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

Section VI: Backcountry Medicine 227

Inflammatory or uncooperative talk may be accompanied by actions that are quite the oppo- site. It may be more valuable to observe actions rather than react to words. Many patients know their condition well and are aware of exacerbations as they happen. They may be able to reassure you, let you know what they need to feel better, or forewarn you of more serious problems to come. Don’t be afraid to obtain a pertinent history, as you would with any other patient. Field Treatment of Behavioral Problems Provide reassurance and protection. Be vigilant for any threat of violence. Do not try to talk the patient out of their symptoms. Protect yourself, your crew, and the patient if possible. Call for help or initiate an evacuation if serious signs and symptoms develop.

It would be far safer to remove yourself and other from the scene. In fact, taking the pressure off may allow the patient to calm down. Early involvement of law enforcement personnel, if available, is ideal. If you are authorized to carry medication, the judicious use of an anxiolytic like lorazepam can keep symptoms under control and reduce risk to the patient and other group members. Beware of combining this type of medication with other drugs like alcohol and opioids that are also respi- ratory depressants. Use the lowest effective dose. Drug and Alcohol Overdose One positive aspect of drug or alcohol overdose is that the substance will eventually wear off if the patient lives long enough. Treatment is focused on airway and ventilation, body core temperature, and hydration. Violent patients should be deflect- ed and avoided, with restraint as a last resort. The use of naloxone has become recognized as a first response emergency treatment for life-threatening opioid overdose. It is given by intranasal spray or injection. If successful, you should anticipate potentially aggressive or violent behavior in the patient you have just resuscitated. Use naloxone in an uncontrolled setting only if absolutely necessary.

Behavorial Issues

General Principles

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Serious (Red Flags): • Verbal or physical threats to harm self or others • Unwilling or unable to feed and protect self • Delusions or hallucinations that could result in injury to self or others. • No obvious temporary or treatable cause • The symptoms are getting worse.

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Unless you are a trained provider working in a dedicated treatment program, it is not your job to provide specific treatment for a behavioral diag- nosis. Allowing inconvenient but safe concessions may de-escalate an evolving confrontation while you work on evacuation or another solution. In most cases, everyone in your group who is affect- ed should be aware of the plan. Beware of being manipulated by the patient or others in the group into an unsafe or overzealous response. Physically restraining a patient who is violent or aggressive is a high-risk treatment for both patient and rescuers, even with the appropriate training.

Naloxone nasal spray