How do you deal with psych/ETOH/etc patients?

[fiznat]

Hey all,

I just finished a shift tonight that consisted of mostly 911 psych and ETOH calls. ...Had a ton of combative and generally disagreeable/uncooperative patients that really pushed my buttons tonight. I was thinking the whole time about the best way to really approach these kinds of patients. I've been working in an inner city EMS system (as an EMT) for about 2 years now, and I still haven’t quite mastered the technique.

It seems like there are a few different approaches. There is the kind and understanding approach, where slow talking and an unassuming posture can win the day with logic. ...And there is the rough "do what I say now or I will call the police, don’t mess with me" technique. It seems that most uncooperative patients require a little bit from each side, but I am interested to find out from you guys how you like to modulate those two urges. At first it seems like it is always best to speak slowly, but with a lot of patients that means that they will either walk all over you, or you will be on scene for hours on end. Likewise the rougher approach can agitate a patient even further and make the situation much worse.

I know there are no clear answers, but I would like to hear from you guys how you tend to approach these patients and under what circumstances. What works for you?

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[ISU_Steve]

For non-combative patients:
I just talk in a calm and non-threatening manner. The course in negotiation tactics has come in handy a couple of times in getting psych patients to do what I want them to do.

For violently combative patients:
I find that the approach of telling the cops "We'll be outside until he's handcuffed and otherwise restrained" works very well. It's not my job to risk getting hurt by some beligerent POS. That's why we have cops and that's why they have guns and ASP batons.

 

[Daedalus]

I agree with letting the police deal with the aggressive ones. I love working out of a police station and having a good relationship with the officers. I just let them do their thing, but will usually try to talk to the pt while he/she is has 5 cops on top of them, see if there's any CP, SOB, assess breathing, willingness to answer questions, etc.

I haven't had many non-combative psych patients, and obviously your approach to a psych pt will vary with each case. Usually when you calmly explain that the only choice they have is to go quietly or to be placed on a 5150 hold and go in restraints, things go relatively smoothly.
As far as ETOH goes, they are so hammered its hard to get them to do anything. When I was new, I tried the nice, non-confronting approach. Now, not so much haha . Some medics I work with a lot will just use the "GET YOUR ASS ON THE GURNEY RIGHT NOW!" dont-screw-with-me approach right off the bat lol.

 

[12R34Y]

When I was a newbie years ago I used to take the "tough guy" "get on my cot now or die" attitude, but over the years I most definately DON'T do that anymore pretty much regardless.

I mean you eventually realize that getting all pumped up and angry at patients and becoming verbally assaultive stresses YOU out as well. I personally don't like being stressed out at all.

I began to realize that you can't rationalize and use logic on someone who is hyped on drugs/ETOH or psychotic. so, yelling at someone who thinks he is a chicken and can fly off of a balcony at 2 a.m. makes little sense to me.

Do you think that suddenly he is going to say "oh, you yelled at me to do something I'll go ahead and behave now".

I love the cops approach. let them deal with it and the less I have to talk to the patient the better.

Unfortunately, now in the ED I don't get that luxury. I do have to figure out what is going on. In the pre-hospital arena however, you don't need to do much figuring out what is going on. Just haul their butt to the ED and drop 'em off.

later

 

[Jambi]

...yelling at someone who thinks he is a chicken and can fly off of a balcony at 2 a.m. makes little sense to me.

Do you think that suddenly he is going to say "oh, you yelled at me to do something I'll go ahead and behave now".

It is sad that it takes some of us some time to realize this, it took me a couple of years. I picked it up from similarly "young & dumb" partners. I eventually learned that Pt's will pick up on and feed off of your emotions and behaviors. Now, I treat each Pt with respect regardless of their actions. I try to be professional in all situations (can't get in trouble this way ).

BTW, since chicken was brought up...
I had a Pt that was scared of the giant chicken that lived on his street, he didn't want to get into my ambulance because he was worried about the FBI and CIA. I just told him that OSHA didn't allow the FBI and CIA into ambulances. That was apparently good enough because he agreed to get in, he was a perfect Pt after that. (I also read a story similar to this, you can imagine my amazement when this happened to me )

I'm sure we all have some interesting stories...

 

[southerndoc]

I had a Pt that was scared of the giant chicken that lived on his street, he didn't want to get into my ambulance because he was worried about the FBI and CIA. I just told him that OSHA didn't allow the FBI and CIA into ambulances. That was apparently good enough because he agreed to get in, he was a perfect Pt after that. (I also read a story similar to this, you can imagine my amazement when this happened to me )

When I was a first-year medical student, I worked part-time as a medic during the summer between my first and second years. I once spent nearly 20 minutes talking this paranoid schizophrenic guy down so he would agree to go with us to the hospital to seek help. He thought the CIA was tapping his phone, following him around, putting things in his food, etc. I talked him down that he was very calm and was carrying on a nice conversation.

So as I walk him to the ambulance, my partner tells him that I used to work for the CIA. Needless to say I had to bring out the Haldol and restrain him to transport him.

I needed Haldol myself for things I wanted to do to my partner when he told the guy that. UGH!

 

[jaylily]

I went on a ride along the other night with a friend who's a paramedic, and man, I had no idea how difficult a good lot of the patients can be. The medics I was travelling with had the "Don't piss me off" approach. Well, usually it started off trying to reason with them calmly, and then escallated to "Sit down and shut up".
It was such an exciting night though!

 

[Oats]

When I was a first-year medical student, I worked part-time as a medic during the summer between my first and second years. I once spent nearly 20 minutes talking this paranoid schizophrenic guy down so he would agree to go with us to the hospital to seek help. He thought the CIA was tapping his phone, following him around, putting things in his food, etc. I talked him down that he was very calm and was carrying on a nice conversation.

So as I walk him to the ambulance, my partner tells him that I used to work for the CIA. Needless to say I had to bring out the Haldol and restrain him to transport him.

I needed Haldol myself for things I wanted to do to my partner when he told the guy that. UGH!

I would have kicked his ass.