By Thom Dunn
Recently, there has been concern about . Generally, these kinds of transports fall into two types: The patient is contacted in the field and transported () or that the patient requires transport from one facility to another ().
A psychiatric patient contact in the field is fairly straight forward: scene safety, evaluate the patient, transport or refuse. Often there are many EMS providers and police present.
Interfacility psychiatric transfers are far more complex, especially when relegated to BLS crews who may lack training and experience. We ask interfacility crews to decide if the patient should go in restraints, consider whether sedation is indicated, if the patient should walk to and from the ambulance, and where the patient should sit.
If someone is going to a treatment facility, an ambulance is indicated. Arguments that the ambulance is somehow 鈥渄angerous鈥� are not made with the patients who put EMS providers at the greatest risk: the disinhibited or disoriented. Thousands of times a day, across the U.S., EMTs and paramedics treat potentially combative patients who are intoxicated, post-ictal, brain-injured, hypoglycemic, demented or intellectually disabled.
No one would think to transport a head-injured patient who has been combative, but needs no further intervention, in a police car. Yet, these are one of the most dangerous patients EMS providers come into contact with. A 2009 article in JAMA: Psychiatry found that mental illness alone does not make psychiatric patients any more dangerous than those in the general population. [1] Yes, some psych patients are dangerous, but it is inappropriate to automatically equate psychiatric illness with dangerousness.
I think it is dangerous and misguided to consider psychiatric patients differently than medical patients. Doing so perpetuates the stigma against the mentally ill which, in part, may come from ancient beliefs about aberrant behavior being caused by possession of demons or by evil spirits.
Thinking that psychiatric patients should not be transported by ambulance because they are dangerous harkens back to a dark time in this country鈥檚 history and is part of a long history of discriminating against the mentally ill, including lengthy detention, forced sterilization and the stripping of civil rights. It has only been since a 1975 Supreme Court decision ordered that states could not treat all mentally ill people as if they were dangerous. [2]
Violence against EMS providers
Assault against prehospital providers is pervasive and a significant issue. My colleagues and I completed a study of over 2,500 EMS providers and asked them about their experiences with violent patients.[3] More than 90 percent of field providers have been assaulted or threatened. There are also high rates of sexual harassment against female EMTs and paramedics.
EMS providers need to make their ambulances as safe as possible 鈥� not just for psychiatric patients, but for any patient. Here are five tips for both field transports and interfacility transfers of psychiatric patients.
1. Thorough patient history during handoff
EMS providers need to insist that the handoff they get from a sending facility about the patient they are transferring includes whether the patient has a history of violence; if restraint, sedation, or redirection have been necessary; and whether the patient has previously tried to elope. The sending mental health professional should give a recommendation to the transport crew if restraints are indicated.
2. Early patient notification of transport
Discourage sending facilities from not telling the patient about their transfer until the last second so as 鈥渘ot to cause problems.鈥� Just before departure is not the time to learn whether the patient is going to escalate.
3. Patient always on the cot or stretcher
The safest place for any patient is on the ambulance cot or stretcher with all of the seat belts in use. It has the lowest center of gravity and allows for easy monitoring of the patient. Be certain the side of the seatbelt buckle that reads 鈥淧RESS鈥� is turned upside down. Direct all patients to not touch the seat belts. The provider in the back needs to be aware of the patient and his/her hands at all times.
4. Distress signal
The patient attendant and driver need to have a pre-arranged distress signal that indicates things are going south in the back and that the ambulance needs to be brought to a stop. Any patient who touches the seat belt, for example, is not following directions. The ambulance should be brought to a stop, its location broadcast, and the provider who is driving should come back to help restrain the patient. If needed, all providers should flee and seek cover or concealment from a violent and combative patient. The scene is unsafe.
5. Restraint and sedation protocols
All EMS providers should have clear protocols that allow for patient restraint and sedation. Indeed, it is incumbent on ALS providers to keep hospital staff safe by adequately sedating the patient before arrival at the emergency department.
EMS systems and providers are sophisticated enough to handle a wide variety of patients, psychiatric and otherwise. Ambulances can be made safe by the providers who work in them. EMS system administrators, chiefs and other stakeholders need to insist on training for psychiatric patient treatment and transport.
References
1. Elbogen EB Johnson SC The Intricate Link Between Violence and Mental Disorder. JAMA Psych. 2009;66(2):152-161.
2. O鈥機onnor v. Donaldson, 422 U.S. 563 (1975).
3. Dunn TM Johnston JW Dunn WW Doty C. Assaults Against EMS Providers. Presentation to 26th Annual Meeting of the Association for Psychological Science, San Francisco, 2014.
About the Author
Dr. Thomas Dunn is an Associate Professor of Psychological Sciences at the University of Northern Colorado. He earned a Ph.D. in clinical psychology and clinical neuropsychology in 1999. Dr. Dunn is on faculty at Denver Health Medical Center as a licensed psychologist and is a member of its ethics committee. Thom also has 25 years of experience in EMS having worked in a number of EMS settings including backcountry rescue, fire-based EMS, and is presently a paramedic field instructor for Denver Paramedics, the 911 provider to the city and county of Denver, Colorado.