Simulated Patient Scenario

Scenario Details

MDT Information

• Urgent response - Behavioural Disturbance / Possible Psychosis
• 24-year-old male, agitated, paranoid
• Police requested to attend / en route (Paramedics arrive first)
• Patient potentially aggressive
• Flatmate present

On Arrival

Paramedics are met outside the apartment by the flatmate, who appears anxious. Flatmate states the patient has been increasingly erratic over the past 24 hours, not sleeping, talking nonsensically about conspiracies, and accusing the flatmate of spying on him. Today he became highly agitated, shouting, and threw a chair. He is currently locked in his bedroom. Paramedics can hear shouting and banging from behind the bedroom door. Scene safety check: No immediate hazards visible in common areas, await police backup before attempting entry to bedroom if deemed unsafe.

Initial Impression and Primary Survey

(Initial assessment may be limited until safe access is gained, potentially with police assistance)

Secondary Survey and Simulation Progression

History (Collateral from Flatmate, Limited/Unreliable from Patient)

Vital Signs/Assessment (Obtained once safe, may require restraint/sedation)

Physical Examination (Brief, Focused - once safe)

• **General:** Agitated, restless, pacing, diaphoretic, flushed. Disorganised appearance.
• **Head/Neck:** Check for signs of trauma (especially if fall or struggle occurred).
• **Chest/Abdo/Limbs:** Brief check for obvious injury, signs of track marks (IVDU).
• **Neurology:** Gross assessment - pupils dilated, significant thought disorder, paranoia, possible hallucinations (auditory/visual). No obvious focal motor/sensory deficit noted (difficult to fully assess). Tremor may be present.
• **Mental State Exam (Brief):** Appearance (dishevelled), Behaviour (agitated, restless, poor eye contact), Speech (rapid, pressured, tangential), Mood (irritable, fearful), Thought Content (paranoid delusions), Perception (possible hallucinations), Cognition (impaired attention/concentration), Insight/Judgement (poor).
• Consider potential organic causes: Substance intoxication/withdrawal, infection (encephalitis/meningitis - check for neck stiffness if possible), metabolic disturbance (check BGL), head injury, hypoxia.

Assessment and Treatment

Appropriate Management

• **Prioritise Safety:** Scene safety, personal safety (PPE), safety of patient and others. Await police if necessary. Maintain safe distance. Plan escape route.
• **Communication & De-escalation:** Attempt verbal de-escalation in calm, non-threatening manner. Use simple language, acknowledge patient's distress (without validating delusions). Avoid confrontation. Build rapport if possible.
• **Team Approach:** Work closely with partner and police (if present). Clear roles and communication.
• **Assessment:** Attempt primary survey and vital signs once safe. Focus on ruling out/identifying immediate life threats and reversible causes (e.g., hypoglycaemia, hypoxia, head injury). Obtain collateral history.
• **Chemical Sedation (if de-escalation fails and patient remains significant risk):**
  • Follow local guidelines for sedation in ABD.
  • Consider options like IM Droperidol, IM Olanzapine, or IM Midazolam (often used in combination or alone depending on protocol and suspected cause). Ketamine may be an option in some services for severe agitation.
  • Choose appropriate dose based on age, weight, frailty, level of agitation, suspected substance use.
  • Administer safely (ideally with police assistance for restraint if required).
  • **Monitor closely post-sedation:** Airway, breathing (rate, depth, SpO2, EtCO2), circulation (HR, BP), LOC. Be prepared for airway management/respiratory depression.
• **Physical Restraint:** Use only as a last resort for safety, apply minimum force necessary, follow local protocols. Ensure humane application, monitor neurovascular status, remove as soon as safe (often post-sedation). Requires police involvement typically.
• **Medical Assessment:** Once sedated/calmer, perform more thorough assessment including 12-lead ECG, temperature, BGL. Establish IV access if possible/necessary.
• **Transport:** Transport to Emergency Department equipped for mental health assessment and management of ABD. Consider need for security escort.
• **Pre-notify:** Inform receiving hospital about presentation, suspected cause, vital signs, behaviour, any sedation/restraint used, response to treatment, and police involvement.
• Documentation: Thoroughly document assessment, interventions, rationale for sedation/restraint, response, and monitoring.