Sedating mentally ill

[Happiness]

http://www.theglobeandmail.com/news/national/british-columbia/bc-rules-requiring-sedating-mentally-ill-for-transport-risks-lives-mds-say/article2436519/

So I am looking for a solution to a problem that we deal with here. This is a fair artical as far as I can see but the one thing that is not mentioned in this artical is the policy for Transport Canada. I did get a response from them when I enquired about their policy. It says that no patient being tranported in an aircraft can be physically restrained to any fixed part of an aircraft. So using physical restraints is not an option. Now we had the old shackel type of leathers at one time but they are also not used these days, and the pt could still do damage

I hate everytime I go into the hospital for a phyc transfer because there is going to be a problem between us and the drs. I get their side of things but our safety in any situation has to be first and foremost. I also get the fact that some people are pigon holed into this mental health senerio even if they are not being sent out for a mental health issue at the time. This is a problem being in a small town you know most peoples issues. I was even subject to that not long ago, knowing violence what a pt did days before they were medivaced and they were to be sedation or they were not getting on the Heli.

Our policies are also PDF on the side so you can get the whole idea of who is sedated. Also some of the comments are interesting.

I would like to know what you guys think and how do your flight medics deal with this. Also if anyone can point out other policies for other places I could take a look and compare.

We have had a few suicides here that have bothered me and mental health is really on my mind lately. Living on a island our mental health system here sucks the big one. They go off for a week or two and are sent back with pills. To me that is a lazy way to treat them.

Thanks

Happi

[paramedicmike]

It's article.

So, no patient may be restrained to any fixed part of the aircraft. What about restraining them to the litter? I am familiar with one RW service that used wrist restraints on every patient, mentally ill or not. The wrist straps were affixed to the flight litter and not to any fixed portion of the aircraft. Arm movement was limited so they could not reach the buckles to any of the other straps. Strap adjustment was at the foot where the straps were actually secured.

It worked well.

Edited May 26, 2012 by paramedicmike

[Happiness]

Thank you Mike. Is the litter the portable Stretcher we call a number 9. If so, once the stretcher is snapped it becomes a fixed part of the plane. I am familular with welcro wrist straps and have used them many times. I would like to use less drugs because, for one thing not all patients are violent but on the other side of the coin you never know how someone who is being committed is going to act. The other problem with drug sedation with this intensity is that it can take a few days before the doctors can even deal with them (so I have heard). We are in such a unique location it not going to be a win win in this case but if I can some how make it better, maybe these pts will get the help they need.

[systemet]

I think you have a fairly unique situation there, as some of your flights are crewed BLS, right? The article seems to suggest that "paramedics" can't give sedation, but you're EMA-3 / ACP medics must have some sort of standing orders for benzos or haldol right? The flight ACPs have an expanded scope, don't they?

From what I get reading the news story, it sounds like there's a blanket policy that any psych transfer requires a fairly heavy degree of sedation, regardless of the perceived risk? And also that this is being applied in some situations where the patient's being transferred for another complaint but has a history of a psychiatric disorder? Am I reading that correctly?

If this is the case, I'd suggest that the policy is dysfunctional and needs to be changed to allow the transporting paramedics the discretion to decide what degree of sedation is required, and which patients should receive it? It might be worth re-designating psychiatric transfers that are judged by a PCP crew to require sedation to go ALS. Or continuing the existing policy of allowing any crew (BLS or ALS) to refuse to transport any patient they feel is not adequately sedated.

But any attempt to demand that all patients with a psychiatric diagnosis, or being transferred for a psych referral be sedated into a danger zone for losing airway control, would be grossly unethical.

-------------

Also, regarding the argument that benzos/antipsychotics can interfere with the receiving physicians assessment, it should be remembered that the use of chemical restraint is also to protect the patient, so that the transport is less distressing for them, and to prevent them from harming themselves!

While these patients may be manageable in a clinic environment without medication, the flight environment provides a bunch of additional stressors must be anticipated.

Some of the problem with longer acting agents, e.g. valium, can be mitigated by choosing agents with a shorter half-life, such as midazolam. But even accepting that this is a problem, any inconvenience to the receiving physicians should be outweighed by the risk of a catastrophe if a high risk patient is flown without proper precautions.

I don't want to seem like I'm doing an about turn on my previous statements, I'm not. The crew has to have the ability to refuse a potentially dangerous transport, and the tools to mitigate any risk that is judged acceptable. But any blanket policy that removes that choice from them, and results in overaggressive sedation of low-risk patients is a problem.

[Happiness]

I think you have a fairly unique situation there, as some of your flights are crewed BLS, right? The article seems to suggest that "paramedics" can't give sedation, but you're EMA-3 / ACP medics must have some sort of standing orders for benzos or haldol right? The flight ACPs have an expanded scope, don't they?

I am a PCP and I have 2 other PCPs in the station. I also have EMRs (Basics) I am pretty sure the ACPs have those standing orders but again some of the Flight crews (Transfer) are also PCP so they would not.

From what I get reading the news story, it sounds like there's a blanket policy that any psych transfer requires a fairly heavy degree of sedation, regardless of the perceived risk? And also that this is being applied in some situations where the patient's being transferred for another complaint but has a history of a psychiatric disorder? Am I reading that correctly?

Yes

If this is the case, I'd suggest that the policy is dysfunctional and needs to be changed to allow the transporting paramedics the discretion to decide what degree of sedation is required, and which patients should receive it? It might be worth re-designating psychiatric transfers that are judged by a PCP crew to require sedation to go ALS. Or continuing the existing policy of allowing any crew (BLS or ALS) to refuse to transport any patient they feel is not adequately sedated.

The Policy is in the works of being revamped. Our medics here have the ability to refuse a pt if they feel unsafe tranporting them. Personally no one in our station has ever refused but in other ones on the island have. In 15 years I have had 2 crews do the iffy thing but took them on my personal knowledge of the pt. My rule of thumb with sedation is , if I am having a normal conversation in the room and the patient wakes up and participates in the conversation they are not sedated enough, if they open their eyes and go back to sleep I am happy. I also have a discussion with the drs on how much is given. Many years ago there was a girl that took 3 days of drugs to be able to be sedated enough for transport. Now she was a definent extreme phyc pt.

Now to be honest there are those that have made this into a pissing match and since the Drs do want their pts to go they just give in. I dont feel this is appropriate and really would just like to find a common ground on this one. I have worked in the hospital where the nurses have really just thought of us as taxi drivers, and I have worked many years to get rid of that thought. We have a good relationship right now and Im trying to keep it that way.

But any attempt to demand that all patients with a psychiatric diagnosis, or being transferred for a psych referral be sedated into a danger zone for losing airway control, would be grossly unethical.

I agree with this statement but again as I mentioned before there are those that have the ability to be very violent at any given time and if they are being transported by air I do request sedation. In 15 years I have done this once. When I did this, the nurse thought I was being unethical but in my mind I was keeping the crew safe from an unpredicable patient that was withdrawing from street drugs.

-------------

Also, regarding the argument that benzos/antipsychotics can interfere with the receiving physicians assessment, it should be remembered that the use of chemical restraint is also to protect the patient, so that the transport is less distressing for them, and to prevent them from harming themselves!

It is not always seen this way by the medical community

While these patients may be manageable in a clinic environment without medication, the flight environment provides a bunch of additional stressors must be anticipated.

See above

Some of the problem with longer acting agents, e.g. valium, can be mitigated by choosing agents with a shorter half-life, such as midazolam. But even accepting that this is a problem, any inconvenience to the receiving physicians should be outweighed by the risk of a catastrophe if a high risk patient is flown without proper precautions.

Agreed but again not seen this way by the medical community

I don't want to seem like I'm doing an about turn on my previous statements, I'm not. The crew has to have the ability to refuse a potentially dangerous transport, and the tools to mitigate any risk that is judged acceptable. But any blanket policy that removes that choice from them, and results in overaggressive sedation of low-risk patients is a problem.

Agreed, so you know the pilots also have the abilty to refuse as per transport canada.

Thanks for your comment. The only thing i didnt like about the artical is the mentioning of kids. I have had two pts at the age of 16 be sedated because of violent suicide attemps.

thanks again

[JPINFV]

I get their side of things but our safety in any situation has to be first and foremost.

If what is being said is true, and anyone with a mental health disorder, including simple depression, are being knocked out, then it's stupid, dangerous, and the "but our safety" people are idiots who can't assess patients. It's everything that's bad with "zero tolerance" or "always do ___" policies or rules.

There's a time and place for chemical restraints, but just as the indication for a non-rebreather mask isn't "ambulance," the indication for chemical restraints should not and cannot be "history of any mental illness."

on the other side of the coin you never know how someone who is being committed is going to act.

You never know how anyone is going to act, ergo everyone should be knocked out. Not everyone being comitted is being comitted because they are a danger to themselves or a danger to others. Furthermore, since this sounds like middle of nowhere frontier rural, just because someone is being admitted doesn't mean that they are being comitted.

If psychotropic medication is the sign of, to use your term, lazy physicians, then making every patient with a history of any mental illness unconcious is the sign of a lazy flight crew.

My rule of thumb with sedation is , if I am having a normal conversation in the room and the patient wakes up and participates in the conversation they are not sedated enough, if they open their eyes and go back to sleep I am happy.

Is that for patients who actually need sedation, or the insanity of "any patient with a history of mental illness, regardless of how slight, gets to go to lala land because... well... because we said so, regardless of if the patient actually presents a danger to... well... anyone"?

It is not always seen this way by the medical community

Or is it because the medical community views putting patients under heavy sedation for no better reason than "because" to be malpractice? Alternatively, is it a combination of HEMS induced malpractice and a misunderstanding on the appropriate uses of chemical sedation?

[Kiwiology]

I am mentally ill, please sedate me

[Happiness]

If what is being said is true, and anyone with a mental health disorder, including simple depression, are being knocked out, then it's stupid, dangerous, and the "but our safety" people are idiots who can't assess patients. It's everything that's bad with "zero tolerance" or "always do ___" policies or rules.

No not everyone is being sedated and someone who has simple depression is not being sedated nor are children. And I will disagree about the safety because I am one of them and I assure you I have a very good ability of assessing phyc pts out in the field or in a controlled setting. We do have a zero tolerance the same as the hospital but we don’t do the "always do" not in our station anyways

There's a time and place for chemical restraints, but just as the indication for a non-rebreather mask isn't "ambulance," the indication for chemical restraints should not and cannot be "history of any mental illness."

Agreed

You never know how anyone is going to act, ergo everyone should be knocked out. Not everyone being committed is being committed because they are a danger to themselves or a danger to others. Furthermore, since this sounds like middle of nowhere frontier rural, just because someone is being admitted doesn't mean that they are being committed.

And when I am referring to this topic they are not being admitted they are being committed and normally on their own accord. The last guy I had to sedate was paranoid schizophrenic; he came to hospital on his own accord because the TV was telling him to kill himself and other violent acts.

If psychotropic medication is the sign of, to use your term, lazy physicians, then making every patient with a history of any mental illness unconscious is the sign of a lazy flight crew.

No you took that the wrong way. I feel that people who are like the above need intensive phyc care which does not include 2 weeks in a phyc ward and a bottle of pills. They need to be in a controlled hospital setting for much more than that. By the way the day after this guy came home he did committe suicide and it was very violent. That is what I mean by lazy. As for the flight crew they are going on by what has been told to them. Even though the policy says certain things if the pt is going for an ultrasound and there is no mention of their, let’s say prior suicide attempts they are NOT sedated. It is a tricky situation all around and I do a case by case assessment but if dispatch has said violent tendencies or psychosis I am required to follow the policy

Is that for patients who actually need sedation, or the insanity of "any patient with a history of mental illness, regardless of how slight, gets to go to lala land because... well... because we said so, regardless of if the patient actually presents a danger to... well... anyone"?

So as I see it, it is not everyone that has a hx of mental illness, we would be sedating everyone. It is there for those that actually have been diagnosed with a medical condition (they are listed in the policy) also for those that have been deemed violent (the case I keep mentioning is a drug addict that in the past year has stabbed 3 people and the last person was stabbed 8 times) Most of the people that are sedated are going to a phyc ward and not because they want to, they have been committed.

Or is it because the medical community views putting patients under heavy sedation for no better reason than "because" to be malpractice? Alternatively, is it a combination of HEMS induced malpractice and a misunderstanding on the appropriate uses of chemical sedation?

I really don’t disagree with that statement but I have to say exactly what is the appropriate uses. Now please remember this topic is on Flighing people out. We cannot drive because it would an 8-52 hr ferry ride. I don’t believe that people going by car should be sedated to the same level by any means, because you can physically restrain them to the stretcher or pull over and jump out, you don’t have that luxury in a plane.

So the solution to me is for Northern Health to have a Psychiatrist on the islands. The money that is saved by not transporting them would pay for that. Now with that being said we are not rural we are isolated and you really have to love living here to stay here. Our system just sucks all around in the north and then being isolated makes it 100% worse.

[Arctickat]

Thank you Mike. Is the litter the portable Stretcher we call a number 9. If so, once the stretcher is snapped it becomes a fixed part of the plane.

Who told you this? If it was someone at TC I would suggest getting a second opinion.

http://www.tc.gc.ca/eng/civilaviation/publications/tp10839-section11-231.htm

Restraint Systems

All stretcher and incubator restraint systems require Transport Canada (Airworthiness) approval. Each restraint system, including anchorage to the primary aircraft structure, shall be designed for an average occupant weight of 170 pounds and for the maximum load factors corresponding to the specified flight and ground load conditions, including the emergency landing conditions prescribed in the applicable sections of the Airworthiness Manual. (Refer to Section 561, 785, 789 and 1413 of Chapter 523, 525, 527 and 529, as applicable). A safety factor of 1.33 shall be applied to the ultimate inertia forces stated in Section 561.

Application for approvals shall be directed to the Regional Division, Airworthiness.

The attachment of the stretcher or incubator to the aircraft structure shall allow its rapid detachment for evacuation.

Patient Restraint

The patient restraint shall be designed to prevent unwanted movements of the person using it during turbulence or in an emergency landing, and to apply the restraining loads over a large area of the body.

All patient restraint systems require TC (Airworthiness) approval. Each patient restraint system, including anchorage to the primary aircraft structure, shall be designed for an average occupant weight of 170 pounds and shall protect the patient when subjected to the maximum loads corresponding to the specified flight and ground load conditions, inlcuding the emergency landing conditions prescribed in the applicable sections of the Airworthiness Manual. (Refer to Section 561, 785, 789 and 1413 of Chapter 523, 525, 527 and 529, as applicable. A safety factor of 1.33 shall be applied to the ultimate inertia forces stated in Section 561.)

Application for approvals shall be directed to the regional division of Airworthiness.

Each patient restraint system shall have a quick-release means to allow its rapid detachment in an evacuation.

Some patients may be so injured that the restraint system used will be based on a medical opinion. Medical evacuations, as a rule, involve stabilized patients. An emergency situation involving a patient who is unable to be restrained on a stretcher prior to being stabilized is very rare. However, should this occur, the patient should be transported on a flight whose sole purpose is the medical evacuation.

All medical equipment shall be appropriately restrained in a manner acceptable to TC.

http://www.tc.gc.ca/CivilAviation/certification/guidance/551/acsi32.htm

Stretcher

Road ambulance stretchers may be used when transferring patients by aircraft. There are no technical specifications for stretchers used or intended for use in civil aircraft at this time. Road ambulance stretchers used in aircraft installations would not require approval and would not be considered as aircraft parts (as related to maintenance and quality control) unless they are permanently installed on an aircraft.

Therefore, if your Number 9 cot can be removed from your aircraft, it is not a fixed part of the craft, the mounting brackets are. The only requirement that I can see regarding a patient restraint is that it must have a quick release mechanism, like a belt buckle, or, in our case, a velcro strap. There is no reason that the patient can't be restrained to the cot.

However, you're asking the wrong people in this forum, Transport Canada would be the proper authority here. Also, the pilot would be the one responsible for ensuring the CARS are followed.

[Bieber]

I can see where a blanket protocol of sedating any psychiatric patient might not be the wisest decision out there, but I can also see it from the policy makers' point of view that that's a couple million dollars of aircraft, equipment, and irreplaceable human life. At the same time, there's the chance for any and everyone to freak out once they get up in the air. Are they sedating people with a fear of heights? What about anxiety/panic disorders?

You also said that most of the people being sedated are going to a psych ward? Is that what they're being transported for? Because if so that's a massive risk being undertaken (air transport) for no major benefit. Could they not transport people by boat or ship?