Psych Hold - How do you assess?

[JPINFV]

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]

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

 

[DesertMedic66]

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]

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

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

 

[EMS123]

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]

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

 

[MMiz]

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]

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]

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]

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]

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.

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]

"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]

"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]

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]

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]

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]

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.

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.

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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

Perhaps my partner felt I over stepped his role too

ehhhh

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.

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]

* asked the patient how come they where here.

* The patient was a minor so I asked if the parents were present.

* 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.

* I asked what grade she was in,

* and then asked if finals were going on and if that's why she's stressing?

* "Oh, my partner will actually take your report. He's hunting for you right now." (to the nurse)

* I told the parents about HIPAA

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]

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]

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.