INFORMATION SHEET 16.

1-1
Supervising On-road Operations
Learning Objective:
After reading this information sheet, the trainee is expected to acquire
knowledge, skills, & right attitudes involving day-to-day management of ambulance in
on-road operations.
Lecture continuation:
SCENE MANAGEMENT & PATIENT TRANSPORT DURING BEHAVIORAL CHANGES
Many situational stresses, medical illnesses, and legal or illegal drugs, including
alcohol, can alter a person's behavior. For example, diabetic individuals may show a
change in behavior, such as aggressiveness, restlessness, or anxiety, if the level of
sugar in their blood drops. In such cases not enough energy is reaching the cells, and
the brain suffers from the lack of nutrients, resulting in an altered mental status.
Lack of oxygen and inadequate blood flow to the brain are other causes of an altered
mental status, resulting in similar behavior. These conditions may result from head
injuries or other trauma with loss of blood.
Other possible causes of behavioral changes are the use of mind-altering substances
and extremes of body temperature. Many medications can affect a person's mood and
behavior. When considering the potential that medications are affecting a patient's
behavior, assess for prescription, over the counter, and illicit drug use. Extreme
changes in body temperature can also affect a person's behavior. Excessive cold as well
as excessive heat can cause a person to act irrationally.
Be aware of the environment in which you find the patient, and document any findings
such as temperature, lack of food, lack of proper ventilation, cleanliness, and so on.
These findings may be important for you and the receiving facility to treat the patient
properly.
PSYCHOLOGICAL CRISES
Other changes in behavior may result from mental illness and may produce psychotic
thinking or depression. A person experiencing a psychological crisis may panic easily
as a result of very little stress or may become agitated with no apparent or obvious
provocation. These patients may be a danger to themselves or to others. They can be
provoked to violent behavior, and their behavior can change quickly and unpredictably.
Patients experiencing certain psychoses think and behave differently. A patient with
paranoia may be convinced that people are plotting against him or her. A manic
patient may be very agitated, moving and speaking rapidly without producing clear or
complete sentences. A depressed patient may not want to move or answer any
questions. Treat these patients gently, and avoid making sudden movements or actions
so as not to scare or agitate them.
SUICIDAL GESTURES
When you examine a patient who may be experiencing an abnormal behavior,
determine whether the patient may be at risk of harming himself or herself or others.
A person who is notably depressed may be expressing thoughts of death or suicide
and may seem very sad in expression and behavior. It is important to recognize signs
of depression and suicidal gestures before the patient behaves self-destructively. The
fact that patients do not have any risk factors for suicide, however, does not mean that
they are not at risk, and patients who have some risk factors may not be considering
suicide. Find out from family members and friends if the patient has been depressed
recently. Patients may seem cheerful when you are present, but previous indications of
risk factors are extremely important. Depressed patients may be too exhausted to
commit suicide but may be at risk thereafter.

Risk Factors for Suicide

Patients over 40 years of age, widowed or divorced, alcoholic, or depressed
Patients who have spoken of taking their own lives
Patients with a previous history of self-destructive behavior
Patients with recently diagnosed serious illness
Patients in an environment in which there is an unusual gathering of
destructive items (e.g.:guns or large amounts of pills)
Patients who have recently lost a loved one
Patients who recently were arrested or imprisoned
Patients who have lost their job
SCENE SIZE-UP
The first action EMS should take in the emergency medical care of a patient with a
suspected behavioral emergency is the scene size-up. Be careful when examining the
patient's environment. The environment may be unsafe, or the patient may have an
unsafe object that presents a risk. The patient may be seated in a defensive position or
may have the fists clenched. Note whether the patient is calm or standing and yelling,
and observe how the patient is moving. Try to determine whether the patient is under
the influence of alcohol or other drugs. If you believe the scene is unsafe, do not enter.
Contact law enforcement personnel as needed. Gather information from family
members or bystanders about the patient's behavior prior to your arrival. Do not let
the patient get between you and the nearest exit route. Stay near doors or exits if
possible. If the scene becomes unsafe and cannot be secured after you have entered
and begun care, exit as quickly as possible.

ALERT!
Stay near doors and exits. Never let the patient position himself or herself
between you and the door, blocking your route of escape.

You may need to remove the patient from the surroundings and bystanders in order to
perform the assessment. For example, an adolescent with peers present may not
answer questions correctly for fear of embarrassment or may not want to admit a
problem in front of friends.
If the patient was or is displaying destructive behavior toward himself or herself or
others or if you feel threatened or sense that the situation may get out of control and
you require additional assistance, first leave the scene and then contact law
enforcement officers.
Signs of Potential Patient Violence
Sitting on the edge of the seat as if ready to move
Clenched fists
Yelling and using profanity
Standing or moving toward the EMS
Throwing things
Holding onto a potentially dangerous object
Any behavior that makes the EMS uneasy
As you enter a situation, approach the patient from the head (if supine) rather than
from the side or the foot in case the person has a weapon. Don't forget that violent
patients can also use items EMS bring into the situation (e.g., flashlights, clipboards,
and scissors) as weapons.

ALERT!
Use caution! Any item near the patient may become a dangerous object if the
patient intends to do harm.

Often violence erupts in a domestic dispute. Scenes involving interpersonal violence

are highly charged emotionally for both the patient and the abuser, and it is essential
to have law enforcement personnel on scene if violence is suspected. Interview and
treat the patient separately if possible. If you suspect abuse to a spouse, child, or
elder, request law enforcement assistance.
COMMUNICATION AND EMERGENCY MEDICAL CARE
After determining that the scene is safe, introduce yourself and explain to the patient
why emergency medical services personnel are there (if the patient is not the one who
called EMS). Then assess the patient for injury or illness. If there is a medical
problem, perform the appropriate interventions while explaining everything to the
patient. Assess how the patient feels and whether he or she is experiencing suicidal
tendencies. Ask questions to determine whether the unusual behavior has a medical
or psychological cause, although too much prying may provoke aggressive behavior in
some individuals. Ask basic questions to assess the patient, such as, What is your
name, the date, and your address? How do you feel? Would you like some help with
your problem? Do you have a history of diabetes or heart disease? Usually the
answers to simple questions such as these can help you determine the patient's
psychological status.
Observe the patient's appearance, activity, speech, and orientation for time, person,
and place. If you suspect a drug overdose, take any drugs or medications found at the
scene to the medical facility with the patient. Always treat the patient with respect and
dignity. In cases of interpersonal violence in which you may suspect abuse of a spouse,
child, or elder, request assistance from the police. Document any abuse observed or
your reasons for suspecting abuse and report that information to the receiving medical
facility. Medical providers are generally required to report suspected abuse, so know
the laws in your state regarding the documentation and reporting of suspected abuse.
CALMING THE PATIENT
Try to calm the patient if he or she is upset, and do not leave the patient alone unless
you are in danger. Ask all questions in a calm, reassuring manner without judging the
patient. Repeat the patient's answers to show that you are listening. Always
acknowledge how the patient feels, and do not challenge or argue with the individual.
During questioning, remain a comfortable distance from the patient, use good eye
contact, and do not make sudden movements. It is imperative to remain calm.
Question family members and friends to obtain a detailed history of the patient,
including medical and psychiatric illnesses. Perform an initial assessment of the
patient, including an evaluation of mental status and the potential for violence or
suicide.
RESTRAINTS
In some situations you will be unable to calm the patient sufficiently to approach and
provide care safely. Family members often insist that the patient be taken to a medical
treatment facility or that the person be treated for his or her own safety or well-being.
Patients who cannot be calmed and who are showing destructive behavior toward
themselves or others may need to be restrained before treatment and transport. Follow
your local protocols and laws regarding restraints. In many areas restraints cannot be
used without the cooperation of law enforcement officers or without consultation with
medical direction. Some EMS providers may be prohibited from restraining patients
under any circumstances.
Use of restraints can be dangerous to the patient. Suffocation, poor circulation distal
to the restraints, poor access to the airway or an injury, and poor access to the patient
are medical problems that can arise from improper use of restraints. Never turn
patients face down on the stretcher to restrain them. Numerous cases of suffocation
have been documented in patients who were restrained in this position, in which it

also is impossible to monitor the airway adequately or treat any changes in the
patient's condition.
Restraining a Patient
1. Have adequate help, including police assistance if possible.
2. Have a plan of action.
3. Use only necessary force.
4. Stay beyond the patient's range of motion.
5. Act quickly.
6. Talk to the patient.
7. Work with another EMS or other personnel; decide in advance how each of you
will restrain a limb, and approach together.
8. Secure the limbs with approved equipment, such as soft restraints.
9. You may cover the patient's mouth with a surgical mask or an oxygen mask if
the person is spitting or biting.
10. Reassess the situation frequently, including the patient's vital signs and
physical status. If the restraints are too tight when you reevaluate them,
they should be loosened, not removed.
11. Once restraints have been applied, do not remove them; restraints should
be removed by the receiving facility or law enforcement officers.
12. Document all your actions and the patient's actions.

Sample of restraints

Techniques for Restraining a Patient

1. Four EMS approach the patient; each restrains one extremity.

2. Place the patient supine and secure the extremities with soft restraints.

CONSENT
Patients generally have the right to choose whether to be treated for their medical
problem and/or transported to a treatment facility. Patients with behavioral
emergencies represent a unique challenge in that they may not be competent to make
decisions about their own care, particularly if they are a threat to themselves or
others. If an emotionally disturbed patient consents to treatment and transport, the
decisions are more easily made and the legal problems are avoided or greatly reduced.
RESISTANCE TO TREATMENT
Unfortunately, emotionally disturbed patients often resist treatment or transport. The
patient may threaten to harm you or others if approached. Once again, follow local
protocols regarding the care of patients who refuse treatment. In general, you must
decide whether the patient is mentally able to make an informed
decision. Consider the patient's psychological status, level of consciousness, age, vital
signs, and injury (if present). A competent adult may choose to refuse treatment even
after being informed of the consequences. Adults showing abnormal behavior or an
altered mental status may refuse treatment after being informed of the consequences
because they do not understand the seriousness of the illness or injury. Such patients
may be transported without consent after you contact medical supervisors. To treat or
transport a patien without consent often requires the assistance of law enforcement
officers to restrain a patient. If you are unsure of the mental capabilities of the patient,
you should choose to treat and transport.
USE OF FORCE
The use of force in behavioral emergencies should be limited to reasonable force, which
is the force necessary to keep patients from injuring themselves or others, including
yourself or other personnel. Law enforcement officers usually are needed if force is
necessary, although sometimes you also may be involved in the process.
Use only enough force to keep the patient from injuring himself or herself or others,
and avoid physical force that may injure the patient. Be aware that after a period of
combativeness and aggression, some calm patients unknowingly may be provoked to
cause unexpected and sudden injury to themselves and others.

ALERT!
Reasonable force depends on:
1. The patient's size and strength
2. The type of abnormal behavior exhibited by the patient
3. The patient's mental status
4. The method of restraint used
DOCUMENTATION
EMS cannot be too cautious when dealing with an emotionally unstable patient.
Documentation of all abnormal behavior exhibited by the patient is extremely
important. Because patients may accuse EMS of sexual misconduct, have a witness
present for treatment and transport. If same-sex attendants are available, let them
provide or assist you with care. You or your partner should never be alone with
psychologically unstable patients.
Important Documentation for Behavioral Emergencies
The position in which the patient was found
Any aggressive or abnormal action by the patient
Anything unusual the patient says, documented in direct quotations if possible
Assessment findings in detail
Restraining procedures used and assessment findings before and after their use
Persons assisting or witnessing the treatment and transport of the patient