facility, if the administrator notifies the court that facility personnel are available to transport the patient;

(3) a special officer for mental health assignment certified under Section 1701.404, Occupations Code;

(4) a representative of the local mental health authority, who shall be reimbursed by the county; or

(5) the sheriff or constable, if no person is available under Subdivision (1), (2), (3), or (4).

We are none of those things, it goes on to further state:

(b)The court shall require appropriate medical personnel to _accompany the person transporting the patient_ if there is reasonable cause to believe that the patient will require medical assistance or the administration of medication during the transportation. The payment of an expense incurred under this subsection is governed by Section 571.018.

Basically, its a grey area, but I am reasonably sure that we not given the legal authority to transport unless A) they consent or B) are deemed to be not of sound mind and thus not capable of consenting or not.

As an aside, the actual paperwork even says "to be remanded to a peace officer" at the top.


----------



## systemet (Jan 11, 2012)

Aprz said:


> *TL;DR Anyhow, in short, tell me how bad I did. What I could've done to improve. If you work IFT, what kind of questions do you ask a psychiatric hold patient. What's involved in your assessment? Does it change for pediatric patients?*



Firstly, I don't think that you did anything wrong here.  Unless you're sitting there looking bored going, "So you tried to killed yourself, right? How'd that work out for you?", I think these questions are all appropriate.

My goal in these situations is to establish some sort of rapport with the patient (if possible), calm them down a little, and get an idea of whether they're likely to be a problem, and make a bit of a judgment as to whether I want to convince them to take a sublingual ativan, or ask the facility to give something more, and whether I need to restrain them.  

As someone pointed out earlier, I think the difference here, compared with a scene call, is that the patient has already been placed on a psych hold, and evaluated by a physician or physician(s).  So it's not necessary to go on a fishing trip to find reasons for PD to arrest them, to take them to the ER, and as a result a lot of the questions about suicidal ideation, attempts, methods, etc. have probably already been asked by someone else, and may be present in the chart of available from the RN / RPN.  That being said, I don't think it's wrong that you asked these questions, and I think they need to be asked if the information isn't available via other means --- I just don't think it's absolutely necessary to ask the patient.  [It would be nice to know, for example, that they weren't just admitted 3 hours ago, with a history of a potential overdose --- althought this is unlikely].

While I've had my moments, and I'm sure everyone here has, I try to treat psych patients like normal decent people.  Because most of them are.  A lot of psych patients are have a single major depressive episode, often for a good reason (not that whether you or I judge their reason for being depressed to be reasonable is really all that important).  The overwhelming majority aren't violent.  A friendly attitude goes a long way.  A lot of these people are often just scared, especially if they're delusional / hallucinating / altered.  Simple body language even helps a lot.

I don't believe in trying to do armchair psychology in the ambulance.  If I have someone who doesn't want to talk to me, I'll pretty much tell them, "We can talk about this if you want, but if you want to be left alone, we can just ride to the hospital, but I need to check ...... first".  I don't think you have to get their life story as long as you've done your best to rule out any acute life threats.

I think in this situation, the best approach would be to try and ask the security guard and nurse exactly what they had issue with.  Because it may have been something else, it may have been the way you asked the questions, or your demeanor or general approach.  It might be something you don't realise you're doing, and you might get some decent advice as to how to change what you're doing.

On the other hand, you may have an issue where the RN / RPN simply doesn't understand your role, and thinks that you're just a medical taxi, and don't need to be aware of the specifics of the patient's condition.  In that case, this is a great opportunity to try and (gently) educate them.

I would say that my general approach doesn't change much for pediatric patients (how young is this patient anyway?).  I'd prefer to have the parents in the ambulance, if possible, to protect myself.  But in some situations the parents are the problem, or part of the problem, or they're decent people but their presence just makes things worse.


----------



## systemet (Jan 11, 2012)

Sasha said:


> Off topic but what are the opinions on "playing into delusions"? I know the books say not to but sometimes its easier just to pet an imaginary cat then to deal with the agitated patient when you tell them there is no cat.



I don't believe in doing this, but I don't see any harm in the specific example you're describing.  What I was taught to do, was to say to the patient "I realise that this cat / fire-breathing dragon / talking garbage can / phalanx of roman soldiers coming to crucify you, seems real to you, but I want to let you know that I can't see them, and I don't think that they're really there.".  That way you're grounding them a little bit, but you're being supportive / comforting, and not ignoring them.

I can't tell you if this is the best thing to do, it's just what's worked well in the past for me.


----------



## Aprz (Jan 11, 2012)

The patient was a sophmore in high school, I forget the age. Probably around 15-16 years old.

I was thinking there may have been something else, but their complaint to my parfner was "inappropriate questions". Maybe they don't understand our role like you said. It could be cause they already asked those questions and didn't want the patient to be asked those multiple times. All possible.


----------



## Fish (Jan 11, 2012)

Aprz said:


> The patient was a sophmore in high school, I forget the age. Probably around 15-16 years old.
> 
> I was thinking there may have been something else, but their complaint to my parfner was "inappropriate questions". Maybe they don't understand our role like you said. It could be cause they already asked those questions and didn't want the patient to be asked those multiple times. All possible.



They were not inappropriate, rest assured. They are necessary for many reasons.

The only way I could see these as inappropriate is if they are asked in an unprofessional manor.


----------



## TLettuce (Jan 22, 2012)

beano said:


> ...i ask why do you want to get high? he says the psych meds hes on dont work. did you tell your dr? he says no. you should tell him and they can try different meds...
> 
> anyways, when i dropped him off he was smiling, unrestrained, understood why he was on a hold, understood why what he did was stupid and everyone was making a big deal about it, and as I was leaving the room he said "hey Beano, thankyou".
> 
> this isnt to toot my own horn, but APRZ, you need to do what you think is best for your Pt and screw everyone else cause its not their Pt.



Great example of good pt. care. 

Why anybody thinks you should not be talking to your pt. about their personal life on an IFT is beyond me. My mother spent her last few years in an alzheimer's ward at a care facility. That definitely taught me some important values about how to care for someone with psychiatric issues and one is to almost always (for me anyways) treat them as though there is nothing wrong with them in the first place. 

Nobody wants to be treated like an animal and no one will respond well to it.


----------



## SliceOfLife (Jan 22, 2012)

Tact is everything.


----------



## SliceOfLife (Jan 22, 2012)

Let me follow that up with it may have taken considerable time and effort for the staff to get those answers out of her and also to get her to a manageable state.  She probably has been asked those questions at least three times; EMS, Triage, hospital shrink, nursing staff, medic students needing psych evaluations...

So she may feel like no one is listening to her and getting frustrated.  IMHO get a full report from the nurse, work up a good rapport, then work the questions in.  Not everything needs to be fired off like a shopping list when you first meet the patient.


----------



## Melclin (Jan 22, 2012)

My 50c:

I'd be more inclined to ask a lot of questions if I were at the persons house having been called there via 000 (911). 

For transfers, I cover a few basics that will be relevant en route. Current suicidal intent is definitely one of those questions. I have never had a bad reaction to those questions from patients and I have never heard of a pt reacting badly to those questions. 

Reacting badly to excessive questioning... perhaps. When you're involuntary, you do get a little sick of the same questioning over and over again, if you don't agree with being there in the first place (from personal experience). But thirty seconds to establish a few important points is not excessive and in fact I think its absolutely essential for your safety an theirs. 

-?Suicidal thoughts, do they intend to act on those thoughts, if so how.
-Thoughts of persecutions, paranoia.
-Feelings of agitation/anger, if so at whom are they directed and why. 

This usually happens while they tell me their story and I just ask them to clarify the above at the appropriate points *during* their narrative. You are assessing their risk of absconding (particularly out the side door at 100km/h), and their risk of becoming violent. Both are of paramount importance to you, regardless of whats in the "packet" or "notes".

For the rest of the transport, we just chat. More than often I find that people wanna talk and you don't have much to do except listen and nod. At the end they sing your praises for being so nice :blush:

In short, I think it was totally appropriate to ask those questions. If it pisses people off in your area, do it once you're in the truck. Not ideal, but better than nothing.

*I'd like to add that I think its an occupational risk in EMS to end up believing that psych pts all sitting on the border between suicidal and violent. *While violence is always a possibility, people with mental illness are far more likely to be the victims of violences than be the perpetrators. To avoid asking questions that are important to both your own and your patient's well being because of a fear of "setting them off", shows a lack of understanding of mental illness in general, most probably a lack of understanding of the particular mental illness in question and a poor ability to interact with this pt population in a therapeutic way (to me this is the psychiatric equivalent of not being able to put a line in or some equally as important skill).


----------



## simple (Apr 23, 2012)

Aprz said:


> I asked if she had any intention to hurting herself or others, did she have a plan, and if she did, how she planned to do it.
> 
> When I asked, she said she really didn't mean it, it was the heat of the moment, no plan. She just told somebody that she wanted to die. She is stressed out about school. I asked what grade she was in, and then asked if finals were going on and if that's why she's stressing?
> 
> ...



Some key points I highlighted in red.
1.) If they are transferring care to you it's not up to what the nurse thinks. Nurses are 90% of the time :censored::censored::censored::censored::censored::censored::censored::censored::censored:s anyways ( 2nd only to bad dispatchers lol ). I love going into a hospital them handing me paperwork and asking me "is there anything else I can get you? ...ummm maybe a report?" The security guard is more laughable than anything because he has 0 credibility.

2.)You mentioning the chest pain, headache questions aren't assessment questions per say they should be pertinent negatives. They don't necessarily have to be asked if you understand they aren't related to the existing case. But anything extra you do can't hurt. 

 I think your only mistake was asking about the actual suicide attempt itself. The schematics of an attempt shouldn't matter to you as a caregiver I'd think. The reporting nurse should tell you whatever you need to know on top of that. By asking the patient ( who already is obviously emotionally unstable) it stirs things up a bit sometimes, which is bad if you want to build trust with the patient.

Overall I have a feeling  you went in there kind of timid and they got the alpha demeanor and tried to walk over you. Just focus on what you KNOW is right and can be justified!

sorry for old post.


----------



## Sasha (Apr 23, 2012)

simple said:


> Some key points I highlighted in red.
> 1.) If they are transferring care to you it's not up to what the nurse thinks. Nurses are 90% of the time :censored::censored::censored::censored::censored::censored::censored::censored::censored:s anyways ( 2nd only to bad dispatchers lol ). I love going into a hospital them handing me paperwork and asking me "is there anything else I can get you? ...ummm maybe a report?"



Please refrain from nurse bashing and remember there are quite a few great posters who are nurses as well.


----------



## 18G (Apr 23, 2012)

I wouldn't necessarily say the questions were inappropriate but they were really redundant. This "minor" patient is already in an awkward situation anyway and has already been drilled with the same questions so there is no need repeating them. If you want to know, ask the nurse or wait to ask your partner who got report.  

With a psych patient, you really should speak to the nurse and get the report before you come into contact with the patient. You need to know what the patient's background is and why they are committed so you know what questions, statements and subjects to potentially avoid to keep from upsetting or "setting off" the patient. I see nothing wrong with asking a patient what led them to be committed during transfer to make conversation. And sometimes the patient will want to share how they are feeling. 

Even with medical patients, I always get report before making contact with my patient so I know what exactly is going on.


----------



## Aidey (Apr 23, 2012)

I agree about getting report first, no matter why the pt is being transported. It has helped me avoid/mittigate some sticky situations.

Knowing if you should avoid certain questions is definitely important. When transporting the rape victim who was diagnosed with a personality disorder after the assault, kicked out of the mitary and just attempted suicide after her discharge appeal failed you should probably avoid asking about her military tattoo.


----------



## hibiti87 (Apr 23, 2012)

i agree with report first. If the nurse defaults to" i just got on" which is in most cases, after ill read the 5150 report, talk with security, check level of restraints, then make my initial assessment. Of course always make sure the pt is medically cleared to go, JGP is more then happy to turn you away for sudden chest pain. :unsure: maybe i shouldnt have said that for all you potential 5150s.....


----------



## MiddleEastMedic101 (May 1, 2012)

Maybe they just thought you were being nosey. 

Then again, it's Cali. You can't do anything these days without someone getting butthurt.


----------



## airborne2chairborne (May 2, 2012)

I agree with the overall consensus of getting a report from a nurse first... but that depends on the facility. There's some places (hospitals included) where I'd take the word of a janitor over the head nurse, and you get your fair share of medical personel ranging from EMT-Bs to MDs who are burned out and will just check off a generic box without really checking. So nothing wrong with doing your own assessment. Security guards for some reason think they have a medical say in matters. They don't, if one tries to tell you how to do your job tell him to go :censored::censored::censored::censored: himself and to go away before you have your dispatcher hit up the REAL police about him interfering with your patient care. Finally, nurses seem to forget that if they're giving you a patient then once you sign for him/get him on your gurney he's YOUR patient, not theirs anymore. They're not on your medical chain of command by any means and don't have the same protocols. So unless an MD is chiming in with them about you being wrong, who cares?


----------



## TheLocalMedic (May 2, 2012)

Thank you, 18G for mentioning getting a report first.  Always always always talk to someone before you make patient contact for IFTs.  

And be careful with psych patients!  I worked at an IFT company for several years and a good portion of our transfers were of the psychiatric variety.  I was always pretty relaxed about these guys, and few ever gave me any trouble.  (But then again, I'm 6'1'' and 270, built like a Mac truck)  But I did have one patient (a twerpy teenager too) who damn near killed my partner and I.  I was lucky enough to escape with a few broken ribs, but had I not been quite as quick I would have had a nice stab wound in the chest from the scissors he had concealed on him too.  Now, I generally restrain any and all psych patients.  Too bad for them, life sucks when you're crazy, and I apologize to no one.  

Also, all of those questions you asked, like about having a plan or suicidal ideation?  Yeah, the hospital already asked about all that.  Not really your place.  And why do you need to know?  All you need is their diagnosis, their complaints, and whether or not you should just restrain them or really really restrain the crap out of them.  Yeah, sure it might be interesting, but unless you have some actual psych training those things have no bearing on how you will deal with this patient.  And it's awkward.


----------

