# Severe Psychosis PT



## PNWMedic (Jun 15, 2008)

It was my second week in Wilderness EMT-B Training & I went to my clinicals at a local ER; a 10 Hr Shift, and at about 3AM everything was kind of slow, when a code orange blasted across the PA, and an RN Came running into the ER and pointed to me and my fellow student, and said "you two, come with me!" So we ended up chasing him through the hospital and up to the second story where the "PT care ward" ie. Psychiatric Ward was and then instructed us to take off our stethescopes, meanwhile we didn't really know what was going on (as we were only 2 weeks into our emt training). Well we took off our stethescopes and watches then were buzzed into the ward. Well there was a female PT, about 40 years of age in a small cafateria type room, refusing to go into her room, and refusing medication screaming obsenities at the top of her lungs.

Well the head RN up there told us what was going on, and came up with a plan that we were all going to go in there again, and ask her ro take her medication, and go to her room, so we went in and she went into hystarics again, and threw a cup of urine (she had urinated in her drinking cup) all over the head RN, so the RN had us leave the room and we discussed another plan, and then went back in and told her that if she did not go to her room we would have to forcibly move her; so she complied and went into her room, but she refused to take her meds and sedatives and started acting violent again, so we locked the door, and she started going hysterical again.

Again, we left into the hallway to discuss another plan, and the Rn decided that we would go in and do a four point restraint (I was charged with restraining her head), and the RN would administer a SQ Sedative, so we entered the room and it was our lucky day because she had deficated all over the floor on purpose! Well we managed to get her down on the bed, after she bit a chunk out of the arm of one of the RN's, and we started restraining her with leathers, all the while she is spitting on us, cursing us to hell, and saying a bunch of other things. What really got me was her MPD, because she was switching personalities, and at one point she thought she was a young child, and she thought we were raping her, and not having ever been in a situation like this, it really got to me because she really sounded like a young girl being raped and screaming for her life.

Well eventually we administered the SQ Sed, and left the room, but I was definatly not expecting to deal with anything like that, especially as in our course we hadn't even covered restraints. Well all in all it was one heck or a ER rotation!


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## traumateam1 (Jun 15, 2008)

Very interesting, thanks for sharing. It sorta reminds me of a p/t I had like that. We had to transport her from a assisted living home that was temp. to our hospitals psych ward. Anyways when we got her in the ambulance she was sure that her daughters husband, or boyfriend (it kept changing) was a millionaire race car driver that was paying to get her killed, and that we were in on it, and where we were taking her, he was going to be there to kill her. Luckily she never became violent or anything, and we got her to the ward nice and peacefully, but none the less it was fairly interesting, as there was more than just the crazy boyfriend/husband trying to kill her. 

Gotta love those patients


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## VentMedic (Jun 15, 2008)

WildEMT said:


> Well eventually we administered the SQ Sed, and left the room, but I was definatly not expecting to deal with anything like that, especially as in our course we hadn't even covered restraints. Well all in all it was one heck or a ER rotation!



Welcome to the hospital!

Some EMS providers believe everything is nice and controlled in the hospital setting.  Most don't even consider that the combative and psychotic patients brought to the ED will be the hospital's problem 24/7.  There are more assaults on inhospital staff than outside according to the statistics.

The hospital staff must care for with patients in DTs and withdrawals from many different substances as well.  One RN may have 2 - 3 of these patients for 12 hours along with 6 other patients.  We try not to intubate everyone in that situation or there would be little room left in the ICUs for the other medical and trauma patients.  Many of the patients will still need their medical problems taken care of before they can go to a psych ward or admitted to a substance abuse center for further treatment.

There are some patients we don't find out about their psychosis until a day or two into their stay when they have been off their meds for a while.  They may have been your average looking PTA mother type that tears her room apart and injures a couple of nurses.  

Even geriatric dementia and psychosis are difficult to deal with.  These patients may need restraining but even as strong as they are when combative, they are still fragile.  In the psych wards we have high topped covered beds to keep these patients in their beds without restraining their limbs. 

Placing restraints in patients in the hospital also involves a lot of continuing staff education since every patient is a little different as are the rules, paper work and careful documentation of observation once the restraints are applied. 

We also deal with gang members on a continuing bases both as patients and those who come to finish the job.  The trauma center has armed police officers for security and bullet proof glass in the doors.  That is a very healing environment to work in.   In some hospitals, violent people have been successful in killing their intended victims be it a patient or staff member. 

Everyday we hear the different codes announced for staff members with special training to assist in restraining as well as those to tell all staff members to clear the area.  Those usually involve a weapon. 

What hospital staff really "loves" is the patient with violent and/or psychotic tendencies that has been verbally agitated by EMS providers on the way to the hospital.  The anger toward EMS will then be used against a nurse or some other staff member. 

I have seen this first hand in the field and continue to see it in the hospital ED as EMS is bringing in the patients.  I have even seen ground providers continue to agitate a violent patient at a trauma or GSW scene and then expect me to load them onto the helicopter immediately.  They called the helicopter because they didn't want to deal with the patient in the back of their truck even if it is an acceptable ground transport distance.  

Sorry about the rant but I also see this every day I work in the hospital and occasionally on transport either by air or ground.


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## PNWMedic (Jun 15, 2008)

Yea, what really got me most that I wasn't expecting was when the PT entered a state where she believed she was a young child, and if you were not in the room you would have thought it was a young child, probally 5 or so, screaming for her life as someone was raping her. Her voice changed, mental status changed, verbalizatio changed, and really caught me off guard. I guess many of you are used to situations such as that, being a new EMT, or rather not even an EMT while I was still only half way into training caught me off guard.


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## BossyCow (Jun 15, 2008)

So, WildEmt... plan on seeing a lot of these in the wilderness?  :wacko:


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## VentMedic (Jun 15, 2008)

Some may have observed this before but few will understand what they have seen.  

We just had the discussion on another forum about Psychology classes and their usefulness as part of an EMS degree (Associates or Bachelors).  Many consider anything other than the essential  "skills" classes and bare minimum of required core education a waste of time.  

You will also only get the bare minimum of training about psych issues and how to control violent patients in either your EMT or Paramedic training.  I would recommend that you seek more education and training outside of your program at your first available opportunity.

I am rather surprised the RN supervisor selected 2 students to help restrain this patient.  Size helps but is not always necessary.  When someone is not trained for these situations, there is more risk for you, other staff members and the patient to be injured.  

In your employment, you will need to learn proper restraining techniques that minimize risk of injury to you and your patient.  You will also need to know when a police officer will be necessary to accompany you.  Your state may also have specific statutes for involuntary detainment of patients with psych and/or substance abuse problems that you must be familiar with. 

You may want to check out this website for more information about violent patients:
http://www.dt4ems.net/


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## PNWMedic (Jun 15, 2008)

Hopefully not lol, though u never know. I'm thinking about taking a job as an wilderness EMT up in a remote mining camp in Alaska, so that may be a little crazy lol


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## fma08 (Jun 15, 2008)

thank god for IM Haldol and Versed  But on a serious note they are very difficult to deal with. I give it a try to talk them down as much as possible. I have no problem administering Haldol or Versed IM, but as a last resort. They best thing I was taught, was to bargain with them. Give them something they want, as long as they do something you want. And don't lie to them, cuz they will hold it over your head, and you lose any amount of trust they may have had with you.


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## PNWMedic (Jun 15, 2008)

Yea, Thanks VentMedic, It did surprise me that he wanted us to go assist, seing as we were EMT's on a clinical while still in training, but it was 3AM, and there wasn't much in the way of staff at that time. There were 2 "security" guards assisting in restraining the PT as well, although in my personal opinion they wern't much help at all, as they were holding down the PT's legs improperly, and one of them got a kick to the head, and it made it somewhat difficult as she was still kicking and screaming. I am however going to take some Psych clases; in my current training we did not cover much in the way of psych or restraining, but I am considering go to school to get my nurse practitioner (possibly RN), then my paramedic after that so I can have pre and post hospital education, and I will definatly take psych classes in addition to the bare cirriculum requirements. Im a true believer in that it is always best to get more then just the required education so I can be fully prepared rather then just briefed when it comes to a complex or difficult situation.


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## LucidResq (Jun 15, 2008)

WildEMT said:


> I am however going to take some Psych clases; in my current training we did not cover much in the way of psych or restraining, but I am considering go to school to get my nurse practitioner (possibly RN), then my paramedic after that so I can have pre and post hospital education, and I will definatly take psych classes in addition to the bare cirriculum requirements.



FYI you have to be an RN with your bachelor's degree (BSN) to enter a nurse practitioner program, which is a minimum of a master's degree program (some are doctorate programs). Nurse Practitioners are registered nurses who have completed additional education and training and therefore have a wider scope of practice, usually in a specific field such as neonatology, women's health, or emergency medicine. In most states they can prescribe medications. 

But as far as meeting crazy people out in the wilderness, don't be surprised if you do. A couple of years ago my SAR team found a guy who had been lost in the Rockies for 3-4 days. He was uninjured, but was completely delusional and hallucinating. They decided to evacuate him by helicopter to a hospital. They had to restrain him to get him to the LZ because they had to pass by this tree stump but the poor guy was convinced it was Satan so he was freaking out. They never found out WHY he was freaking out (no history of psych problems) but my guess is that he ate or drank something bad, or just the dehydration and exposure drove him temporarily bananas.


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## PNWMedic (Jun 15, 2008)

LucidResq said:


> FYI you have to be an RN with your bachelor's degree (BSN) to enter a nurse practitioner program, which is a minimum of a master's degree program (some are doctorate programs). Nurse Practitioners are registered nurses who have completed additional education and training and therefore have a wider scope of practice, usually in a specific field such as neonatology, women's health, or emergency medicine. In most states they can prescribe medications.
> 
> But as far as meeting crazy people out in the wilderness, don't be surprised if you do. A couple of years ago my SAR team found a guy who had been lost in the Rockies for 3-4 days. He was uninjured, but was completely delusional and hallucinating. They decided to evacuate him by helicopter to a hospital. They had to restrain him to get him to the LZ because they had to pass by this tree stump but the poor guy was convinced it was Satan so he was freaking out. They never found out WHY he was freaking out (no history of psych problems) but my guess is that he ate or drank something bad, or just the dehydration and exposure drove him temporarily bananas.


What I was refering to was a Practical Nurse which is a 12-18Mo program and is on the entry level, The level before an RN LPN.


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## VentMedic (Jun 16, 2008)

WildEMT said:


> What I was refering to was a Practical Nurse which is a 12-18Mo program and is on the entry level, The level before an RN LPN.



Skip the LPN which is losing popularity in the hospitals in many states.  Take some college science classes like A&P, Pharmacology, Psychology, Pathophysiology and Microbiology.  You will then be well on your way toward a degree  either as an RN or EMT-P.


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## mikeylikesit (Jun 16, 2008)

VentMedic said:


> Some may have observed this before but few will understand what they have seen.
> 
> We just had the discussion on another forum about Psychology classes and their usefulness as part of an EMS degree (Associates or Bachelors). Many consider anything other than the essential "skills" classes and bare minimum of required core education a waste of time.
> 
> You will also only get the bare minimum of training about psych issues and how to control violent patients in either your EMT or Paramedic training. I would recommend that you seek more education and training outside of your program at your first available opportunity.


I agree whole heartedly about getting the psychology classes done for paramedics. My school for the degree required Microbiology, A&P, English Comp 1 & 2, Kinesiology, college algebra, sociology and general psychology just to take the paramedic program for the associates. i feel that with all the added prerequisites while they didn't help me right away minus A&P during classes, they definitely came in handy when i hit the streets.


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## Ridryder911 (Jun 24, 2008)

I believe every patient (yes, every one) is a psych patient. Truthfully, can one really say they behave or think their "normal" pattern during an illness, being in pain or in a crisis mode? 

Look at the definition of "stress"; do you think that most patients fit that mode? 

If we understood the behavior and correlation between physical and mental psyche then we will become better practitioner's. So many attempt to differentiate between the two or excuse that we do not have the time, education level, or "not our job".


True, the majority of those in EMS have a poor educational level of psychology and even lack of formal training with those that are having problems. Again, this is a shame when again nearly all patients are having some form or another psychological problem. 

One would think that every healthcare providers would have at the least a very minimum level of such training. Oh yeah, that's right; *almost* all do, except for one medical profession.. guess who? 

R/r 911


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## mikeylikesit (Jun 25, 2008)

Don't tell me that every medic didn't have to go through a year of Psych and socialolgy!...guess I'm an overachiever.


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## jazminestar (Jun 25, 2008)

probably one of the most beneifical classes i've have taken in college is physiological psychology.  this class went through in depth how the brain works and then you learn how the pathologies work, like schizophrenia, dementia, bi polar, depression, anxiety, autisim, different learning disorders,sleeping disorders, etc. how exactly drugs affect your neurotransmitters and make people act out........alot of things that they used to diagnose as psych problems are really neurological diseases.......if your college offers this class, i highly suggest taking it   it really went hand in hand with my human anatomy and a&p classes...........


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## BossyCow (Jun 25, 2008)

Hmm psych and sociology are required for an AA at the ccc I attended.


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## firetender (Jul 17, 2008)

I guess I want to focus on one of the parts that tripped you up.  

Here you are, being taught to be the best flesh technician you can be and in the middle of it shows up a real human being with bizarre behavior that could only come up for a person in an incredible amount of pain. The pain has nothing to do with the current circumstances.

When she "became" that molested child, it rang so true it probably dredged up every nightmare you may ever have had in relation to children in pain. Of course, somewhere in there would have to be your own included. How could it be any other way? 

The way we can understand anyone at all is through a connection through some sort of common experience.The pain is so explosive that you have to wonder -- if you're still a human being and not a machine -- is that what happens, and is that something that could happen to me? We do it all the time with positive experiences. It's the denial or suppression of the other side of the human coin that eats us away. In the profession, it's called burnout.

YES, that's what you went through, and YES, it did hit you as a human being, and YES, by all means, don't be afraid to talk about it and even explore it.

And my point is _*That Is Exactly What You Just Did,*_ by posting this to seek different perspectives.

This one is mine, and I'm really thankful you asked!


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