Sedating mentally ill

[systemet]

I have a question about chemical restraints in a prehospital setting. At a Level I that I worked at the infamous B-52 (haldol/ativan with a seperate syringe of benadryl) was often prescribed in in-patient psych when patients were combative or a danger to self or others. What chemcial restraints do you use in the field?

I've typically used benzodiazepines, +/ - haldol / droperidol. Droperidol isn't commonly used anymore due to concerns with QT prolongation. Of the benzodiazepines, midazolam seemed to work best, with a rapid onset, and predictable IM absorption, if the patient's too agitated for IV initiation. Diazepam seemed fairly poor even when given IV, has a horrible half-life, and can't really be given IM. Lorazepam is a little slow-acting, but works, but has a longer half-life compared to midazolam. Because of the slow onset, I've seen people (including myself) get in trouble by giving repeat doses too quickly. In situations where someone is problematic but not actively violent, they can often be convinced to take a sublingual ativan.

Droperidol / haldol are ok, but they carry some risk of arrhythmia, which might be amplified if the patient's been taking street drugs (especially droperidol). They can also cause hypotension (haldol more than droperidol), and both can lower the seizure threshold, which might not be ideal for sympathomimetic overdoses. The risk of EPS is supposed to be lower with droperidol; the n = 2 cases I've seen have responded rapidly to benadryl. Both carry a risk of neuroleptic malignant syndrome. Personal opinon -- in many cases, especially when the likelihood of stimulant ingestion is high, benzodiazepines alone may offer a similar effect with a better risk profile.

[Arctickat]

Thanks Happy.

Given that ambiguous response, I see no reason you can't secure the patient to the cot. It's up to the policy of the airline if they prefer the patient to be restrained to the aircraft or to the cot. Regardless, the only regulation I can locate is the requirement for a quick release mechanism.

[Iowa Medic]

I worked at a facility with the only mental health facility in a large radius. This facility for the most part was outstanding but in one instance I felt they failed a patient.

19 year old girl who was a stellar athlete and student with a paid 4 year tuition. This young lady was having a legitimate and what had to be a terrifying mental break minus any hallucinogenics or other mind altering substances.

I arrived at the facility to find said girl in the corner cyring and shaking uncontrollably with a nurse stating "this is your patient, take them to X hospital"

I inquired about sedation, impressing upon said nurse that the sedation wasn't for ease of transport but for patient comfort as she was having visual and audible hallucinations and I was about to put her in the back of a strange vehicle and transport her 1.5 hours. Given I was a strange man which is often very disconcerting to females especially young females having an acute break it may be more human and appropriate to make the patient comfortable prior to transport to lower the potentially traumatic impact which could further devolve the patient.

I was told that she did not require any type of sedation i.e. valium, halodol etc and I should just do my job.

With the assistance of family I loaded the patient into the ambulance and went the 200 yards to the ER where I explained my concerns to the physician. I further explained in a very respectful manner that I would not transport a patient with a broken hip etc 1.5 hours without pain medication and respectfully requested something to make the trip less impactful on the patient.

The physician did not need my input as I'm sure had it been his patient initially he would have appropriately medicated the patient prior to transport. the physician thanked me on behalf of the patient for treating a mental illness as a legitimate medical issue in need of treatment and not as some attention seeking endeavor that some jaded practitioners see these types of situations.

The trip was not uneventful but it was made much more comfortable for the patient with some medication that allowed for complete awareness without the full impact of terrifying hallucinations.

From that point on I will call med control if I feel a patient is suffering unnecessarily due to lack of protocols.

There are patients who require restraints but they are few and far between if you utilize proper de-escalation skills, anxiety reducing medication and compassion.

Edited May 31, 2012 by Iowa Medic

[JPINFV]

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

So it's not every patient or any patient with a history of mental illness. As long as that's the case, then discretion is available and discretion should be used.

Also, I'm a bit confused. How can you have zero tolerance, yet not be required to "always snow paitnets"? Are you simply ignoring that directive (and bad directives should be ignored)?

If it's not zero tolerance, then why is it being presented as any history of mental illness gets snowed?

If paramedics can adequately assess psych disorders why have a zero tolerance policy? There's cognitative dissonance in saying "Well, we can adequately assess patients, but we're required to do X regardless of our assessment." If you can adequately assess, then you should also fight to not be required, as a group, to do X.

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.

You can't be comitted on your own accord because treatment while committed is, for all but certain extreme treatments, not voluntary and not on their own accord.

Additionally, the threat assessment for a patient who presents because he is listening to voices and a patient who hears voices and knows that they are bad and is seeking treatment on his own isn't the same simply because the latter recognizes that those voices are abnormal. The last thing I'd want is that second patient to not come in because he doesn't like getting needlessly snowed.

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.

Apparently the patient above has something working because he recognizes that the voices aren't normal, isn't listening to said voices, and knows he needs a med adjustment. Group therapy isn't going to make the voices go away. What are you expecting? Him being an inpatient until the voices go away?

]By the way the day after this guy came home he did committe suicide and it was very violent.

Was anyone else injured in his suicide? Taking a human life, including ones own, often involves violence, and I'll put patients suffering from severe mental illness seeking death in the same category as someone suffering from ALS or other chronic, cureless disease with an immense amount of suffering seeking death. Hearing your TV talking to you isn't exactly the same on the suicide scale as someone suffering from depression because their BFF left 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.

So any patient with a prior history of sucidie attempts gets sedated if the crew knows about it? "Sorry ma'am, it looks like you tried to commit suicide 20 years ago when you were 15. We're going to have to sedate you for this trip... for all of our safety."

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.

What are those conditions? Also what do you mean by "those that actually have been diagnosed with a medical condition"? As compared to all those people running around crying about their fake mental illness?

...and wait a minute. We go from "schizophrenic who knows the voices in the TV are in his head and knows that he needs help, thus seeks it" to "violent drug addict." That's a bit of a jump. Similarly, we go from "any mental illness" to "those being forced to go." However I've seen enough holds for dubious reasons (The, "Whaa, my BF broke up with me and I'm drunk on wine and want to hurt myself, but I don't have a plan and I'm just depressed and was venting to a friend over the phone" holds) that even the "only those on a hold" is a bit too far.

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.

I get that it's a plane or helicopter and I agree that the threshold should be lower than an ambulance. However when it's presented that everyone on a hold or everyone with a history of mental illness, regardless of any assessment, gets snowed, I'm going to call foul. There's a difference between a lower threshold, and not having any threshold.

I get a bit snippy when it comes to mental illnesses because I've seen how being needlessly agressive can negatively impact a patient, I've seen stupidty, both from system protocols, the people writing holds, and other EMTs, and I've seen how a patient can be completely different even a few hours and a couple of meds later. Not necessarilly enough to let them off of a hold 2 days early, but definitely in the right mind set to not require them to be strapped down in 4 point restraints. Similarly, my undergrad research project was in schizophrenic and bipolar patients looking at how well they filter stimuli. It's a big difference when mental illness is looked at as a neuro problem and not a mind problem.

[Happiness]

I get a bit snippy when it comes to mental illnesses because I've seen how being needlessly agressive can negatively impact a patient, I've seen stupidty, both from system protocols, the people writing holds, and other EMTs, and I've seen how a patient can be completely different even a few hours and a couple of meds later. Not necessarilly enough to let them off of a hold 2 days early, but definitely in the right mind set to not require them to be strapped down in 4 point restraints. Similarly, my undergrad research project was in schizophrenic and bipolar patients looking at how well they filter stimuli. It's a big difference when mental illness is looked at as a neuro problem and not a mind problem.

OK JV just so you know I get the snippy part. Please understand I am trying to find a solution to a problem. I am starting to feel abit shreaded by you because of something that really I have no control of. I dont like this policy but I understand it from a flight crew point of view, as if they are not compfy with the pt they just dont go. It really is that simple. Be aware I have not refused any pt. I have been the advocate for them, also with this policy I dont let it run my call I make it work for me. The one thing that is not mentioned in this policy is required doses, so that in its self gives the Drs the ability to work outside the box.