EMT Lecture: Behavioral Emergencies
[Music] So, I suppose this is where I have to get started. So, this is behavioral health emergencies, chapter 23. Um, there are a lot of things on here that you guys are going to hear about that you’ve maybe heard before or you’ve, I don’t know, done a class or something. Um the big things on here that I or with this that I want you to understand is that we do talk about like excited delirium, acute psychosis, well excited delirium a little bit um and psychosis and things like that. It’s not your job to diagnose anybody. Uh the diagnostic process of these conditions is very complex for the most part. Okay. So um even though we talk we’ll talk a lot about suicidal risk because as EMTs those are a lot of the calls that you guys will take will be suicidal ideiation. uh whether they actually attempt or not kind of changes the call. Um but you guys will be doing a lot of that. So it’s a lot of it is recognizing, hey, I don’t understand this condition, but figuring out how you can talk to people that are in maybe a variety of different categories. It’s unrealistic for you guys to say or for me to say, hey, you need to figure out how to interact with a bipolar person versus a borderline personality versus an OCD person. Right? So just looking at these as categories is maybe going to help with interacting with some of these populations. Um also before we get any further just want to you know make the full disclosure of if we don’t have anything nice to say we don’t say it at all right this is a very vulnerable population of people greatly underserved but also greatly misunderstood. Um, and I think if you’ve ever worked in particular on like a uh I don’t know like a psych floor or with psychiatric patients in our job, we are the people who show up, right? So if someone has a behavioral crisis, we’re the ones who show up in in uh conjunction with the police. So we deal with a lot of it and unfortunately we don’t get much education on it. But that’s kind of the goal of this is to at least have you approach these is maybe more categorically rather than getting overwhelmed with the individual idea of it. How do you guys feel about interacting with psych patients just in general? And when I say that, I mean like are you comfortable? Are you intimidated by saying the wrong thing? What do you guys think? Pretty comfortable. Do do any of them make you nervous? And and it’s okay if if it if they do. The point of this is to maybe desensitize some of not desensitize, inform you, but al also I guess desensitize it, right? because there is a ton of stigma that carries with these mental health conditions. So, I’ve had a lot of students say that they’re intimidated by a lot of them. Um, specifically like schizophrenics and bipolar, like manic bipolar, things like that. I get it. I totally get it cuz they’re manic or they’re elevated. Um, those are usually when I started in the field, those are the ones that scared me. However, for what it’s worth, I think those are maybe a little easier to execute than people think is just interacting with people that are in like psychosis and whatnot. The reason I ask that is because it doesn’t take much to push someone into a psychotic episode. And when we say psych psychosis, we’re talking about complete separation from reality, right? We’re not talking about delusional, which thank god Tik Tok can’t Tik Tok has a lot of really good things. Um, but the whole dulu thing, you guys know that delusional, right? They’re like, “Oh, I’m so dulu.” Well, so delusional is very different than psychotic, right? And that’s an important distinction to make. Delusional means you’re out of touch with reality. Um, psychotic means you’ve completely disconnected from reality. Okay? And that’s a big big difference. I’ve been on calls for people who have gone into a psychotic episode from all kinds of things. It could be a divorce. It could be the death of an animal, loss of a job, obviously, all that kind of stuff. But what a lot of people don’t consider. I’ve been on a lot of calls for people who are like, “They just snapped out of nowhere.” How many times have you guys heard that before? They just snapped. That’s us. Isn’t there a show snapped? I think that’s what it’s about is people who literally just like have their break. That’s kind of what we’re talking about, right? Is their break. So, it’s not just this mental illness that we’re talking about. There’s always the consideration of acute medical situations like hypoglycemia, obviously, like we talked about the other day. um as far as neurological stuff goes, but very much with the drugs obviously and then stress. That’s why I never wait for like family or the patient to say, “I had this big catastrophic thing that happened to me and it pushed me over the edge.” It’s not always this big catastrophic thing. Sometimes stuff just builds up over time. Um and respecting the fact that it doesn’t take um much, especially if someone already has a psychiatric condition, especially if it’s unmanaged, right? and unmanaged or lack of management of sight conditions is one of the biggest problems I personally think we have right now. So, um most of us go through this. We may not have a psychotic episode. There’s actually some really interesting work uh coming out with uh genetics that’s uh kind of showing us who is more likely to go into psychosis and who’s not. There is actually a very big genetic influence into the type of person that can go psychotic from drugs or from illness. It’s really interesting and sometimes all it takes is one little break. Have you guys heard of that before? Someone has a psychotic episode and then they develop like a full-fledged psychiatric illness like bipolar. I don’t know if that’s necessarily how it works. I’ve just heard a lot of stories about it. I just usually assume the disease was there, but it took some kind of event to kind of kick it off. That also ties into the genetic side of it. So, I do think that’s interesting. If you’re anyone that’s into that kind of stuff, there’s some cool research coming out. Whole point is don’t jump to conclusions, obviously, right? Be nice. Talk to these people the way they deserve to be talked to. Don’t just assume they’re going to hurt you. Okay? And that’s one of the things I think that makes me the most sad is that people just assume people are these patients are going to hurt them. I get it. I respect it. But anybody can hurt you, especially in 911, right? So, um, the other thing is that, um, this one drives me insane. I’m sure we can all appreciate how annoying it gets to be told like, “Oh, you don’t look sick,” or whatever that looks like. When it comes to psychiatric illness, we don’t even have MRIs or CTS or stuff like that to help us diagnose these conditions, right? They’re much more hidden than things like that. There are conditions that we can see on like functional MRIs where they take an MRI of your brain and then they do they have you do things or think about things where they can see those areas light up. We’ve done some research on that. However, we don’t really understand how these work. These are largely hidden diseases and I think that’s kind of what carries over this idea, right? um is that it’s not a real thing. I just want to put it out there that when you have um some kind of disorder in here, usually you have some degree of a true physiological problem and that has to do with your hormones and your neurotransmitters. Okay, this is a legitimate problem. It’s not just the whole I don’t feel well, I’m sad. Well, you are sad, but it’s way more complex physiologically than that. So if you can appreach approach these guys with the appreciation of this is a true problem with the way their brain is functioning then I think it gets a little more digestible because a lot of people want to do the whole well you know that like this next line it says well they had a divorce of course they lost their something like that well it’s not always that simple okay there are a lot of layers that go into it physiologically genetic predisposition the environment that they’re in all of those things play a role. Um, now as far as um, we’ve already talked about a lot of this stuff, but if we’re talking about the dangerous people, I’ll give you guys some, uh, or we’ll have conversations, uh, later on in the lecture about types of like situations maybe to be wary of, situations in which you carry uh, larger crews into the call with you, obviously, things like that. But the biggest point on here is communication is key. How do you guys feel about talking people down? We’re not just talking like panic attacks necessarily, like talking people down. If you’ve ever had to where you’re like, “Hey, you need to breathe. We need to chill out for a second.” Uh, deescalation is the official term. How do you guys feel about deescalating? Some iffies, huh? Yeah. Um, just my little tip for you guys, the big thing that I’ve found, it’d be interesting to hear uh your guys’ thoughts on it because I bartended for a long time. And deescalation is pretty much one of the top skills you learn very, very rapidly. And the big thing for me was you go here, you go here. And that’s actually a tip I’ve been given by a lot of police officers as well, because communication is important and people can’t communicate if there’s too much stuff going on. Um, how do you is that the philosophy for you guys then is like the separation to try and simmer things down the situation. But yeah. Yeah. Okay. That that makes me feel better then cuz I was like, “Oh, the cops are doing it.” And then I had a a guy a cop tell me he’s like, “Yeah, it just kind of helps diffuse the situation.” But even more more than that, well, you know, if you have people screaming at each other, I’m not going to be able to communicate with you either. It’s hard to communicate even as the people on the call when it’s a whole messy scene, right? So, uh, that’s kind of my approach and my philosophy on deescalation is giving people the actual opportunity to communicate because the opportunity is very important, right? Just because you’re in front of them doesn’t mean they have the have the opportunity to talk to you. Does that make sense? Giving them specific time is really valuable. Um, all right. So, a behavior is the way that someone responds to their environment. And where this is important in my mind is recognizing behaviors not just in um your patients or like the things that their family are going to tell you, but also on a personal note for your family, your friends, and your partners. Um I always paid attention to some of my behavior or my partner’s behaviors like uh and that probably sounds a little wild, but I cared about my partners. They’re, you know, the closest thing to family essentially in my mind that I could get. Um, so when I pay attention to stuff like that, it’s things like eating habits. How do they respond when someone’s talking to them, right? What’s their sleeping habits like? Things like that. It might not be very easy to tell, but a behavior is anything that um tells you how that person is interacting with their environment. Good behaviors, bad behaviors. How long does it take to develop a habit? Do you guys know? It’s like 28 days or 21 days, like 3 weeks or something like that, right? I would argue that um this is just my thought. I would argue it takes less time than that, especially if it’s a bad habit. And I think the thing with that is that a lot of people let things go for a long time and then what happens? A person goes into a behavioral crisis or a behavioral episode and then we show up. And that’s not their fault necessarily. It’s just people not maybe recognizing the things that are worth paying attention to. stress reactions are pretty obvious usually, you know, like you see someone who’s screaming, freaking out, having a panic attack maybe, but it’s the other behaviors of like, oh, um, Kyle’s not coming out for drinks. He we’ve been getting drinks every Wednesday for the last 6 weeks or 6 months, whatever. You know, that might be considered a behavior or an abnormal behavior. And the thing is, a lot of family members will say, “Yeah, they just haven’t been acting right.” Well, what does that mean? I don’t know. They just aren’t acting right. Okay, well, that doesn’t give us very much to go off of. people have acute uh personality. I don’t want to say changes, but you know, ch things that they maybe change temporarily because of a work thing or whatever. I want to know more of the uh life structure things. What has changed in there? Because in my experience, it’s a lot of that side of things where you can really see the depression. It’s not showing up like this, right? It’s actually what’s going on at home. What does their car look like? What does their bathroom look like? Right? That’s where these behaviors seem to pop out. It’s not the obvious stuff. Um, a behavioral crisis technically includes anyone who’s agitated, violent, or uncooperative. Um, or who are a danger to themselves. And where this becomes important is the danger to themselves or others because that’s the whole point of why the people or the police take people on those uh involuntary holds, right? That’s the whole point. You’re a threat to yourself or other people. We say you are a human. humans in, you know, just the rule of thumb of humans is we try not to kill ourselves or kill other people, right? That kind of goes against what our brains want to do. So, if this is the current place that you’re in, well, you’re probably not in the best place and you need to be supervised. I very much appreciate that, but it’s the part of it that you’re going to see the most of is that people that are a danger to themselves. Um, I’ve personally only interacted with a few other people who admittedly um were a harm to other people and it’s always a little unsettling when you’re in the back of a 7 by10 box and you say, “Do you have any thoughts of hurting yourself?” And the patient says yes. And you say, “Okay, do you have any thoughts of hurting other people?” And they say, “Yes.” And you’re like, “Right now?” Is that happening right now? So, um, always keep in mind this doesn’t mean they’re going to be violent, right? I’ve seen a lot of people who when you ask them that question afterwards like do you have any thoughts of hurting other people? They’re like uh because it’s not even on their radar, right? So don’t just assume that they want to actually hurt people. I think it’s just a weird question for a lot of them in that vulnerable place. Um this is all pretty straightforward. Technically the definition of a disturbing pattern of behavior or abnormal behavior presentation is a month or more. But that’s what I was saying where it’s like I think it does happen a little sooner than that. I pay attention to that kind of thing. But technically the definition is a month. If and this is more for like a personal thing. If you notice it going on for longer than like a week, two weeks, I think it’s worth mentioning. And my thought on that comes from interacting with family members of people who have been in situations like this. So that’s kind of why I feel that way. Now, this next um slide is or these next couple are going to be a little patronizing, just a heads up. And the reason I say patronizing is because um it talks about the US in particular. Um there are so many psychiatric disorders we’re coming out with. Um and a lot of people have feelings about it when I say coming out with new diseases. We’re recognizing things that were mislabeled a lot of it, right? So, we’re actually regrouping and recategorizing a lot of our conditions. And that’s why you hear some of the changes that happen. It’s not very common for uh psychiatric illnesses to just pop up out of nowhere, right? We have to study them more and then try to link them to other diseases and make groups out of them, which is what we’re headed into next, like functional versus organic, okay? Uh uh mental disorders. So, um, as far as the I don’t know what the United States rates are. Uh, I want to say it’s like one in 10 people report, which is insane. I figured it was like eight out of 10. Um, report feelings of like unhappiness or u lack of satisfaction or something like that. It’s u not a very high number, but why do you think that is? Do people report that kind of thing? Honestly, I sure as hell don’t. like, you know, but you know what I mean? I’m okay. I’m I’m okay. I’m safe. But the reason I say that, right, is because what? You fill out your form at your doctor’s office. That’s the suicide risk uh uh questionnaire, whatever that one’s called. And then you be honest and you say like, “Yeah, I’m kind of sad. I don’t want to hurt myself or hurt other people.” But then they go, “Hey, you scored really high on this. It’s time to take your grippy sock vacation.” as they call it that a patient patients call them that which I think is funny because I appreciate the humor but um it’s I I don’t know as far as these disorders go. I can’t give you these uh which ones have the most uh pre uh prevalence as far as the US goes, but I’m sure depression is pretty far up there along with anxiety and your other anxiety disorders. Um, we’ll talk about some of those here soon, but anxiety disorders and depression were easily the most common thing as far as the not that they’re simple, but if you want to think about maybe the m more straightforward mental disorders, uh, those were the ones I ran into the most. When I say straightforward, I mean just that straightforward. We’re not getting into the complexities of like schizophrenia, bipolar, borderline, stuff like that, okay? We’re just saying the pretty standard stuff that people have. Um, now these are your overall anxiety disorders. Honestly, most of us probably have at least like two of these. And the reason I laugh about it is because I do think anxiety is part of the human experience. Um, it sucks. It’s a horrible part of the human experience. But it’s not just anxiety that we’re talking about, okay? We’re not just talking about, oh, I have to go to work tomorrow. That might actually be moral depression, right? We’re talking about the people who can’t sleep at night. the people who can’t eat, the people who have poor hygiene, things like that, that level of anxiety. Okay, that’s your your and again I can’t diag or I can’t give you the specific diagnostic criteria, but that’s more so the generalized anxiety disorder. Panic disorder is different. Most of the time you’ll have general anxiety with a panic disorder and that’s because you have panic attacks or something similar to that. There’s anxiety and anxiety sucks. We can all appreciate that. But then there’s panic. panic up here is in my experience where you see a lot of these people pushing it into that maybe like not psychotic episode, but maybe that like they’re really really starting to lose their right? And they’re starting to become more and more detached. It’s very much with these panic disorders. Um, social and other phobias. What uh phobia do you guys think we run into quite a bit? Fair. Yeah, I don’t know what that’s called, but fair. Um, that’s not what I was thinking, but that’s a good one. Spiders. Spiders is a good one. Arachnophobia. That’s a great movie that we run into like as like EMTs. Yeah. Um do can you think of anything? What’s that? Claustrophobia. Um we do run into that some. I actually learned on a structure fire that I’m claustrophobic. Right. Not an ideal time. Um I’m surprised no one said this. Agorophobia. Not wanting to leave your house. who I mean, what better situation, right? You got 911. And I’m not saying that they’re milking it. I’m just saying, right? Like I mean, that kind of easily could potentially feed into it if you think about it like that, right? Um I’ve actually encountered a number of agorophobics and uh it’s not as obvious as you think. Um it’s when they go out of their situation or they experience their phobia and they usually do it in a situation, at least in my experience, not just the agorophobics people in general, but they’re like, I’m going to push it today. How many of you done that before where you’re like, I’m gonna overcome this fear. I’m gonna do it and then something happens, right? And then maybe you end up in this kind of side of things. That’s what I’ve seen a lot of the agorophobics maybe trying to leave their house. Um heights are a big one, too. Can’t tell you how many people we did rescues on cuz they got stuck somewhere um from climbing or whatever. That’s a little different obviously, but again, people pushing themselves out of their limits is where I saw a lot of that. PTSD’s uh obviously has its prevalence in multiple different categories. And then OCD um OCD is interesting. Well, these are all interesting in the way of that they usually stack on to each other in some combination. Your PTSD folks usually have some degree of anxiety. They might have panic. Your agorophobics usually have um to some extent a panic disorder. Maybe the agorophobia is caused by your PTSD. Very common, right? These are very frequently intermixed with each other. Now, this is the slide that’s kind of patronizing. And the reason it quite frankly pisses me off is because the US mental health system provides many levels of assistance. Um and while that may be true in the overall um format of what our government or how our government um handles these kinds of things, it’s not true in the the display of it, especially in lowincome areas uh that rely heavily on like um clinics like Terry Riley Health Services that we have here locally um any of your um like uh government funded behavioral centers, things like that. We do not have that many. And the bigger problem is that counselors in particular can’t always take people on for insurance billing because insurance doesn’t pay them well. Right? So, it’s a it’s a multi-layer problem that we’re not going to get into, but I just want you to appreciate that it’s not as simple as going to the counselor and saying like, “Oh, hey, I have insurance. Let’s build this.” Right? Can you afford the co-pays? Can you actually afford to go to the counselor? Are there counselors that fit you that have openings for you? Right? Um, do you even have insurance at all? If you don’t have insurance, can you afford to pay for that counselor? Or do you go to the the public assistance counselors who probably can’t see you because they have a full schedule, right? But because they only do maybe 20 hours of contracting a week because that’s all they do as a part of their contract with the government for Medicaid and Medicare and whatnot. So, it’s very very complicated. Okay. Um, another layer to add to this that is its own beast is medications, right? Getting people, these psych patients, access to medications that not only um actually help people very much in the long run, but really aren’t that big of a deal for people to take in acute doses. It’s not uncommon at all for people to go and get a script from their doctor for an anti-depressant for a certain period of time with the goal of getting off of it. But can you actually access those medications? if you don’t have insurance, paying for that is definitely not going to happen. So, just so you know, um those are some other layers to it outside of just having availability for it. Right now, the other part of it that I always also we saw a lot of it because um here’s your system. You have counselors. So, you’ve got like uh licensed clinical social workers, licens licensed family counselors, um uh clinical counselors, things like that. LPCC, LPSW, whatever they’re um for I guess I can’t think of the word credentials are. Um essentially those guys are your master’s level, okay? They do good stuff. They’re the majority of the mental health providers that you’re going to encounter. Um now a psychologist, you can kind of think about them like a counselor or social worker on steroids, right? So they have their doctorate in psychological studies versus a psychiatrist is a medical doctor who went to medical school and then did their um I believe this is just a residency program but did their residency in psychiatry. So the cool thing about those is that frequently you’ll find psychologists and psychiatrists that co-house um or like counselors and psychiatrists that co-house. So you’ll have the prescribing physician psychiatrist and then you’ll have the psychologist or the social worker there. And the nice thing is that helps people that are complex cases like schizophrenic, bipolar, um, uh, severe refractory depression, things like that. You can have both worlds. Doc, the psychiatrists are, um, less involved in the talk therapy side of things compared to the psychologists. They’re more involved in like the pathophysiology, complex disease diagnosis, uh, true testing, medication management, that kind of thing. So, if you’re someone who has a complex case, then you need to see a psychiatrist. Well, getting into a psychiatrist is really difficult because psychiatry is not a common residency choice. So, you see what I mean? It just keeps adding on. Um, the other thing about these behavioral health units, we have a handful of behavioral health units here um in the Treasure Valley, but there’s still not enough room in most of these. And I’m sure the um law enforcement side of things has probably had to pay more of a price for it than we do because if we don’t if they don’t need to go to the hospital with us and it’s maybe a behavioral episode that just the police are dealing with. Well, what do they do, right? How do they figure out if it’s appropriate to send someone to the hospital versus to the behavioral unit? So, they have to have their protocols in place for it. Um, but we as 911 for the most part, um, especially where I worked did not transfer people to behavioral hospitals. We only did 911, but if you do inner facility, which a number of you have for your clinicals, you might have done a secure transfer, if that rings a bell. Did you do some of those? I believe so. Yeah. Yeah. there you like in a specific van or car and it’s got like the the wire and stuff between the seats or not wire, sorry, but the like metal thing uh between the seats. Uh I believe that’s what they use. They might not. Um but those secure transfers are usually from bringing people from the ER to the behavioral hospital or um hospital to hospital, whatever it looks like. Um so some people do need to go to the behavioral health hospitals. We do not make that decision. Most of the time we just take them to the hospital and then they make the plans from there. Um, if you are someone who finds this kind of stuff interesting, um, and when I say interesting, maybe like a level above what we’re going to talk about today, I would encourage you to seek out the social workers in the ERS. Um, the social workers in the ERS are not only super super cool people because they’re social workers and um, counselors that work in the ER prime time, I imagine, for some of their studies, right? they probably get to see a lot of stuff that they otherwise wouldn’t have. They want to teach you guys and anybody about these disorders. So if you have a question, if you have like a um let’s say you have a schizopeeffective patient, does anyone know what schizopeeffective disorder is? And I might butcher this, but this is the explanation I got. It’s basically schizophrenia meets bipolar. Talk about a complex case, right? That’s a very complex patient. I didn’t know what that was. So I went up to the social worker at the ER and I was like, “Hey, can you explain schizopeffective disorder to me and give me just a quick rundown on maybe how to interact with this person?” 10 minutes later, I had a complete different understanding of that disease. So highly encourage you to utilize them. Uh they have a lot of great resources, but they’re also great people to help you when you’re talking about these cases and making sure they go to the right place, right? If you maybe go on a call where someone lives in squalor or something like that or maybe like their um hygiene, things like that are worth mentioning to someone, the social workers are the ones, the nurses in text care obviously, but your social workers are the ones who like that’s really their big focus, right? So, if there’s something specific that you think they need to know, the majority of them in my experience have been super happy to chat with us um and receive that information. Um, otherwise we’ve already talked about some of this stuff. Behavioral health disorders can have all kinds of underlining underlying causes. Um, the big thing that a lot of people forget though and what I always wonder about our psychotic patients cuz that’s what we’ll get dispatched to and it’ll just be somebody doing something. Um, much of the time when people are like, “It just came out of nowhere and I can’t find something that works for it.” First thing I go to think of is electrolyte imbalances. If you haven’t noticed, that keeps coming up um throughout my lectures in particular where I say I always think maybe it’s electrolytes because electrolytes not only obviously like we’ve talked about determine how your body’s going to work. Also though, electrolytes when they’re imbalance can cause problems in your brain, they’ll cause heart problems, problems with your kidneys, obviously the list goes on. So it could be something as simple as having a UTI that gets out of hand. You remember talking about that? Exactly. Right. So it might look like a behavioral episode when in all reality it’s just a UTI that’s gotten out of control. And that’s very much one of the things you guys will encounter as EMTs. So we’ve already talked about this, but is not your responsibility to diagnose obviously, but you should have the idea of at least these two categories. There’s organic and functional. Okay. So, when we’re talking about organic brain disorders, we’re talking about something actually being off with the maybe structure of it, the actual um way that these nerve cells interact with each other. And when I say that, I’m not just talking about how they function. I mean literally their structure might just be different. They might be um made differently. There might be some kind of, I don’t know, some error in the way that that tissue or that nerve cell was created. whatever it looks like, this is something that is going to alter the actual structure of the brain. A big example that I use is TBI, traumatic brain injuries, and then also um Alzheimer’s. Alzheimer’s and dementia are a little different. Um Alzheimer’s is very aggressive and is actual an actual own disease process. And when I say it’s aggressive, it seems to be much more aggressive than dementia, which is the general decline in mental status. Alzheimer’s patients actually like literally have holes in their brain. And that’s why I show you guys this um Alzheimer’s MRI. So um I’m not actually that’s a bad example. Let’s do so healthy control. So in anytime you’re comparing anything, you’ll always have your control sample, right? This is the control and this is the Alzheimer’s brain. So, if you guys remember the other day when I was talking about these ventricles in here, right? You’ve got these um caverns if you want to think about them. They hold like CSF and they play other vital roles. But in your Alzheimer’s patients, this is what their brain’s looking like compared to this. All of this here in the middle that looks white, that is your white matter, and that is myelinated. That means it has little fat deposits around it. And that myelin help not only helps speed up conduction but it helps protect those nerve cells. Those are your fast nerve cells. Those are the ones that are communicating information super rapidly. Now and that’s why we tell you to take your fish oils, right? Make sure you get your good healthy fats. It’s because this white matter in here relies on fats to be white matter. Okay? And the other side of it too though um is not only can you obviously see the decrease in brain mass but it’s losing a lot of the white matter in particular which is where you see a lot of your Alzheimer’s patients actually have physiological problems as well. So, a lot of people don’t know that your Alzheimer’s patients not only have the issues with their brain obviously, but they have a lot of other physiological problems that develops like a lot of kidney problems, um, other metabolic disorders that actually develop from the brain kind of dying off like this if you want to think about it. Now, another thing I just want um to show you is this is a CTE brain. That looks kind of familiar, doesn’t it? looks very similar to an Alzheimer’s brain. Um, and so, and I’m not making any assumptions here, um, but it’s pretty obvious where the loss of mass is coming in. Now, this gray stuff out here on the outside, this is your gray matter. It is unminated. It also has important jobs, but the white matter is the good stuff, as we say. So, that’s Let’s see here. um baseline two years. So you can look Oh yeah, you can actually see a decent bit of loss of mass on this one even just from two years. I don’t know what this person’s deal was and we’re not necessarily talking about CTE, but we are talking about TBI where CTE plays a role, right? CTE is the chronic traumatic encphylopathy. If you guys haven’t seen that movie, Concussion with Will Smith, it’s a great movie. they talk about the South African doctor I think uh who basically kind of came out with the whole CTE uh protocols with the NFL and all that uh because TBI’s uh not just in your athletes obviously we’re talking uh veterans are a large population anybody who’s done a lot of uh manual labor is always at risk for this if you’re a younger sibling I firmly believe you should you should be maybe maybe in this category I’m pretty sure I have a couple brain injuries from my siblings um but Notice how all of these are things that are actually changing the anatomy of the brain. In particular, drug and alcohol abuse. That’s going to come up later because how many of you have heard of drug induced schizophrenia where people do like a lot of meth or something like that and then they develop schizophrenia. That’s a very interesting conversation because schizophrenia itself is not technically considered an organic disorder. It’s a functional disorder, but they also have changes in their brain. Their brains are different from the very get-go, but they still work if you want to think about it like that. Um, other things that can cause organic brain disorders. So, remember organic disorders are just anything that alters the brain um, anat or just think about it like the brain anatomy. These are also the things that cause your altered mental status, right? So, your AEIOU tips that we just talked about the other day. Well, all of those things if they continue on can cause an organic brain disorder. It’s just another term. You don’t have to worry about that. Um, just know that this category of things obviously is going to alter the brain structure. Hyperothermia cooks it. Hypothermia stops it. Um, impaired cerebral blood flow either uh it’s not getting enough or it’s got too much pressure like in the case of a stroke. Hypoxia is obvious. Think of like your drownings, your overdoses, and then hypoglycemia. So remember hypoglycemia, hypoxia, those are stroke mimics. Okay, which is another reason I always say certain psychiatric presentations can also be stroke mimics, especially if someone’s acting abnormally, right? Because speech, remember we’re talking about speech the other day. Even if it’s erratic speech, that could easily be considered a stroke symptom in in certain populations. So that’s why I threw that in there the other day. Now, again, um this considers uh schizophrenia a functional disorder. We’re talking about the brain function in here. It’s not the structure of it. It’s how these uh nerve cells are talking to each other that’s the problem. Okay. So, um with the anxiety conditions again, that’s the big one. Schizophrenia is involved in here because schizophrenia um has a a lot more to it and a lot more or a many more different areas of the brain. We’re not just talking about like, oh, this one area, this one area. We’re talking about their entire brain functions differently. And that’s why for a long time we didn’t really understand where all of their problems were coming from. And when I say problems, we’re talking about like the problems, right? Schizophrenics have a lot of stuff going on. But we didn’t realize that part of the reason schizophrenics work a certain way is because certain part of their brain doesn’t work. So we’re figuring these things out over time. And as we figure things out about schizophrenia in particular, it helps us look at other conditions as well, specifically like bipolar um and then depression and whatnot. So, I am going to give you guys the opportunity to let your presumptions fly for a second because I want you to look at this picture and I want you to just based off the things we’ve talked about in class, right? For scene hazards, um, interacting with patients in general, if you were to look at this, so you’re a firefighter on this call. You’re just standing in the corner watching this interaction go down. What? Anything’s fair in here. the room, the patient, the provider, the things in the room. What are you thinking? What’s What’s under his clothes? Like just for scene safety, like I don’t Oh, sure. Um I can appreciate that. Like over here. Yeah, sure. Absolutely. Um what’s that covering? Right. What else? PPE. PPE. This is a COVID picture. Oh, is that why? They had to they they had couldn’t let us forget that CO happened. So, a bunch of the pictures in this textbook are are PPE pictures. Um, I’d say like I don’t know like the marks on the wall could be like a focus area maybe. Oh, like uh these spots over here. Yeah. Okay. All right. What else? Like for me, like somebody that big, if I was like crouched, if I had to get up real quick, I probably shouldn’t. Sure. And and that’s an important thing to to note, right? Like we’re petite enough people that if you’re not a petite person, I don’t mean this in like the cute small girl or whatever the heck people say about that. What I mean though is like if you’re not a small person, it’s really hard to appreciate how intimidating it is to be in front of a large person. Um, and even still, I don’t know what it’s like to be a large person in front of another large person. However, the point that she’s making is the even more important part of it. You can be the nicest person and I’m still going to be intimidated by the fact that you’re a big dude and you’re standing this close to me. But the thing with and where I get or what I get out of this is I always crouch down or I um squatted down. I never put my knees down on scenes cuz they’re gross first of all, but second of all, I want the ability to run. That works for me though cuz I can do that. My next point to that though is where’s your egress? Right? So, if you’re going to be So, ingress is how you get in. Egress is how you get out or you exit. Um, if it’s back here, I mean, yeah, not bad. You’re doing kind of the best that you can, right? But you never want to box yourself in. So, I would imagine that the door is probably over here. But that’s another thing you should be thinking about, right? Where’s the door? What else? I don’t like that bucket. No, that’s so funny. You know, I So, this is like my second time doing this lecture in in the last couple of weeks, and I’ve never had anybody bring up the bucket, and this is the third class in a row. Someone’s brought that damn bucket up. Uh, and I think it’s funny because like we all pay attention to different things, right? And that’s the point of this is like you should be hearing your classmates looking, oh, I maybe you don’t like this pillowcase. That’s a little silly. However, what is in this bucket, right? Anything’s a weapon. Anything’s a weapon. I’ve seen lamps get thrown, right? So, what’s in the bucket? Is it within reach? It could easily be thrown thrown around. Sure. What else? What do you guys think of the state of the house? Not great. Not great. Okay. It looks like he has like two different colored carpets on each side of the bed. Like right side’s lighter. Do you shampoo your floor? No, I’m just kidding. I’m just kidding. No. And cuz that’s that’s kind of what you’re thinking about, right? Is is things like, “Hey, has something not been moved in a while?” You know what I mean? Like things it’s the the big picture of like, “Okay, well, this house doesn’t look awesome.” He’s bringing up the carpet, which is a good point, right? You walk on this every day. This is your room. This is where you live. Okay. Now, I’m gonna take everything you just said and I’m gonna flip it for a second for a perspective shift. Um, I look at this room and what I see in my mind are halfway houses. Um, or I I don’t know if they’re officially called this I really hope this isn’t an offensive term, but beehive homes where they’re like houses. They’re literally out in your neighborhoods, but they’re houses that have people that have like neurocognitive disorders, um, traumatic brain injuries. Maybe they’re like a severe neurocognitive, like very um advanced like medical or uh mentally kind of thing. They might live in a house like this and they look like this because spoiler alert, these are state funded, right? And so here’s the point I would make. And I wanted you to or someone to say that so I could make this point. If that’s the case, this room is pretty great to me. And here’s why I think that. Um, this is fairly organized. Um, and people who want to live messy lives will they will, you know what I mean? Like my desk um might be chaotic, but there’s still a system to it. And that’s where I say you can you can look at this from that viewpoint and go maybe the homeboy is not actually doing as bad as we want to think he’s doing. He’s in a house. Great point already. He’s in a room does look a little disheveled. However, it is far more organized and set up than most people’s rooms are. You would be amazed how many people sleep on the floor with blankets, with no mattresses. They don’t have sheets, things like that. And these are professionals, right? Um, he’s wearing full clothing. The clothing actually doesn’t look too bad. We’re not going to dig into the the uh what the heck sleeves are those muscle shirt. We’re not going to make fun of him for the muscle shirt, but there’s no holes in it. There’s no holes in his pants. They actually look quite clean. He’s got shoes on. Um maybe his hair is a little greasy, but maybe he’s just a greasy boy, right? Um my No, honestly though, but that’s something you have to think about, right? Like if you see me after 3 days of not washing my hair, you might have the same assumptions about me. Um and that’s why I say that, right? It’s all relative. And that’s where you look at like, okay, well clearly he’s sleeping here. Clearly he’s actually using this bed. There’s not a ton of stuff on the floor and it might not be vacuumed, but it’s a lot more organized in a lot of people’s spaces. So, that’s the other viewpoint that I can offer you. It’s lot a lot of this is going to be influenced by the way that the person interacts with you. However, the big point of this that they’re trying to make is the provider’s position, how they’re interacting with them. They’re on their level, right? Which poses the risk for us, right? And when I say us, I mean anybody is at risk, but in particular the petite females pe especially if you are of any psychotic state where you’re hypersexual. Um, in particular, just to put that out there, if you have female um, providers on a call with someone who’s hypersexual, please look out for us. Please look out for us. It gets pretty pretty bad out there sometimes. But anyways, um, the last point I wanted to make is I don’t know what’s in here. I think it’s a bathroom. It kind of looks like it to me. That looks like a shower drain up in here. And if that’s the case as well, that might give me another clue into how this person is doing. Cuz remember, in behavioral patients, we’re not just looking at the person and what’s going on with them. We’re also very much looking at how their behaviors had have affected their lives. Whether that’s interacting with family, uh their house is a disaster, whatever. This is a huge part of your scene and your understanding of this patient that you need to be looking at. I will say it did take me a little bit of time to start actually paying attention to that level of things, but now you kind of get an idea for some of the things that pop up in my mind. Is there anything else? You thinking anything? He’s probably even better at reading scenes than I am. Truthfully, my personal opinion is that that dock or EMT dude is way too close. Um, agreed. Like you was saying about the room, you have paint chips that full of water. So roof is probably I think it might be the shadow truthfully cuz the light source is coming from up here. But regardless, it’s still something to pay attention to. But I don’t know. It’s just uh Is it making your skin crawl a little bit? Yeah, there’s probably bed bugs there. Um, okay. Fair fair point. So actually bed bugs, you can say MRSA, cadiff, Ebola around medical providers and we’re going to go, eh, but you say bed bugs and we’re going no bed bugs are a great point though. Um, usually dispatch is pretty good about giving us that heads up. The patients will usually tell them, hey, we have bed bugs or we flag their address as a bed bug address. Yes, that really happens. Um, so good point on that. Um, and that’s why I kind of wanted to ask because I also posse calls as a little bit maybe more like I’m just here to help, you know, like I don’t have to worry as much about like when I say that I’m not just saying, “Oh, I’m just bimbo.” I’m saying like I’m here to help. Safety for me means something different than it does for him. And that’s why it’s interesting to hear his viewpoint because I also feel like this person is too close. But that’s why I say like, you know, I kind of wanted to hear it cuz I think we’re a little different in that case, right? Like I’m used to getting a little more up in people’s grills and in these types of interactions. That doesn’t always mean it’s a good thing. People have to earn their space with me. So if I’m going to be in closer proximity to you, you have to be very very nice. And for me to get actually probably even like this close to to the patient, you have to be very nice. You have to make it very clear. Um and when I say nice, I mean like you have to make it pretty clear that you really are or you really do want me there. It really is a a situation in which you’re in pain. You need help. whatever. Um, but yeah. Does anyone else have thoughts on that? I was going to say, well, it’s kind of hard to tell the picture, but um, you probably tell like by like skin on his arms, you know, like maybe what condition he’s in. Oh, sure. Uh, uh, sorry. What was that last part? I I don’t know what I’m saying. I can’t hear you. He said, you know what I’m saying? Oh, yeah. No, I don’t know what you’re saying. Um, he’s given me uh um gosh, I can’t think of words today. The farmer’s tan. He’s giving me farmers stand as well, which is another clue. Maybe he’s a hardworking dude, right? So, that’s a good thing to know. All of these things are definitely worth pointing out, right? His hygiene is its own thing. And when I say hygiene, he’s wearing sandals. Remember what I said about foot hygiene the other day and how foot hygiene is a great way to determine how someone’s actually taken care of not just by themselves but by other people too. Okay. So, um this scene size up part is where I’m going to go more in depth into some other things um as far as like specifically with the history side of it as far as suicidal ideation and whatnot cuz it does talk about those a little later but it’s very applicable in this case cuz this is how we’re going to run our call, right? So, as far as the scene safety of this goes, um many many of your behavioral calls, and when I say many of them, I truly can’t think of a time that I went on a call that the police weren’t there. Um the other nice thing is depending on the system you work in, the police usually or frequently a handful of them or something like that usually scan the other like the EMS and fire channel and they’ll listen for stuff like that. like we if we call for help, which you are always encouraged to do, if you’re on a scene and something starts getting out of hand or you can feel it start escalating, you can always ask for help. Um, only thing with that is take into consideration that if you’re on like a medical call and someone starts getting squirly with you, um, police are always an option, right? Are the no offense obviously to law enforcement, but are the police the best option is something to think about. And the reason I say that is the gun and the badge, the shield, right? So we all we all have our shields as a part of our public service membership or whatever says paramedic, firefighter, police officer, sergeant, whatever, right? The shield is the one of the things that scares them. So, I just encourage you to take into consideration if you have your fire crews and all that, you have the manpower to handle this person, maybe take into consideration whether law enforcement’s appropriate cuz that can easily exacerbate the situation. However, I will say there have been a number of times where nobody on my scene was able to reason with somebody or get them to listen to us. They sure as hell listen to the police. And if not, they will get a different taste of listening because they’re going to have to listen, right? the police presence can def definitely um bolster or um harm your scene depending on the scene type. I personally like having the police around and I always make it very clear that they’re my friends and you don’t get to pick on them anyway that you don’t get to pick on us. So, just some thoughts for you to have. Um always a good idea to have your fire crews with you obviously because there’s a lot of them. They need things to do, right? They haven’t pulled enough hose today, so they can come out. Come on. No one laughed at that joke. They didn’t clean enough fire hydrants. They got they got to come help us. So, always get your manpower. Um, if you are by yourself, obviously, or if you’re in a situation where it’s not safe, you leave. I think not enough people are comfortable doing that because they’re it’s the whole like, well, we’re here to help them. Yes, we’re here to help them, but who’s going to help them if we get hurt? You truly have to look at it like that. Um, excuse me. Other things, are there legal issues involved? Um, great points. If it’s a crime scene, right? We try not to touch anything. Um, and sorry, I’m picking on firefighters again. They are naturally a little more destructive just because their nature is to control things, right? They don’t like they’re controlling a fire, right? So, they are a little more bull in a china shop. Um, I will say that. I think our thing is like EMTs and medics is we’re more more used to doing like delicate things like delicate procedures and whatnot. So, um the only and that sounds weird to bring up, but I definitely have had to remind people, hey, this is a crime scene. You need to pick your up, right? Like if we’re leaving our bags all over the place and whatnot, that’s not a good look and it’s not a good move for the police either. So, always approach your crime scene with some kind of method to it. And then as far as consent goes, if someone is threatening to harm themselves or other people, they have no consent. Okay? If they do harm or hurt another person um or whatever, they don’t have consent anymore. Where this comes in is that a lot of your behavioral patients that maybe have like a u um oh my gosh, I cannot talk today. A medical proxy or a guardian, someone who makes decisions for them. The hard part about that is they might say the person’s not acting right. they haven’t been acting right for a couple of weeks and we say they’re fine. They’re doing okay for us. They’re actually they’re just a little depressed, right? But they’re not saying anything um that’s concerning or whatever. And they say no, they have to go. I’ve been on that call a lot, which I think is a real shame because a lot of that is people pushing off people that they don’t want to deal with, which is really, really sad. And these are complex cases, so it you might run into that. but also obviously if there’s a minor involved, anything like that, you need to need to consider what type of consent is this person eligible for and then how do I meet that if I need to remember implied consent um on our end is pretty easy as long as there’s a threat to life or limb and then on the police’s end there’s the involuntary as far as like psych holds and things like that go for your um your suicidal subjects. Um do you have anything to expand on that either the psych holds either of you uh or advice maybe? Well, if it’s something like that, our department has a a set of policies and procedures that we use and these people have to meet our criteria and then so it’s department based the state has their uh policies and pro procedures as well. Okay. But then we can expand on that with our own criteria and whatnot. So, so it’s very similar to like our scope of practice model. Yeah. Where the state has their own system for things and then each department has their own. Right. Okay. That makes sense too because with restraining, I’ve noticed like all the local departments all have different philosophies on that as well. Cuz that’s another thing that we’re talking about too, right? Is restraint. Did I ever show you guys the restraints, the soft restraints? Okay. Oh, sorry. And if you have anything else, Luke. Um, so we’re going to be talking about this here in a second. Um, but like I said, the restraint conversation is another layer to this. When you get into the consent side of things, if we’re restraining someone, remember, there’s a reason we’re restraining them. Either it’s involuntary and the police are asking us to take them or it’s implied consent and we’re doing what we have to do in that case, right? Which I will say is very much something I’ve had to do in this category of people. Um, other things that are very specific to this call type, um, trigger warning for you is your PPE. The re Why would I encourage you to have PPE on psych patients? In case they spit at you. Spitting. Can we all agree spitting is one of the most degrading things I think in the I think that’s the one thing I’ve never met a single human that does or that’s like, “Yeah, that doesn’t bother me.” every single person I’ve met. Like, it seems to be a a universal human experience that that is incredibly insulting, but also it’s disgusting. The human mouth is very gross. And the reason I bring that up is these um if you spit on me. So, this is what they look like. If you spit on me, and my thing is I give warnings. You can Have you guys ever seen someone like gearing up to spit before? It’s pretty obvious, I think. Um, in in a sense, right? It’s that whole like you can see people like pooling up their saliva. It’s disgusting. Um, but I’ll see it and I’ll tell them I’ll be like, “Do not spit on me.” Not only is that, like I said, foul, right? But it’s incredibly inappropriate. And that type of thing actually gets taken quite seriously when you’re talking about doing it to medical providers like us, right? That’s technically, is it assault then? If the spitting Oh, so okay. Battery. Oh, yeah. Because the salt is someone making the threat, right? Battery isn’t actually doing it. These are spit hoods, though. Um, these it looks like it’s much more meshy than it is meshy. Um, these are incredibly difficult to break or tear. Um, I’ve seen someone get pretty darn close to tearing this with their teeth cuz they’ll like lick it and they’ll stick to their tongue and they’ll pull it in their mouth and they’ll start chewing on it. Um, this might not be allowed in your agency. It would I’m just going to say I’ve seen this be done before. Um, and by I’ve seen this be done before. Most of the time it happened in the hospital, which I very much appreciate, but they gave them two. They gave them two spit hoods. And then I saw one time where they gave them three spit hoods and I was like, you know what? I’m here for it. I get it. But also, the thing about the spit hoods though is when you’re going to put them on, people are going to lose their minds. They’re going to be furious. Just so you know though, I did this. I did it for a training video. It’s out there somewhere. Um, there’s me in my uniform and I’m putting the spit hoods on and then I put a pulse oximter on and then I ran around our station a couple of times and my SPO2 did not go down at all. They can still breathe through these. They’re going to tell you they can’t breathe. You usually have to coach them through it. Yes, you can breathe. Just try to breathe in through your nose, right? Try to control it like that. But this is going to piss them off. Um, completely understand why, but again, don’t be afraid to put spit hoods on. The other side of this that you might see, and this comes up a or more in the restraint thing, but this is a common pipeline for it is the police wrap. Jeez. Um, I’ve seen a lot of people get the spit hood and then they were kind of in the process of getting put in the wrap. Now, this is also something that I I’ve we usually are the ones restraining people. I’ve seen these deployed a handful of times. They look like this and then they actually they’ve got the hood or the helmet right here because what people will do once you restrain them is they’re going to start smacking their head into things. Um I’ve been called to assist with the application of this, which my uh answer to that was no. Um, I’m not trained on this piece of equipment and if I’m going to restrain somebody, I’m going to chemically sedate them as well. Uh, nine out of 10 times I chemically sedate my uh physically restrained patients because it’s the most humane option in my mind. Um, but remember this isn’t just for everybody. Like the police don’t call us every single time someone needs to be transported to the jail or the hospital or whatever, right? Um, this is very, very demeaning for sure, but it’s also kind of a pain. How do you feel about it? It’s awesome. Yeah. No, they are. They It totally Sorry. No, you’re good. Cuz in the past, we would just hobble them, which we take like a dog and we wrap around their cuffs and their legs, right? The hog tie. Yeah. Not very good positional exfixiation, all that good stuff. Can I pause that for a second? Did you guys hear what he just said where he was saying they used to hog tie them? So they had their cuffs, handcuffs, they had uh ankle cuffs, and then they were So it’s a hog tie, right? If you’ve never seen a hog tie, they tie them like this so that their stomach is to the ground and their extremities are tied back together like that. That is prone positioning. And that’s why he said we don’t do that. Any you don’t do it for obvious reasons, right? Um, there’s a lot of reasons why, but the biggest one, I’m sure, is that positional asphixxia because they can’t move and actually open up their chest wall because now they’re in like a scorpion if you want to think about it like that. So, another example of that positional asphixxia. I know this is super awesome because before we even start deploying that, we have to get trained on it. We have to get put in it. We have to learn how to apply it and then stow it. But it’s like a nice little bear hug where you can just relax. Yeah. And if you need to administer an IV or we need to take blood for whatever reason, we can do it how her arms are behind her back. Oh, yeah. Like that. Or there’s a ring at the front where her knees are where we can uh then right there. Yeah. Do it up front as well. But it’s a great piece of equipment. Yeah. It’s super comfy. I think these are exponentially better than these restraints that I’ll show you here in a second. Um the problem with us is that we don’t um rodeo the same way. I’ll get to in just a second, right? We don’t rodeo the same way as the police. And that what I say it’s a problem is because there’s only a couple of us and when they’re deploying something like this, there’s multiple of them, right? So it’s just a difference not only in the job description obviously, but very much so with the equipment. Um there that’s why I said no, is cuz he had to do training on it, right? These restraints are wildly different. So if if you go into law enforcement, the RAP is not something or if you go into EMS, the RAP isn’t something that most people are standardly trained on. Okay. When you guys chemically sedate, do you guys do it through an IV or do you do intramuscular? Um that depends on the provider, the situation, um the medications you have. Some medications cannot be given um intramuscular, but that they’re still good sedatives, right? Um, in my experience, I usually did um injections and I’m sure you’ve experienced where we we just kind of have to sneak in and give the injection really quick while the police and the firefighters usually are the ones kind of rodeoing with them. And that what do you the injection incular? Again, it it depends on the call and it depends on your provider. So remember, you cannot call for ALS and expect like if you’re in a BLS rig and you call us and you say, “I need help.” and we show up. I don’t necessarily have to take that call just because you’re asking for help. Okay, that’s an important thing to remember. There are times where it is obviously the most appropriate for your paramedic to take it. Um especially if you’re like rendevousing, but in that case, um again, I hate to give such a blanket answer, but it really just does depend. The there is intramuscular, intraasal, IV. Um those are going to be intramuscular and intraasal are going to be your easier. Yeah. I was just mostly asking because like it has to be like intra. Well, it doesn’t. So, IVs are all over. You can get IVs in their hands. Yeah. Or just like if they’re moving around, it’d be like anything. Um, I’ve had It’s If you have enough people, you can usually pin an arm down. Yeah. Um, sorry. It’s just a broad question. There’s a lot of layers to it, but again, you can’t request somebody to. However, it’s always a good idea to consider getting a paramedic or whatever your ALS unit, closest ALS unit looks like to as rendevous path, whatever that looks like for you, because you don’t want to do it alone, especially not if one of these people stops breathing. And that’s one of the big fears with excited delirium. Okay. Um, now as far as mechanism of injury, nature of illness, I will say, um, and again, no dig towards law enforcement, um, if people run away, right, they’re automatically, even if it’s a medical patient, like if they’re trying to run away from the police or they’re trying to get away from us, um, they’re pretty much now a trauma. That’s my philosophy of things. And the re really the big idea right behind that is just these are some big dudes, right? Right? And if you get tackled to the ground or something like that, they should be a medical med trauma until proven otherwise. Obviously, they need to have trauma involved. But that’s just another thing to consider. Um, always consider your nature of illness. Remember though, this is very or this is a theme that keeps popping up. Your call type that you get dispatched to um is not and is frequently not a behavioral subject. It’s often times something else. Um, I don’t know about you guys, but for us, depending on it might just be um abnormal behavior. Um, or it might just be sick person or something like that. So, don’t just assume you’re going to get or you’re going to know what’s going on from your call or your disposition, dispatch information, and all that. Um, we’ve already talked a lot about this, uh, your general impression. Use your AV poo. This is where, um, paying attention to your scene. Your scene always matters, right? But paying attention to your scene like we did on with that picture, that’s where this is going to come in a little more for you, maybe reactively. You should be doing that on every call. But it’s usually these call types where people learn how to do that because they’re a little more nervous about things. Anytime you walk in, you should uh into a room, you should be thinking, how do I get out? Right? What is my point for getting out of here? Are there any weapons? How close is the patient to me? What’s the patient’s size relative to mine? And these are all things worth considering. Um, airway. Anyone who’s screaming or crying has a patent airway, right? So, that’s pretty much it. Um, I guess I’ll come back to this for a second. Pulse occimmetry. Um, if it’s on the the pipeline of restraints, um, if you are restraining someone, having pulse occimmetry is not only obviously pretty necessary, but it might be difficult to get, especially if they’re in the wrap, okay? Especially if their hands are like tied back here or something. Just be aware SPO2 can be a pain if someone’s restrained. Um, circulation. Um, the nice thing though about uh using restraints, whether it’s ours or the police, is that you can still check CMS as well, which you should always be do be doing anytime you’re wrapping something around someone’s extremities, right? Whether it’s a SAM splint with curlex or it’s restraints um tourniquet, right? You’re checking CMS how it relates to that situation. CMS needs to be checked on your restrained patients and it needs to be documented. Okay? It should always be documented. If you don’t and something comes up of where the patient says like, “Oh, like I have nerve damage in my foot after the paramedics restrained me.” How do you prove that, right? How do you prove it wasn’t you? You proved it by going back to your chart to proved it as much as you can by saying, “I checked CMS before and after as best I could or whatever, and the patient had adequate CMS throughout our transport.” Okay, so that’s very important to make note of. Uh skin color, condition, temperature is always good. Um don’t be surprised if you walk in with psychotic patients and they look like a heat stroke or like your excited deliriums are super hot, super red, stuff like that. As far as transport goes, um transport uh largely depends on the system you work for. If you’re eligible to go to a behavioral health unit, maybe you go there. You’ll probably go to the ER, though. Um, now for history taking, um, sample history obviously is always going to be your skeleton for history taking, but this I do appreciate this line of questions. And the big reason I appreciate these is because this is going to hit the big points of behavioral episodes for potential causes, right? Is their central nervous system functioning properly? The big point of that is, is it functioning properly? Right? So, are they someone who maybe has like an advanced um type of autism? Maybe, you know, they have some other neurocognitive disorder, they have Alzheimer’s, things like that. You have to consider is it actually functioning properly in the first place. Drugs or alcohol, hallucinogens are the big one, I would say, as far as what people perceive to be behavioral episodes, but it’s actually just like a drug induced psychotic episode. um hallucinogens like acid in particular. I think we were talking about this the other day. When I was in high school, the hardcore kids did acid and now they’re like experimenting with like cocaine, meth, and stuff like that. So, in high schoolers in particular, I usually go to drugs uh before anything cuz kids these days are getting very adventurous with their drug consumption. Um but anybody is fair game to me. Um remember drugs affect everybody and everybody has some type of relationship with them and not by doing them necessarily just has a relationship with them. Um significant life changes. Has anything happened recently? I always ask my patients that every single patient though I I always ask them how’s life going? How how is everything? Is there anything that’s been uh has anything changed for you lately? because you’d be amazed what people want or what people tell you because if you ask them that question, what has changed for you recently? They’ll tell you what’s bothering them. So, if you say or if you say that and they say, “My friends don’t talk to me anymore. I’m not close with my family.” Oh, okay. Well, they just told you this is a psychiatric thing, right? Versus if you say like, “Oh, like my health has been bugging me. My my chest has been hurting.” Oh, well, it kind of points you in that direction. What has changed recently? What’s been going on recently? That’s a really good question. Um, and then, uh, history of behavioral health illness. That’s always helpful. However, be careful about assigning, uh, preconceived notions to someone because they tell you that at some point they had a psychiatric diagnosis. People do go into recovery from things like depression, uh, panic attacks, things like that. Maybe recovery is not the word, but you get the idea. Is that is that the iPhone sound? because if it is, I need to get rid of it. My iPhone has it’s been making all types of noises and I don’t know what they mean. Um, none of this is that different. What is reflective listening? Engaged. You like engaged to an to an extent. That’s a part of it. So, you’re engaged. What’s that? send me to like see like like how much they’re paying attention to you ask your back saying basically right so it’s basically me saying like okay so you’ve had chest pain for 3 days it started it woke you up right out of a dead sleep and you took your nitro and it didn’t help that sound right like that style right reflective listening is me tell or me showing them that I’ve actually been listening to them by providing information that shows them. I’m listening to them, right? And the important thing about that is it’s not just with their sample history. Reflective listening is very important for developing rapport with somebody. So, if you’re on a call with someone, you know, and and it’s this little old lady who’s obviously having a bad day, she’s stressed and she goes, “Oh, I’m sorry. My little dog’s in the way.” Whatever. Uh part of reflective listening is maybe when you’re in the ambulance going, “Oh, so that was your little dog. That was cute. What’s their name?” Right? And it’s it’s very important for the sample history and the story of it obviously because telling the story back is a great way to actually know the story. Um help you with your pass report, but it also builds rapport. Reflective listening applies to more than just getting a a medical assessment done. Um and then I really don’t mind this. Um this is kind of just general questions that you can consider. Um, the other ones I say definitely uh take priority in my mind, but the other ones uh does the patient seem to understand you? You guys have all talked to drunk people before who have open eyes. They stand there and they look at you and you’re talking to them and you’re like, “Does that make sense or isn’t that crazy?” And they’re like, “What?” You know what I mean? Like, do they actually understand you? The important thing about that is that if we’re going to get into consent, right, outside of let’s say they’re like a suicidal subject or whatever, they have to be able to understand you. But also, if they don’t understand what you’re saying, is this going to be a very smooth call if someone has to go to the hospital and they don’t understand why? No. So asking them or not asking, sorry, clarifying if they actually understand you is very important. Um and then does the pre patient express disordered thoughts, delusions or hallucinations? Those are always worth mentioning because uh what do you guys think is the difference between disordered uh and delusional? Delusional might be like they think they’re a unicorn or something. Um yeah, I I would even say maybe that’s a a borderline hallucination, right? But delusional still the idea is that you’re disconnected from reality. Right. So what does the word disordered means? Mean disorient disorienting. Disorienting. Is that you’re good kind of. So like disordered like what do we think of when we think of a disorder like a medical disorder. It means something’s not or the pieces aren’t coming together. Right? So that’s how you think about disordered thoughts. These are the people who are maybe speaking at 1,000 mph and none of the points are coming back to connect. That might be like a uh disordered thoughts. Um people who can’t seem to keep on a straight path with their conversation. That’s another example. And then hallucinations are their own category. Um which we’ll get into here in a second. Uh this is all pretty obvious. Be careful doing a physical exam on anybody um who is already maybe touch sensitive, especially if they’re in this category of things. You have to consider PTSD and a lot of these things come from somewhere, right? So maybe it’s not appropriate to be touching your patients in certain ways without talking to them, touching or uh talking to them first, walking them through it, whatever. Um but also, unless they have a traumatic mechanism um involved, I’m probably not going to even consider touching them unless I’m doing like vitals or something like that just from the get- go. So obviously trauma takes precedence but this is a population where if I don’t have to I’m not going to I either don’t want to worsen the wound or um maybe push it. Um so is I mentioned this the other day I believe but a blank gaze or rapidly moving eyes could mean central nervous system dysfunction. Uh, do you guys remember me talking about that where I was saying people’s eyes doing this where they can’t talk to you or when people have this presentation where they were like pulling their head off to the side and they had those like tremors and whatnot. Um, that’s very much in the realm of what I’m talking about here. This is a neurotransmitter problem. Okay? And the reason that is so significant is because your brain should be able to not only take in extremely complex information, but it should be able to regulate the way that your body actually processes and executes that information. If your eyeballs, if you cannot speak and your eyeballs are moving side to side, your brain is not working. And this patient is no longer like a sad depressed person. They are now a complex neurological patient. Okay? which again is something that can happen in your patients that take um pretty complex psych meds which is what I was talking about the other day. Right? So those medications, those presentations, the ticking and like that mouth uh smacking and clicking that I was talking about those are not good. If you see someone doing that, that means that their brain is f uh has stopped functioning at a lot of those higher levels. That’s a big deal. And that can come up in some of these conditions, which is why I say it is not just sadness. It’s not just sadness, right? These are complex neurological disorders much of the time. Um, we’ve already talked about transport stuff. Um, see, see, I just turned it off, too. No, that wasn’t you. I wasn’t looking at you. I’m sorry. Let me turn my sound off. Um, never let your guard down. Obviously, we’ve already talked about a lot of this stuff. Um, as far as the restraints go, I can’t show you on that gurnie cuz I took one of the side rails off. These are really, really crappy restraints. Hopefully, your system has better ones than these. These are like Hollywood like uh Alfred Hitchcock movie type soft restraints, you know what I mean? They’re not very good. They do have this foam on the inside, which is nice, but the part about them that makes them really annoying is that the first step is actually getting this around their wrists with this Velcro and then being able to tie it to the gurnie. So, this actually is pretty strong, but yeah, I mean, I could probably with the right angle just rip that like I did. And I’ve seen people do that before. So, please be careful when you’re putting people in these restraints. your agency will put you through a training for whatever type of restraints they use. Um I it’s there’s so many different types out there, but don’t be surprised if they have these cheapo ones. Um there’s nothing inherently wrong with them. I don’t like the fact that they break so easily. The ones that they have in the hospital are pretty slick, though. Most restraints these days, if they have like the more modern ones, are actually going to stay on your gurnie and they’re going to have the same kind of material on it that you just wipe off and you just disinfect. These are single use obviously so they’re not as effective. Um but that’s what we have. So I’m also of the philosophy it depends on your system but if you restrain someone’s upper extremities you extre you you restrain their lower extremities too. I feel like that makes sense. Um depends on your system and what you’re allowed to do but you don’t need to give people any ability to kick you. If you’re restraining their arms, consider restraining everything, right? Why would you restrain the arms when their legs are arguably stronger and now available? Um, and then chart everything carefully. We’re not going to do charting in here, obviously. However, um, just make sure you take into consideration certain things that might might come up with these patients. If you’re a male provider and you have a young female patient who’s a psych patient, maybe it’s best to consider having an additional provider right in with you, right? And yes, that is the world that we live in. It’s not saying anything against either sides. It’s just the world that we live in. People are going to do stuff like that, right? So, just take that into consideration. If you’re restraining someone, you need to take people with you in your ambulance. All right, any questions on that stuff? Okay. So, now we’re going to get into some of the disorders. Um, and I do have a video about schizophrenia to show you. So, psychosis, uh, we’ve already talked about this. Um, we’ve, well, kind of. So, we’ve gone over the disordered delusional thoughts and then hallucinations, right? Well, disordered and delusional thoughts um, and hallucinations can easily feed into psychosis. Psychosis is truly a state a like um how do I say I almost said have you guys ever met someone on ketamine? Cuz I obviously my answer for that is yes. Um but I was going to say if you’ve ever interacted with anybody who’s on a powerful drug like ketamine or LSD or u mushrooms or something like that, you might see where people are like we say they’re on Jupiter, you know, like they’re not in our solar solar system. That’s what these people look like. Uh frequently though you lack the drugs. It’s this is the the disconnect from reality because of their psychiatric condition. Now um psychosis is a state. It is not an actual um disease process. Well, when I say disease process, I don’t mean like um you aren’t schizophrenic and then go into psychosis and leave the schizophrenia. You are a schizophrenic patient that experienced a psychotic episode. Okay, you are a bipolar patient that experienced a psychotic episode. So, that’s how we refer to it. It’s a state that they’re in. These um are the common causes. I think these are all very reasonable mindaltering substances. Remember, just because someone’s in psychosis doesn’t mean they’re actually violent and they want to hurt you. They just don’t know what’s going on. They’re on Pluto, right? And as far as they know, you might be a threat to them. That’s the thing about hallucinogens. Um, I in general don’t have much of a problem with them because they’re quite mild as far as the drug interactions go with people that I’ve dealt with. However, when you do get someone who’s all uh spun up on like acid and they’re trying to fight the dragons or you know the the sealorns is what I had a patient tell me a sealorn is a seal unicorn that wrecked my night. It still messes with me. It’s that. Oh my gosh, I just made that connection. It’s a narwhal. I genuinely thought they were like, “It’s Well, they were like, “It’s a sealorn.” And I was like, “Homie, I don’t know what that is.” Uh, I took biology and we didn’t learn about that. Um, but things uh that’s part of it, right, is just realizing, okay, they’re on Jupiter. Um, they’re not here to hurt me. They’re just trying to protect themselves because they’re fighting the aliens. That’s the way I always look at the mindaltering substances with the exception of methamphetamine. It’s the head knot. The I get that. And my reason for that is the uh methamphetamine psychosis is much more of the um fight orflight side of it if you want to think about it. It’s much more of the something’s out to get me, the government’s out to get me. Um the different types of psychosis. Have you guys heard about that? There’s the different types. There’s like the religious psychosis where they think they’re the savior. Um, the bird bird psychosis is a very real thing. Um, and so I’m not I’m laughing cuz I think of this Tik Tok for this girl. She was in uh she’s bipolar. She went into a psychotic episode and she experiences bird psychosis. And she showed all of her little hiding spots for her money because she was convinced the birds were going to come take her money. Yes, it’s funny. You can laugh about it a little bit cuz it is funny. Um, she laugh and she said that. She’s like, “You can laugh about it. It’s okay.” Um but that’s the level that they’re on to a normal person. When I say normal, right, us uh presumably uh neuronologically intact and functioning p or people that’s kind of a little out there, right? So now you can appreciate where some of these things that people say where we’re like, okay, are they quote unquote crazy is what people say or are they actually experiencing something? For some people, that is the fine line that their families tread for years and years and years of their life. are they actually psychotic or are they just um out there, right? Specifically, if they have schizophrenia um and when, sorry, I’ll go back to the meth thing really quick, but the reason I say that is those types of psychosis are usually the ones where they have potentially violent undertones, especially if it’s government or religious in context. Um so, schizophrenia, um I have a big huge soft spot in my heart for schizophrenics. um someone who uh was very close to me at one point in their life. Um their dad sustained drug induced schizophrenia and then he ended up killing himself as well as his partner. Um but that’s is that story all that wild for uh drug induced schizophrenia? Not as wild as you would think. I’m not saying it’s a common thing. However, um the pipeline from schizophrenic uh behaviors to a full-blown meth addiction is incredible. And we finally understand kind of why it works. Schizophrenia is very, very complex. And part of why it’s so complex is because now we’re only just now figuring out how it works, but also what medications actually do work on it. We were treating it in a way that doesn’t make any sense. we did what we thought we knew at the time, right? But now, um, we’re actually able to look at schizophrenics and say, “Hey, this part of their brain doesn’t work.” And by the way, the part of their brain that doesn’t work is the reward center. So the reward center of your brain is that thing that goes, “Hey, you got you guys rocked your skills.” Which, by the way, good job on that again. You guys rocked your skills. Heck yeah. And that little high that you have, that’s your reward center. That’s messed up in schizophrenic patients. So these patients are frequently already this is like let’s say this is the normal human baseline like neurological baseline these guys are already functioning up here because they have problems with their neurotransmitters. So they’re already hyper excited compared to us they’re neurological baseline is already elevated. How do you feel anything if your neurological baseline is already more elevated than the rest of the population? you do meth. And if you’ve never been somebody who wants to just feel something, um, you don’t know what that’s like, I’m happy for you. But if you’re like the rest of the world where life happens and life sucks sometimes, you just want to feel something. That’s one of the only things that works for these guys. Alcohol and heroin and whatnot. I I’ve asked a number of these patients, why not alcohol? Why not heroin? A lot. There are a number of them that do either or both. Um, and a lot of them say, “I don’t want to go to sleep. I want to enjoy the life I have while I’m awake.” That’s very basically the answer I’ve gotten across the board. Isn’t that sad? These are people because a lot of people drown their sorrows, right? And they just want to go to sleep. So, a lot of these people are very much like the no, I’m here and I’m awake, but life is just kind of hard every second of every day. So, naturally, they just want to feel something and that requires they do a a pretty heavy duty drug. Um now the pipeline of schizophrenic uh behaviors to full-blown meth addiction goes like this and this is the patient type that you’re going to come across. Um heroin incidents and um other drugs is much much lower than schizophrenia and meth. So usually what happens is um this schizophrenic person has taken their medications, they’ve gone down the diagnostic route, they’ve got their counselor, psychologist, whatever. Um they take their medications and they start feeling better. Okay. So maybe the hallucinations stop. You guys are aware of the hallucinations with schizophrenia. I assume auditory hallucinations much of the time. Um so uh for them they’re like okay well I feel better. They quit taking their meds. So now their baseline goes back up. Instead of going like staying here it goes back up and they go damn I just want to feel something again. So they use meth. They usually go depends on the person. It’s typically a couple of weeks um of the meth bender and then something happens. They don’t sleep for a week and have a psychotic episode. Family shows up, we show up, whatever. We take them to the hospital. They get uh often times forced medication. What’s that called? No, the the government process for where a judge forces you to take a medication. I don’t know. Do you know what I’m talking about, though? Um, it’s a it’s a a position that someone can get in if they are so severely psychologically unwell. The courts can actually get involved in it and force that person to take medications for a certain period of time, but it usually caps out after a certain period of time. And the thing with that is that once they take those medications, they start feeling better again. Well, they quit taking them and then you’re back to that meth cycle. Does that make sense? Okay. Um, and the reason I bring that up again is cuz like I said, you’re going to see that a lot. Um, but also it’s really sad. I think it’s extremely sad because a lot of these guys are doing the meth because they also don’t have access to their medications. And if you know anything about conditions like ADD, ADHD, bipolar, schizophrenia, things like that that require more stimulus to feel good, drinking is not going to do anything for them, right? Um, and I guess the reason I say that with like ADD and whatnot is because we’re also talking about people that are just in an elevated state, your ADD, ADHD, whatnot, but also PTSD. And that’s why a lot of your PTSD user or PTSD patients also engage in s uh stimulants. Stimulants are a popular choice for people who um need more excitement. And I don’t mean need more excitement in like their personal life. Their brain needs more excitement. Okay, does that make sense then? All right. So, the thing with schizophrenia also that is very interesting is how it presents. Do you guys know what the age range is for men to start experiencing symptoms of this where it breakthrough like where it really starts to come out? Um, yes. So, it’s late teens into your late 20s and that’s when it pops up for men. Um, so don’t be surprised if you go on a call and it’s a young man who’s 19, 20, 21, something like that, and they’re walking down the street naked. Um, maybe with like the savior uh savior complex, right? Like I am the messiah, which is very common. Very, very common. My first first thought whenever I go on a behavioral uh late teens into late 20s yearear-old male is a schizophrenic breakthrough. Um, and the it’s kind it’s not that the schizophrenic breakthrough necessarily is going to kill them. Um, obviously, but the big thing is the danger that they put themselves in. You’ll see them wandering down the street. They’ll be breaking into stores, burglarizing things sometimes. Uh, churches are a common ground for that. So, it might just be something you run into. When does it present for women? What’s that? Late. Uh, how late? Late 30s. Early 40s. Late 30s. Yeah, late 30s. Early 40s. Um, interesting, isn’t it? Huh? No, I just said later. Yeah. No, you’re good. And I guess the reason I was asking for later is cuz you mean like 70s, right? Or do you mean like your 30s? And uh with that uh I actually I heard that the thought is is cuz remember 30 I would be a geriatric pregnancy right now. I’m 32. Um so 30s are like for women um we’re kind of supposed to be getting out of our baby making process actually having and making babies um producing babies. You get what I mean? Um but the thought is is when you get into your late 30s that’s like p menopause. uh pre perry premenopause. The thought is is that certain uh certain women are uh more prone to it once perry or premenopause kicks in because the hormones that normally protect our brain drop down. So that’s some thought. I think that’s really interesting. Um I’m going to have to cl or uh double check on that to make sure that’s still the thought, but we just found that out about women with schizophrenia, which I think is really interesting. Um, other things that can cause it though, obviously brain damage, um, psychological and social influences, that gets into the really interesting side of psychology that we’re not going to get into obviously, but genetics is the big thing. Um, so some of the symptoms of schizophrenia, this is not an exhaustive list, but it’s got the big ones on here. Delusions. Um, there that’s kind of their baseline. Have you guys interacted with schizophrenics before? No. No. Interesting. Okay. Um, so when when I say delusions, I mean being their baseline. I mean it really kind of is their baseline and much of that stems from mistrust of whatever system, their family, the hospitals, um, the judicial system, whatever, right? Um, the delusions feed into that. The hard thing is trying to figure out where is their delusional behavior maybe bordering that psychotic behavior, right? So, you’ll get people who are like, “No, it’s it’s the government. It’s the government.” And you’re like, “Well, you’re not wrong.” Right? Like, it really is the government. But then they like keep talking and you’re like, “Right.” I mean, but they sound paranoid, right? That paranoia is something that you often times see in these guys. Very much so in line with that uh meth use, but the delusions feed the paranoia. And then the hallucinations also feed the delusions and the paranoia. Now the the idea behind hallucinations is you’ve got two different types. You’ve got auditory and um visual. If you’re hearing the voices, that’s more indicative of a neurological problem. If you’re seeing the ponies and the walls melting, that’s more of a drug induced state or something like that. Okay. You can have schizophrenic patients that do have visual hallucinations. It’s much more common for them to have auditory though. Um, now in as far as drug use goes as well, if you’ve ever talked to someone who’s hallucinated before, they almost always uh talk about the visual hallucinations. That’s what people like. Uh, that that does not sound fun to me. The walls melting. No thanks. Right. I also don’t think hearing voices sounds very nice. So, that’s uh honestly both of them sound very anxietyinducing to me. However, right, imagine you’re trying to go about your day and you have little voices and sounds in your head. It’s not just voices either. It’s very much sounds, okay? Sounds um maybe you can think about them like ticks even is things that just come up out of nowhere almost kind of non-consensually. That’s why a lot of your schizophrenics also report things like OCD with intrusive thoughts. So, um the lack of interest in pleasure is because of what I was talking about with their neurological baseline. it is already much higher than the average person. So, they require much more stimulus to actually feel things. And then there’s the erratic speech. This is kind of a not nice way to say it, but this is what I’ve heard and I don’t know the actual term for it. Gas station language. I know that sounds horrible, but uh do you know what I’m talking about? The very erratic speech almost kind of like mumbled like the like that thing. Um a a lot of people think that that’s what the erratic speech is. in in that case. And I I can see that, but it’s much more so of the very rapid, very disordered thoughts that don’t seem to make any sense, but they’re not quite so like drunk looking, if that makes any sense, or drunk sounding. I don’t know how else to explain it. Um, so, uh, I’m going to show you a video here in a second. Um, I just want to bring this up really quick. Uh, as far as any psychotic patient, you’re going to do all of these things. be calm, clearly identify yourself obviously, but maintain an emotional distance. Um, and my reason for that is because people are going to say really awful things. Um, they’re going to tell you they’re going to find you, they’re, you know, they’re going to hurt you or whatever. I very it’s hard to do for a little bit, but I’ve have definitely gotten to the point where people can say stuff like that and it doesn’t bother me anymore. Especially when I consider that there is a severely neurologically and psychologically unwell patient. They’re going to say some not very nice things to you. Do be very careful about dulging information to patients in general, but that’s where a lot of these patient populations get uh get sticky is because part of what they do is manipulate, right? That’s very much part of their communication tactic. So, be careful. And when I say that, it’s not just the, “Oh my gosh, you’re so pretty.” I don’t mean that. I mean, it’s also though that they can they can say really awful things to you. So, the reason I like to show this video, it is also kind of a difficult video to listen to. So, if you want to plug your ears after a little bit, you can. I will pause it. But this video is by a uh patient who has schizophrenia. Um he made this video and it’s an example of what goes on in his mind when he’s not doing well. He said when he’s not well. Um I don’t know what that means for him. Much of the time when someone says they have like uh you know bipolar, um schizophrenia, any of those pretty complex psychological disorders, when they say they’re not doing well, it usually means either they become more manic, um they’re more delusional, they have more disordered thoughts, they’re unable to control their thoughts, things like that. Now, uh the other last interesting point before I get to this video is that schizophrenic um uh well I guess they’re schizophrenic service animals. Have you guys heard of those? One of the coolest things I’ve seen come out. So, um people schizophrenics can get service animals and they’re trained service animals. Uh basically if they hear something they’ll say, you know, so my dog’s name is Poppy. Let’s say she was trained like uh to to that level, I could say, “Hey, Poppy, acknowledge.” And if there’s nobody there, she’s not going to acknowledge it. But if there is somebody there, then they will acknowledge it. And that helps the person um who the dog is trained for not only recognize maybe that’s a hallucination, but also stay safe, right? Because there are a lot of instances where these people are hyper aware and maybe a little more protective over things, right? Making them a little more dangerous. So, um I really wish this guy could have had it cuz this is awful. Just a heads up. [Music] So then imagine that someone’s trying to talk to you about your day, right? They’re like, “Hey, how was your day? How was class? How was your test the other day? What grade did you get on it? You’ve got a skills exam coming up here in a couple of days. Do you remember what skills you’re testing off on? Do you remember how to do that skill? Can you tell me what the first step of that skill is?” Isn’t that awful? Huh? Well, he’s all It’s BSI safe. Yeah. Um, so what do you think about that? It’s kind of like it just makes my my insides turn black, I guess, is the only way I know how to explain it. You know what I mean? Like it just sounds like the soundtrack for Annabelle. I don’t know. You know, but um that’s why so like I was saying, can you imagine someone trying to ask you about your day trying to fend off those voices all the time? That’s why they’re easily distracted and why is oftentimes if you’re trying to talk to them, it’s really difficult to actually have conversations with them about these things is because they can’t keep track of what’s going on. Okay? There’s too much stuff too much stuff not only going on out here, but they have a whole universe in their mind that they have very little control over. So, um don’t argue u and get the people that they love involved. Uh, that’s one of the best things that I’ve found is there’s always someone that people trust always. Might be a neighbor, might be a friend, something like that. You’d be amazed how many people I’ve facetimed with that were across the country from their loved one at 4:00 a.m. cuz we’re trying to get them to convince the patient to go to the hospital. Um, these guys are standardly not safe to stay at home when they’re or to be alone when they’re in a situation like an advanced delusion, psychotic state, whatever. Obviously, however, um getting the people, the family and the loved ones in completely changes the dynamic in my experience, usually for the better, but that’s why you ask the patient who someone they trust is. Don’t leave it up to other people because then they end up calling their dad and they don’t like their dad, right? So, ask if there’s someone they’re comfortable with. Last point and we’ll take our quick break. Um true or false? Actually, no. Um, A or B. Uh, when you are on a call for a schizophrenic patient, you either A acknowledge the hallucination or B do not acknowledge the hallucination. Your patient says, do you see that person sitting over over there? Do you say A? Yeah, I do. B, no, I don’t. Who thinks A? Who thinks B? No, I don’t. Raise them high. I’m short. Okay, some of you didn’t answer. Do you think it’s a then would you kind of like say can you describe it for me or something like that? Kind of play along and kind of not acknowledge it exactly. Um I appreciate the curiosity of it, but maybe that’s not the way that you answer it quite yet. Right. So, and the re I’ll get to that in a second because the answer is no. They do not want you to acknowledge their hallucination. All that does is feed into their disconnect with reality. Right? If they say, “Do you see that person?” And you’re like, “Yeah, right.” They’re going to be like, “Uh, so you do? Oh my gosh, are you delusional as well?” Because much of the time they’re aware that that has the potential to be um a delusion or a hallucination. And where I say that is I’ve been on calls, I’m not sure if you have, but where we show up and they’re like, “Are you real? Are you real?” And that’s a sad question. Like that’s a really sad question. I tell them I am real. Are you or I usually say something to this effect. I am real. Are you worried about anything else in here or any anyone else in here not being real? Cuz I can introduce you to every single one of my teammates. And that’s usually what I do. Um just to try to maybe introduce the group because it’s a bunch of people they’ve never seen before talking in a language they probably don’t understand. I don’t blame them for thinking that. Um, now the other side of that is if you have a patient who’s pretty well medicated and has a good grip on it if you’re trying to engage in the conversation with them, that might be something you ask, right? Because the only way you’re going to get to know these conditions is by asking people who actually deal with them. So you might ask them, hey, what are your hallucinations normally like, right? and they if if it’s appropriate, I’d say avoid these questions if they’re doing well or if they’re agitated obviously, but if they’re willing to have the conversation, which most of them are, you can just ask them, hey, would you mind just telling me about your hallucinations? I’m I’m just trying to understand this condition more because I interact with a number of schizophrenic patients or something like that. I’m very much of that philosophy. I do it all the time. So, all right. So, excited delirium, just to give you guys a heads up and a bit of a warning because it is a frustrating topic. The reason it’s frustrating is because if I remember correctly, it’s like the American Medical Academy or something like that is kind of who gives us our um general diagnosis like our list of diagnoses. excited delirium is not recognized as a formal diagnosis, which is wild to me because you’ll go on a lot of calls for uh people who are in a psychotic episode. I always collectively refer to these patients as psychotic patients. Whether that’s appropriate or not, I’m not totally sure. The majority of them are in a psychotic state, but what it gets brought on by is the difference between other psychotic states and excited delirium. The thought is is that excited delirium actually has um more metabolic and uh neurological implications compared to or sorry um I guess when I say neurological I mean like uh the metabolic processes um basically take over their brain is what some people think because these are the people that have like the superhuman strength right they pick the cars up or whatever they take on like seven police officers all that kind of stuff. um excited delirium is not easily linked to one specific thing and that’s why there are people who die and I guess the reason I say in particular with the police and the reason people die is because they’re getting restrained by us or the police and then they just die and we’re like what the heck what’s going on? Some doctors will say it was excited delirium because there were no other things that could cause the psychotic episode. you can actually uh when they’re like doing autopsies and stuff on people, they’re actually getting samples of things and they’re testing it, right? So, they’ve done tests on people and they’re like, “We don’t know what is causing this.” And that’s how excited Delirium kind of came about is they were like, “It’s not exactly like a schizophrenic psychosis because this patient doesn’t have schizophrenia, but it’s not necessarily like a stress psychosis.” So, the thought is is that for whatever reason you get elevated like um you’re running from the saber-tooth tiger for some reason, right? Maybe you get into a fight with your loved one and then for whatever reason your metabolic processes are not um able to overcome that and actually control it so that your brain can kind of cool down. So then you just continue to ramp up and ramp up and ramp up. Um that makes sense to me especially when you consider these guys are the very physically aggressive. They’re usually unable to speak to you, right? But they look like they’re on meth is what is what a lot of people think. I would argue that the and this is purely anecdotal. I would argue um that meth patients that are in a like an excited delirium type state or psychotic episodes are are even more like or are even more capable of having a conversation if they can. I’ve seen people that I can only assume are in that state that they’re talking about that they’re like, “We don’t know what happened to these people because nothing else fits.” and they just snap out of nowhere and then they die. I’ve seen that and I’m like, “What the heck?” They they couldn’t even talk to me. Remember what I was talking about when I said people that can’t speak and have that rapid eye movement are considered neur uh highderee neurological patients? Well, that’s kind of my reasoning for it is a lot of these guys I’ve seen can’t actually talk to you. They can’t walk or stand up. All they can do is run and then the moment they try to stop, they have to do something else because they’re just so elevated. There’s no real answer for it. I apologize. I wish I could give you one, but depending on the doctor that you go see or you bring the patient to, they might see the this collection of symptoms and go, “Did they have a medical history of anything?” And we say, “No, no psychiatric history, no recent illness, no recent traumas, all of their vital signs were good, their blood sugar was normal, whatever.” Um, they might look at this and say, “All right, they’re excited delirium.” Um, or they might look at them and say, “A psychotic episode.” The problem in the ER is that um ER docs are not psychiatrists. Uh they do their absolute best with what they can, right? But getting the appropriate providers to come down and do assessments on these people isn’t always as quick as people like or as uh would be ideal. So that’s why you see this getting slapped on a lot this title getting slapped on a lot of people. This looks like someone who’s on meth, right? Or someone who’s on any other type of sympathomimedic uh PCP. I tell people excited delirium um is to PCP as methods to psychotic episodes. That’s the only way I know how to explain it. If you’ve ever seen someone on PCP, they are very similar to excited delirium patients. They usually can’t talk. They can’t do anything at a slow pace versus like my meth psychosis I’ve seen. I’ve actually been able to interact with these people to some extent. That’s just my experience because you will notice a difference. People are going to say it doesn’t matter. There’s not a big difference. there is a difference between them. We just haven’t collectively agreed on what that uh actual criteria is. So this is all running from the saber-tooth tiger, right? Uh dilated pupils allow your eyeballs to take more light in so you can take in the environment around you. Diapheresis is because you’re running, right? You’re running from the saber-tooth tiger. Tacocardia obviously for your increased oxygen demands because that’s how we’re just looking at this. We’re just looking at running from the saber-tooth tiger. Um and then the hypertension. um as well uh obviously cuz your blood pressure is just going to go up. The hyperactive irrational behavior can also be hypersexual as well. Um especially in the psychotic states that are induced by drugs like I was talking about. I’ve seen a lot of those people be hypersexual. And when I say hypersexual, I don’t just mean they’re like cat calling you. I mean these people have low inhibitions, right? Like they don’t know how to control themselves much of the time. So I’ve seen a lot of people get groped. a lot of people be grabbed and pulled on top of them or things like that. So, just be aware. Um, otherwise though, uh, when it comes to someone, anybody, you just look at this as anybody who is in a state where you can’t reason with them, right? You can’t talk to them. They can’t make decisions for themselves. You’re going to treat them all the same way like this. Try to limit physical contact. Don’t be surprised if you have to restrain them. No patient gets left unattended, right? because that’s abandonment in certain situations. Even if they’re alone by themselves in the back of your ambulance for a couple of minutes, that’s still considered abandonment, right? You have to be with them or someone, one of your teammates has to be with them. Um, but these guys in particular, if they are just in your seat belts and they’re not actually restrained to the gurnie, it is not uncommon for people to bail out of an ambulance. I’m sure you guys have probably seen some of those dash cam videos. There’s one going around right now of this guy who was in an ambulance. They come up to a stoplight and this guy just busts out of the back of the ambulance and takes off running. Um, that’s going to be in this population of people typically. Um, how would you guys handle that? What would you do? You footing it after him? He’s like, absolutely not. No. Yeah. I was going to say call call the cops. Sure. Yeah. He’s like, ah, we had a we had a guy get transported to St. here in Boisey and uh with an officer falling behind that ambulance, a dude downtown Boisey jumped out of the ambulance and just took off on foot. So, our guy booked it after him. But we got a a few excited delirium in Yeah. And there and from the lens point of the police, uh they’ve been blamed for a lot a lot of these excited delirium deaths. I would argue that it’s not very fair to do that to blame the police when this who else is going to handle them. If it was the paramedics that were handling them and not the police, then the paramedics would be to blame, right? If it was the parks and wreck that would handle him. They don’t even handle geese. So, they’re not going to handle people. Yes, that was a dig. Yes, that was a dig. Um, so I it’s interesting hearing it from for like talking to you about it because the cops get blamed for a lot of this and I don’t think that’s very fair. We don’t we can’t even agree on what the di or the criteria is for these people but we still blame the cops for a lot of their deaths. The excited delirium patients are a big reason we quit restraining people prone. A big reason because the other thing that happens and part of the idea that kind of bolsters the metabolic process thing that I was talking about is that these people literally cook. They will literally cook themselves to the point of becoming hyperothermic and heat stroking like so acutely. So that’s the other thing where I say they’re just different. I’m not smart enough. I don’t have enough letters behind my name to tell you why it is. I just have a gut feeling and one day I swear it’s going to come out that excited delirium is inherently different. We just aren’t there yet. Um, anytime, like I said, uh, someone can’t interact with me, when I say interact, I mean they can’t even acknowledge when I say, “Hey, what’s your name?” Because that’s a very fundamental question. This is what I go to in my mind. Um, but again, you’re still going to treat everybody like um, in this category of things the same way. Um, as far as overdosing goes, um, I have been on calls for people who swallow, sorry, trigger warning, um, swallow bags of drugs, right? And then the fear is is what’s happening with that bag, right? If it breaks, um, throughout their GI tract, well, their GI tract is still going to absorb it potentially depending on the drug, right? So, um, that sounds weird and kind of specific, but I say that because a lot of the times it’s during traffic stops, right, or something like that. They’ll swallow it, bag breaks, and then next thing you the cops know it’s just a patient who’s freaking out kind of thing. Um, not super duper common, but I have seen that. Um, otherwise though, um, any of your stimulants, cocaine is a really easy one to push people into psychosis, I feel like, because it’s so rapid for um, their usage, right? People are using it way more frequently than a lot of your other drugs like meth and PCP and whatnot. Um, but uh if you find bottles of anything, um, I I don’t mind taking overdose bottles to the hospital with me, but I try to refrain from uh taking people’s home like medications to the hospital with me if I can cuz I don’t want them to lose it or anything. Some systems say you can, some say you shouldn’t. People will say you can. That’s my personal philosophy on it. Overall though, try not to use lights and sirens with these guys. if they get to be really squirly and they’re starting to make threats or they’re gearing up to like spit on you and stuff like that and they’re just getting harder and harder to control with your BLS maneuvers. Obviously, you can and should have already called ALS. However, um the big thing about this where I say ALS in particular comes in is not just sedating them, but also treating them if they do go into cardiac arrest because I’ve seen that happen too. And that was when I started believing in excited delirium. I had a guy who was on a meth vendor. He was super wound up. We restrained him and it was no, it was like a typical restraint situation. We just restrained him to the gurnie. I went to I was literally about to give him a sedative and the way I was facing him, my monitor was right behind him and I looked at his monitor and his heart rate started to drop and I was like, “Well, that’s not good, right? That’s never good.” And then lo and behold, he coded. um never did find out what happened to him, which is kind of on brand for us sometimes. Uh but that also, like I said, fed into my quase because this was a normal person. Normal person in their late 30s. Nothing wild had happened. He just had some something happen and then he went into excited an excited delirium state. So, I wish I could give you more answers on it. I just can’t. Yeah. Are they typically just like oneoffs these episodes? Honestly, I couldn’t even give you an idea for it because not only is uh not only is it something people don’t agree on, but it’s a heated topic, right? So, there’s a lot of like the information that we have around it is either it’s kind of like it plays both sides. You know what I mean? The specific information is just not there. From what I understand though, it this is much more common in males than it is females. um especially males I want to say the thing I cuz I read something on a couple days ago. It was like um more typical in males like over 25 um or something like that, but it was pretty much after brain development stops for both parties. So, which is where you see a lot of things come up, right, is when brain development stops. Um all right, we’ve talked about restraints quite a bit, so I’m going to skip over most of this. Do you guys have any questions on it? Okay. I do just want to revisit the false imprisonment thing, right? People are going to tell you you’re kidnapping me, you can’t hold me, all that kind of stuff. Yes, I can. Yes, I can. And I’m legally obligated to sometimes. Um, yeah. Is restraining BLS or is it ALS? Um, it depends on the state that you’re in, but I was going to say this is Idaho’s lensure. I don’t know if it’s actually on here. Most of your systems are going to require um your restrain patients to be under paramedic supervision, but I’m not sure. Um y’all can do taser barb removals though. Uh it doesn’t say on there, so I’m not totally sure. So, I know a lot of places do have BLS restraint, but um a lot of systems will require you to have ALS um at least supervision. Um the big thing for that that I hope changes sometime soon is when well I guess when I say the big thing that I hope changes is a lot of people don’t do this and I don’t really understand why. most of the problems that we have with restraining people would be mitigated if people would monitor their airways better. I don’t and I guess what I mean by that is like it’s easy when someone’s, you know, um someone’s act actively fighting you, but the thing is is like let’s say you go on one of these calls where the person’s fighting you and then they just give up, which a lot of times they do, right? they realize they’re restrained and then they just chill out. Especially after I give them a sedative. These entitle nasal canulas, regardless of your lensure, if you can get that number, remember you guys just need the numbers of 35 to 45 mm of mercury for normal. If you put this on your patient, this is going to help prove your case of managing your patients that are restrained. And when I say managing them, I mean you’re actually managing them by paying attention to their airway. Okay? So, if you restrain anybody, whether you’re with a paramedic or you’re on a BLS crew or not, this is going to be one of the most important things that you can use. Okay, this is an entitle nasal canula. Remember, anything that has an orange tip indicates it’s an that is an entitle monitoring device. This is the part that goes into your monitor and actually interprets that number that you’re trying to get, that 35 to 45. This is your oxygen tubing. The nice thing about these is you don’t have to use the oxygen. Um, I do much of the time, uh, if I, especially if I’m restraining someone, um, especially if we have them in a position where we didn’t they’re not in the wrap like with the police, but we maybe restrain them a little more securely. When I say that, I mean like we’ve padded around them and stuff like that. Not always are they put in the best of breathing conditions. This is going to help me determine that because my um, ability to assess that person’s airway goes out the window once I strap them to my gurnie, doesn’t it? like full assessment. So, this is going to help with that. Okay, use this if you restrain someone. Your system will probably require you to do it here in the next couple of years. Um, if they don’t have entitle nasal canulas, then that’s not anything you can fix, right? But they are a great solution and a great protection for you guys because it’s going to go into your chart as well as it’s a medical treatment, right? So, highly encourage you to utilize these for any breather, any breather at all, but especially your restrained patients. Um, now back to the false imprisonment thing. Um, I we’ve already talked about this, but people will threaten you with it. And I always gently remind them, I would not take you to the hospital against your will because I want to. I’m doing this because I have to, and it’s because it’s the best option for you. You’re going to hate me now, but I promise this is all for the better or something like that. Um, sometimes I don’t even usually uh go to that level. I just say, um, I’m sorry, I have to take you. It depends on how that person can interact. Right? If they can’t talk to me or interact, well, maybe I just have to leave it at that. Sometimes restraining people and talking to them isn’t the best move. I love this picture. This guy was was going for the Emmy with this one. But you can see these soft restraints right here. Um, in this case, this is where they’re kind of doing some rodeo stuff. Uh, but they’re trying to get his arm pinned down here. Now, you’ll notice a lot of the police when they’re restraining someone, and please correct me. Um, but they do a lot of this where they isolate one extremity down and one extremity up. Is that just for mobility? We don’t I mean I mean like when we’re when they’re putting them on the gurnie. Sorry. I’ve seen like when they’re putting them on the gurnie, like if the police are putting the person on the gurnie and we’re trying to restrain them extremity by extremity. That’s what I’ve seen a lot of um is holding their arms in a position like this, but that’s restraining them to our gurnie. So, we’ve just done it how like we gain control of each arm and we’ll usually just ask like the the EMTs like where do you want his arms? Perfect. Okay. For them. Cool. Um like that. That’s also a great position to be in if you’re going to um giving a be giving a medication like an intramuscular injection if you guys get to that point in school. Just so you know. um that is uh having one arm down is nice for that reason. Um but also like he was saying, it’s kind of just whatever works, right? Use your manpower. And by manpower, I mean use your manpower, right? These people are super strong. Um but all of this is pretty straightforward. Um always try deescalating, obviously. Um this whole five person to help or five people to help, sure. Um I’ll be honest with you, I’m not usually in on the pounce. I’m not really a uh probably much of a a good person in that case. Um I’ve got I fight with my words, right? But I also fight with my syringe in my vial. Um which is where I come in. And I guess the reason I say that is because I’m probably not the best to talk about how to actually physically hold someone down. But as far as the process of it goes, much of it’s going to go like there’s a person who has a problem. The cops show up. You make your agreement that everybody’s going to like Luke’s going to take this position, Cody’s going to take this position, Brantley’s going to take this, and oh my gosh, Jaden is going to take Jaden. Hayden. Hayden, thank you, but I’m sorry. Um, uh, Hayden is going to take this one. And then we’re going to say, “All right, those are your that’s your responsibility.” And then you make your game plan. Um, and then when I say my role is much more so of coming in later, that’s when they say, “Hey, we’ve got them restrained.” And then I jump in and I give the injection. So that’s very very nor uh very consistent with how it normally goes. Keep in mind though that the brute force is going to be brute force. It’s it’s just that simple. How many people do you guys have a policy for how many you require just in general for a restraint? Uh it depends on the situation. Uh it depends on how many people you have available. But if we’re going to use a wrap, we need at least four people. Okay. That’s what I thought. I was going to say the wrap itself has a minimum. I’ve I’ve thought um I’m a big proponent for no less than one ambulance crew and one fire crew if the police aren’t there. If there’s not a full fire crew, which is generally about three people, you’ve got your engineer, captain, hoseman, um and then your two uh EMTs or EMT, paramedic, whatever on your ambulance. That to me maybe if I had to, but that’s like the bare bare minimum if the police aren’t there. Okay. If I’m there with my partner, we’re we’re flying out of there basically. Um, and this we’ve already talked about. Make sure you wear your PPE. Avoid direct eye contact because we are still a bunch of primates, right? Staring someone in the eyes is an incredibly intimidating thing to do, especially when they’re restrained to the table or to the gurnie and that’s going to piss them off. Um, it really does come down to things like that. Just keep it in mind. It’s also very hardcore, like just staring someone in the eyeballs like that. It will piss them off. Just talk to them, treat them as like like a normal person as best you can. Okay. Um, and we’ve already talked about that. So, the potentially violent patient, we’ve also talked about this a bit. Um, just a few points that I like to bring up in here. I don’t do pacing at all. People who are pacing are people who stress me out. If you are so anxious or wound up that your energy, your emotional energy has to come out in a physical manifestation of that. I don’t like that. Um, and my reason for that is because also if they’re pacing and they’re pacing around a room and I’m in that room, do I have control over that what that person’s relationship is to me? Not at all. No. Which is why you’ll find a lot of people say, “Yeah, would you mind sitting down?” Uh, is that why you guys do that? Okay, that’s what I figured. I always start it off with someone who’s sitting there. I’ll be like, “Hey, you know, paramedics, is it cool if we talk to you?” And if they say, “Yeah,” I’ll say, “Okay, would you mind just sitting down for me for a second? Um, they’re again usually fairly receptive, but it depends on their ability to take in that information.” So, just keep that in mind. Um, pacing’s not for me. People who walk around and they slam cupboards closed or like they slam the door closed, those little microaggressions are hints as to how that person responds to uncomfortable stimulus. It’s also a great gauge for your personal life as well, right? Like you’ve been around people who you’re like, “This person’s just waiting to explode.” That’s what we’re talking about. Uh posture plays a big role into that. Obviously, as far as history goes, don’t be surprised if you wind up on a call with someone whose address has been flagged. Um flagged for aggressive behavior towards the police or whatever. Um are there any weapons around? Anything is a weapon. These are weapons. I’ve been beaned with a remote before. This little lady had a great arm and a great eye. Um, to be fair, I was trying to put her dog in the bathroom because we always try to keep people’s animals safe, right? Um, I didn’t hear her obviously and she hucked a remote to get my attention and it happened to be me. Um, so they anything is a weapon. Uh, she was trying to get my attention. Bad method. Bad method obviously, but that’s that’s a story I always tell because anything’s a weapon. Um, we’ve already talked about that. And, um, anyone who’s fiercely protecting their personal space, your good example of that is going to be when you go to take vital signs. And that is why you ask permission before you put a blood pressure cuff on someone or grab their arm. I see people or I’ve seen people do this so many times and I’m like, “What are you doing? You’re just going up to people and grabbing their arm.” Cuz they’ll walk up. It’s okay if I touch you. They’ll walk up and it’s just no one who’s been talking to them and they’ll take their arm out of their sleeve and then they’ll put the blood pressure cuff on and it’s like, “Get out of my space, first of all, but second of all, you don’t know this person, right? You don’t know this person.” Ask them, “Hey, is it okay if I do some vital signs? I’m going to have to put a cuff around your arm.” If you explain it like that, they’ve already dealt with it. Okay? So, just be careful about going up and putting a blood pressure cuff on someone. Um, that’s all pretty obvious. Anyone who’s got uh a poor impulse control history, impulse control means your ability to say, “Hey, Kylie, you don’t need another tattoo today.” Right? That’s impulse control. It might be, “Hey, this will be your second time in the last two weeks having Chick-fil-A for dinner. Maybe you shouldn’t.” Right? You really want to, but maybe you shouldn’t. Right? That’s impulse control. Usually, people in this category don’t have that. to an extent. Now, um, suicide is its own topic. We’ve already kind of delved into it some. Now, suicide can be a cry for help. Suicide is very dependent on that person and what their idea is um, for that situation. What I mean by that is it can be a cry for help or it can be a very well I I hate saying well executed, but you know what I mean, right? like it can be very well played out. Um the thing about suicide is that it’s going to be all age groups, right? Nobody is immune to it. However, there’s a population that has some of the highest suicide rates and it’s not young um teenagers. Who is it? Middle-aged white men. Huh? Middle-aged white men. Um elderly white men, but middle-aged white men have or I shouldn’t say elderly white men. Um, middle-aged white men do are there up there as well, but elderly men in particular have a very high suicide incidence, especially after their spouse dies. What is it, like a year is usually what they say is the life expectancy after your long-term partner dies. Um, makes a lot of sense, especially in the case of men. Uh, these they usually pick uh violent suicides, right? The theme is kind of men usually pick violence, women usually pick overdose. Um, very very consistent. I would agree with that completely. Um, the thing though is that in our world, if someone’s threatening it, if they’re doing anything that makes it look like they might actually do it, that’s still the threat, right? That’s still the, “Hey, I might hurt myself.” You don’t have to necessarily even just have a plan. It’s still the threat of doing something where we get concerned. Um, now I will say uh teenagers, especially in Idaho, Idaho has an extremely extremely high pediatric suicide rate. Extremely high. Like we’re in like the top three for pediatric suicide rates. Our babies are killing themselves, which is very uh very complex topic, right? But the reason I bring that up is because if you’re going to go to work here locally, that’s why I say every age, this happens to every age group. Okay? Well, roughly every age group. So when you see someone who is very clearly deep deep deep into the throws of depression, these things that um might seem like I had one kid one time who was like some of this sounds really pathetic. And I was like it kind of is pathetic. If you’ve experienced it, you know how pathetic it might feel to actually have these things like have this um uh tearfulness, sadness, unable to talk about the future, which is a major symptom. It’s called an unforeseeable future. Like, yeah, it might sound pathetic to you, but when people actually talk like this, it’s sad. And I don’t just mean like, oh, I mean like when you actually go on calls for people who want to kill themselves and now they’re in an ambulance with you going to the hospital against their will. That’s a very hard situation to be in. I big sister it most of the time, but I usually offer to people after I get my assessment done, obviously, I’ll say, “Hey, we have 5 10 minutes or whatever. I’m more than happy to keep you company or and talk to you or I’m happy to give you the next 5 to 10 minutes of privacy just obviously with the caveat of I’m going to take vital signs and continue to assess you. um that has gone over very very well for me because if they want someone to chat with they can totally talk to me but much of the time they don’t want to talk and so that’s why I offer hey you can have this 5 to 10 minutes of privacy uh with the exception of my assessment and vital signs um because these people are going to spend the next however many days of their life in a wing right some wing in the hospital they’re going to get moved to a psych unit stuff like that being being nice goes a long ways obviously but especially with these guys uh the young kids in particular, uh the teenagers, especially if you’re one of those people like that can do the big sister thing. Um these are I mean the risk factors for suicide, sure. Um I think the risk factor for suicide is just the hum being a human, right? Anything anything can push people, but I do appreciate certain things. Um children of an alcoholic or abusive parent, that’s one in particular that I’ve seen a lot of because why? Does anyone know why? Not just the obvious, like, you know, that’s a shitty situation, but cuz they need to get out. They need to get out of the house. Does that make sense? That’s a that’s something. And I’ve had this conversation with a number of young girls in particular is, hey, this is the third time I’ve seen you for suicidal risk. What is going on? What is going on? And unfortunately, the case that I’m talking about, this was an isolated case. um she had to get out of the house because she was being sexually abused, right? So, this was the only way that she could see getting out. So, while it is a when I said it’s a cry for help, while yes, it is a cry for obviously many ways of help that might be another thing, right? Because resources are resources. And if you say you’re going to kill yourself, you’re going to get resources. So, were you raising your hand? I was just we do clinicals in a pediatric psych facility and like we’d see people as early like six years old that would kill themselves and stuff and I don’t think we had a single one that it wasn’t like there wasn’t a parent related it wasn’t what wasn’t a parent related issue or like issue yeah sometimes people are just born with maybe a little more morose than other people right hard to say why but like she said as young as six pediatric psych is one of those things that like h gosh I don’t know that’d be a tough one. Um and I think the other thing that’s worth mentioning here though is that if you are going to go on because we’re talking a lot of teenagers here. Um, this is everybody, but I want to specifically mention the teenagers because not only um, obviously are they kind of in their own world just being teenagers, but you also are in a unique position to actually get a gate or get an idea for what’s going on in that house. Um, there’s a lot of nice houses with white picket fences where a lot of questionable things happen. And when you show up, the parents are like, “Oh, this troublemaking kid. they’re just such a pain in the ass. They, you know, they go to the best school and they’re just not doing well. That kind of thing. That’s always a red flag to me, right? And when I say red flag, I mean, okay, well, the child has a home, right? But children need what? Food, oxygen, warmth, comfort, and the ability to poop, right? Babies. That’s all they do. So, just think about it like that, right? You’re in a very unique standpoint to watch how people interact with this patient. So, you might figure out some things about them that people weren’t telling you before. That’ll give you some good clues. Um, otherwise, keep it keep in mind we don’t have very many cults in this area that I’m aware of. Anyways, maybe I shouldn’t say that. I’m just the the paramedic. There’s a lot that goes on out there. We see it, but we don’t know the details, right? We don’t have very many of these, but it’s always worth mentioning. And when I say we don’t have very many of these, just in general, there’s not many suicidal cult things that go mainstream these days. I actually just watched uh what was it? Jonestown. Jim Jones. Jim Jones. Yeah, I just watched something about that the other day. That’s where drinking the Kool-Aid came from. Duh. Yes. It took me this long to figure it out. Don’t laugh at me. Um and then last point as well. Always ask them, “Do you have any thoughts of hurting yourself? Do you have any thoughts of hurting other people?” Okay, this is the last little bit. Um bear with me. Um, this point is kind of obvious in ways, but there are a few additions I have for PTSD. PTSD, it’s very important that you guys appreciate the fact that PTSD is a complex neurological problem. And when I say complex, remember when I was talking about the midbrain, like your brain stem, all that area, your memory, your hippocampus, like that’s what that part of your brain is called. The hippocampus is how you remember stuff. Okay? That’s where your memory center is. You have to send information to your hippocampus. It doesn’t just go there. So when you have a traumatic event happen, it literally stays and lives in your midbrain, which is where your blood pressure center is, your respiratory center, your fight or flight, everything. That’s all staying there. That’s why people that have PTSD are stuck in that uh sympathetic state. If you’ve ever noticed, they’re very, very easily excitable. um maybe a little more uh touchy on certain things, it’s because their neurological system hasn’t calmed down. Okay? So, in order for that to get better, you have to actually move that from that area, your short-term into your long-term. That’s where PTSD counseling comes in. Okay? So, we know now, we know now for sure that as you actually do these therapies and you move that into longterm, your body physically changes the way it reacts to stimulus. So, that’s just important for you guys to know in general. Now, anything anything can kick off PTSD. And don’t be the jerk who’s like, “Well, some people have it really good. You don’t know what happens behind closed doors, right? That’s not the point. The point is is you appreciating that you don’t know what happens behind closed doors with that.” Um, there’s obvious things like, you know, sexual assault, child abuse. Um, accidents are a really interesting one, like car accident trauma, if you’ve ever talked to people with that before. Um, it’s very real. But other things that I like to bring up are war and natural disasters. And I’m not just talking about veterans on the side of war. I’m talking about survivors of war. And the reason for that is in Boise especially, we have a lot of refugees, right? A lot of refugees from war torn countries. And when I say war torn, we mean war torn, right? like really really gnarly stuff. Um, these people are in a new place, right? Like they’re in a new environment, new sounds, all that kind of stuff. Just remember that wartime not on the side of the veterans. It’s veterans as well, but very much on the side of the victims and the people that were there. There’s proof that war and natural disasters alter your DNA for generations to come. It’s called a generational trauma. It’s not just something you learned on Instagram. It’s a real thing, right? That’s that generational trauma we keep talking about and part of why these are so nasty. Um, Hurricane Katrina, if you guys heard the stories about that, how Hurricane Katrina has literally wiped out like family lines and whatnot. There are people who have massive survival or uh survivor trauma, but also PTSD in general from these disasters. It’s a very real thing. That’s why a lot of people go back, right? Like Louisiana, a lot of the people moved back down there because that was comfortable for them. Even though it was a scary place, you’re in a state of of needing comfort. So, you’re going to engage in the things that give you comfort. This is this is ridiculous. I can’t believe they put this in the book. Seven it. So, an estimated 7 to 8% of the general population will experience PTSD. Um, that seems insanely low. Obviously, the military um side of things is going to add to that, but we just talked about all of these things being causes of PTSD, right? That’s way more than 7 to 8% of the population. So, that’s why I say anything can cause it. Try not to be someone who gets so cold and jaded to the world that you think other people can’t have trauma from other things cuz you’re going to have to you’re going to need some of that grace. Um, otherwise, obviously, first responders are very high uh very at risk for this. And it’s why I always say, go to counseling, guys. When you’re working for these departments and you have employee assistance or some other program that helps you pay for counseling, please use it. Please use it. That you need to take care of yourselves. And I’ll tell you what, these symptoms happen on a daily basis for a lot of people. And that’s why I say go to counseling is because you might not realize you have some of these symptoms or your partners or friends do or whatever. But they pop up in a lot of ways. Anxiety, anger, fear. You’re still running from the saber-tooth tiger, right? You have to think about it like that. That’s why people experiencing PTSD flashbacks look like they’re running from the saber-tooth tiger. And that’s why a lot of your behavioral episodes can be misconstrued as drug use is because meth makes you look like you’re running from the saber-tooth tiger. and so can a PTSD exacerbation. Does that make sense? Both of those things can render you so psych or so neurologically impaired that you can’t speak either. Right? So that’s why when we say neurological, we also say factor in psych. Um the other things though um aside from the whole running from the saber-tooth tiger thing is this stuff. Nightmares, flashbacks, intrusive thoughts. um getting a grip on these things uh because the intrusive thoughts I’ll tell you are one of the most difficult things especially if you’re a visual person like I am. Um but the nightmares, the flashbacks, um intrusive thoughts, those are the things that people don’t talk about enough. So if I’m on a call for someone, which we actually go on calls for this somewhat, I don’t know, uh it’s a frequent enough call. Um I usually ask people, okay, I’ve got the whole you’re not sleeping well, you know, this is this is this. What are your thought processes like? Do you feel like you can actually reason through things? Because a lot of times they can’t. And that’s why people PTSD, meth, those kinds of things have low inhibition controllers trying to feel good because their brain can’t process what the actual complex information coming in means. Does that make sense? That’s why you see a lot of them doing things like that. Um, and that’s why I check in on those little little clues cuz it can help uh paint the picture. This is already again pretty obvious. uh combat vets. And I would argue um when you’re talking combat, there’s even other things added to that, right? Especially with PTSD. But um the big point here is what I want to mention, loss of brain gray matter. There’s also loss of white matter, which is that picture I was talking or those uh scans I pulled up. So CTE, Alzheimer’s, and PTS PTSD brains actually look very similar. That’s kind of interesting because if you think about their patterns, some of them behave very similarly, don’t they? What’s one thing that P severe uh PTSD patients complain of? Memory loss. Dissociation. Very, very common. A lot of that has to do with your decrease in brain matter. That’s why they look this look very similar. Um, last point about this as far as the caring, and I’m not I’m going to remove the combat veteran. I’m just going to say PTSD in general. Um, in general, obviously, be careful how you phrase things and whatnot, but um, none of this changes much for me, for someone that has PTSD for someone that I’m evaluating for a psychiatric call, I treat them all the same. The added point to this though is that if you are treating a veteran of some kind, unless you are a veteran yourself, there will be a veteran on that scene. There will be, I swear, cops, firefighters, paramedics, we’re all very, very militaryheavy. Um, I always find it best to get a fellow veteran. Um, especially especially with the police. Um, what’s your guys’ incidents? Do you know? Um, like do you have a veteran? What’s your veteran percentage? Oh, it’s up there. I was going to say I feel like most of the departments, especially here locally, are very high, like over half. I’m pretty sure uh Boisey is over half. Say 40%. Yeah, that’s a big number though, right? So, it’s always better like if we were on a call or if we were in a situation out in the wild, right, and there was a a firefighter having a panic attack, I would probably be the better person to talk to him, right? Cuz I know what it’s like. Well, it might be better to have the other veteran go talk to them. So, that’s one thing. All usually that connection happens anyways. I just I really really strongly advocate for that and also giving them their space if it’s appropriate for the PE two people that are talking. If that person displays aggressive behavior, be careful with that, right? [Music]
You better behave through this whole lecture as Kylee talks about Behavioral Emergencies.
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4 Comments
Every emt/paramedic student should listen to you guys, I appreciate your material so so much, thank you!
Thank you. Far too many of these pt are abused. They should not feel scared of EMS but often times they are.
Emt student here, thank you for representing schizophrenics the way you did ❤ very compassionate.
Great lesson! Your question about our own fear when interacting with mental illness to break that ice. Never thought to say it out loud before.