Tia Dickson, RN, BSN

Primary Children's Hospital

I attend many local and national EMS conferences and one of the most well-attended topics is mental health. We all know mental health issues are on the rise especially among our youth, but our training lags behind. As recent mass shootings highlight, it is time to address mental health training, resources, legislation and EMS response. What is your agency doing? If you do not know, find out. It they do not have something in place, start here.

Natalie Tedford, MD, Pediatric Emergency Medicine and Global Health Fellow, PGY5

University of Utah and Primary Children's Hospital

Excerpts from May 9th, 2022 PETOS—Pediatric mental health and suicide in prehospital and ED settings

Mental health is becoming a crisis in both adults and youth. Across the country, youth are undertreated for depression and the number of youth who experience major depressive episodes is increasing (up by 197,000 cases from last year). Utah ranks in the highest prevalence of these episodes.

The COVID-19 pandemic has taken a toll on adolescent mental health especially in children of color. During the pandemic we also saw a drop in preventive screening. Regular doctor visits are among the most widely available resources for mental health screening so foregoing these visits will likely lead to an impact on this crisis.

We have also seen an increase in behavioral health complaints in both the prehospital and emergency department visits. There has also been a rise in preventable deaths.

Behavior is what you can see of a person's response to the environment (his or her actions). Behavioral crisis is any reaction to events that interferes with the activities of daily living or one that has become unacceptable to the patient, family, or community.

In the prehospital setting, the underlying cause of a behavioral crisis or psychiatric emergency is NOT needed but some understanding of the basics will give you a framework for providing care. Most mental health diagnosis fall into either organic or functional categories.

• Be prepared to spend extra time
• Have a definite plan of action
• Identify yourself calmly
• Be direct
• Assess the scene
• Stay with the patient
• Encourage purposeful movement
• Express interest in the patient’s story
• Don’t get too close to the patient
• Avoid fighting with the patient
• Be honest and reassuring
• Do NOT judge

Acute Psychosis: a state of delusion in which the person is out of touch with reality. Causes include mind-altering substances, intense stress, delusional disorders, or schizophrenia.

Prehospital guidelines for dealing with a psychotic patient

• Determine if the situation is dangerous.
• Identify yourself clearly.
• Be calm, direct, and straightforward.
• Maintain an emotional distance.
• Do not argue.
• Explain what you would like to do.
• Involve people the patient trusts, such as family or friends, to gain patient cooperation.
  
• Involve police support as needed.

Suicide: Depression is the most significant factor that contributes to suicide. It is a common misconception that people who threaten suicide never commit it. Suicide is a cry for help. Someone is in a crisis they cannot handle alone.

Myth vs. fact about suicide

There are many myths about suicide but here some facts:

• Asking someone about suicide lowers anxiety, opens communication, and lowers the risk.
• Anyone can stop a suicide: listen, show you care, provide hope.
• Most suicidal people have given some sort of clue or communicated an intent prior to their attempt.
• Those who talk about it may try and even complete a self-destructive act.
• Suicide is a preventable form of death, almost any positive action may save a life.
• If people in crisis get the help they need, they are far less likely to attempt suicide.

Agitated Delirium: a condition of impairment in cognitive function that can present with disorientation, hallucinations, or delusions. Agitation is characterized by restless and irregular physical activity. These patients are more likely to be combative.

Approach to agitated patients

• Be calm, supportive, and empathetic.
• Approach the patient slowly and purposefully and respect the patient’s territory.
• Limit physical contact.
• Do not leave the patient unattended.
• Try to indirectly determine the patient’s state.
• Pay attention to the patient’s ability to communicate, appearance, dress, and personal hygiene.
• If you determine the patient requires restraint, make sure you have adequate personnel available to help you.
• If the patient has overdosed, take all medication bottles or illegal substances to the medical facility.

Restraints

• Use only as a last resort.
• Use restraints only to protect yourself or others from bodily harm or to prevent the patient from causing injury to himself or herself.
• Use only reasonable force as necessary to control the patient.
• Secure with approved equipment only.
• Treat the patient with dignity and respect.
• Monitor closely (airway and cardiovascular stability).

National

• 1-800-273-TALK (8255)–National Suicide Prevention Hotline
• 1-800-SUICIDE (784-2433)–National Crisis Hotline Network
• 988–National Suicide Prevention Lifeline (new legislation)

Utah

• DHHS Resource Guide

• Utah Crisis Line–1-800-273-8255

• Utah Warm Line–1-800-587-1055

• Blomquist Hale (free and confidential services for DHHS employees)

• County-specific resources and additional hotlines for Utah

Where to start,

EIIC’s Pediatric Advocacy and Education Kit (PEAK): Suicide

• https://emscimprovement.center/education-and-resources/peak/pediatric-suicide-screening-mental-health/

Counseling on access to lethal means:

• https://zerosuicidetraining.edc.org/enrol/index.php?id=20

Preventing suicide in emergency departments:

• https://zerosuicidetraining.edc.org/enrol/index.php?id=30

More learning resources at:

• https://suicidepreventionlifeline.org/

• Talk with youth about mental health–kids, nieces/nephews, grandkids, communities, students, patients.
• Prioritize a patient’s dignity in all situations.
• Advocate for mental health resources. Contact your local representative and weigh in on mental health resources and legislation https://nami.quorum.us/action_center.
• Speak up on the current bipartisan mental health legislation for youth.

Supporting Children's Mental Health Care Access Act (H.R. 7076/S. 3864)

• reauthorizes the Pediatric Mental Health Care Access (PMHCA) program for 5 years, ensuring the continuation of these telehealth consultation programs while also expanding them to all states and enhancing their capacity to support schools and emergency departments

Youth Mental Health and Suicide Prevention Act (H.R. 1803/ S.3628)

• provides direct funding to schools by the Substance Abuse and Mental Health Services Administration that can be used for a variety of mental health promotion and suicide prevention purposes, such as educational seminars, awareness campaign materials, peer-to-peer program support, telehealth, and training programs.

National EMSC is working to optimize care for children and adolescents presenting to EDs with acute suicidality through an upcoming collaborative.

https://emscimprovement.center/news/enroll-now-in-the-emsc-pediatric-suicide-care-collaborative/

Pediatric Behavioral Health: A Growing National Crisis thorough Imagetrend

Resources to support children, families, communities, and health care professionals in the wake of the shooting or other violent events. The National Child Traumatic Stress Network has developed resources to help children, families, educators, and communities navigate what they are seeing and hearing, acknowledge their feelings, and find ways to cope together. View resources.

Several non-profit organizations are working to get bullying prevention programs into the elementary schools. One currently working with Davis County is Stand For the Silent https://standforthesilent.org/.

Bullying prevention in schools is a full-time exercise. For true change to take place, the culture of a school must be transformed. But it’s not as difficult as it sounds. With a year-round bullying prevention program, clear expectations of faculty and staff, and established guidelines for how to treat incidents, students and adults can be a part of a culture of caring.

https://drive.google.com/file/d/1dEvRRJ8jvvJRpql3Sn9vsq_TcMrelmN2/view

Name Change for the Bureau of Emergency Medical Services and Preparedness (BEMSP)

The Utah Department of Health has undergone some changes. The bureau now falls under the Utah Department of Health and Human Services (DHHS) and is now called the Office of Emergency Medical Services and Preparedness (EMSP). None of the contact information has changed at this time. EMSC continues as a program within the DHHS Office of Emergency Medical Services.

Utah EMSC congratulates Primary Children's Hospital on it's 100th birthday (May 31st).

Happy Pride month

Utah's Governor Cox issued a proclamation marking LGBTQ+ Pride month. EMSC wishes you a happy Pride month and thank all our LGBTQ+ providers. We recognize this population is especially vulnerable to mental health struggles and encourage all to lend support where you can.

On Topic:

Suicide and Self-Harm Prevention

Mental Health Surveillance Among Children—United States, 2013–2019 | CDC Morbidity and Mortality Weekly Report

Changes in Suicidal Ingestion Among Preadolescent Children From 2000 to 2020 | JAMA Pediatrics

Suicide Is Rising Among Younger Students. Here’s How Schools Can Prevent Tragedy|Education Week

For further information about National Mental Health and related resources and events, visit:

Youth.gov’s Mental Health Youth Topic

Office of Adolescent Health, Adolescent Mental Health

Substance Abuse and Mental Health Administration, Caring for Every Child’s Mental Health

Substance Abuse and Mental Health Administration Mental Health Services Locator

Seasonal Prevention:

Approximately 600 children and adolescents die from pedestrian injuries each year. The highest rates of death occur in children ages <1-4 and adolescents ages 15–19. In CSN’s new child pedestrian safety infographic, All Children are Pedestrians! Prevention Tips and Recent Stats, learn more about how to prevent these injuries and keep kids walking safely.

Save the Date!

Our 2nd annual PECC Conference is planned for September 16, 2022. You should have received an email RSVP. We are trying to determine who would like to attend in person and who prefers virtual. Please respond to that email as soon as possible. If you are PECC and did not receive the email, contact Jared Wright at jaredwright@utah.gov.

The National Association of EMS Physicians (NAEMSP) has launched a podcast

The Pediatric EMS Podcast* <https://sites.libsyn.com/414020#> provides

case-based discussion with evidence-based recommendations by content
experts in prehospital pediatric medicine to advance the care of children
outside the hospital. In their first episode, hosts Dr. Joseph Finney and
Dr. Joelle Donofrio-Odmann talk about safely and effectively managing pain
in our pediatric patients.

The CDC now recommends a booster dose of the COVID-19 vaccine for children ages 5-11. They can receive a booster if it’s been at least 5 months since they completed the primary vaccination series. The booster is shown to raise antibody levels in this age group, keeping them and the people around them protected from COVID. Like the primary vaccine series, the COVID booster is safe and effective. Talk to your child’s doctor if you have questions.

More than 4.8 million children ages 5 to 11 have been diagnosed with COVID-19 since the pandemic began, 15,000 have been hospitalized, and more than 180 have died. Vaccine boosters help the body create longer lasting, more durable protection against infections by stimulating immune memory cells. The CDC recommends parents have their children ages 5 and older receive a booster dose, and those who haven’t completed their primary series should also get up to date on their vaccines.

Have you attended a home birth transfer of an infant or a mother to a hospital and noticed ways the process could be improved? Have you seen midwives who have really great systems and communication and wish they all did? Help us learn how to improve the collaboration and communication about birth transfers by giving feedback to the Utah Women's and Newborns Quality Collaborative!

Find out more about our work and the improvement tools we have created here: https://mihp.utah.gov/uwnqc/out-of-hospital-births

Do you have a question for our EMSC Medical Director, Hilary Hewes, MD, PCH, ER Attending Physician about this newsletter topic or anything related to pediatrics? Shoot an email to the following address tdickson@utah.gov.

Pediatric Education for the Prehospital Provider

Register online at www.peppsite.com. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($21.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, no matter where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth