Psych pts
- Thread starter akemt
- Start date
hometownmedic5
Forum Asst. Chief
- 806
- 612
- 93
The best advice I have is let them talk. Find out what their issue is(the most pressing issue this minute) and if possible, solve it. For example, I have taken many patients who know their going to the hospital, have accepted that they're going, but would like to smoke a cigarette before they go. Given that you cant hardly smoke anywhere anymore, this usually becomes a huge problem causing almost irrecoverable escalation. What started out as a simple problem frequently ends in restraints.
That being said, not all patients have rational, solveable problems. When faced with that situation, I have a simple rule. I dont fight anymore. I will try to negotiate with you for as long as it takes to get you on the stretcher without force, but if its going to go the hard way, I'm bringing a lot of guys and loaded syringes. Back in the day I would have happily gone to town with you physically, but no longer. The commonwealth has bestowed upon me the great honor and responsibility of a big box of shut the eff up and I'm happy to use it.
Solve their problems if you can, sedate them if you have to, but never ever place yourself in a position where your patient can harm you.
That being said, not all patients have rational, solveable problems. When faced with that situation, I have a simple rule. I dont fight anymore. I will try to negotiate with you for as long as it takes to get you on the stretcher without force, but if its going to go the hard way, I'm bringing a lot of guys and loaded syringes. Back in the day I would have happily gone to town with you physically, but no longer. The commonwealth has bestowed upon me the great honor and responsibility of a big box of shut the eff up and I'm happy to use it.
Solve their problems if you can, sedate them if you have to, but never ever place yourself in a position where your patient can harm you.
WolfmanHarris
Forum Asst. Chief
- 802
- 101
- 43
I make every effort to treat the mental health condition as I would any other. I don't hesitate to ask them about their medications, symptoms, triggers etc they way I would a cardiac history or COPD. I find that is the key to a non-judgemental approach.
Of course when patient's are in a major crisis or suffering from psychosis this isn't necessarily workable but the key thing to remember is these patients are a very small subset of the total population of persons with mental illness.
In severe cases when the patient is violent or a risk to themselves, I vastly prefer chemical sedation to physical restraint to reduce agitation. Do not hesitate to call for ALS back-up in these cases. Also remember while law enforcement may have a necessary role in maintaining safety for providers and the patient, this is still a medical issue and you must continue to advocate for the patient.
Of course when patient's are in a major crisis or suffering from psychosis this isn't necessarily workable but the key thing to remember is these patients are a very small subset of the total population of persons with mental illness.
In severe cases when the patient is violent or a risk to themselves, I vastly prefer chemical sedation to physical restraint to reduce agitation. Do not hesitate to call for ALS back-up in these cases. Also remember while law enforcement may have a necessary role in maintaining safety for providers and the patient, this is still a medical issue and you must continue to advocate for the patient.
E tank
Caution: Paralyzing Agent
- 1,627
- 1,479
- 113
Believe that they believe to their very core the things they say to you no matter how unbelievable.
I don't feel like there is anything special I do about psych calls. I'll usually ask questions like what happened that lead up to me being there? Do they want to hurt themselves or others? If they plan to hurt themselves or others, how so? Have they ever had this problem before? When and what happened? If they are on psychiatric medications, are they compliant with them? Any recent changes with their psychiatric medications? I try to make sure I know their specific psychiatric issue (usually limiting it to depression, bipolar disorder, and schizophrenia rather than just lumping it all together under "psychiatric"), patients are usually in the know with what they have have and are honest about it. Are they having auditory or visual hallucinations? If so, what are they seeing or hearing? Any drugs or alcohol involved?
Among their other vital signs, I make sure to get their blood sugar (if violent and closing their hand, I'll do it on other body parts eg sole of their foot), temperature, and check their pupils. By the way, I'll give them a couple of tries for blood sugar, and tell them I'll do it in a probably more painful and unusual spot before I got to the feet. If they are a suspected excited delirium case, I'll just get it off the IV, which I'll do in it "immobile" spots like the feet (I have a foot fetish) or holding down the hand against the rail. If they are a suspected excited delirium case, I'll usually monitoring their EtCO2 with a nasal cannula as well.
In regard to restraints, I kind of wing that one. I am very liberal with using it. If I feel like the patient is acting squirrely, the restraints are going on. I don't screw around. I'll tell the patient what's going on, and won't lie like "Oh, these are to prevent you from falling off the gurney." Pfff!!! When I did IFT, I don't know why hospital staff liked saying that... If the patient has handcuffs are restraints already, I'll continue it.
In my county, we can give 5 mg Midazolam IM once. We have to call base for further. In my experience, this is 100% complete waste of time. I have yet to have this actually calm a patient. Maybe I am doing it wrong? For me, it just hasn't worked. Get lots of guys and make sure the restraints are good.... If they weren't restrained and all of the sudden want to hop out, I'll try to use verbal reassurance to slow them down or stop them. I will yell for my EMT to pull over, so they can safely get out. I, of course, try to minimize those incidents, and thankfully haven't had one leave yet. I did have one patient that went from being a calm and cooperative psych call to pulling off their seat belt, acting antsy, and having my EMT pull over. With verbal reassurance, we manage to get them to get to the hospital with restraining them or having them jump out, but I was very scared.
I have had two incidents where psych patients go very violent unexpectedly. Once was when I was an EMT, and I was up front driving, and the medic and the patient just started wrestling in the back. He just yelled to upgrade code 3 and ask for PD and tell them to meet us at the hospital. When we got to the hospital, I opened the back door and he had the patient pinned down on the ground, so I hopped in to help with that. The hospital staff and law enforcement came and went to help carry the patient onto the gurney outside of the ER. I just remember it was a chest pain call, and then the guy thought my medic partner was going to cut off his genitals. I then had a call, as a paramedic, where a construction worker was probably high on gas not wearing a mask while painting inside. His co-workers last saw him normal hours ago, and then they saw him walking around aimlessly and yelling. With verbal reassurance, I got the guy to sit on the gurney and tried to assess him. I know that I want to let them go, but for whatever reason, my mind said no, and when he tried to escape, me and my partner grabbed both of his arms. He was a 6' buff construction worker, and both me and my partner are 5'6"ish (at least I am 5'6"). We got tossed around before I yelled for PD who was right outside of our ambulance. They had additional officers show up, I gave 5 mg Midazolam IM which did nothing, restrained him, and then we transported. I was very shook up from that call. I knew that we shouldn't physically try to stop them, especially who definitely could over power me physically. Hopefully I don't make the same mistake again.
Kind of counter intuitive, but if you aren't a threat to the patient, they tend to respond better even if not perfect. I am usually smaller than most of my patient, usually the one doing the most communication with them, and I feel like they respond better to me than some of the buff firefighters or tall medics I've seen; It's like they try to pick a fight. Almost like little dogs growling at the big ones.
Last thing... don't forget to check for weapons or things that can be used as weapons. I don't even bother asking PD if they checked; I confirm it myself. I have pulled out many knives/dagger out of patient's pockets. This is true on a lot of calls, but especially true on psychiatric calls.
Among their other vital signs, I make sure to get their blood sugar (if violent and closing their hand, I'll do it on other body parts eg sole of their foot), temperature, and check their pupils. By the way, I'll give them a couple of tries for blood sugar, and tell them I'll do it in a probably more painful and unusual spot before I got to the feet. If they are a suspected excited delirium case, I'll just get it off the IV, which I'll do in it "immobile" spots like the feet (I have a foot fetish) or holding down the hand against the rail. If they are a suspected excited delirium case, I'll usually monitoring their EtCO2 with a nasal cannula as well.
In regard to restraints, I kind of wing that one. I am very liberal with using it. If I feel like the patient is acting squirrely, the restraints are going on. I don't screw around. I'll tell the patient what's going on, and won't lie like "Oh, these are to prevent you from falling off the gurney." Pfff!!! When I did IFT, I don't know why hospital staff liked saying that... If the patient has handcuffs are restraints already, I'll continue it.
In my county, we can give 5 mg Midazolam IM once. We have to call base for further. In my experience, this is 100% complete waste of time. I have yet to have this actually calm a patient. Maybe I am doing it wrong? For me, it just hasn't worked. Get lots of guys and make sure the restraints are good.... If they weren't restrained and all of the sudden want to hop out, I'll try to use verbal reassurance to slow them down or stop them. I will yell for my EMT to pull over, so they can safely get out. I, of course, try to minimize those incidents, and thankfully haven't had one leave yet. I did have one patient that went from being a calm and cooperative psych call to pulling off their seat belt, acting antsy, and having my EMT pull over. With verbal reassurance, we manage to get them to get to the hospital with restraining them or having them jump out, but I was very scared.
I have had two incidents where psych patients go very violent unexpectedly. Once was when I was an EMT, and I was up front driving, and the medic and the patient just started wrestling in the back. He just yelled to upgrade code 3 and ask for PD and tell them to meet us at the hospital. When we got to the hospital, I opened the back door and he had the patient pinned down on the ground, so I hopped in to help with that. The hospital staff and law enforcement came and went to help carry the patient onto the gurney outside of the ER. I just remember it was a chest pain call, and then the guy thought my medic partner was going to cut off his genitals. I then had a call, as a paramedic, where a construction worker was probably high on gas not wearing a mask while painting inside. His co-workers last saw him normal hours ago, and then they saw him walking around aimlessly and yelling. With verbal reassurance, I got the guy to sit on the gurney and tried to assess him. I know that I want to let them go, but for whatever reason, my mind said no, and when he tried to escape, me and my partner grabbed both of his arms. He was a 6' buff construction worker, and both me and my partner are 5'6"ish (at least I am 5'6"). We got tossed around before I yelled for PD who was right outside of our ambulance. They had additional officers show up, I gave 5 mg Midazolam IM which did nothing, restrained him, and then we transported. I was very shook up from that call. I knew that we shouldn't physically try to stop them, especially who definitely could over power me physically. Hopefully I don't make the same mistake again.
Kind of counter intuitive, but if you aren't a threat to the patient, they tend to respond better even if not perfect. I am usually smaller than most of my patient, usually the one doing the most communication with them, and I feel like they respond better to me than some of the buff firefighters or tall medics I've seen; It's like they try to pick a fight. Almost like little dogs growling at the big ones.
Last thing... don't forget to check for weapons or things that can be used as weapons. I don't even bother asking PD if they checked; I confirm it myself. I have pulled out many knives/dagger out of patient's pockets. This is true on a lot of calls, but especially true on psychiatric calls.
Read the pt, see who you deal with. There’s a world of difference between a schizophrenic gangbanger with a meth relapse and a depressed 21 y.o. chick who tried to off herself with 5 Tylenols because she had it rough in school. Nothing irritates me more than a brain dead straight-out-of school EMT who shotguns everything and everyone, just because they’ve been told so during their orientation/field training.
SpecialK
Forum Captain
- 457
- 155
- 43
Patients with a psychiatric problem, in the absence of an immediate threat to themselves or others, are an ambulance problem, not a police problem. The police are not routinely required. These patients often have had bad experiences with the police before and it just makes things worse!
Many of these patients will require 15-20 minutes of verbal rapport building to gain trust and enable you to approach, assess, treat them etc. Many personnel just give up after a couple of minutes and this is pointless. One person needs to speak to them, not 3 or 4. If friends or family or bystanders don't shut the hell up get them out. Turn down your handheld radio and turn the telly off. Offer choices such as a fag or cuppa. Tell them you're there to HELP them and that you're NOT the police. Helps a treat.
Many of these patients will require 15-20 minutes of verbal rapport building to gain trust and enable you to approach, assess, treat them etc. Many personnel just give up after a couple of minutes and this is pointless. One person needs to speak to them, not 3 or 4. If friends or family or bystanders don't shut the hell up get them out. Turn down your handheld radio and turn the telly off. Offer choices such as a fag or cuppa. Tell them you're there to HELP them and that you're NOT the police. Helps a treat.
EpiEMS
Forum Deputy Chief
- 3,845
- 1,164
- 113
Things to not offer your patient in the U.S.
"You want to give me a what?"
(but yes, agreed - if they want a cigarette, meh, go for it...)
DrParasite
The fire extinguisher is not just for show
- 6,289
- 2,162
- 113
1) realize you're not going to fix the issues of a psych patient with less than an hour of talking to them.
2) realize that a psych patient can go from crazy to violent very quickly; however most won't, especially the ones who called you for help. They just need a ride to the ER to get transferred to a psych place. But don't let your guard down, because that can change quickly
3) Arguing with a psych patient is like trying to put lipstick on a pig
4) always check your patients for weapons, and potential weapons. I've been burned in the past. Ask them to empty their pockets and put everything in a plastic bag. then confirm there is nothing left.
5) if you do get stuck in the back of the ambulance with a violent psych, GET OUT OF THE AMBULANCE. Some would say wrestle with him and try to restrain him while you call for help. I say have your partner pull over, and step outside while you call for help. Let him trash the truck. If he wants to flee, have law enforcement chase after him.
6) psych patients want help. they are sick people, with an actual condition. don't demean then, or ignore their concerns as they can't fix themselves. give them a nice comfy ride to the appropriate facility, and talk to them like they are a real person, not just a psych patient. and if they don't want to talk, don't push them. It's not worth aggravating them.
2) realize that a psych patient can go from crazy to violent very quickly; however most won't, especially the ones who called you for help. They just need a ride to the ER to get transferred to a psych place. But don't let your guard down, because that can change quickly
3) Arguing with a psych patient is like trying to put lipstick on a pig
4) always check your patients for weapons, and potential weapons. I've been burned in the past. Ask them to empty their pockets and put everything in a plastic bag. then confirm there is nothing left.
5) if you do get stuck in the back of the ambulance with a violent psych, GET OUT OF THE AMBULANCE. Some would say wrestle with him and try to restrain him while you call for help. I say have your partner pull over, and step outside while you call for help. Let him trash the truck. If he wants to flee, have law enforcement chase after him.
6) psych patients want help. they are sick people, with an actual condition. don't demean then, or ignore their concerns as they can't fix themselves. give them a nice comfy ride to the appropriate facility, and talk to them like they are a real person, not just a psych patient. and if they don't want to talk, don't push them. It's not worth aggravating them.
iExposeDeformities
Forum Crew Member
- 30
- 1
- 8
Number 1 tip: DO NOT EVER let the 5150 pt access your stethoscope. My partner was in the back with a 5150 and the pt tried to strangle him with a stethoscope
Kevinf
Forum Captain
- 397
- 171
- 43
Most people I've worked with that wear a scope around their neck do a fine job strangling themselves with it without any outside help.
There are two major issues with the picture you painted: 1) your 5150 wasn’t restrained (which, I am pretty sure, goes against your company’s policy) and 2) your tryhard partner wearing the steth around his neck.
iExposeDeformities
Forum Crew Member
- 30
- 1
- 8
I can assure you I restrained his wrists. My partner had a full on brain malfunction for a moment and removed a restraint to take a bp
- 4,997
- 1,389
- 113
Most psych patients aren't violent. Most know what's going to happen as it's not their first rodeo. My rule about how the ride goes is very simple: the patient's behavior determines it. Patient acts like a decent human, I'll treat them like a decent human. Patient acts like an animal, I'll treat them like one. For my part, I'll always act like a decent human. I'll ask them very directly if they're hearing things, seeing things, if they feel like hurting themselves or other people. I'll ask them if they've used alcohol, tobacco, recreational drugs or marijuana (because some people consider that a medication). I'll ask about their medical and psych history, if they're supposed to take medications, and if they're taking the meds as prescribed. I'll ask them if they feel safe at home, wherever that is. Just make sure you're completely non-judgmental when you do this and make it sound completely normal and routine. I don't care that you just saw the patient yelling at a tree because the color purple is not a natural part of a baby's foot all the while listening to demons singing mahna-mahna. In their reality, that's what's happening and while it may not even make sense to them, it's a part of their reality and it just is.
- 4,997
- 1,389
- 113
Once I gave a ring-down to the hospital, from the front, with the partition closed. The patient was screaming so loudly and incomprehensibly that all the hospital could make out was my unit ID and the ETA. I was speaking loudly and clearly with the microphone about 2 inches from my mouth. Non-violent patient but... very loudly disorganized. That was a fun one...
Bullets
Forum Knucklehead
- 1,600
- 222
- 63
Let PD transport
DrParasite
The fire extinguisher is not just for show
- 6,289
- 2,162
- 113
I have one major issue with your two issues 1) I'm 100% positive that it's not a requirement for me to restrain all my psych patients. This includes 911 calls and IFTs. In fact, I would estimate that 80% of my psych patients were willingly going to the hospital, either the ER or the psych intake (depending if they were a 911 call or a transfer).
I routinely wear my scope around my neck; but never when I'm on psych calls. leave it in the bag or in your pocket.
NomadicMedic
I know a guy who knows a guy.
- 12,203
- 6,965
- 113
Be polite and honest.
Use restraints if you need them.
Ketamine.
Use restraints if you need them.
Ketamine.
A company’s policy isn’t a requirement for you ?
Bullets
Forum Knucklehead
- 1,600
- 222
- 63
Your company requires you to restrain all psych patients?