EMS Psych Calls: An Area To Specialize?

Last Sunday I was able to join a discussion about psychiatric patients on EMS Office Hours.  A number of complicated issues came up, and many of them have no established best practices.  This is a topic I am particularly interested in. I was a psych major in college and interned as a crisis phone counselor. My EMS Spouse is also a licensed clinical social worker.

We get very little eduation about psychiatric emergencies.  Even though most psych calls are BLS, the EMT curriculum in the US has no clinical time at a psychiatric facility.  I thought it was strange that we spent 16 hours in the psychiatric wing of a hospital in paramedic school after I already handled dozens as an EMT.  My experience at the crisis center was useful to interact with this group of patients and diffuse situations. 

Becasue of our limited education, many EMS people think that psych calls are a waste of our time.   There is a behavioral and biological component to psychiatric illnesses, just like high blood pressure, diabetes, and heart disease.  For some reason we view patients in mental health crises differently from other types.  When people or their family members don’t know what to do, they call 911 and get us.  We aren’t going to do therapy with these patients, but we should at least know how to communicate in a way that will not make them feel worse or more agitated.  A broader knowledge base about different psychological disorders and medications would be useful. 

The next step is to find a better way to manage patients with mental health problems.  Wake County EMS has already done this with their Advance Practice Paramedic Program:

The mean hold time for a mental health patient in an emergency department is 14 hours. Within the first six months of the APP program, we have referred 167 patients, returning approximately 2,400 bed-hours to local emergency departments. This equates to 800 chest pain evaluations in our community.

Another issue was how to handle patients who wish to leave the ambulance.  For patients who are voluntarily being transported to the hospital, are alert and oriented, and change their mind while the ambulance is moving, what are we supposed to do?  If they are allowed to leave it poses a safety risk.  On the other hand, patients may become agitated and violent in an enclosed space if not allowed to leave.  So what are we supposed to do?  No one on the podcast had an answer to this, or knew of any organizational SOPs that cover this situation.  NAEMT, NAEMSP, and NEMSMA, can we have some guidance about this?

The risk of provider and patient injury during physical restraint was also brought up. Ideally this would be a function of law enforcement.  When this is not possible, or if patients continue to fight against physical restraints, then we should quickly intervene with chemicals.  Benzos like Versed, Ativan or Valium can be mixed with antipshychotic medications such as Haldo, Droperidol, or Geodon.  Ketamine is also a dissociative agent that is gaining popularity, and all of these medications are safe and work quickly.  The ACEP Excited Delirium Task Force recommends that law enforcement and EMS work together to provide physical and chemical restraint for the safety of everyone on scene.

Better management of psychiatric patients could be an area for paramedics to specialize.  It may not be for everyone, but neither is HazMat or SWAT.  For psyhicatric emergencies, imagine sending the closest ambulance in case sedation is needed and to rule-out a medical cause of the problem.  A “psych crisis paramedic” could respond with them to direct the patient to the most appropriate resource.  It would create a new career path, save the healthcare system money, and deliver better patient care.

Go listen to the podcast, and tell us what you think.



  1. I’m glad that this topic is getting the attention it deserves. While I don’t think most “psych” patients are truly acutely sick, most do have an illness we don’t know enough about and need to be able to treat better.

    I hate that there is a negative stigma surrounding mental illness. It’s not like the patients can help it.

  2. I like your point about having to spend time in the psych ward during medic school when as EMT’s we have had many interactions one on one with psychiatric patients in the ambulance. Another role that a EMS provider who specializes in this area is to be that liason with other agencies, helping to create and implement SOP for EMS organizations.

  3. I agree that psychiatric patients could indeed by a opportunity area for EMTs or Paramedics to specialize in. I think it presents a lot of challenges, but certainly could be a very real growth area in the industry as well. Thanks for podcast link as well…

  4. For sure! I can’t imagine too many people specialize in psychiatric patients. This could also apply for CNA’s as well!

  5. First thank for podcast link it helpful for me and I AGREE that.

  6. This is certainly a need if you ask me. Not only would patients get better care but it would also provide another specialty among paramedics. Having someone appropriately trained and prepared for the situation is priceless.

  7. Thank you for this article on psych patients. This is a very good conversation for all who serve as first responders and first aid.

  8. I just left a comment on your verbal de-escalation post before I saw this! In our trainings, we bring individuals with mental illness in recovery who have interacted with the police or EMS to talk about their experiences. Many have had experiences that were negative, but I think its just a matter of educating the professionals on ways to interact, de-escalate, etc.

    I look forward to listening to the podcast.

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