In an era of customer friendly service, quality improvement, and increasing litigation, we can gain a substantially competitive edge by incorporating a little psychology into our services.
BY Mike McEvoy, Ph.D., REMT-P, RN, CCRN
Behavioral science can make a tremendous contribution to the fire service. In an era of customer friendly service, quality improvement, and increasing litigation, we can gain a substantially competitive edge by incorporating a little psychology into our services. EMS providers routinely encounter patients with emotional disturbances; we can enhance their care by understanding their unique illnesses. Restraint of such patients has become a highly charged and controversial issue fraught with liability; yet, it is necessary for safety. Knowing the risks and dangers involved can facilitate safe and effective use of restraints.
Let me begin with public relations. Whether we accept it or not, every member of the department is involved in public relations. Anything from the actions of a 911 call taker to the firefighter driving an engine can influence the public’s perception of the fire department. A continual awareness of appearances is critical to fulfillment of expectations. First, we need to have a fairly clear idea of what public expectation is for our fire service and from where the public derives its viewpoint. For most of society, television and movies have the greatest influence on what to expect during and after a call to 911. Unfortunately, the quick responses and spectacular rescues portrayed on mainstream television often compare disappointingly with what we are able to deliver with our funding. Yet the public expectations remain.
The psychological definition of an “emergency” is an important concept for the firefighter. The average citizen is more than capable of handling life’s many crises. An “emergency” occurs when a situation extends outside an individual’s ability to manage it. For police, fire, and medical emergencies, the public has been conditioned to recognize a round-the-clock response capability that delivers trained and experienced emergency professionals. Beyond dialing 911 (or some other emergency number), the public often has little understanding of how an emergency response occurs. Hence it is not uncommon for an engine company to be scolded about a 911 operator’s attitude as though the firefighters themselves had answered the phone. Therein lies our first application of behavioral science to the fire service: creation of a cognition of our own appearance as seen through the eyes of the public.
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The 911 call center is our first representative to the public. Every piece of apparatus serves as a moving billboard for the department: the public observes our speed, where we park, and how the vehicles look. Uniforms speak volumes about professionalism. The way we speak, what we say, how we move about, and the way we interact with each other all convey a message to the public. The best fire/EMS providers are perceived as calm, deliberate, kind, concerned, and intelligent. The potential to apply behavioral science in this area is unlimited. I know of departments that eliminated their fire station rooftop sirens because they served more as a public announcement of slow daytime response than they did as an alerting device. My own department relettered our uniforms with FIRE/RESCUE to decrease chances of the public’s confusing our firefighters with local ambulance crews. On a smaller scale, wearing a stethoscope around the neck portrays an image to the public of a medically competent provider. The value of such stereotypes is greater when off duty or out of uniform. The manner in which we work with each other on the scene is incredibly representative to the public of our overall professionalism and likely of our competence also.
I am often asked about phrases for communicating in difficult situations. To properly choose your words, it helps to have an understanding of how people cope with emergencies. Each of us is conditioned starting at birth to deal with stress in different ways. These coping behaviors, called “defense mechanisms” by psychologists, allow us to handle increased levels of stress. While there are dozens of coping behaviors, we commonly recognize only a handful. These include realistic fears of pain, death, and disability; anxiety stemming from a sense of helplessness; and depression from loss of control over one’s own destiny. Regression is another coping behavior that involves reverting to an earlier form of behavior. Toilet-trained children who wet themselves are exhibiting regression, as are adults who cry. Denial is a coping behavior often seen by police officers: “No one was driving this car. It simply drove itself right into the tree.” Anger and confusion are coping behaviors some people exhibit under stress.
In our communications with patients, we should strive to allow or even encourage coping behaviors yet discourage or limit their excessive or inappropriate use. There are times when it might be appropriate to give your patients “permission” to cry, recognizing that they need to use this as a coping behavior. However, in situations where you observe escalating anger or hostile behavior, it would be appropriate to set limits to ensure that you, others, and the patient remain safe. Understand that the anger is not likely directed at you personally but is a means by which that individual deals with stress. The lead then for “What should I say?” comes from the behavior of your patient, his family, and those around you. Remember that people should not be denied the ability to cope with their emergency in the fashion in which they have become accustomed (unless their behaviors are inappropriate or dangerous). Not every sad person requires cheering up; not every denial requires an injection of reality medicine; and not every tear need be wiped away. The mark of a seasoned medical provider is a confident and empathetic manner, communicating to your patients what you believe is wrong with them and what you plan to do to help.
Mental Disorders
Calls for specific emotional disorders represent a small percentage of EMS responses, yet they contain some of the greatest potential for danger. Understanding the scope of mental disorders and appropriate prehospital management techniques can help you provide better and safer care. You will commonly encounter four prehospital mental health emergencies: acute onset anxiety (AOA), paranoid ideation, disorganization, and suicidal behavior. Each has specific dos and don’ts.
A pitfall in the management of behavioral emergencies is failure to exclude medical conditions that account for the signs and symptoms observed. While it is beyond the scope of this article, the prehospital provider should carefully consider diabetic-related emergencies, hypoperfusion (shock) states, head trauma, substance abuse, extremes in body temperature, as well as other medical or traumatic conditions that could cause behavioral changes. Preconceived notions or “pigeonholing” patients into a mental health category can have catastrophic consequences when a treatable medical condition underlies their altered mental status.
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Acute onset anxiety, also referred to as panic attacks or hyperventilation syndrome, is much more prevalent in emergency and critical care medicine than we currently recognize. It is often challenging to differentiate the symptoms of stroke (CVA or cerebrovascular accident) and myocardial infarction (MI) from those of acute anxiety. And that’s exactly why these patients usually call for EMS: chest pain, shortness of breath, palpitations, or stroke symptoms. Several assessment findings are helpful to differentiate acute onset anxiety from other conditions. Acute onset anxiety involves hyperventilation while other vital signs are usually within normal limits. Respiratory rates in AOA are often in the mid to high 30s, hence difficult to count. The patient will commonly experience numbness around the lips and mouth and in the fingers and toes (circumoral and peripheral paresthesias). Prolonged hyperventilation may lead to spasm of the hands (carpopedal spasm) and/or unilateral weakness resembling a stroke. Most significantly, an AOA patient will rarely ever “look sick.” Having to ask who among a group is the patient should send a flag up in your mind that you might be dealing with AOA. A “look hard” test for acute anxiety contrasts with the “look test” used to quickly pick out the critically ill or injured. In acute anxiety, one often has to “look hard” to find the real patient.
Treatment for AOA is supportive: reassurance and coaching to decrease hyperventilation. Rebreathing techniques such as breathing into a paper bag or an oxygen mask with little or no flow have been shown to worsen symptoms when compared with reassurance and coaching. In conjunction with a confident and calm approach, most AOA patients will be asymptomatic within five to 10 minutes. Failure to see improvement strongly suggests that some other pathology may be responsible for the symptoms. Keep in mind, however, that the “cure” supplied by an EMS provider leaves with the provider. Relapse is common. Additionally, there are several potentially fatal pathologies that can mimic AOA symptoms. These include aspirin overdose (purposeful or accidental), pulmonary embolus, and diabetic ketoacidosis. For all these reasons, it is prudent to insist on transport for further evaluation, even if the patient “feels fine now.”
Paranoid ideation is not a common psychiatric emergency but does pose a significant safety risk. Law enforcement personnel typically see the paranoid patient initially because of unusual behavior. They call for EMS when it becomes apparent that the patient’s thought processes are not normal. Paranoia is a particularly difficult mental illness to understand. Patients often hear voices; suffer from visual hallucinations; or believe that they are being poisoned, spied on, or followed. Until the late 1970s, paranoid patients were institutionalized. Drug treatment now allows most paranoid patients to live productive lives in the community without symptoms. Our encounters frequently involve paranoid patients with significant symptoms because they have either stopped taking their medications or are experiencing unusually high levels of stress in their lives.
There are several pearls to caring for a paranoid patient. Most importantly, recognize that the paranoid patient has insight into the fact that he or she is ill. Resist the temptation to compromise what appears to be craziness with your own version of craziness. Doing so will undoubtedly undermine any chance of gaining the trust and confidence of your patient. From the perspective of a paranoid patient, an EMS provider who offers a “magical device that will clean bugs right off the wall” or some other kind of nonexistent cure is clearly suspect. If I were experiencing paranoia, the last person I’d want to accept help from would be someone who also seemed mentally unstable. Keep it logical: If you do not agree with a paranoid patient, don’t argue; simply explain that there appear to be some differences between what they see or hear and your experience. Offer to assist them with what is quite clearly a problem.
While touch may be therapeutic in medicine, it is absolutely threatening to the paranoid patient-avoid it. Maintain a safe distance, and respect the patient’s personal space. Communication will often be difficult because of the multiple voices or thoughts that interfere with the patient’s listening. Repeatedly identify yourself to overcome this interference. When properly approached, many paranoid patients can be convinced to peacefully accompany you for care at a treatment facility.
Disorganization is an actual psychotic episode. For our purposes, this means that patients with disorganization are dangers to themselves and must be taken for treatment. Fortunately, these patients are generally quite happy and cooperative. The police usually are called first to see these patients, typically when they are entirely out of attire for the environment (i.e.: a person walking naked in a snowstorm). On questioning, these patients are oriented only to person and place. They have little or no concept of time and have essentially lost all memory, both long and short term. Be certain to conduct a thorough assessment of any patient with altered mental status to reasonably exclude the possibility of head trauma, diabetic emergencies, hypoperfused (shock) states, and other common conditions that might alter behavior.
Attempts to treat a person with disorganization should focus on transport. Be prepared to repeatedly explain your role and care, as loss of short-term memory will likely cause the patient to ask the same questions over and over again.
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Suicide, a problem we encounter often, can unknowingly place us in grave danger. Whether responding to a suicidal patient or a suicide attempt, the bottom line for the patient is control. The patient is tired of not being in control of his life. Suicide is the ultimate repossession of control wherein an individual decides to regain control of his life by ending it. If we believe that this devaluing of life is specific to just the individual, we are mistaken: Life in general has little importance. For that reason, we must approach every suicidal patient as homicidal also. Scene safety must be our first priority and remain foremost in our minds. Without a doubt, the gasping patient cut down from a hanging attempt by police responders should be restrained before being given any other treatment. The presence of numerous armed law officers in a room with an active unrestrained suicidal patient is a recipe for disaster. The same holds true for weapons. Make sure guns and knives are cleared from the area before you care for a suicidal patient. Your safety must come first if you are to survive to treat your patient.
EMS personnel can occasionally find themselves first on the scene of a patient who is actively threatening suicide. While awaiting the arrival of trained negotiators, it is important to know what to say and what not to say. The key here is remembering what motivates suicidal behavior: loss of control over one’s life. For this reason, the most important thing to avoid is any statement that presents a challenge, order, direction, or command. Statements such as “Put the gun down now” and “Don’t jump!” are examples of what not to say. Such communications are likely to push a suicidal patient to act. Instead, it is appropriate to express your concern for the patient, offer your help, and suggest that there may be other solutions to the problem. Obviously, persons specially trained in dealing with suicidal behavior should be called to the scene.
Not uncommonly, the need to assess suicidal risk arises in the prehospital environment. Most often, this involves patients with seemingly self-injurious behavior who refuse transport. There are two common means to evaluate suicidal risk (see Figure 1). The first, called the Four-Question Method, asks four questions and indicates increasingly higher risk with each affirmative response. First, ask about intent. Whether responding to a suspicious accident or evaluating a depressed patient, make it a habit to question patients about intent to harm themselves. Second, having a method in mind for self-harm indicates an increased suicide risk. Third, if the means that match the patient’s method are available, the risk is even greater. Finally, very specific suicidal plans correlate with the greatest risk. There are multiple applications for this methodology: interviewing a depressed patient; responding to a car vs. pole with no apparent skid marks; and noticing life insurance policies, a will, and other documents on display as you enter the scene of an overdose.
Another way to assess suicide risk is by tabulating risk factors. Older aged males with a history of depression, a recent loss, and history of prior suicide attempts represent the highest risk by exhibiting the greatest number of risk factors. The predictive value of risk factor assessment may be equally as strong as interview methods.
Restraints
Restraints are a controversial topic in both prehospital and hospital medicine. Two factors tend to complicate EMS providers’ use of restraints. First, there is a tendency to confuse police restraint with EMS restraint. Second, safety issues that guide use of restraints in medical facilities are often mistakenly applied to entirely different circumstances faced by prehospital providers.
Clearly medical restraint is entirely different from police restraint. There is also a difference, although much more subtle, between restraint for behavioral vs. medical reasons. For your own legal protection, it is important to clarify the meaning of restraint. Textbooks define restraint as physical or chemical restriction of movement. That seems appropriate, but what about an arm board used to keep an IV secure? Are the straps on a backboard considered restraints? What about a traction splint used to immobilize a fractured femur? Or the seatbelts used on an ambulance cot? All of these devices restrict movement and could be considered restraints, yet we know they are not.
Two factors actually determine whether a device or drug is really a restraint: reason for use and consent. If the reason for use of a device is to prevent movement and it is done without the consent of the patient (or against the wishes of the patient), it is a restraint. This concept is important, especially when documenting on forms that contain checkboxes for restraint use.
Generally, we use restraints in the prehospital environment whenever we encounter dangerous behavior. Most states have laws, rules, or regulations that govern use of restraints by prehospital providers; you should become familiar with those that apply to you. Typically, some immunity from liability is provided in state or local statues, as are definitions of circumstances in which restraints may be used, such as behavior that threatens harm to oneself or others. The legal perils involved in restraint use stem from the fact that the provider applying restraints is indeed depriving the restrained patient of freedom. In such circumstances, the provider has a clear duty to exercise increased vigilance for the safety of the patient, since he is unable to protect himself while restrained.
Process of Restraint
Safety and the prevention of injuries, as well as attempting the least restrictive means of restraint, call for a process of restraint. This process works on the assumption that no individual really wants to harm himself or another. The big difference between us and those who exhibit dangerous behavior is merely a matter of self-control. It is imperative to maximize the patient’s self-control before deciding to apply restraints.
Self-control. Whether dealing with a hostage situation or an emotionally disturbed patient who refuses transport, the first step is to encourage the patient to exercise every ounce of self-control he has inside himself. A statement such as “I know you don’t want to hurt yourself or anyone else. I want you to reach deep down inside yourself and try to stay in control. I know you can do it” is an example of calling for self-control.
Offer to help. Anxiety can interfere with concentration, and your offer of assistance should reduce anxiety. The person spotting a weightlifter often makes the lifter more confident because he knows he won’t be hurt. Likewise, an offer of assistance will oftentimes allow a person exhibiting dangerous behavior to exercise greater self-control than would be possible otherwise. A statement such as “I want to assure you that we will help you. We will not let you hurt yourself or someone else” is an example of an offer to help.
Show you mean business. You must have present, in clear view of the patient, the resources necessary to physically and safely overpower him. Never attempt physical restraint without the resources needed to safely overpower a patient.
Physical restraint. This is the time when most injuries tend to occur, but you can greatly reduce the number of injuries by eliminating the opportunity for the patient to prepare for battle. Early and swift movements reduce injuries to patients and EMS providers. Be certain that you have adequate help. Plan your activities so that each provider involved clearly understands his role. Typically one person is assigned to each limb, and one provider should communicate with the patient continuously. Once you decide to restrain, act quickly. Use only the force necessary for restraint. Depending on local requirements, it may be helpful to have the police present during restraint. Approval from medical direction or control may also be required.
Types of Restraints
The kinds of restraints used in the prehospital environment vary tremendously. One fact is certain: Police restraints are not medical restraints. It is inappropriate to use handcuffs or law enforcement ties in an EMS or other medical environment. These devices have tremendous potential for injury and present major obstacles to providing good medical care and treatment. Many commercially made medical restraints are on the market-from simple wrist restraints to full leather restraints. Leather tends to break down over time and eventually weakens enough to break or tear with minimal force. The ideal restraint is a towel and roll of one-inch cloth adhesive tape (see photo 1). The folded towel is looped around an extremity (see photo 2) and then secured by wrapping several times with the adhesive tape close to the extremity (see photo 3). The two remaining ends of the towel can then be secured to another extremity or a stretcher (see photo 4). This simple device has restrained patients who have broken out of leather restraints and even police-applied handcuffs, all with excellent results.
Facedown vs. Faceup
Facedown restraint is another controversial issue in the prehospital environment. In the interests of safety during transport in a moving vehicle, facedown restraint is often employed. The majority of EMT textbooks recommend facedown restraint.1-4 Many providers apply wrist and ankle restraints and then place their patient in a carrying device that cocoons them in a fashion that prevents escape by struggling loose. Extremely active patients are often easier to control when facedown. While there is clearly a subset of patients who should not be restrained facedown, this is not every patient. In medical facilities, the dangers associated with facedown restraint stem from lack of continuous supervision by staff trained in airway assessment and management. The ability of prehospital providers to continuously monitor and treat their patient allows for facedown restraint when appropriate.
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In 1995 and 1996, medical and forensic journals reported several deaths that occurred in restrained patients being transported by paramedic units. 5, 6 These deaths, with others reported by law enforcement and mental health facilities, led to the term positional asphyxia. Death from positional asphyxia is thought to occur from facedown restraint that severely restricts the ability to breathe. Originally, most deaths were thought to occur in patients who had their wrists restrained behind their backs and also had their ankles pulled up toward their wrists-a technique referred to as “hobble” or “hog-tie” restraint. Subsequent reports have occurred during simple prone restraint. Although there are no specific autopsy findings that indicate positional asphyxia, it is often assumed in restraint situations when all other causes of death have been excluded.
Today, we can identify a specific subset of patients at increased risk of positional asphyxia.
- Large, protuberant abdomen. Seemingly, placing such a patient facedown would compress the abdomen up against the diaphragm and severely constrict expansion of the lungs.
- Drug psychosis with violence.
- COPD, asthma. People with already impaired lung function from chronic obstructive pulmonary disease (COPD) or asthma are also at great risk for positional asphyxia.
- Down’s syndrome. This developmental disorder is associated with a flattened face, an extremely large tongue, and often a large abdomen. The combination of these features makes facedown restraint ex-tremely dangerous in this population.
The pathophysiology of positional as-phyxia seems to be related to a supply vs. demand situation with oxygen in the body. During physical re-straint, patients often require a maximal level of breathing to support their struggle against restraint. Interference with the ability to breath at maximum levels from lung disease, a large belly compressing the diaphragm, or a drug-induced state that significantly increases oxygen demands can have disastrous consequences. These are patients who should be restrained faceup.
Do Not Remove Restraints
What provider has not been asked to remove restraints from a patient who promises that he will behave? A guide for these circumstances is to remember that a cooperative patient will cooperate with restraints. Patients who ask for their restraints to be removed don’t fit this criterion. In fact, it would be uncommon in the short transport times that EMS generally experiences to have a previously restrained patient who no longer requires restraints.
Documentation
Documentation of behavioral emergency calls should include assessment information that demonstrates the absence of medical problems or trauma that might produce changes in behavior. Altered mental status would include a description of the problem as well as evidence of trauma, seizures, fever, or hypothermia. For other behavioral emergencies, it may be helpful to quote how the patient feels. Include information on suicidal tendencies, as well as whether the patient has threatened or harmed others. Medical history, mental health history, and consideration of medical causes for unusual behavior are important.
Documentation of mental status usually includes a description of the patient’s general appearance, activity level, speech content and speed, and orientation level. If you use restraints, it is important to document the behavior that made them necessary as well as the restraint technique used. I cannot stress enough the importance of continually reassessing restrained patients. Be certain that your documentation reflects your continual concern for the patient’s safety and well-being.
Understanding the role of behavioral science in the fire and emergency medical services can vastly improve our image in the community and help us give better care to all of our customers. In our highly litigious society, knowing the proper use of restraints as well as their associated risks will make the scene safer for everyone involved.
Endnotes
- McSwain, N.E. and J.L. Paturas. The basic EMT: comprehensive prehospital patient care – 2nd edition ( St. Louis: Mosby, 2001).
- Limmer, D, M.F. O’Keefe, H.D. Grant, et al. Emergency care – 9th edition. (New Jersey: Prentice Hall, 2001).
- Browner B.D., A.N. Pollak, C.L. Gupton, eds. Emergency care and transportation of the sick and injured – 8th edition. (American Academy of Orthopaedic Surgeons, 2001).
- Henry, M.C. and E.R. Stapleton. EMT prehospital care – 2nd edition. (Philadelphia: WB Saunders, 1997).
- Stratton, S.J., C. Rogers, K. Green, “Sudden death in individuals in hobble restraints during paramedic transport,” Ann Emerg Med, 1995; 25:710-712.
- Reay, D.T., “Suspect re-straint and sudden death,” FBI Law En-forcement Bulletin, May 1996.
- Moscicki, E.K., “Identification of suicide risk factors using epidemiologic studies,” Psychiatr Clin North Am, 1997; 20:499-517.
- Doyle, B.B., “Crisis management of the suicidal patient.” In: Blumenthal S.J., D.J. Kupfer, eds. Suicide over the life cycle: risk factors, assessment, and treatment of suicidal patients. (Washington, D.C.: American Psychiatric Press, 1990), 381-423.
- Fawcett, J.; D.C. Clark, K.A. Busch, “Assessing and treating the patient at risk for suicide,” Psychiatr Ann, 1993; 23:244-55.
- Rich, C.L.; D. Young, R.C. Fowler, “San Diego suicide study. I. Young vs. old subjects,” Arch Gen Psychiatry, 1986; 43:577-82.
- Goodwin, F.K. and G.L. Brown, “Risk factors for youth suicide.” In: Report of the Secretary’s Task Force On Youth Suicide. Vol 2. (Washington, D.C.: Dept. of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, 1989), DHHS publication no. (ADM) 89-1621.
- Shea, S.C. Psychiatric interviewing: the art of understanding. Philadelphia: Saunders, 1988.
- Hirschfeld, R.M. and J.M. Russell. Assessment and treatment of suicidal patients. N Engl J Med 1997; 337:910-5.
Mike McEvoy, Ph.D., REMT-P, RN, CCRN, is the EMS coordinator for Saratoga County, New York. For the past 13 years, he has worked in the Cardiac Surgical ICU at Albany Medical Center. He teaches at Albany Medical College and lectures at hospitals, colleges, and conferences. McEvoy is a paramedic for Clifton Park-Halfmoon Ambulance Corps and medical advisor for the West Crescent (NY) Fire Department. He currently serves as a member of the New York State EMS Council and the State Emergency Medical Advisory Council and chairs the EMS Section of the New York State Association of Fire Chiefs. His first career was with the Justice Department as a forensic psychologist.
Figure 1. Evaluation of Suicidal Risk
Four-Question Method:
Intent
Method
Available Means
Specific Plans
Risk Factors Method:
Male
Older age
History of depression
Recent loss
Prior attempt*
* 50 to 80 percent of suicides have a history of previous attempts.
Adapted from endnotes 7-13.
