Understanding Behavioral Emergencies
A behavioral emergency exists when a patient's behavior becomes a threat to themselves or others. These calls represent some of the most challenging and potentially dangerous situations EMS providers face. Behavioral emergencies can result from psychiatric conditions (schizophrenia, bipolar disorder, severe depression), substance intoxication or withdrawal, medical conditions (hypoglycemia, head injury, hypoxia, infections), or extreme emotional distress. Your approach to these patients must balance empathy and therapeutic communication with scene safety and crew protection.
The most important principle in behavioral emergencies is scene safety. Request law enforcement assistance whenever there is a potential for violence. Identify exits and avoid being cornered. Remove or secure potential weapons. Do not physically restrain a patient without law enforcement assistance unless there is an immediate threat to life. Restraint-related deaths, while rare, are a serious legal and medical concern.
Suicide Risk Assessment
Suicide is a leading cause of death across all age groups. Every patient with depression, hopelessness, or suicidal ideation should be taken seriously. Ask directly: "Are you thinking about hurting yourself or ending your life?" Asking about suicide does not plant the idea; research consistently shows that direct questioning is safe and often welcomed by patients in crisis.
Risk factors for completed suicide include previous attempts (the strongest predictor), specific plan and means available, recent loss (relationship, job, loved one), substance abuse, chronic pain or terminal illness, social isolation, and male gender (men complete suicide at four times the rate of women, while women attempt more frequently). A patient who has a specific plan, the means to carry it out, and a stated timeline is at the highest risk and requires immediate intervention.
Excited Delirium
Excited delirium is a medical emergency characterized by agitation, aggression, hyperthermia, diaphoresis, extraordinary strength, and resistance to pain and restraint. It is most commonly associated with stimulant drug use (cocaine, methamphetamine) but can also occur with psychiatric illness. Patients in excited delirium are at high risk for sudden cardiac arrest. Management priorities include chemical sedation (typically with benzodiazepines or ketamine per protocol), active cooling, and avoidance of prolonged prone restraint. Monitor the patient closely, as they can deteriorate rapidly once the agitation subsides.
Legal and Ethical Considerations
Involuntary transport of psychiatric patients raises legal and ethical questions. Most states allow EMS providers to transport patients against their will when they present an immediate danger to themselves or others. Know your state's laws regarding involuntary commitment (often called a "mental health hold" or "Baker Act" depending on the jurisdiction). Document your assessment findings, the patient's statements, and the specific behaviors that led to your determination. Treat psychiatric patients with the same dignity and respect as any other patient. Mental illness is a medical condition, not a character flaw.