Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

Chapter 31: Behavioral Issues

As with most other chapters in this book, the goal here is to frame a large and complex topic in terms that are simple and practical enough for field use. This is not intended to impart any psychologi- cal expertise or provide a substitute for training on the topic beyond patient and rescuer safety considerations. Those of you who are operating within programs specifically dedicated to mental health and rehabilitation will need significantly greater insight and education than we can pro- vide here. Unlike the topics of other chapters, primary behavioral problems do not come with a char- acteristic mechanism of injury or vital sign pat- tern. People are less likely to reveal a psychiatric history like depression or bipolar disorder than they would be to discuss a physiologic problem like hypertension or diabetes. The practitioner in the field is sometimes left with a confusing pic- ture and little information to go on. Fortunately, general principles apply and a generic diagnosis is all that is necessary in most situations. Unless you are dealing with a well-known pre- existing condition, your first job is to exclude a metabolic mechanism. Use the STOPEATS mnemonic; is there anything going on that could cause a change in brain function? Only after you have excluded an organic illness or injury can you attribute unusual or inexplicable behavior

to a psychological problem. This is particularly important with outdoor programs working with youth at risk, PTSD patients, and others where behavioral issues are expected. In these situations you could be tempted to jump to a diagnosis like malingering, acting out, or attention seeking and miss the low blood sugar, stroke, sepsis, or toxin. Assessment of Behavioral Problems The list of available diagnoses is huge. Problems can range from situational anxiety reactions to personality disorders to severe psychoses. You are not going to make a specific diagnosis in the field. Keep it generic; serious or not serious? The patient may be unable or unwilling to care for and protect themselves. There may be talk or actions that suggest an intent to harm someone else or themselves. The patient may lose touch with reality to the point that they attempt to fly off a cliff or walk on water. Anything this severe is a backcountry emergency regardless of the specific diagnosis. Milder cases tend to be more of a logistical and social dilemma than a medical emergency. Sometimes, what a patient says is alarming out of proportion to what they are actually doing.