FIRST PRIORITY--SAFETY: The very first priority is your own personal safety, followed by the safety of your crew. Perform an adequate scene size-up and make sure your scene is safe before arrival.

INITIAL ASSESSMENT:

A systematic approach to someone with altered behavior will follow an algorithm:

1. Look for diminished consciousness and then for neurologic disorders with any acute focal neurologic deficit. If either is present, that chief complaint determines your approach, such as support for the effects of stroke, TIA, or head injury.

2. If there is no neurologic deficit, check a patient who is awake and alert for attention span and cognitive ability. If there are problems with attention, short-term memory, and cognitive ability, this is confusion/delirium; if not, it is a thought disorder--psychiatric.

Approach to Patients with Psychiatric Conditions

There are many categories of behavior disturbance. In agitated patients, every effort should be made to calm the patient and de-escalate tensions. Keep a safe distance, ask questions and speak in a calm, reassuring manner, and encourage the patient to talk. Explain everything in detail and respond honestly to patient questions. Never "play along" or "play into" a patient's auditory or visual disturbances or paranoias. When possible, involve trusted family members in the care to help keep patients calm.

A non-confrontational, but attentive and receptive manner without conveying weakness or vulnerability is optimal. Some patients become angry because they feel they are not being taken seriously or that they are being treated disrespectfully, but their anger abates when these concerns are addressed. A calm and soothing tone of voice should be used.

It is important to avoid excessive intense or prolonged direct eye contact or approaching the patient from behind or moving suddenly and to stand at least two arm's lengths away.

Use slow and purposeful movements, and foster a friendly, safe environment. Never belittle or threaten patients. Be reassuring and patient and try to encourage voluntary cooperation. Treat the patient with respect and reduce stressful stimuli.

While interviewing patients, acknowledge that you are listening when they are talking by nodding or saying phrases like, "I understand." Be supportive and empathetic when interviewing and limit interruptions. Move slowly, deliberately, and limit the physical touch in patients who show signs of agitation.

When assessing your patient's psychiatric health, you're trying to assess the ability for the patient to make logical decisions. The patient may have delusions, hallucinations, unreasonable anxieties and paranoia. Respect the patient's territory and avoid threatening actions, words, and accusatory questions.

Try to keep the patient calm and do not leave the patient alone unless your scene becomes unsafe. Consider the need for law enforcement or assistance from other units.

Teenagers have a greater risk of suicide attempt related to the general hormonal psychiatric chaos of adolescence.

Geriatric patients experiencing psychiatric health concerns are also at a higher risk for depression and suicide.

Anyone with severe depression at risk for suicide mandates transport. "Hopelessness" is a red flag for depression with suicide risk.