Definitions

Behavioral Emergency

A call where altered behavior, psychiatric symptoms, or substance use is the primary presenting issue. Includes psychotic episodes, suicidal ideation or attempts, severe anxiety, and substance-induced altered behavior.

Decisional Capacity

A patient's ability to understand the relevant facts, appreciate the consequences, reason about alternatives, and communicate a stable choice — applied in real time, situation-specific.

Crisis Intervention Team (CIT)

Specially trained law-enforcement responders for behavioral emergencies. Coordinate with CIT when available.

Excited Delirium Syndrome

A medical emergency historically associated with agitation, hyperthermia, and sudden death — this department follows current evidence-based guidance and treats the underlying medical needs (hyperthermia, hypoxia, acidosis) rather than relying on this diagnostic label.

Purpose

To establish a trauma-informed, medically focused, and provider-safe response to behavioral emergencies — minimizing the use of restraint while ensuring patient and crew safety.

Scope

Applies to all calls dispatched as psychiatric / behavioral / suicidal, and to any encounter where a patient presents with significant behavioral disturbance regardless of the dispatched complaint.

Scene Safety & Approach

1. Stage at a safe distance until law enforcement clears the scene, unless a delay would result in patient death.
2. Approach calmly. One primary provider speaks; the second observes for safety.
3. Identify yourself by first name and role. Use the patient's preferred name.
4. Remove unnecessary stimulation — turn down radio, reduce crew size near patient, dim lights when possible.
5. Maintain a safe interpersonal distance until rapport is established.
6. Keep an exit accessible.

Verbal De-escalation

• Acknowledge the patient's distress without minimizing.
• Use short, clear statements. Do not lecture or argue.
• Offer choices when possible — water, where to sit, who can be in the room.
• Avoid threats, commands, or ultimatums.
• Allow silence. The patient may need time to respond.
• Avoid jargon, sarcasm, or humor.

Medical Assessment

Behavioral symptoms can mask life threats. Every behavioral patient receives a primary medical assessment.

1. Check glucose — hypoglycemia presents as agitation.
2. Assess oxygenation — hypoxia presents as agitation.
3. Assess for head injury, stroke signs, hypothermia, hyperthermia.
4. Review medication history — new prescriptions, missed doses, drug interactions.
5. Consider toxic ingestion or withdrawal.
6. Vital signs as patient tolerates.

Suicidal Ideation

• Any patient with current suicidal ideation, recent attempt, or active plan is presumed to require evaluation. Refusal is not accepted without medical control consultation and law-enforcement involvement.
• Use specific, non-judgmental questions: 'Are you thinking of hurting yourself or ending your life?'
• Remove access to means when safe to do so (firearms, medications) — coordinate with law enforcement.
• Document statements verbatim, not paraphrased.
• Notify receiving facility of suicidal ideation before arrival.

Restraint

Restraint is a last-resort medical intervention, not a control technique. It carries significant morbidity including positional asphyxia, rhabdomyolysis, and sudden death.

1. Attempt all reasonable de-escalation first. Document the attempts.
2. Restraint requires the involvement of law enforcement for any forcible application.
3. Never restrain a patient in the prone position. Lateral or supine only.
4. Never apply restraint that compromises the airway or chest excursion.
5. Soft restraints preferred; medical restraint (chemical) per medical control orders.
6. Continuous monitoring after restraint application — pulse oximetry, capnography if available, vital signs every 5 minutes minimum.
7. Document the indication, type, duration, and patient response.

Transport

• Determine destination based on patient need and your region's psychiatric receiving capacity.
• Law-enforcement accompaniment per state mental health hold rules and patient acuity.
• Restrained patients are continuously monitored by an EMS provider in the patient compartment.
• Notify the receiving facility en route with patient status, restraint status, and ETA.

Refusal in Behavioral Emergencies

A patient with capacity may refuse care. Suicidal ideation is presumed to impair capacity until rebutted. See the Patient Refusal SOP for full requirements. For any behavioral refusal, consult online medical control. Document the capacity assessment in detail.

Crisis Intervention Team / Mobile Crisis Coordination

Where available, CIT-trained officers or mobile crisis teams are requested early. They are trained partners, not adversaries — coordinate care plan, not just custody.

Pediatric Behavioral Emergencies

• Engage a parent or guardian whenever possible.
• Use age-appropriate language.
• Pediatric psychiatric resources may be regionally limited; identify destination early.
• Adverse childhood experiences may be contributing — trauma-informed approach is essential.

Provider Wellness

Behavioral calls are emotionally significant. Officers ensure crews have time to debrief after high-impact calls (suicide, child mental health crisis). Members may request a Critical Incident Stress Management contact at any time.

Documentation

• Patient presenting complaint and your assessment.
• De-escalation attempts and patient response.
• Specific statements regarding self-harm or harm to others (verbatim).
• Capacity assessment.
• Medical findings — vitals, glucose, oxygenation.
• Restraint details — indication, type, duration, monitoring.
• Coordination with law enforcement / crisis team.
• Destination and rationale.

Training Requirements

• Initial training for all members in mental health first aid or equivalent.
• Annual refresher on de-escalation and restraint.
• Joint training with local CIT / mobile crisis unit annually.
• Provider wellness training annually.

References

• NAEMT Mental Health First Aidnaemt.org
• Crisis Intervention Team Centercitinternational.org
• NAEMSP Position Statement on RestraintPrehospital Emergency Care, current edition
• State Mental Health Hold Statute[INSERT STATE]

Adapt this template

Before this template becomes your department's policy, review the following items and adjust accordingly. Anything else that does not match your operation should be updated as well.

• List your regional psychiatric receiving facilities.
• Name your mobile crisis or CIT coordination contact.
• Attach state-specific involuntary hold paperwork.
• Cross-reference Patient Refusal SOP and Use of Force coordination protocols.