In the emergency medical services (EMS), paramedics and emergency medical technicians (EMTs) or similar are often called upon to respond to behavioural emergencies.
In the United States (US), mental and behavioural health conditions affect approximately 57 million adults (National Highway Traffic Safety Administration (NHTSA), 1998). The American Psychiatric Association defines a behavioural emergency as:
‘an acute disturbance of thought, mood, behaviour, or social relationship that requires immediate intervention as defined by the patient, family or the community’
Within the context of paramedicine, behavioural emergencies are defined by the NHTSA as covering a broad range of behavioural and psychiatric disorders characterised by abnormal and maladaptive behaviour, which may result in a disturbance in normal functioning, caused by emotional or physiological conditions, leading to undesirable consequences (NHTSA, 1998). Behavioural emergencies have also been referred to as psychiatric emergencies, although the former is the preferred term among EMS (Tucci et al, 2015).
Current studies
Anecdotal evidence indicates that EMS call volumes for behavioural emergencies are increasing, but the empirical evidence is limited. One study found that approximately 6% of transports to hospital (n=4 285) in the US were identified as behavioural emergencies (Cuddeback et al, 2010). A 2006 study of the National Hospital Ambulatory Medical Care Survey (NHA-MCS) found that among patients transported to hospital, 31% were transferred via EMS as a result of problems related to mental health issues (Larkin et al, 2006).
While pre-hospital information is otherwise sparse, there is strong evidence that behavioural emergencies are increasingly being seen in emergency departments (EDs). A 2004 study reported a 15% increase in patients seen for psychiatric-related concerns between 1992 and 2000 (Hazlett et al, 2004), and another study noted an increase from 4.9% to 6.3% of all ED visits between 1992 and 2001 (Larkin et al, 2005).
Furthermore, a national study of paediatric mental health in the US indicated that 10% of paediatric hospitalisations were for a primary mental health diagnosis (Bardach et al, 2014). While the evidence offered by some of these studies is dated, the statistics show a trend towards EMS encounters with behavioural emergencies becoming commonplace.
Given the extant evidence, inquiry into the quality of EMS training has become germane. What do paramedics know about how to manage behavioural emergencies? Cuddeback et al (2010) suggested that EMS personnel may fail to recognise behavioural emergencies, and that the EMS system has not responded to its increasing role as a behavioural healthcare provider in the field. Moreover, little research to date has examined what paramedics are being taught in the classroom regarding the appropriate management of patients experiencing behavioural emergencies.
In fact, only one study, published over 30 years ago, discussing behavioural emergency training in EMS personnel was identified (Bassuk et al, 1983). This lack of emphasis on behavioural emergencies may be the result of the low importance given to behavioural emergencies in EMS outcome research (NHSTA, 2003). EMS outcome research is used to empirically derive best practices for patient care, which is then disseminated throughout the profession. However, despite the increased need for behavioural emergency care and research in emergency medicine, little interest has been generated in the pre-hospital environment.
Standard curricula
Another challenge to assessing the state of training in the management of behavioural emergencies is the historical lack of standardisation in curricula. Dawson et al (2003) commented that little was known about paramedic education; that few programmes were accredited; and that paramedic education was without a curriculum ‘master plan’.
This situation has been ameliorated, as starting in January 2013, the National Registry of Emergency Medical Technicians (NREMT) requires all paramedic candidates to have graduated from an accredited paramedic training programme teaching a standardised curriculum in the US (NREMT, 2013). However, this is a recent development, which may explain the paucity of research in this area.
In addition to accreditation, another recent change in paramedic education involved a significant revision in paramedic curriculum. Completed in 2009, the National EMS Education Standards laid out the ‘minimal terminal objectives for entry level EMS personnel to achieve’ within their scope of practice (NHTSA, 2009).
In terms of psychiatric conditions, these revised curriculum guidelines emphasise the following:
‘Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of, at a complex depth and comprehensive breadth, acute psychosis and agitated delirium. In addition, paramedics are expected to know at a fundamental depth and foundational breadth about cognitive disorders, thought disorders, mood disorders, neurotic disorders, substance-related disorders/addictive behavior, somatoform disorders, factitious disorders, personality disorders, patterns of violence/abuse/neglect, and organic psychoses’
(NHTSA, 2009a).
While the criteria are designed to be less prescriptive than previous versions of standardised curricula, there are also ‘Instructional Guidelines’ which are more detailed in terms of what should be taught (NHTSA, 2009b).
Asking the research question
Given the recent changes in paramedic curriculum guidelines and accreditation standards, as well as the evidence of increasing contact between EMS personnel and behavioural emergencies, there is an opportunity to ask the question:
‘To what extent do paramedic textbooks include the content outlined by the National EMS Education Standards Instructional Guidelines (NEMSES-IG) on the management of behavioural emergencies?’
NEMSES-IG integrates comprehensive knowledge of EMS systems, safety and wellbeing of the paramedic, as well as medical, legal and ethical issues, which is intended to improve the health of EMS personnel, patients, and the community (NHTSA, 2009b).
To answer the above question, the current descriptive, exploratory study assesses the state of education for EMS personnel at the highest level of certification. Individuals certified as paramedics have the most training and the widest range of interventions available to them (Bureau of Labor Statistics, 2017). As such, becoming a paramedic requires the most extensive pre-hospital education.
There are challenges in assessing paramedic education for the management of behavioural emergencies. The most standardised element of paramedic education was identified as the target of this study: the paramedic textbook. It was assumed that all accredited programmes, and the textbooks they use, would cover 100% of education standards outlined by NEMSES-IG. To accomplish this task, the current study identified the most commonly used textbooks by surveying accredited paramedic programmes, and then using the Instructional Guidelines (NHTSA, 2009b) as a framework, tested the adherence of the texts to the recommended content.
Methods
Programme search
Paramedic programmes were selected from the list of accredited programmes provided by the Commission on Accreditation of Allied Health Education Programmes (CAAHEP) website. At the time of the study, winter 2012, 305 accredited programmes were found. The researchers followed links to the majority of the programmes. If there was not a web link available (e.g. the link was ‘broken’), the researchers used the search engine Google to locate the programme online.
For the purpose of the current study, the school's current official academic catalogue was chosen to locate the paramedic programme course requirements, and search through paramedic course descriptions. Courses were then selected for the study if they contained behavioural or psychiatric emergencies in the course description. If course descriptions were vague, or did not specifically indicate behavioural emergency content, then courses were selected that might include the behavioural emergency content (e.g. ‘medical’ or ‘medical emergencies’ courses).
Upon finding courses that covered behavioural or psychiatric emergencies, the school's online bookstore was used to find the textbooks used in that particular course. The researchers recorded all data from the bookstore website, including textbook title and author. In addition, if multiple terms and course sections were offered, each term and course section was examined for differing textbook material.
Textbook review
To review the content of the books, the steps recommended by White and Marsh (2006) for quantitative content analysis were followed. After the textbooks had been identified, the chapters within them pertaining to behavioural emergencies were compared to a checklist devised by the researchers, based on the Instructional Guidelines (NHTSA, 2009b) on recommended curricula for behavioural emergencies. This checklist contained 158 separate points, which the guidelines indicate should be addressed. Two independent reviewers with backgrounds in social work and medicine coded the five textbooks using the following metrics:
Results
Of the 305 paramedic programmes generated by the search feature on the CAAHEP, 222 (72%) programmes did not have the required information available or did not list required textbooks publicly. Textbook information could only be found for 83 (27.3%) programmes. Of these, there were 26 different textbooks used relating to behavioural and medical emergencies. Of the 83, 66 (79.5%) used one of the five most frequently used, current edition textbooks, which are identified as follows and in Table 1:
| Textbook title | Year of publication |
|---|---|
| Paramedic Care | 2012 |
| Nancy Caroline's Emergency Care in the Streets | 2012 |
| Essentials of Paramedic Care | 2011 |
| Paramedic Practice Today | 2011 |
| Mosby's Paramedic Textbook | 2014 |
As an interesting side note, two programmes (2.4%) reported using a textbook dedicated to behavioural emergencies: Prehospital Behavioral Emergencies (Polk et al, 2008). The authors reviewed the texts and the results are the average across both raters (Table 2).
| In the chapter | In the book but not in the chapter | Not present | |
|---|---|---|---|
| Paramedic Care | 55.38% | 18.67% | 24.68% |
| Nancy Caroline's Emergency Care in the Streets | 73.42% | 3.48% | 21.84% |
| Essentials of Paramedic Care | 63.92% | 6.33% | 28.48% |
| Paramedic Practice Today | 68.99% | 8.54% | 21.20% |
| Mosby's Paramedic Textbook | 74.36% | 5.38% | 18.99% |
Discussion
The current study found that of the five most commonly used paramedic textbooks in the US, chapters on behavioural emergencies varied from covering between 55% and 74% of the educational standards outlined by the NEMSES-IG. These results indicate a wide variation between textbooks in what they cover on behavioural emergencies.
Interestingly, not one textbook covered more than 80% of the curriculum guidelines, which raises the question of whether current textbooks are adequately preparing students to respond to behavioural emergency calls.
While the current study does not provide evidence that these deficits may be linked to challenges in patient care, it does add urgency to the need to improve how behavioural health is taught to paramedics. The consequences of poor paramedic training have been demonstrated by Cuddeback et al (2010), who found that paramedics often fail to recognise behavioural emergencies—possibly because they are not properly taught how to define or recognise one. Similarly, Colwell et al (2003) examined data from a 6-year period in which 286 complaints were filed against paramedics. Findings suggest that many complaints made against paramedics were made regarding rudeness or unprofessional behaviour when dealing patients experiencing a behavioural emergency, and the use of excessive force during the application of patient restraints.
It must be noted that paramedic textbooks are only one part of a paramedic student's educational experience. Extant research demonstrates that the quality of a paramedic instructor is more important than the quality of textbooks and other materials used, as well as the quantity of instruction (Cannon et al, 1998; Russ et al, 2005). Paramedic instructors may be the most crucial factor in a paramedic student's education, yet these instructors are often also paramedics who have been through the same educational systems. The quality of the paramedic instructor is only as good as the quality of education the paramedic instructor received; the lifetime experience of the instructor; and the research which informs the instructor's continuing education (Blau et al, 2012).
In relation to behavioural emergencies, resources for instructors may be limited, as best practices to inform curricula and patient care are vague or out of date. Specifically, in outlining best practices, the NEMSES-IG identifies three criteria in the management of behavioural emergencies, listed as ‘Providing Empathetic and Respectful Management’:
It is unclear what the authors of the NEMSES-IG were hoping to capture in their description of ‘crisis intervention skills.’ The new literature informing best practices for the management of agitated patients recommends using verbal de-escalation as the first line of management for patients displaying agitated behaviour (Richmond et al, 2012). This new best practice guideline advises against using physical or chemical restraints, unless as an absolute last measure (Richmond et al, 2012). While this new recommendation is quite recent in the literature, it would be beneficial to include as much empirically supported evidence and professional consensus as possible.
Limitations
A limitation of the current study was the reliance on postsecondary institution online bookstores to collect data. The large number of scores in the ‘information not available’ textbook category (63.5%) left the study with only 36.5% of the programmes reporting usable information, which may lead to potential bias owing to missing or minimal data. Future studies may wish to address this issue by seeking correspondence from individual institutions to inquire about the textbooks used in teaching courses. Another limitation of the study is the researcher-derived checklist. The checklist was fabricated by the researchers, and was designed to mimic the NEMSES-IG; however, its creation was still based on the subjective interpretation of the authors, i.e. the authors decided what material warranted inclusion in the checklist and what did not.
Conclusion
The current study shows that among the five major textbooks published for US paramedic education programmes, information about behavioural emergencies as outlined by NEMSES-IG guidelines is included at a rate of 71.5–81%, with chapters on behavioural emergencies varying in coverage between rates of 55–74% of required curriculum. It may be argued that individual instructors may ‘fill in the gaps,’ but the diversity of instructor experience, including individual willingness to address behavioural emergencies and expertise in the area, mean that this compensation is not a certainty.
Given the growing prevalence of behavioural emergencies in the pre-hospital setting, it makes little sense to send someone to a scene if the care providers are not equipped to manage the emergency. Increased paramedic skill in management of behavioural emergencies must come from the top down; leaders in the field must make sure that student paramedics receive education on empathic and skilful handling of individuals experiencing behavioural emergencies.