Psychosocial interventions for paramedics - exam review

Physical aspects

Homelessness patients may present with specific physical issues. They lack basic necessities such as a proper bed and proper nutrition thus their weight may be lower and they may be quite malnourished.  They may lack proper hygiene as well due to the lack of proper access to facilities among other reasons. They may also be inappropriately dressed for the weather especially in cold conditions. Homeless people are more at risk for assault and rape due to their very unstable living conditions. The environment they are faced with is darker and sometimes much more violent. Women may turn to prostitution for money making them more at risk for this type of situation to happen to them. Lack of a steady income may also mean that they may look for alternate ways of getting money through criminality for example. They may have negative coping mechanisms leading to chronic alcoholism and drug abuse used as a means of escaping their troubles.

Medical aspects

AIDS, venereal diseases and hepatitis are common among the homeless. Lack of hospital testing among this population coupled with an increase in incidences of unprotected sex may lead to infection. Accidental injuries and trauma are also higher in the homeless. They may often be present in at busy intersections leading to higher chance of them getting into pedestrian vs vehicle accidents. Poor living conditions also increase their chances of contracting parasitic infestations such as lice or bedbugs. Not being followed by a dentist regularly means that they are more at risk for periodontal and dental diseases leading to infections of their pericardium or even sepsis. Chronic alcoholism as well as hepatitis can lead to cirrhosis of the liver. Diseases such as diabetes, hypertension and  dyslipidemia, more common among an ageing population can go untreated in the homeless. Diabetics may present with complications from their disease such as necrotising fasciitis and nerve damage due to their lack of care. COPD instances also increase due to smoking or even because of the risk of developing lung damage from chronic infections in the lungs.

Psychosocial aspects

What has lead a person to become homeless is usually not personal choice. Many have chronic mental disorders that can explain the root cause of their current situation. It may prevent them from holding a steady job, many also do not have family that can help them and take care of them long term. Including alcoholism and drug abuse their behaviours may be maladaptive leading to a seemingly never ending cycle that is  extremely difficult for them to get out of. These patients may have personality disorders, social anxiety, phobias, depression, dementia and chronic schizophrenia among other disorders. The problem is that with a lack of care, medication and the fact that they live unstable lives their disorders may be exacerbated. Also they are at risk for developing other disorders throughout the time they are homeless and depending on their lifestyle and habits.

Paramedic interventions  

Challenges for EMS personnel include the fact that their medical history may not be accurate or clear. Homeless people may often have medical issues that are left untreated due to a lack of regular care. They may be unaware of their medical issues thus making it difficult for the paramedic to care for the patient. Patients should be assessed fully to rule out any potentially life threatening illnesses provided that they consent to this assessment and any subsequent treatment as well. Because patients who are homeless are at risk for so many psychological and medical disorders it is important to advocate for them. They may be unable or unwilling to help themselves thus not only is it important to try to bring this to their attention but it is also important to bring it to the attention of other health care providers. Too often, these patients fall through the system's cracks leading to worse outcomes for them as individuals but also leading to recurrent financial pressures on the system. Interventions by paramedics may include forced transport to the hospital because they may be a danger to themselves or others. Sometimes they may be violent and police presence as well as contentions may be needed. If they have parasitic infections the paramedics should use proper body, substance isolation equipment to prevent from becoming infected themselves. Treatments and interventions should be done as per protocol but full health assessments should be performed at the hospital due to their lack of proper/ regular care.

Physical aspects

Schizophrenia can be described as a chronic mental disorder. It is characterized by distorted disturbed thoughts and behaviours that make the patient feel disconnected from reality. This psychosis will interfere with one’s ability to distinguish reality from hallucination. It also hinders a patient’s ability to interact socially as well as their ability to function independently. Their thoughts may lack a proper sequence and may be quite disorganized.

Medical aspects

The psychosis is a result of biological factors that are exacerbated by social and environmental factors. No one cause exists, it often differs between individuals. Sometimes, in genetically predisposed patients it can appear after drug use or when an individual is in their twenties or early thirties. Possible causes of first-time psychotic breaks can originate from other conditions other than a patient’s refusal to medicate or unwell adjusted medication dosages. These conditions can included; head injury, cranial bleed, electrolyte imbalance, metabolic disturbances, endocrine disorders, alcohol or recreational drug abuse, toxin exposure, and nutritional deficiency.

Positive symptoms: These include hallucinations which are perceptions that occur independently from external stimulation. These come in the form of insulting of commanding voices that the patient hears. Delusions can also occur and are described as false beliefs that are quite detached from reality. The patient may also present with a disorganized speech meaning that is will lack cohesion. Likewise, their behaviour can also be incoherent, it may be inappropriate; childlike, sexual in nature, etc. Their affect may also be inappropriate for the situation they may seem completely detached from the situation (flat affect) and their emotions may seem completely inappropriate.  

Negative symptoms: These include the loss of the absence of normal behaviours such as lacking fluent speech and the ability to take care of themselves in other words they are missing some essential adaptive behaviours.

Psychosocial aspects

The incidence of schizophrenia is highest in the homeless. Sometimes, it is also paired with depression. The depressed patient may feel worthless, uninterested and fatigued. They may lose their appetite as well as their interest and motivation for activities they would have previously been up for.

Paramedic interventions  

The paramedic needs to keep in mind that the patient may be presenting symptoms of psychosis which include agitation, violent actions, and behavioral issues. This may complicate the paramedic’s intervention since the patient’s cooperation might be hard to obtain. Agitation and aggression should be addressed as early as possible to avoid escalation. If the patient shares their hallucinations or delusions with the paramedic it is important not to encourage and aggravate the patient’s symptoms such as participating in their grandiose delusions (e.g. The patient mentions he is the king of the world and the paramedic answers “Yes you are”). Acknowledge the patient’s symptoms but do not encourage them. When questioning the patient, avoid questioning his hallucinations or asking the patient to explain what he hears and sees, this may aggravate the symptoms and make his differentiation of reality vs fantasy harder to grasp, making the intervention harder. As a paramedic intervening with a schizophrenic patient there are tools one can use in order to properly assess and document the patient's behaviour as well as evaluate them overall. Common medications that patient may be prescribed are antipsychotics such as; Abilify, Zyprexa, or Seroquel. Count the pills left in the bottle while checking when it was prescribed in order to rule out overdose or underdose of the prescribed medication.  

S- Speech

E- Emotion

A- Activity

A- Alertness

A- Appearance

A- Affect

M- Memory

O- Orientation

T- Thoughts

H- Hallucinations

It is to be noted that this tool may also be used in every psychosocial intervention the paramedic encounters.

Physical aspects

Depressed patients will often try to isolate themselves socially. Feeling worthless, they will have lost interest for activities they once enjoyed. Fatigue and loss of appetite are also common. These patients will have a pessimistic outlook on life. Often, they may feel a sense of overwhelming hopelessness. They will have difficulty maintaining their appearance and subsiding to their basic needs. Depression may diagnosed as major depressive disorder if it is recurrent for two years or more. It may also present as a major depressive episode interfering with daily functioning, it will be qualified as severe if it  lasts for more than two weeks. The patient may present with hypersomnia or insomnia both contributing to the patient’s fatigue. They may present with vague and generalized aches and pains as well that do not have a specific onset time or cause.

Medical aspects

This mental disorder is characterized by the interactions of genetic and environmental influences. Chronic depression can lead to negative impacts on brain as well as on immune function. Lack of proper nutrition can lead to other disorders such as anorexia nervosa. Depression can lead to higher incidences of a negative body image in these patients. The main medical issues that depressive patients face are suicide attempts by different means such as cutting and taking too much of their medications. Medications that patients may be taking are; Celexa, Paxil, Zoloft, Luvox, and Prozac.

Psychosocial aspects

Often isolated, people suffering from depression tend to stay away from the public and most often refuses help since they may think trying is worthless combined with a loss of interest and decrease in ADL (Activities of Daily Living). This antisocial behaviour may aggravate the patient’s isolation and in turn, worsen his/her depression. Most often, the patients tend to have constant negative thoughts about life and themselves, which promotes a low self-esteem. Patients may also feel a sense of guilt or failure and may promote thoughts of suicide. The combination of these psychosocial aspect puts the patient at high risk of suicide.

Paramedic interventions  

Paramedics must first rule out life threats with this patient. Have they taken any medication today? If so how much? What is their usual dose? Have they tried to hurt themselves in any way? Are they bleeding from anywhere? If they have taken a significant amount of a medication, what are they at risk for? There are three questions a paramedic must ask the patient in order to determine if they are a at high, moderate or low risk for suicide. 1. Do they have a plan? If so, what is the plan? 2. Have you ever tried before? If so how? 3. What is the trigger today? The paramedic’s assessment should be aimed at establishing trust and support with the patient to make them feel safe and comfortable even though they may not want to talk about what they are feeling. If they do, it is important to establish that trust and to validate their feelings. It is important to ask the patient if they take their medications according to the prescription. Count the pills left in the bottle while checking when it was prescribed in order to rule out overdose or underdose of the prescribed medication.

Institute of Medicine (US) Committee on Health Care for Homeless People. Health Problems of Homeless People. Homelessness, Health, and Human Needs. https://www.ncbi.nlm.nih.gov/books/NBK218236/. Published January 1, 1988. Accessed November 15, 2017.

Johnson D. Homeless patients pose unique problems for EMS. EMS1. https://www.ems1.com/medical-clinical/articles/1119239-Homeless-patients-pose-unique-problems-for-EMS/. Published September 6, 2011. Accessed November 15, 2017.

Learn More About Schizophrenia. Learn about what is schizophrenia and schizophrenia treatment options. http://www.schizophrenia.ca/learn_more_about_schizophrenia.php. Accessed November 15, 2017.

Maness DL, Khan M. Care of the Homeless: An Overview. American Family Physician. http://www.aafp.org/afp/2014/0415/p634.html. Published April 15, 2014. Accessed November 15, 2017.

Schizophrenia. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml. Published February 2016. Accessed November 15, 2017.

Trivedi MH. The Link Between Depression and Physical Symptoms. Primary Care Companion to The Journal of Clinical Psychiatry. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC486942/. Published 2004. Accessed November 15, 2017.

Ministère de la Santé et des Services sociaux. Depression. Gouvernement du Québec - Dirige vers l'accueil du Portail santé mieux-être. http://sante.gouv.qc.ca/en/problemes-de-sante/depression/. Accessed November 15, 2017.

Prehospital Management of the Psychotic and Aggressive Patient with Bipolar Disease. EMS World. https://www.emsworld.com/article/10323481/prehospital-management-psychotic-and-aggressive-patient-bipolar-disease. Accessed November 15, 2017.