Psychiatric Emergencies and De-escalation Techniques

As an EMS professional, you will have the opportunity to assist patients in crisis. Each patient will present uniquely as “crisis” can look different for each person and each precipitating factor. On arrival, some may feel relief, while others may feel threatened.

The initial approach of the EMS team matters when responding to someone in crisis. In addition to ensuring the scene is relatively safe for you to approach the team should consider the following safety precautions:

• Provide extra space when approaching and don’t get too close.
• Have multiple exits.
• Don’t let the person get between you and the exit.
• Keep equipment and personnel clear in case a hasty exit becomes necessary.
• Do not swarm the patient with multiple team members.
• Select one individual to engage while the others hang a few feet back.

People experience a state of crisis for a variety of reasons. The crisis may be precipitated by several individual or combining factors including, but not limited to, history of trauma/PTSD, sexual or physical assault, life stress, prior mental illness, recreational over/underdose, medication over/underdose, or because of a medical condition (See section on Altered Mental Status).

As your team begins the patient interaction, keep the following tips in mind:

• Introduce the team lead / point of contact for the person.
  • Select this individual based on skill, demographics, and appropriateness of the situation. (i.e., if the patient is a male veteran experiencing crisis from PTSD, the team lead might be another person with military experience).
  • You do not need to introduce each individual team member until they become relevant to the patient.
• Keep a low tone of voice that is calm, reassuring, and compassionate.
• Ask the person’s name. Use the name they give you.
• Do not attempt to touch the patient unless required and permission is given.
• Physically lower yourself to eye level with the patient.
• Slow down. If ABCs are present and there is no life threat, you have time.
• Do not buy into hallucinations, however, acknowledge it and don’t dismiss it.
  • Try a relevant variation to the following: “I understand that you see bugs. I do not see them. That sounds scary. We care about you and I would like to try to help you with that.”
• Building rapport is the priority.

De-escalation is an art. It is effective in helping patient’s trust you but unfortunately won’t always work. As you build rapport remember to:

• Ask slow carefully thought-out questions to gain further information.
• Listen to the patient’s requests fully. Comply if you can and if it is safe to do so.
• Explain all that you are doing before each task is performed.
• Refrain from sudden motions and elevated voices.
• Encourage patients to be a part of any decisions that may affect them, and where possible provide them options on how the care team can move forward so they have some agency in the treatment decisions.

If de-escalation is not effective, keep your distance, call for ALS and police assistance. Remain on scene within sight of the patient and restrict bystander access. You may need to participate in physical restraint with the ALS team. The process of physical restraint needs planning and chemical sedation available through ALS.

Practice de-escalation techniques by communicating with a partner or small group in class.  Discuss with your teammates how you felt in your communication delivery and discuss how they felt as a patient to train in a better communication style.