Appendix 7: Psychiatric Emergencies For The New, yet-to-be Published Edition, CARPA Manual

PSYCHIATRIC EMERGENCIES

A psychiatric emergency is where a person is thinking or behaving in a very irrational disturbed way and that there is risk of harm to themselves or others.

This usually involves any of these four things:

• Violence, threats, aggression that are unprovoked.
• Suicidal behaviour (attempts at suicide or suicidal threats).
• Neglect (not looking after themselves), for example not eating tucker for weeks, wandering into the bush with no water.
• Impulsivity (doing dangerous things without thinking), for example running in front of vehicles.

Follow these steps but remember sometimes step 2 and 3 can not be done fully if there is great urgency to restrain and/or sedate the patient.

Safety

• Get help from other people, for example family, night patrol or, if needed, police.
• The Ngangkari has a very important role in helping emotionally disturbed people and his help should be sought.
• If the person is aggressive and has a weapon, do not approach them alone and consider getting police help.
• Find a quiet, well lit area to talk to the patient.
• Remove anything that could be used as a weapon.
• Talk to the person in a calm way and tell them you are trained to help them.
• The presence of the family will help with the next step (as you may not get much information from the person).

Ask About

• The start of the problem.
• Any past mental health problems including suicide attempts.
• Any hallucinations (for example, seeing things, hearing voices that no one else can hear).
• Paranoid ideas (any unreasonable fears that other people are going to harm the person).
• Any thoughts of harming themselves or suiciding.
• Any thoughts of harming others.
• Any abuse of alcohol or other drugs (for example, petrol. marijuana).
• What medications the patient is on, including any psychiatric medications.

Look for

• Signs of injury, for example, head injury (see Head Injuries protocol), self harm such as cut wrists.
• Signs of impaired consciousness, for example, drowsy, cannot pay attention, doesn't know where he/she is.
• Routine observations (BP, pulse, temperature)
• Hyperactivitv (cannot sit still) or hypoactivity (not moving very much).
• Thought disorder (talking but not making any sense).
• Disturbed mood (very sad. very angry, elated or changing quickly between these extremes).
• Signs that the person is hallucinating, for example talking to themselves, distracted for no clear reason.
• Strange behaviour, for example adopting strange body postures.

Do

• If possible contact the doctor to see if the person needs emergency transport to hospital. If so, then follow the protocol in Transport of Patients Who May Become Violent.
• If you cannot contact a doctor and you need to sedate the person because they are either very upset, aggressive or impulsive, then follow the directions in the Sedation section in the chapter on Transport of Patients Who May Become Violent.
• Remember that if you have to give intramuscular medication in an uncooperative patient a team of six people is needed to restrain the person.
• Many patients in a Psvchiatric Emergency will refuse treatment. A doctor or police can write a Section form to make the patient involuntary under the Mental Health Act to allow staff to restrain and sedate the patient. Often because of remoteness it takes too long to get this form filled, but in a genuine emergency if you need to restrain and sedate the patient you should do this under duty of care, without the section form.
• After the person has been given antipsychotic medication (for example, haloperidol. chlorpromazine) oculongyric crisis can sometimes happen (person goes stiff, bends their back, twists their back and rolls eyes up). Give Benztropine 2mg IM/IV and call the doctor.
• If the person does not go to hospital then discuss a management plan with the doctor and/or the Mental Health Services (for nonurban Central Australia including the Pitlands this is the Remote Mental Health Team, telephone 8951 7836 B.H.).
• It is important to involve the family and the Ngangkari in the management plan.

Australian Academy of Medicine and Surgery