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INTRODUCTION

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EMS providers are often called to evaluate patients who are behaving oddly or who are having an emotional or mental crisis. Although these conditions are not necessarily all from diagnosable psychiatric disorders, all involve—to some extent—disorders of thinking. These patients are therefore often labeled as “psychiatric,” even if the cause of the patient's symptoms is from another medical condition.

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OBJECTIVES

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  • Discuss the initial prehospital evaluation and management of the acutely psychotic patient.

  • Discuss common psychiatric conditions in prehospital patients.

  • Discuss the initial prehospital evaluation and management of the suicidal patient.

  • Discuss the initial prehospital evaluation and management of the homicidal patient.

  • Discuss commonly encountered drugs of abuse and their toxidromes.

  • Discuss the involvement of law enforcement in prehospital psychiatric patients.

  • Discuss some pitfalls associated with these conditions in the prehospital environment.

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BACKGROUND

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There are three key points to understanding behaviorally disordered patients. First, patients with odd behavior or who are having a mental or emotional crisis are “real patients.” These patients need capable, caring EMS providers just as much as other patients who are suffering from medical conditions that can be treated with a paramedic drug kit. Providers who dismiss many of these patients as “just another psych patient” not only do not appreciate the varied causes of odd behavior, but may also miss an early opportunity to intervene in a potentially life-threatening condition. Second, these patients often present unique challenges to EMS providers. Since these patients often have impaired reasoning about their situation, they may have difficulty giving a history or answering questions like other patients. This can sometimes be frustrating to providers, especially those who are not used to utilizing creativity in order to obtain information. Finally, patients with impaired reasoning skills in chaotic environments may respond unpredictably. More so than with other types of patients, providers must always be mindful of their own safety as well as for others at the scene.

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There are very few studies in the literature that specifically investigate prehospital management of behavior-disordered patients. Many of the recommendations in this chapter, therefore, are taken from the much larger literature on emergency department management of these patients. Nonetheless, prehospital providers are the “eyes and ears” of the clinicians who will eventually be treating these patients in the emergency department and will be the ones offering early intervention, which is key in the management of these patients.

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COMMONLY ENCOUNTERED BEHAVIORAL CONDITIONS

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Behaviorally disordered patients are common in the prehospital setting, although not all conditions have a definable psychiatric diagnosis. Such conditions include agitation and acute psychosis, suicidal patients, and homicidal patients. These conditions are often called presentations or syndromes, as each is only a label for symptoms which are produced by a variety of medical conditions. Each of these syndromes is discussed in turn.

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AGITATION AND ACUTE PSYCHOSIS

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