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" There is no more honored sterward than he who compassionately serves; not out of subjugation, but moral obligation."

First Responder, Pt III

Medical Emergencies: OD

    In the wake of actor Heath Ledger's death earlier this year from a deadly combination of pharmaceuticals, I felt this could use some attention. Many people aren’t aware of all the nasty reactions you can find when people start mixing various incompatible drugs. I own a copy of this text, but I don't recommend it unless you have a LOT of time on your hands.

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    Instead, I suggest you refer to the blog I posted regarding the pocket EMS handbook.

    Where some other cultures more graciously understand and embrace the vacillation between well and not well, the ups and downs, Americans are encouraged to run for the pharmacy shelves after experiencing the slightest hint of discomfort.

    It is in this climate that children grow into the teenagers that will reach for the easily accessible over the counter drug to dull the pain of life and give them a good feeling that they are unable to find in an un-bottled form.

    It is hard to escape the painful irony that the very medications that were developed to solve problems are providing another more serious one, that of over the counter drug addiction. And the players on this particular stage are the teenagers who are particularly susceptible to a drug option that can be easily purchased without prescription and no pusher necessary.

    Alarming mythologies surround this particular corner of the drug abuse world. There is the belief that because these medications grace the shelves in the family home and are FDA approved they are less dangerous than their street drug cousins. Taking a slug out of a cough syrup doesn't feel the same as shooting up.

    Over the counter drugs come nicely packaged with pictures of smiling children and proud parents on the boxes. It is easy enough for anyone to walk into their local grocery store and purchase any or all of the liquid, tablet or gel forms. For some children there is the ready supply at home.

    Unconscious parents may unknowingly keep replenishing supplies of this substance that is both a safe and effective cough suppressant when used correctly and a dangerous dissociative anesthetic when it is not.

    Just this morning, I was listening to a podcast for paramedics and emergency care providers, The Medicast. The author of the podcast mentioned towards the end that approximately 7100 accidental overdoses occur every year with children younger than 12 taking over the counter cold/flu-type medicines. Something to think about. Keep all your medications well out of the reach of children.

http://www.mediccast.com/blog/ 
(also available for rss feed on iTunes. Hey, Jaimie Davis- if you're reading this, then somebody actually followed the link to your show! Sorry, no wi-fi over here, haven't downloaded any new shows since August.)

The Role of First Responders in Preventing Suicide

    Each year, more than 30,000 Americans take their own lives. Another 500,000 visit emergency rooms for self-inflicted injuries. Emergency medical technicians (EMTs) and firefighters are often called to respond to these deaths and injuries.

    Suicides and suicide attempts take an emotional toll beyond those of unintentional injuries. Any sudden death is a shock to the family and friends of the deceased, as well as to bystanders and first responders. The shock to family and friends is compounded when the death or injury is self-inflicted, provoking disbelief, anger, and guilt. Those who have injured themselves during a suicide attempt can be confused and distraught, which can also be true of their friends and families. How first responders act in these situations can make a difference for the patient, as well as for the family and friends of a person who has died by suicide or tried to kill him- or herself. At the same time, responding to these incidents can also take a toll on the emotional health of EMTs and firefighters.

    This short publication offers some information on helping those who have attempted suicide; responding to friends, families, and bystanders; and preventing suicide among EMTs and firefighters.

Helping Suicide Attempters

    First responders spend much of their time responding to medical emergencies involving people who had no desire to be killed or injured. Having to use their time and resources on caring for people who intentionally inflict injuries on themselves may raise mixed emotions. It is important to understand that, in the words of a major report on suicide, "in the United States, over 90 percent of suicides are associated with mental illness, including alcohol and/or substance use disorders" (Goldsmith, Pellmar, Kleinman, & Bunney, 2002). It is important to treat those with intentionally self-inflicted injuries as compassionately as you would treat those who are injured unintentionally. In particular, it is essential that you do not blame them for their injuries.

    Compassion will also help you elicit the information you need to treat a person injured in a suicide attempt. Many people who survive suicide attempts feel embarrassed and ashamed. Some may deny that their injuries were self-inflicted. Some will attempt to refuse treatment. Establishing a rapport with your patient will help you provide effective treatment at the scene and assist the patient and other health care providers in finding appropriate long-term treatment that may prevent another suicide attempt.

    The principles of facilitative communication (Fortinash & Holoday-Worret, 2003) can be useful in establishing a rapport with a person with self-inflicted injuries (or a person whose injuries you suspect are self-inflicted):

Genuineness. Sincerity on your part can evoke sincerity on the part of your patient.

Respect. Respect the patient, regardless of your personal feelings about suicide. Establishing a sense of self-worth is an important step toward recovery for a person who has attempted suicide.

Empathy. Empathic understanding is the ability to perceive the client's understanding of life as if it were your own.

Concreteness. Your ability to say precisely what you mean, rather than rely on abstraction or metaphor, will help you question the patient to determine vital information, such as the availability of a means to carry out suicide, the intensity of the patient's wish to die, the specific nature of any suicide plan, and the presence of associated risk factors.

    People who have harmed themselves may try to reach out to you-sometimes directly, sometimes indirectly. Warning signs that a patient may be at risk of suicide (even if the patient will not admit injuring him- or herself) include:

Talking about suicide or death

Giving direct verbal cues, such as "I wish I were dead" and "I'm going to end it all"

Giving less direct verbal cues, such as "What's the point of living?" or "Who cares if I'm dead, anyway?"

Expressing feelings that that life is meaningless or hopeless

    These signs are especially critical if the patient has a history or current diagnosis of a psychiatric disorder, such as depression, alcohol or drug abuse, bipolar disorder, or schizophrenia. Recent life events, including physical illness (especially if associated with pain) and emotional trauma (resulting from, for example, the loss of a job or a loved one), can also contribute to the risk of suicide (Jacobs, Brewer, & Klein-Benheim, 1999).

    Decisions about whether a person with self-inflicted injuries should be transported to an emergency room must take into consideration the person's emotional state as well as his or her medical condition. One of the primary risk factors for attempting suicide is a previous attempt. Thus, you should assume that any patient who has attempted suicide is at risk.

Never leave a person who has attempted suicide alone. You can help protect a patient by doing the following:

Transporting the patient to an emergency room where he or she can be kept under observation and further evaluated.

Helping the patient's family, friends, or caregivers develop a plan so that someone is with the patient at all times.

Helping the patient's family, friends, or caregivers make sure that lethal means, especially firearms and medications, are not available to the patient.

Helping Suicide Survivors

    If you respond to a situation in which a person has died by suicide in a home or workplace, you probably will be faced with distraught friends, relatives, and co-workers. Those who were close to or affected by a suicide are called "suicide survivors." Survivors may be overwhelmed with grief, anger, or disbelief. They may, for example, want to see the body because they cannot believe that their friend or loved one has died. You may need to gently explain why it is necessary to secure the area until, for example, the coroner arrives. Family members may resent strangers (even those who came to help) "taking over" their home following a suicide. They may be in psychological, or even physical, shock. They can respond with anger, which may be directed at you or others at the scene. They may also have a need to tell you about their relationship with the deceased.

    You should prepare them for what is going to occur at the scene, such as the arrival of the coroner. Friends and family also need emotional support during the crisis caused by a suicide-sometimes more than you can, or should, provide. While you can offer some support, it is far more effective in the long run to help survivors mobilize their own support networks, including friends, relatives, and clergy. Offer to call family or friends for them. There are suicide survivor support groups throughout the United States. Let survivors know that such help is available and that you can help them find these groups. (Information on finding suicide survivor support groups in your community is included under Resources, below.)

    You may find yourself being questioned by journalists at the site of a suicide. It is extremely important to be sensitive to the family (and to investigations in process) after a suicide. It is also important not to contribute to news coverage of suicide, as research has shown that this can contribute to suicide attempts by other vulnerable people. The easiest response to media requests for information is to refer the media to the designated communication or press officer at the local police department, fire department, or hospital. If you do speak to the press, it is important that you don't glamorize suicide, defame or criticize the victim, or portray suicide as an inexplicable or senseless act about which nothing can be done. If at all possible, use press coverage of a suicide to convey the message that people who are considering hurting themselves should get help by talking to a friend, a family member, a mental health professional, or the National Suicide Prevention Lifeline at (800) 273-TALK (8255).

 Helping Yourself and Your Fellow First Responders

    Job stress is common for EMTs and paramedics, due to their irregular hours and constant need to treat patients in life-or-death situations (United States Department of Labor, 2004). This stress can result in post-traumatic stress disorder (PSTD) and other problems that can affect first responders' emotional, professional, and personal lives (Alexander & Klein, 2001). The stress and emotional weight of the work takes a toll and needs to be addressed in order for first responders to maintain their professionalism and effectiveness. Responding to a suicide, in particular, can be stressful. It can be helpful to discuss these situations with colleagues and supervisors afterward.

    A colleague who is considering harming him- or herself may try to reach out to you-sometimes directly, sometimes indirectly. You should be especially alert for imminent warning signs, for example:

Talking about suicide or death

Giving direct verbal cues such as "Maybe I'll just kill myself"

Giving less direct verbal cues, such as "Soon you won't have to worry about me," and "People would be better off it I didn't exist"

Isolating him- or herself from friends and family

Indicating that they feel that life is meaningless or hopeless

Giving away cherished possessions

Exhibiting a sudden and unexplained improvement in mood after being depressed or withdrawn

Neglecting his or her appearance and hygiene

    These signs are especially critical if this individual has attempted suicide in the past or has a history or current problem with depression, alcohol, or PTSD. Research indicates that a combination of alcohol use and PTSD produces a tenfold increase in the risk of suicide (Violanti, 2004). The American Psychiatric Association outlines three categories of PTSD symptoms (American Psychiatric Association, 1999):

Intrusion. Flashbacks or sudden and dramatic re-experiences of a traumatic episode.

Avoidance. Shunning or evading personal bonds with family, friends, or colleagues.

Hyperarousal. A constant feeling that danger is imminent; it can be characterized by irritability, nightmares, and insomnia.

    If you believe that a colleague is thinking about suicide, you can ask that person directly, in private. If your colleague admits that he or she is thinking about suicide, or you have a serious concern that your colleague will harm him- or herself in spite of your colleague's denials, there are a number of steps you can take:

    Express your concern to an appropriate person, such as a line supervisor or your agency's mental health professional or consultant. It is important that you seek support in your efforts. Ask your colleague to call the National Suicide Prevention Lifeline at (800) 273-TALK (8255).

    Offer to help your colleague find, or accompany him or her to, a mental health professional who is better able to evaluate your colleague's risk and to recommend next steps.

    Help your colleague's family and friends develop a plan so that someone is with your colleague at all times until the crisis is resolved.

    Responding to a colleague in need may not be easy. You may feel like you are meddling or overstepping your role and intruding into your colleague's personal life. But coming to the assistance of a colleague in crisis can be as important as responding to a serious motor vehicle collision or fire.                                                                         

References

Alexander, D. A., & Klein, S. (2001). Ambulance personnel and critical incidents: Impact of accident and emergency work on mental health and emotional well-being. British Journal of Psychiatry, 178(1),76-81.

American Psychiatric Association. (1999). Let's talk facts about . . . posttraumatic stress disorder. Retrieved March 18, 2005, from http://www.psych.org/public_info/ptsd.cfm

Bongar, B. (2002). The suicidal patient: Clinical and legal standards of care (2nd ed.). Washington, DC: American Psychological Association.

Fortinash, K. M., & Holoday-Worret, P. (2003). Psychiatric mental health nursing (3rd ed.). New York: Mosby.

Goldsmith, S. K., Pellmar, T. C., Kleinman, A. M., & Bunney, W. E. (Eds.). (2002). Reducing suicide: A national imperative. Washington, DC: The National Academies Press. Retrieved March 14, 2005, from http://www.nap.edu/books/0309083214/html/

Jacobs, D., Brewer, M., & Klein-Benheim, M. (1999). Suicide assessment: An overview and recommended protocol. In D. Jacobs (Ed.), Harvard Medical School guide to suicide assessment and intervention (pp. 3-39). San Francisco: Jossey-Bass.

United States Department of Labor. (2004). Occupational outlook handbook. Washington, DC: Author.

Violanti, J. M. (2004). Predictors of police suicide ideation. Suicide and Life-Threatening Behavior, 34(3), 277-283. 

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