Approaching the Patient With Behavioral Symptoms

Late at night, Patient A, a 32-year-old male, staggers across the parking area behind a local nightclub. He refuses to stop and yells at your crew to “get lost” as he weaves his way across a crowded boulevard. Exchanging glances, you follow police officers, who catch up and cuff him.

Does your assessment change if the patient (Patient B) is 62? Do you vector along other roads if you find a medical alert tag stating that this patient is a diabetic? Might gender alter your perception of the situation?

The original scenario finds us immediately going down the alcohol/recreational drug lane, while small changes in history find us in the cardiac or diabetic lane. Perhaps our patient sustained a head injury in a fall. Might that affect behavioral changes? Patient B might have a cerebral bleed or hypoxia secondary to congestive heart failure. Diagnosing altered mental status is complex. The approach differs with each patient; our assessment has to reflect those differences.

Reviewing the Possibilities...

Aside from the basics of scene safety and assessing the ABCs, thorough early assessment of mental status is vital. Commence the “ruling out” process of diagnosis. Find the major, and hopefully correctable, cause of behavioral alteration. Review the possible causes of each patient’s symptoms.

...Then Ruling Them Out, One At A Time

Both patients’ problems require that altered mental status and underlying medical condition be diagnosed based on history and assessment. Misdiagnosis can harm the patient by delaying appropriate treatment, which is what EMTs must strive to avoid. The mnemonic AEIOU-TIPS—alcohol/anemia, epilepsy, insulin, overdose, uremia/unknown, trauma, infections, psychosis and stroke—can be a valuable assessment tool.

The following process is recommended:

1. Contain the crisis, whatever it might be, that precipitated the patient’s current status.

Assuring scene safety, remove the patient from a violent or potentially violent setting or from the cause of the situation. Containment may include use of restraints or being accompanied by law enforcement officers. The EMT’s role remains that of patient advocate throughout the process, from time of call to completion of transport and transfer of the patient to an appropriate facility.

2. Provide appropriate care as soon as feasible. Ensure BLS and, where appropriate, ALS; make the best diagnosis; and provide proper care, such as dextrose or glucose paste for diabetics, or reassurance for a psychologically distraught patient.

3. Transport expediently to appropriate definitive care, which may be to a specialty care center, such as a psychiatric, detoxification or stroke unit, as designated by local standard operating procedures.

Case Reviews

Nothing beats reality to demonstrate our points. Following are real case scenarios that we have seen recently, which provide glimpses into behavioral emergencies with biological bases.

Neuro Checks

A 37-year-old female’s family stated their daughter “wasn’t acting right.” She appeared lethargic, but became combative upon EMS’ attempts to complete a physical assessment and flailed violently at the EMTs. A second neuro check revealed unequal pupils. When she began posturing, the family remembered that she had complained of a bad headache when she got home from work 10 hours earlier. The patient had no history of drug or alcohol abuse.

Dementia or Diabetes

The family of a 57-year-old woman called 9-1-1 after a family dispute got out of hand and she became unreasonable. Extremely irritable upon arrival of the team, she became combative to the point of requiring restraints (with police assistance). Although the family neglected to inform the responding crew of the woman’s diabetic history, the seasoned team realized that because her behavior deteriorated so rapidly, her condition should be treated as altered mental status. Fifty grams of dextrose later, the calm woman was treated and released from the hospital the same day.

Drugs Revisited

The family of a 33-year-old man returned home from a funeral to find the patient unconscious in a bedroom. The EMS team found him apneic, with constricted pupils, pinpoint bilaterally. Physical assessment revealed fresh needle marks in the right antecubital area. Because the young man had been drug- and alcohol-free for 10 years, family and friends did not anticipate that the recent death of his father would cause a slip back to heroin use. Because he had been “clean” for 10 years, the amount injected caused an overdose. Diagnosis: narcotics overdose.

Heart

The family called because the 82-year-old was acting strange and had passed out. He was conscious, but very uncooperative, when the crew reached him. After much cajoling, he permitted examination. His BP was 90/50, pulse 98 and respirations 24. The cardiac monitor showed he was in atrial fibrillation. This was a patient without any previous cardiac history. Diagnosis: Syncope due to dysrhythmia. (Rule of thumb: If an elderly patient has a syncopal episode, it is cardiac-related.)

Overdose or Obstruction

A 42-year-old female passed out at the lunch counter in a neighborhood diner. She was conscious on arrival, and the smell of alcohol permeated the air around her. She was able to walk to the ambulance, but only nodded yes or no to our questions. As she sat on the bench of the rig, she became unconscious and apneic. The EMS team placed her on the stretcher and unsuccessfully attempted to ventilate her. Repositioning produced another unsuccessful attempt. Basic life support was performed en route to the ED, resulting in improved ventilatory status. Through direct laryngoscopy, the ED team removed not one, but two intact pigs’ ears from her airway. Apparently, they had blocked her epiglottis and trachea when, in her drunken state, she attempted to swallow them both whole. Diagnosis: obstructed airway.

Conclusion

Determining the root cause of a patient’s altered mental status requires observation and assessment, questions (of the patient, bystanders, family) and initial treatment for organic causes, if possible. Because EMTs cannot treat many medical problems of a chronic nature (such as Parkinson’s or brain lesions), we often simply render appropriate emergency care and transport for continued treatment. However, we need to recognize and rule out the causes of altered mental status that we can treat in the field (such as diabetic coma, hypoglycemia, ETOH or drug intoxication, etc.) and provide prompt medical care, which often improves the patient’s condition and may even save his life.

Bibliography

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