Paramedicine Care of Diverse Patients 1

Legal & Ethical Frameworks

NSW Mental Health Act (2007)

This Act governs the care and treatment of people with a mental illness or mental disorder. Your primary concern is understanding your powers and responsibilities.

• Mental Illness vs. Mental Disorder:
  • Mentally Ill Person: A person suffering from a mental illness and, owing to that illness, there are reasonable grounds for believing the person may cause serious harm to self or others. Mental illness means a condition that seriously impairs, either temporarily or permanently, the mental functioning of a person.
  • Mentally Disordered Person: A person whose behaviour is so irrational that there are reasonable grounds for believing the person requires care and temporary detention in a mental health facility. Their behaviour is more than just eccentric.
• Paramedic Powers (Section 20): This is your key power. A paramedic may take a person to a declared mental health facility if they believe on reasonable grounds that the person is mentally ill or mentally disordered and is at risk of serious harm to self or others. This is an involuntary transport.

Capacity and Competence

A fundamental principle. A patient with capacity has the right to refuse treatment, even if that decision seems unwise.

• Assessing Capacity: The patient must be able to:
  1. Understand the information relevant to the decision.
  2. Retain that information.
  3. Use or weigh that information as part of the decision-making process.
  4. Communicate their decision.
• Important Note: A diagnosis of mental illness does not automatically mean a person lacks capacity. Capacity can fluctuate and is decision-specific. You must presume an adult has capacity unless there is evidence to the contrary. If a patient lacks capacity and is at risk, you act in their best interests, which may involve using the Mental Health Act.

Stigma & Lived Experience

Myths, Stigma, and Misunderstandings

Stigma is a major barrier to people seeking help. It exists in the community, within healthcare, and even among paramedics.

• Common Myths: People with mental illness are violent and dangerous; it's a sign of personal weakness; they can't recover.
• 'Lived Experience': This refers to the firsthand experience of individuals with mental illness. They often report feeling dismissed, judged, or not listened to by healthcare providers. Your interaction can either reinforce or challenge this negative experience.
• Self-Reflection: Be honest with yourself. Do you hold any biases? Do you find yourself thinking "it's just anxiety" or "they're just attention-seeking"? Recognising these thoughts is the first step.

Mental Health Assessment

Mental Status Examination (MSE)

The MSE is the psychological equivalent of a physical exam. It's a systematic way to describe a patient's mental state. In the prehospital setting, it's often abbreviated.

Suicide Risk Assessment (SRA)

A systematic approach is essential. Ask about:

1. Ideation: "Have you been having any thoughts of harming yourself or ending your life?"
2. Intent: "How serious are these thoughts?" "Do you want to die?"
3. Plan: "Have you thought about how you might do it?" (Assess for lethality and accessibility of means).
4. Past Attempts: "Have you ever tried to harm yourself before?"
5. Risk Factors: Depression, substance use, recent loss, social isolation, access to means.
6. Protective Factors: Family support, children, pets, future plans, engagement with treatment.

Non-Suicidal Self Injury (NSSI): Deliberate self-harm without suicidal intent (e.g., cutting). While the intent isn't to die, it is a sign of significant emotional distress and increases the long-term risk of suicide. It should always be taken seriously.

Paediatric Mental Health

Key Principles

• Capacity (Gillick Competence): In NSW, a child under 14 is generally presumed not to have capacity. From 14-16, they may have capacity for some decisions. A 'Gillick competent' child is one under 16 who has achieved a sufficient understanding and intelligence to enable them to fully understand what is proposed. This is a high bar.
• Confidentiality: Is complex. While you want to build rapport, you may have a duty to disclose information to parents or authorities if there is a risk of significant harm.
• Communication: Get down to their level (literally). Use age-appropriate language. Involve parents/carers, but also try to speak to the child or adolescent alone if possible and appropriate.
• Assessment: The MSE is still relevant but must be adapted. Observe play in young children. Ask about school, friends, and family life. Collateral history from parents is crucial.
• Common Presentations: Anxiety, depression, disruptive behaviour disorders (e.g., ADHD, ODD), and self-harm are common reasons for paramedic attendance.

Geriatric Mental Health

Key Principles

• Epidemiology: Depression and anxiety are common in older Australians but are often under-diagnosed. Suicide rates are highest among older men. Delirium, dementia, and depression can overlap and be difficult to distinguish.
• Dignity of Risk: The right of individuals, including older people, to make their own decisions and take calculated risks, even if we disagree with them. This is linked to capacity. An older person with capacity has the right to refuse to go to hospital after a fall, provided they understand the risks.
• MSE Modifications: Be patient. Allow more time for responses. Consider sensory impairments (hearing, vision). Use cognitive screening tools like the Abbreviated Mental Test Score (AMTS) in addition to your MSE. Always rule out underlying medical causes (the 'D' in I'WATCH'DEATH mnemonic for delirium - Drugs, Electrolytes, etc.).

Communication & Sedation

De-escalation and Crisis Management

Your primary tool is your voice. The goal is to build rapport and reduce agitation without resorting to restraint or sedation.

• Personal Safety: Maintain a safe distance, be aware of exits, and do not let the patient get between you and the door.
• Verbal De-escalation:
  • Use a calm, quiet, and confident tone of voice.
  • Listen to the person. Let them vent. Validate their feelings ("That sounds incredibly frustrating").
  • Be respectful. Use their name.
  • Set clear, simple boundaries ("For me to help you, I need you to lower your voice").
  • Offer choices and options to give them a sense of control.

Cultural Competence

Key Concepts

• Explanatory Model: This seeks to understand how a person from a different culture understands their health problem. Ask questions like: "What do you call this problem?", "What do you think has caused it?", "What do you fear most about it?". This helps you tailor your care to their beliefs.
• Indigenous Australians & 'Dance of Life': This model views health holistically, encompassing physical, mental, spiritual, and cultural wellbeing. Mental illness may be understood in a spiritual context. Acknowledge the impact of intergenerational trauma and build trust by being respectful and listening. Ask about family and community connections.
• Refugee & Immigrant (CALD) Populations: May have experienced significant trauma. May be mistrustful of authority figures. Language can be a major barrier; use professional interpreters (via phone if needed), not family members. Mental health concepts may differ significantly.
• Intellectual Disability: Communicate using simple, concrete language. Be patient. Involve carers or family who know the person's usual communication style and baseline behaviour. A change in behaviour may be a sign of physical illness the person cannot otherwise communicate.

Patient Journey & Disposition

Pathways of Care

• Journey to ED: After transport (voluntary or involuntary), the patient is triaged. A mental health clinician (e.g., from the hospital's Psychiatric Emergency Care Centre - PECC) will perform a full assessment. The patient may be admitted to a mental health inpatient unit, or discharged with a community follow-up plan. Your handover is vital to this process.
• Community Mental Healthcare: This includes services like community mental health teams, GPs, psychologists, and non-government organisations (NGOs). Paramedics are a key link in this system.
• Paramedic-Initiated Referrals: In some cases, a patient may not require ED transport. You may be able to refer them to other services.
  • NSW Mental Health Line: A 24/7 telephone service that can provide advice and link people to local mental health services.
  • GP Referral: Advising the patient to see their GP for a Mental Health Care Plan.
  • Suitability for Non-ED Referral: The patient must be low-risk (no acute suicidal ideation, psychosis, or risk to others), have capacity, have insight, and have good social support. This is a high-level decision requiring careful risk assessment.
• Schizophrenia & Psychosis: Key signs include positive symptoms (delusions, hallucinations, disorganised thought/speech) and negative symptoms (flat affect, lack of motivation, social withdrawal). Your role is to assess for risk, de-escalate, and transport for assessment.

Substance Use: Public Health & Harm Minimisation

Approaches and Strategies

• Harm Minimisation: A key public health strategy in Australia. It accepts that people will use drugs and aims to reduce the adverse health, social, and economic consequences, without necessarily stopping use. It has three pillars:
  1. Demand Reduction: Preventing uptake (e.g., health education).
  2. Supply Reduction: Law enforcement to disrupt production and supply.
  3. Harm Reduction: Reducing harm for people who are using (e.g., needle exchanges, opioid overdose response).
• Paramedic Role: You are at the forefront of harm reduction. This includes resuscitating people from overdose, providing wound care, treating associated trauma, and offering non-judgmental care that may encourage a person to seek help in the future.
• Health Promotion: Every patient contact is an opportunity. This could be as simple as providing advice on safer injecting practices, giving a leaflet for a support service, or suggesting a follow-up with a GP.

Substance Use: Pathophysiology & Assessment

Key Concepts

• Addiction vs. Dependence:
  • Dependence: A physiological state where the body adapts to the drug, resulting in tolerance (needing more for the same effect) and withdrawal symptoms upon cessation.
  • Addiction: A complex behavioural syndrome characterised by compulsive drug seeking and use, despite harmful consequences. A person can be dependent without being addicted.
• Influence on Care: Understanding the factors that lead to substance use (e.g., trauma, poverty, mental illness) helps you move from a judgmental to an empathetic stance. This improves the quality of care and builds trust.
• Common Opioids: Heroin (illegal), Morphine, Fentanyl, Oxycodone (legal/pharmaceutical).
• Management of Opioid Overdose:
  1. DRSABCD: Support airway and ventilation (BVM) as respiratory depression is the cause of death.
  2. Administer Naloxone: An opioid antagonist that reverses the effects of opioids. Administer as per CPG (IM or IV). Titrate to effect (aim for return of adequate spontaneous respiration, not full consciousness).
  3. Monitor: Naloxone has a shorter half-life than many opioids. The patient can re-narcotise. Transport to hospital is required.

Substance-Specific Management

Recognition and Management

Brief Interventions & Behavioural Change

Concept and Application

• What is a Brief Intervention? A short, opportunistic conversation aimed at motivating an individual to consider changing their behaviour regarding substance use. It's not about giving a lecture; it's about raising awareness and exploring options.
• Key Skills (FRAMES model):
  • Feedback: Provide feedback on their risks. ("Your BGL was low, which is dangerous with drinking.")
  • Responsibility: The responsibility for change is the patient's.
  • Advice: Give clear advice. ("I'd advise you to talk to your GP about your drinking.")
  • Menu of options: Provide choices for what they can do next.
  • Empathy: Show warmth and understanding.
  • Self-efficacy: Build their confidence that they can make a change.
• Barriers & Enablers: Barriers for paramedics include lack of time, lack of confidence, and perceived unresponsiveness from patients. Enablers include having readily available referral information, supportive CPGs, and training.
• Model of Behavioural Change (Transtheoretical Model): People move through stages: Pre-contemplation (not thinking about change), Contemplation, Preparation, Action, Maintenance. Your brief intervention might just be the thing that moves someone from pre-contemplation to contemplation.