Care of the Agitated/Suicidal Patient

Questions and Answers

Case: A 911 call comes in for a suicidal patient. The basic life support (BLS) unit is dispatched. They arrive at a residence where police are already on the scene. You learn that the mother called for assistance when she arrived home from work 30 minutes ago to find her 18-year-old daughter locked in the bathroom after discovering a suicide note on the kitchen table. She had last spoken with her daughter approximately 3 hours prior and provided additional information that her daughter has a history of bipolar disease and has been extremely depressed over the past week since her longtime boyfriend ended their relationship. Mom states that she could not get into the bathroom as the door is locked. When she tried to enter, the daughter “freaked out,” then started yelling “just let me die” and sobbing hysterically. Mom believes that she may have tried to overdose because she found empty bottles of beer, vodka, acetaminophen, and fluoxetine near her note. The BLS unit on the scene has upgraded for advanced life support (ALS) support.

1 What is the best way to approach the care of this suicidal patient?

The safety of EMS providers is always the top priority. If police or law enforcement are not yet on the scene, wait for them to arrive before engaging the patient to assist with maintaining a safe environment. It is extremely important to ensure that the suicidal patient is not in possession of any potentially harmful items including firearms, knives, medications, or toxic substances. When the scene is deemed safe, and any serious medical conditions or needs have been addressed, then you can then approach the patient and attempt to establish rapport by interacting in a calm, accepting, and supportive manner. Pay attention to the scene surroundings, looking for any evidence of alcohol, pill bottles, or drug paraphernalia. If substances have been identified, collect them to accompany the patient to the hospital to assist the medical staff in determining appropriate treatment. Supervise the patient constantly. Supplement your history from family and bystanders. Transport the patient to the closest emergency department.

2 Does a suicidal patient have the right to refuse medical care?

Each state has its own legal statutes involving involuntary detention of patients with imminent risk of harm to self or others. This is in contrast to a voluntary refusal, where patients who are deemed competent to make decisions may refuse care but they must show no immediate risk of danger to themselves or others. In an emergency, medical personnel may provide involuntary treatment, such as medication administration, but only to control the emergency. In this case, the emergency is the “imminent danger to self or others”; therefore, the patient cannot refuse medical care.

3 Are there any medical conditions that may cause acute agitation?

Multiple medical conditions may cause agitation; always consider these conditions when caring for the agitated patient. These are high-risk patients that cause anxiety to all personnel. It is essential to remember that pathology may be driving agitated (or altered) behavior, some of which may be life-threatening, and we need to try to calm the individual in order to investigate the underlying etiology. It is prudent to consider, identify, and treat the reversible causes of acute agitation ( Table 72.1 ). EMS personnel should check vital signs on all agitated patients, including oxygen saturation, temperature, and blood glucose level and examine the patient for external signs of trauma or localizing neurological findings.

Table 72.1

Medical Causes of Acute Agitation

Infection	Sepsis, meningitis, encephalitis
Metabolic	Hyper- or hypoglycemia, thyroid storm, electrolyte derangement
Temperature	Hyper- or hypothermia
Trauma	Head injury
Toxins	Drug overdose, withdrawal, or adverse reaction
Alcohol	Intoxication or withdrawal
Respiratory	Hypoxia or hypercarbia
Neurologic	Stroke, seizure, hemorrhage

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