Simulated Patient Scenario

Scenario Details

MDT Information

• Urgent response - Behavioural Disturbance / Psychosis
• 32-year-old male, known Schizophrenia, increasingly erratic
• Family concerned, patient talking to self, paranoid
• Police requested/en route for assistance
• Patient potentially unpredictable

On Arrival

Paramedics arrive at a cluttered apartment. The patient's sibling meets them, looking distressed. Sibling reports the patient stopped taking his antipsychotic medication (depot injection overdue by 2 weeks) and has deteriorated significantly over the past week. He is now talking constantly about being monitored by ASIO, believes the TV is sending him messages, and is responding to unseen people. He is pacing in the living room, occasionally shouting at the walls, appears dishevelled and suspicious of the paramedics' arrival.

Scene safety is paramount. Maintain distance initially, await police if behaviour escalates or feels unsafe.

Initial Impression and Primary Survey

Secondary Survey and Simulation Progression

History (Sibling collateral essential, Patient input unreliable)

Vital Signs/Assessment (Obtain once safe, may require sedation/police presence)

Physical Examination (Focused Mental State & Brief Physical)

• **Mental State Exam (MSE):**
  • **Appearance/Behaviour:** Dishevelled, poor hygiene, agitated or withdrawn, pacing, gesturing, talking to self, suspicious, poor eye contact.
  • **Speech:** May be rapid, pressured, loud, illogical, tangential, circumstantial, word salad, neologisms.
  • **Mood/Affect:** Mood often irritable, anxious, fearful, or perplexed. Affect may be labile, blunted, flat, or inappropriate to thought content.
  • **Thought Form:** Formal thought disorder evident (loosening of associations, tangentiality, etc.).
  • **Thought Content:** Delusions (likely paranoid, referential, possibly grandiose or bizarre). Assess for thoughts of harm to self or others (may be driven by delusions).
  • **Perception:** Auditory hallucinations common ("hearing voices" - assess command hallucinations). Possible visual or other hallucinations.
  • **Cognition:** Attention and concentration significantly impaired. Orientation may be intact or impaired.
  • **Insight/Judgement:** Insight into illness is typically absent/poor. Judgement severely impaired.
• **Physical:** Brief check for signs of injury (especially if agitated/combative), infection, or substance use. Rule out obvious organic causes mimicking psychosis (e.g., delirium due to infection, substance intoxication/withdrawal).
• **Risk Assessment:** High risk of unpredictable behaviour, potential aggression (often fear-driven), self-neglect. Assess risk of harm to self/others based on delusions/hallucinations.

Assessment and Treatment

Appropriate Management

• Recognise acute psychotic relapse in patient with known schizophrenia, likely precipitated by medication non-adherence.
• **Prioritise Safety:** Scene safety, personal safety, patient safety, safety of others (sibling). Await/utilise police assistance as needed. Maintain calm environment, minimise stimuli. Have clear exit strategy.
• **Communication & De-escalation:** Approach calmly, confidently, respectfully. Introduce self clearly. Use simple, clear, concise language. Avoid challenging delusions directly. Focus on patient's distress/fear ("You seem very frightened"). Attempt to build rapport, express desire to help.
• **Team Approach:** Coordinate closely with partner, police, and sibling.
• **Assessment:** Attempt primary survey and vital signs once safe. Obtain collateral history. Perform focused MSE. Rule out immediate organic causes (BGL, hypoxia).
• **Chemical Sedation (Consider if severe agitation/aggression persists despite de-escalation, posing risk):**
  • Follow local mental health/sedation guidelines.
  • Preferred agents often IM antipsychotics (e.g., Olanzapine, Droperidol) +/- benzodiazepines (e.g., Midazolam) depending on protocol.
  • Administer safely, usually requiring police assistance for restraint.
  • Monitor closely post-sedation (Airway, Breathing, Circulation, LOC).
• **Physical Restraint:** Use only if essential for safety, minimum force, per protocol, typically with police. Monitor closely.
• **Medical Assessment:** Once calmer/sedated, complete assessment (ECG, temp). Check for injuries.
• **Transport:** Transport to Emergency Department with psychiatric assessment capabilities is required.
• **Mental Health Act:** Patient likely lacks capacity and insight, requiring involuntary assessment/transport under relevant mental health legislation (liaise with police/authorised personnel as per local procedures).
• **Pre-notify:** Provide detailed handover to ED (Mental Health Alert): Known diagnosis, likely trigger (med non-adherence), presenting psychotic phenomena (delusions, hallucinations), behaviour, risk assessment, vital signs, any sedation/restraint used, response, legal status (if under Act). Request urgent psychiatric assessment.
• Documentation: Meticulous documentation of MSE, risk assessment, de-escalation attempts, rationale for/details of sedation/restraint, monitoring, legal status, communication with family/police.