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Management of Behavioral Emergencies in the Wilderness
Few areas of emergency response are as challenging and rewarding as managing an emotional or behavior crisis in the remote setting: the climber in the grip of a panic attack clinging to a cliff face 45 m (150 ft) above the ground; the isolated Antarctic researcher, plagued by suicidal thoughts; or the relief worker, in the throes of psychosis, screaming that snakes are crawling on her skin. Environmental stressors, prolonged evacuation times, and lack of available psychiatric resources add a layer of complexity to already difficult presentations, calling on providers to demonstrate innovation and resourcefulness.
No two behavioral health emergencies are alike, and rarely can providers rely on clear-cut treatment protocols. Compounding this, training often focuses on a few extreme mental health presentations, such as psychosis or violence. This often results in reluctance on the part of the provider to engage in mental health issues that feel complicated, or “out of their scope.” Avoiding mental health presentations is not an option in the remote setting, when the patient with acute mental health concerns may be far from meaningful treatment. This situation creates a real threat to not only the patient, but the expedition and the rescue operation as well.
The aim of this chapter is to increase the comfort and confidence of the remote provider by providing examples of potential presentations and interventions with mental illness in the remote setting. While this chapter cannot provide comprehensive skills for complete psychiatric care in the remote setting, it will offer tangible tools for evaluating and caring for individuals in this unique setting. This chapter will review the most common and most extreme mental health concerns. For each mental health problem, information on the assessment of the patient’s presentation, practical tools for management, and information regarding evacuation in mental health emergencies will be described. As in other areas of mental health treatment, the mainstays of interventions are basic, but important skills of communication, validation, calm presence and often, the use of firm boundaries.
Providers should keep in mind that feeling comfortable with treatment of behavioral crisis in remote settings, ideally starts in the urban context. Providers should challenge themselves to engage with difficult patients in their everyday practice settings. This challenge includes engaging with individuals they ordinarily would avoid. Gaining experience and confidence treating a range of mental health concerns in the urban context is important preparation for treating such concerns in the more challenging context of a remote setting. Avoiding these experiences not only adds to the responder’s anxiety, but prevents the responder from developing the assessment and interventions skills needed to safely resolve individuals in crisis in the wilderness.
Behavioral and emotional emergencies in remote settings pose unique challenges to the safety and continuation of an expedition or activity. Anxiety, depression, or agitation requires enormous amounts of time and resources to manage. The provider will often be in a position to determine whether the expedition can continue, or how an individual can safely be evacuated when they present as dangerous to themselves or others. As in medical rescue scenarios, safety of the provider, fellow rescuers, and other expedition members must be prioritized over diagnosis or treatment.
Once safety has been established, the second priority in the remote setting is stabilization and treatment of the presenting symptoms. Finding the underlying cause of the symptom can be key to stabilizing and treating it, when the symptom is caused or exacerbated by an environmental stressor that is reversible (eg, dehydration, heat stroke, altitude illness, medication side effect, etc.). However, the cause of a symptom may not be clear in the moment. Psychosis in a humanitarian aid worker, for example, might be related to underlying bipolar disorder, infection, or a side effect of taking the antimalarial medication called mefloquine (Lariam). Indeed, even in an acute care setting, it could take hours or days for a skilled clinician to determine the cause of such a symptom. Thus, priority should remain with stabilization of the symptom and exploration of the underlying cause with a thorough evaluation.
Epidemiology and Causes
Anxiety disorders tend to develop early in life, and wax and wane throughout the life span. Anxiety disorders are often related to developmental transitions, such as starting kindergarten or leaving for college, or life stressors such as moving, losing a job, financial stressors, or divorce. One in four persons in the United States meets diagnostic criteria for at least one anxiety disorder.2
Statistically, women tend to be more vulnerable to anxiety than men, with a 30% lifetime prevalence rate for women compared to a 19% lifetime prevalence rate for men.2
The causes of anxiety presentation are often multifaceted. Abnormalities in neurotransmitters, such as gamma-aminobutyric acid, norepinephrine, and serotonin, as well as increases in stress hormones and heightened activity of the autonomic nervous system, all may underlie the development of anxiety disorders. Genetic vulnerability is believed to play a role in one-third of those experiencing anxiety disorders.1
Additionally, there are many medical conditions known to cause symptoms of anxiety (Table 23.2
In the remote setting, the stress of unknown environments, sleep disturbance, separation from loved ones, as well as engaging in perceived risky activities such as climbing, can all induce anxious responses in those already at risk. Ongoing studies into anxiety may show a relationship between the onset of acute anxiety and ascending to high altitude.3,4
Recent studies also suggest that withdrawal from technology may be a significant contributor to anxiety states in adolescent populations. These study results may be possible to extrapolate to adult populations.5,6
It should be noted that medications used to treat anxiety, when stopped abruptly, may cause distressing withdrawal symptoms that include rebound anxiety. Immediate withdrawal of benzodiazepines can be life-threatening.
Everyone experiences anxiety. It is considered a highly adaptive process that initiates action in times of danger, and is the cornerstone of our survival mechanism. Like depression, anxiety becomes problematic only when it interferes with the capacity to complete necessary daily activities and enjoy life. Presentations of anxiety vary widely. For those with more generalized anxiety,
symptoms include constant worry about a myriad of issues, restlessness or irritability, difficulty concentrating, and sleep disturbance. Anxiety can also be very specific, focused on isolated fears such as separation from family, social situations, phobias or obsessive-compulsive thoughts and behaviors. These symptoms may be worsened or emerge unexpectedly in remote settings, when patients are separated from loved ones, feel far from help, or are overwhelmed by their environment. Encounter-specific phobia triggers in the wilderness, such as heights or enclosed spaces, can also initiate anxiety or panic attacks.
Table 23.2 Medical Causes of Anxiety
Hypertension, congestive heart failure, anemia, angina, mitral valve prolapse, myocardial infarction
Cocaine, amphetamines, nicotine anticholinergics, hallucinogens, marijuana
Alcohol, opioids, sedative-hypnotics, antihypertensives
Asthma, pulmonary embolus, hyperventilation, dyspnea
Electrolyte disturbances, systemic infections, anaphylaxis
Anxiety can be experienced as highly physical, and in fact can be mistaken for other medical diagnoses such as cardiac or neurologic events. Physical symptoms of anxiety can include fatigue, increased heart rate (HR), dizziness, trembling, chest pain, muscle tension, and upset stomach. Panic attacks are characterized by these symptoms to the extreme and can be associated with fear of dying or losing control. They generally last between 20 and 30 minutes and rarely more than an hour.
In the remote setting, those paralyzed by anxiety may present a risk to the rescuers, because their reactions may be erratic or unpredictable. Individuals may demonstrate compromised problem-solving and decision-making skills, resulting in the inability to respond to directions, or participate in self-rescue. Anxiety that is well controlled in familiar environments may produce out-of-proportion or incapacitating symptoms in remote settings. Overwhelming environmental stimuli or lack of available coping mechanisms, such as social supports and electronic devices, may contribute to this.
The remote provider should be prepared to address the physical symptoms first and use the assessment to both calm the patient and build rapport. Patients who are experiencing high levels of anxiety feel with certainty that something is physically wrong with them. Because of this, even if the provider suspects the presentation is solely due to anxiety, addressing and validating physical complaints serves to calm the patient and decrease anxiety. For instance, providers may choose to listen to lung sounds, intentionally asking the patient to take deep breaths, as a means to slow the patient’s breathing. This serves to demonstrate concern, while at the same time, evaluating the patient for any underlying medical conditions, and physiologically calming the patient. It should be noted that providers sometimes err by assuming that a presentation is related to anxiety, when the patient is actually experiencing a medical emergency, such as supraventricular tachycardia, myocardial infarction, or pulmonary emboli (Table 23.3
). These techniques form a key component of “psychological first aid”, a technique discussed more fully in Chapter 10
The most common medications used to address underlying anxiety states include selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), serotonin norepinephrine inhibitors (SNRIs) such as venlafaxine (Effexor), and short- and long-acting benzodiazepines such as alprazolam (Xanax) and clonazepam (Klonopin) (see Table 23.4
). These medications are often relevant in wilderness settings, as 10% of Americans over the age of 12 take an SSRI
Abrupt discontinuation of SSRIs and SNRIs can cause symptoms of anxiety, flu-like illness, insomnia, sensory disturbances, and hyperarousal. Benzodiazepines are also commonly prescribed for anxiety disorders. When used on a daily basis and then stopped abruptly, they can have serious and life-threatening withdrawal symptoms, such as seizures. Taking a robust medical history is protective against missing less obvious causes of anxiety such as medication withdrawal.
Table 23.3 Common Medications in Wilderness Medical Kits That Can Cause Anxiety
Many anxiety states can be managed in the remote setting. Some presentations of anxiety will be outside the provider’s comfort level or ability to manage. In these instances, the patient must be evacuated. The following situations related to anxiety can be used to indicate a probable need for evacuation.
1. Severe or recurrent anxiety reactions or panic symptoms disruptive to the group.
2. Symptoms that interfere with the patient’s ability to care for themselves, or keep themselves safe.
3. Anxiety presentations that are beyond the provider’s ability to manage.
4. Anxiety states that render the patient, rescuer, or group unsafe.
Epidemiology and Etiology
Like anxiety, depression is common, with depressive disorders in the United States affecting approximately 7.6% of the population over the age of 12.7
Gender plays a role as well, with females experiencing 1.5- to threefold higher rates of depression than males, beginning in early adolescence.1
Like anxiety states, a variety of issues can contribute to depressive disorders, including genetic vulnerability, early childhood trauma, current life stressors, and belief structures. Deficits in neurotransmitters such as serotonin, norepinephrine, and dopamine are also thought to contribute to the development of depression.
Depression can manifest itself in a variety of ways, ranging from subtle changes in motivation and energy, to complete disruption of one’s ability to perform daily tasks, to loss of desire to live. Although there exist “classic” symptoms of depression, such as sadness, hopelessness, and decreased energy, each individual will be unique in how they manifest their symptoms making depression, at times, difficult to detect. This is in part due to the fact that many depressive states are accompanied by shame, self-blame, social isolation, and a barrage of negative self-thoughts, that result in the inability (or lack of desire) to share how truly painful the experience is. Many individuals endure symptoms of depression without sharing them for weeks, months, or even years. Often it is the objective physical findings (eg, weight loss, weight gain, decrease in energy, or sleep disturbance) that draw the attention of medical personnel. Self-harm, suicidal thoughts or attempts, and, rarely, psychosis account for the majority of emergency department (ED
) visits related to depression.
While the essential feature of depression is sadness or depressed mood, hopelessness, self-blame, negative thoughts, and loss of interest or joy can all present in most who suffer from depression. Sleeping too much or not enough, overeating or loss of appetite, isolation, fatigue, and decreased ability to concentrate, complete tasks, or make decisions, can all be found in depression. Rumination (repetitive and worrisome thoughts), worry, and anxiety can also accompany depression.
Likely the most distressing and dangerous of symptoms of depression are repetitive thoughts about death or dying, suicidal thoughts, or plans to commit suicide. Risk of suicide is ever present among those experiencing depression. Especially concerning are patients with a history of previous suicide attempts, history of family members who have completed suicide, and individuals with highly lethal and available plans already formed. Prominent feelings of hopelessness, substance abuse, and borderline personality disorder significantly increase the risk of suicide attempts. Older males, single or living alone, are also particularly at risk.1
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