# Hallucinations... play along?



## OnceAnEMT (May 14, 2014)

Howdy! I have a question relating to Pts experiencing hallucinations.

Today we recepted a young adult female who was transported via EMS after someone else called. Bloody needle found on scene, track marks on forearm. She arrives very disoriented, and experiencing a few different hallucinations, but her most dominant one was that someone had stolen her face. 

I don't think I've ever seen it said plainly in ink that we are supposed to or not supposed to play along with hallucinations. I've heard arguments from both sides and have seen veteran providers on both sides. Personally, I've always very plainly discredited the hallucination. Whenever, if ever, they start to get pissed, I just say it less often. Am I in the right here?

That said, assuming I'm correct in management of the hallucinating Pt, how would y'all suggest handling a situation in which other providers in the room are playing along? Back to my scenario, one of the medics who delivered her was playing along by ensuring her that we were doing our best to find her face and get it back to her. As he was far senior of me, I didn't dare correct him, as I didn't think it was quite a battle worth fighting.

Thanks in advance for any opinions!


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## PotatoMedic (May 14, 2014)

My psych teacher in school for abnormal psych said to never play along.  Just to say no I don't see xyz.  Or in your case.  I still see your face on your head.


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## STXmedic (May 14, 2014)

No, you do not go along with them. The way I've been taught to handle them, which seems to work very well, is simply echoing and discussing their hallucinations with them. Often times when they actually hear what they're saying, they'll realize it doesn't make sense (not always, but occasionally).

"So you're telling me there are police officers bugging your attic, and helicopters spying on you?" "You're saying there are spiders crawling on you, but I don't see them." 

Don't tell them their crazy, and try not to be demeaning and make them feel like they're crazy. This also usually works best with hallucinations from mental disorders. Hallucinations from drug use don't often respond to anything for me.

I believe you said you're from the SA/Austin area, yeah? If so, there is a 40hr Crisis Intervention Training class that I would very highly recommend. It's one of the most beneficial classes that I've taken. It addresses issues such as this from some very knowledgable and experienced sources.


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## OnceAnEMT (May 14, 2014)

FireWA1 said:


> My psych teacher in school for abnormal psych said to never play along.  Just to say no I don't see xyz.  Or in your case.  I still see your face on your head.



Yessir, pretty much what I do.



STXmedic said:


> I believe you said you're from the SA/Austin area, yeah? If so, there is a 40hr Crisis Intervention Training class that I would very highly recommend. It's one of the most beneficial classes that I've taken. It addresses issues such as this from some very knowledgable and experienced sources.



Thanks for the info. I like that technique that you mentioned. Its actually how we were told in orientation to de-escalate patients and families, but I can totally see it being effective with a hallucinating Pt. I'll do it next time. And yeah, part of why I'm asking this is I really don't know how drug-induced hallucinaters would react, simply because thats the whole issue with them, specifically with safety. Unpredictable.

I will actually be taking that class in a few weeks as part of my on-boarding process for the ED. Definitely looking forward to it, especially if you're speaking so highly of it. 

Thanks for the help guys!


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## TransportJockey (May 14, 2014)

The above two responses nailed it. You never play along


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## STXmedic (May 14, 2014)

Yeah, the only thing the drug-induced agitation/hallucination patients seem to respond to is a healthy dose of versed or zyprexa.


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## OnceAnEMT (May 14, 2014)

STXmedic said:


> Yeah, the only thing the drug-induced agitation/hallucination patients seem to respond to is a healthy dose of versed or zyprexa.



Does it surprise you if I say the medic who played along also didn't push versed?


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## STXmedic (May 14, 2014)

Not in the slightest. You should see some of the people I work with... No amount of incompetence surprises me anymore


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## TransportJockey (May 14, 2014)

STXmedic said:


> Not in the slightest. You should see some of the people I work with... No amount of incompetence surprises me anymore



But aren't you one of those super fire medics? Yiu have people who do things wrong?


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## rmabrey (May 14, 2014)

What they said.


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## STXmedic (May 14, 2014)

I'm not on the fire side anymore. Ironically enough, I trust many of the Fire medics I work with more than the medics on the box.


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## EMDispatch (May 14, 2014)

In the call center world we're taught the same, to not play along with hallucinations, etc. We're taught to acknowledge it, ie. " I understand you think you're in Mordor", but use grounding statements " Right now you're in xzy, and I'm gonna help you." Another big key point in our seminars is to address them by their name frequently. Ideally it also helps ground them in reality.

I've used it plenty of times on all varieties of hallucinations, both drug and psychiatric. It seems to work very well, even in some of the worst cases I've handled it has had some success.


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## OnceAnEMT (May 14, 2014)

EMDispatch said:


> Another big key point in our seminars is to address them by their name frequently. Ideally it also helps ground them in reality.



First off, thank you for your input. Didn't expect to hear from a Dispatcher!

Second, you bring up another point. With this same Pt, she had no identifying information or cell phone on her, and I suppose the caller was no help. She arrived at the ED with no known name. Another tech asked her what her name was while I was talking to the medic, and all I heard was the tech replying to her saying that he can't call her that (so I assume it was a curse word or something obviously silly). He asked again, and she replied (going to change this just in case, you know) Jane. From then, we continued to refer to her as Jane. I hadn't thought of it at the time, dumbly of me. Its very clear that Jane is probably not her real name, given the situation. Are we playing into her hallucinations by calling her what she "wants" to be called? Any suggestions on alternatives?


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## EMDispatch (May 14, 2014)

Grimes said:


> Are we playing into her hallucinations by calling her what she "wants" to be called? Any suggestions on alternatives?



I'm by no means an expert on it, but to me it's making the best of a bad situation. If it's not their correct name but they still respond to it, I'd use it. It can still get them to focus back on you and not on necessarily what else they are seeing or experiencing. The big thing I've taken away from the training I've had is that we function as their reality check, anything you can do to safely and appropriately get their focus will help them.

That all being said, I hope someone with better training ad qualifications can chime in to set the record straight.


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## Milla3P (May 17, 2014)

Grimes said:


> Howdy! I have a question relating to Pts experiencing hallucinations.
> 
> 
> 
> I don't think I've ever seen it said plainly in ink that we are supposed to or not supposed to play along with hallucinations.




This was not covered in your basic class? Or in your book? Really?


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## TheLocalMedic (May 18, 2014)

I find that hallucinating patients respond well to two things:

First, be calm and assure them that they are safe with you.  I repeat over and over, "It's okay, you're safe with me.  It's okay to be upset, but know that you're safe."  

Secondly, don't play into hallucinations.  You can acknowledge the hallucination, but don't support it.  It's the difference between saying "I understand that you believe you are a cat" and "Be a good kitty".  Let them know that you are listening to them when they explain what they see-hear-believe, but just keep talking to them and asserting normalcy into what is probably an unsettling experience.  

It's okay to contradict them, (_No, you don't have bugs crawling on you._) but do it calmly and gently.  Don't do it in a way that's antagonistic, even if they're acting out.  Offer ways to make them more comfortable but insist on safety (_sorry, the seat belts have to stay on_).


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## TheLocalMedic (May 18, 2014)

I had a patient last week that thought he was in his bedroom with his girlfriend nagging him.  He kept talking to her and sometimes yelling, saying "You see what she does to me?"  But after repeatedly reassuring him that he was with me, not his girlfriend, and that we were in an ambulance, he calmed down a bit.  He would still cock his head like he was listening, but keeping him grounded by saying that she wasn't here with us went a long way toward getting him to be calm.


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## STXmedic (May 18, 2014)

Along the lines of auditory hallucinations, its not a bad idea to ask them what the voices are saying or telling them to do. It will most likely be innocuous, but it could also reveal some suicidal or homicidal ideations. My partner had an agitated schizophrenic with auditory hallucinations a few months ago. When she asked the patient what the voices were telling him, it was "Kill the EMTs." Would he have acted on it? Probably not. But at least she knew what to expect- she immediately became more vigilant during that call.


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## Kathead (Jun 16, 2014)

Milla3P said:


> This was not covered in your basic class? Or in your book? Really?


In the Orange Book, page 704, Section 6-Chapter 20-Psychiatric Emergencies in table 20-1. 

"Express interest in the patient's story. Let the patient tell you what happened or what is going on now in his or her own words. However, do not play along with auditory or visual disturbances or hallucinations."

It also repeats it on page 708 in the bullet list under the schizophrenia section. 
"Do not argue. Do not challenge patients regarding the reality of their perceptions. Do not go along with their delusions simply to humor them, but do not make an issue of the delusions. Talk about real things."


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## fngemt (Jun 21, 2014)

^yep


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## fngemt (Jun 21, 2014)

It all comes down to what you feel is good for the patient


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## Ewok Jerky (Jun 21, 2014)

you can "play along" so far as to try to understand what they person is experiencing.  For example: "they are out to get me!!" "who is out to get you? why are they out to get you?".  But you should NEVER affirm someones delusions.  For example: "yes they are out to get you!".  You should always try to keep your patient aware of reality, "there are no bugs on your skin, you are hallucinating, and I am telling you that what you are feeling is not real, its an illusion."


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## lwems (Oct 14, 2014)

I'm a dispatcher but occasionally I get called to jump onto a wheelchair van and run a quick transport because everyone else is booked solid.

One particular time I was asked to transport a patient who was perfectly stable and noncombative, but who nevertheless suffered from paranoid delusions and often accused staff of stealing her things.

The transport was uneventful, although I had to listen to a long monologue about the many supposed thefts and rapes she had suffered. (The DON had already warned me that the rape accusations had been taken very seriously, were investigated by police, and were ruled out by CCTV footage.) So I humored the patient, listened to the stories and responded with sympathy... perhaps that was a bad decision.

Anyway, the patient was going to a doctor's appointment, so I wheeled her in and we went straight to reception. I read the receptionist's name off her badge and then announced to the patient something like this: "Mrs. Doe, this is Jane, she is your protector here. Her job is to keep you safe. So I am going to park your wheelchair right here next to her desk, and Jane will watch over you until I come back for you later."

The receptionist quickly twigged to the game and played along. It seemed to settle the patient's mind wonderfully... although it probably confirmed her delusions, maybe?

Opinions? Am I clever, or am I just creating more problems?


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