PATIENT COMPETENCY and CONSENT, PSYCHIATRIC and COMBATIVE PATIENTS

Per Ohio Revised Code, an EMT, AEMT, or a Paramedic may not “pink slip” (transport to the hospital for mental health evaluation against their will) an individual who is alert and oriented, even if they are threatening harm to themselves or others. Only a health officer (such as police, crisis worker, psychiatrist, or physician) can pink slip a person. The GMVEMSC strongly recommends that each EMS department, in consultation with its medical director and local law enforcement, have a procedure to deal with these types of situations. This does not preclude action being taken to prevent imminent harm to the patient or others, if it is safe to do so.

  •  Determine patient competency and consent.
  • Obtain medical history:
    • Suicidal or violent history
    • Previous psychiatric hospitalization, when and where
    • Location where patient receives mental health care
    • Medications
    • Recreational drugs or alcohol: amount, names
  • Do not judge, just treat.
  • Transport all patients who are not making rational decisions and who are a threat to themselves or others for medical evaluation.Threat of suicide, overdose of medication, drugs or alcohol and threats to the health and well-being of others are considered not rational.
  • Consider a patient to be incapable to make medical decisions if they are:
    • Suicidal
    • Confused
    • Severely developmentally or mentally disabled and injured/ill
    • Intoxicated
    • Injured/ill with an altered mental status
    • Physically/verballyhostile
    • Unconscious
  • Consider and treat possible medical causes for patient’s condition: o Hypoxia
    • Hypoxia
    • Hypoglycemia
    • Drug intoxication/side effects/drug withdrawal
    • Seizures and postictal states
    • Intracranial hemorrhages
  • Consider staging until police have made the scene safe.
  • Have patient searched for weapons.
  • Do not transport a restrained patient in the prone position with hands and feet behind their back or sandwiched between backboards or other items.
  • Recheck often a restrained patient’s ability to breathe and distal circulation.
  • Have the ability at hand to remove restraints if the patient vomits or develops respiratory distress.
  • Explain the need for restraint to the patient. Severe agitation is a medical emergency, and should be treated aggressively with medication.
  • Document thoroughly the restraints used, on which limbs, and justification for restraints.
  • A patient may be combative due to either a medical condition or an injury.
  • A Midazolam 10 mg IN (5 mg each nostril), or Midazolam 2 mg slow IV or Midazolam 4 mg IM.

    P Midazolam 0.2 mg/kg IN (max dose 4 mg) or Midazolam 0.1 mg/kg slow IV (max dose 2 mg) or Midazolam 0.2 mg/kg IM (max dose 4mg) as a chemical restraint.

    A Midazolam may be repeated for combative patients.

    P ♦ Call MCP for repeat Midazolam.

    A In most cases transport a mental health patient to the facility where the individual has been previously treated since they will have the patient’s records. In all other cases, patients should be transported to the closest ED.

    P Pediatric patients with mental health issues should be transported to Dayton Children’s Hospital.

  • Our region has limited inpatient hospital beds for mental/behavioral health (MH/BH) patients. Most hospitals in our region do not have an inpatient MH/BH unit.
  • In many cases resulting from a general 9-1-1 call for MH/BH issues, the patient will be treated and released, and can adequately be cared for in any ED. Further, all of these patients require medical screening.
  • It is difficult for law enforcement or EMS to triage MH/BH patients who require inpatient treatment from those who don’t.
  • When patients have been seen on the same day by a MH/BH professional (e.g., Crisis Care, Eastway, etc.) who indicates to EMS that the patient will need inpatient hospitalization, the MH/BH professional should provide appropriate paperwork at the time of transport, and may indicate where the patient should be transported, with one option being the closest hospital.
  • When calls are received directly from adult patients, take the patient preferentially to a facility where the individual has previously been treated and where the patient’s medical records and providers are available.
  • In all other cases, adult patients should be transported to the closest ED.
  • Pediatric patients (< age 16) with MH/BH issues, including those with underlying medical issues, should be transported to Dayton Children’s Hospital Emergency Department.
  • Exceptions to the above:
    • It is medically necessary to transport the patient to the closest hospital for stabilization.
    • It is unsafe to transport the patient to the preferred/recommended facility due to adverse weather or ground conditions or excessive transport time.
    • Transporting the patient to the preferred/recommended facility would cause a critical shortage of local EMS resources.
    • Patient requests transport to a different facility. 
 

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