Sedation of Mentally Ill Patients for transport

[emtannie]

I spent several hours with a very nice mentally ill patient last night, as we flew her to another city to be admitted to a higher level psychiatric care centre than what our hospital could handle.

She was a very easy patient, was ambulatory, cooperative, and talked all the way to the airport, on the flight, and to the other hospital. She was quite entertaining to listen to, as she spoke about terrorist plots she had information on, the parties she had attended with Yoko Ono, and that she was currently dating Lyndsay Lohan.

According to the documentation we received, she was prone to unprovoked attacks of staff and others, and could be quite dangerous to herself and others.

There were several times on the flight where she was very agitated and fidgety, and we were able to calm her with just talking to her. While we were with this patient, I began to think of our protocols when it comes to transporting patients with a history of violence.

When do we sedate, for our safety rather than theirs? When should we? When do we? Should we ever sedate without the patient's knowledge of what we are giving them?

In this case, I think that if the staff at the hospital had told the patient that she was going to be sedated prior to transport, she would have become more aggressive. Because she was informed throughout the process, she was calm and cooperative. My opinon probably would be different had she tried to assault either my partner or me while in flight though...

At what point do we override the patient's rights in order to protect our own safety?

These thoughts were rolling around in my head as I watched her fidget and listened to her talk, so I am now wondering - what do others think? When do we/should we sedate a mentally ill patient during or for transport?

[Lone Star]

In light of there being documentation that the patient was prone to unprovoked attacks and violent behavior, then the responsibility to decide whether to sedate this patient or not should fall squarely on the staff (ie: Doctor) of the facility initiating the transport.

I don't believe in procedures that are initiated out of 'revenge' or just to make our jobs easier. Since there is a safety concern, then the treating physician should have either ordered restraints or sedation prior to begining the transportation and transfer of care.

Furthermore, it's always been drummed into our heads that we explain everything we do as we're doing it. I really dislike the idea of 'blindsiding' a patient (giving them something without telling them what it is or what it's for).

Far too often, we get frustrated with patients that we see/treat that are taking meds and have no idea WHY they're taking them. We encourage our patients to ask questions to be absolutely sure of what they're taking and the effects of the meds they're tatking. To circumvent that by administering a drug without telling them what it is and what it's for, seems unethical and hypocritical at best.

If we start randomly sedating based on 'feeling unsafe', where do we draw the line as to what's a 'reasonable expectation/feeling'?

[Happiness]

Here we sedate them no questions. I have actually refused a pt and had to explain to the dr why. He was very willing to give the drugs once he realized how easy it could be for a pt to freak in a heli or a plane and make them crash or hurt the medics on board. The most extreme Mentally ill pt was 17 yrs old, was drugged at a party and has had pycosis ever since (very sad really). It took 3 days to get her sedated to the point where she would be accepted by the ALS crew. In our little world all the pt can do with pain stimulas is moan and they are good to go.

I truely belive Anne that you should never take another pt like that on a plane as there will be one look or gesture that you or partner do that will set off your very nice pt and then your in the deepest shit possible.

You may want to talk to your provider and the hospitals and have a mutual agreement with them as it is nice to walk in have a 1/2 sedated pt they give the rest and off you go, quick and easy.

[Richard B the EMT]

What a concept.

I admit uncertainty, here. What are the guidelines your agency follows? What does your OLMC have for these kind of situations?

My local protocols are to have a LEO accompany the patient. I don't know about drugging an EDP for transport, as the person, especially if violent, or potentially violent, is going to be in restraints, by the LEOs.

I've only had one patient in an "I love myself" shirt (Straitjacket), and he was sedated for an hour and a half trip, yet he got out of the jacket enough to light up a cigarette. The admissions officer put the scare into me at the end of the transport. Seems the patient was a homicidal suicidal EDP, and that fact didn't get told me until they were admitting him.

[JPINFV]

The problem with patients with psychiatric disorders is that it's all dependent on the patient, the disease, and recent history. Just the presence alone of a psychiatric disorder shouldn't ever be enough to demand, dictate, or provide any form of restraints (To show the, erm, insanity of that extreme, would you sedate a patient diagnosed with alcoholism or someone with a phobia and nothing else? Both are in the DSM).

I think another issue with EMS and patients with psychiatric disorders is that the EMS training seems to be confined to no restraints, 4 point restraints, and chemical restraints. While this is fine for the acutely ill 911 patient exhibiting active threats to themself or others, it's a completely inappropriate mindset for interfacility transports. For the "might become violent" (especially the ones who are compliant and cooperative at time of transport), did you consider alternative restraint methods? Maybe a vest style restraint (i.e. poesy vest) might have been appropriate. Another thing to think to consider is what are the trigger points (if any are known) and the patient's recent history. A patient who was combative a week ago prior to starting (or restarting if non-complaint) medications might not be a likely threat today because of the medications. Similarly, a patient who is being restrained 'just because' might view the application of restraints as a threat against themselves, and respond in an appropriate manner.

[aussiephil]

I think what we need to remember here is that there are a number of factors involved.

Firstly the assessment must be made of the patient & the possibility (probability) of them causing actual harm to people. Whats to say that a normally sane person, with no mental health history doesnt freak on a helo or aircraft?

Secondly we need to remember that they have a diagnosed illness. Just as a person with Cardiac Illness, Respiritory illness etc. They still deserve to be treated with respect. We need to ask is chemical restraint the most appropriate first action for mentally ill patients, or would a mechanical restraint be more appropriate.

Mentally ill patients have the right to refuse medication, they also have the right to refuse an injection, or any meds we want them to have, just like any other patient. Coupled with the fact that a proper psych examination cannot be done until the effects of any drug have worn off, therby delaying proper assessment. Surley this is not in the best interest of the patient. Mechanical restraint can have a calming effect on the patient, allow for an earlier assessment & for appropriate treatments to begin. They also offer suitable protection to staff & if necesarry, lower doses of chemicals for further restraint.

[ambodriver]

I'm not sure about long term transport with patients, or interfacility pysch transports, but if someone is extremely hostile, or if I think they will be hostile our protocols allows 10mg of versed IM. This is only if they have to go with us to the hospital and are not a refusal. (i.e. suicide attempt etc. etc.) I am quick to use it...I have a daughter to go home too, and at that point I don't care to struggle any longer with them.

I find it weird that pysch patients are being flown in helicopters via EMS, that's crazy!

[stcommodore]

Long term transports are a different story, airplane rides even different. But around here if necessary hard restraints or chemmical. I've used both and do so liberally cause I intubate better then I fight.

[Don1977]

If they are a threat or combative then yes sedate them.

My company has the mental health contract for the county we are in, I transport psychiatric transfers and emergencies everyday I work, sometimes 2 to 4 a day, unfortunately, and In my 8 years at this company only about 20 have been sedated which is a very small number.

Depends on the patient, Ive learned that some hospitals blow it out of proportion, many many times they have said the patient is "combative, blah,blah,blah" and when I get them for transport there okay or "tolerable".

90% of them can walk and act better then most of us and just need "attention" and get 3 free days at a psych evaluation hospital/clinic and need no sedation at all, no reason for it.

[Richard B the EMT]

I have to stay with cookie cutter answers. If local protocols allow, and the need arises, do what you have to do. Follow your local protocols, or work, with documentation supporting another way, to changing those protocols. Don't follow the new possible protocols until they are made YOUR OFFICIAL Protocols by the medical director.