Psych Hold - How do you assess?

[Nervegas]

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]

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]

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?

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]

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]

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]

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]

Psychiatrist or psychologist?

/Psychiatrists are physicians.

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

 

[Nervegas]

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]

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]

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]

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]

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]

...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]

Tact is everything.

 

[SliceOfLife]

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]

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]

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?

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.

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).

Perhaps my partner felt I over stepped his role too

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]

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]

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]

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.