Tag: De-Escalation In the Moment

It can be difficult or impossible to manage services during an escalated event. Therefore, it is important for everyone on the team to understand that they have a role when there is an escalated event, and sometimes that role is maintaining services or, alternatively, depending on the extremity of the event, shutting down services in an orderly manner.

There are no real hacks here other than to discuss, discuss, discuss—have a plan in place for what will happen in the event that various kinds of escalated situations occur, and make sure that part of those plans include how to manage services during such an event.

Your staff should be trained in basic CPR and first aid including identifying common medical emergencies like seizures, heart attacks, or strokes. Space Hacks can not list every potential scenario in which someone might need to have 911 called or go to the hospital. However, staff should be trained to identify life-threatening emergencies so that they can respond effectively, should an emergency arise. Listed here are three of the most common medical emergencies and instructions for what to do. There is more information about their symptoms in the section on overamp.

Cardiac Arrest

• Call 911 immediately and/or go to an emergency room right away BEFORE a person’s heart stops.
• If the person loses consciousness / their heart stops perform CPR (100-120 chest compressions per minute) or use a portable defibrillator where available.

Seizure

• Stay with the person until the seizure is over.
• Make sure the person is in a safe position—on one side is optimal.
• Remove anything hard or sharp from around them.
• Remove any extraneous clothing like ties, scarves or eyewear.
• Put something soft under the person’s head- a pillow or rolled up jacket.
• Call 911 if:
  • It is the person’s first seizure
  • The seizure lasts more than 5 minutes
  • They have multiple seizures in a short period of time, and/or
  • And/or the person has difficulty breathing.

Stroke

• First double check your observation:
  • Ask them to smile, does one side of their mouth droop?
  • Ask them to raise both arms, does one drift down?
  • Is their speech impaired?
  • If you note any of these symptoms call 911 immediately!
• Note what time you notice symptoms started, medical staff need this information for treatment.
• Do not allow the person to go to sleep.
• Do not allow the person to drive.
• If possible, wait for emergency services, but even if the person insists, make sure they do not drive under any circumstances.

Though less common at harm reduction sites than opioid overdose, overamp can happen to people who use stimulants at any time in any place, so it’s important that you first recognize and know how to respond in case it comes up at your site.

First, look for the physical signs of overamp, including:

• High temperature/sweating profusely, often with chills
• Fast heart rate, racing pulse
• Hypertension (elevated blood pressure)
• Irregular breathing or shortness of breath
• Headache
• Teeth grinding
• Convulsions/tremors
• Limb jerking or rigidity
• Feeling paralyzed while awake
• Nausea and/or vomiting
• Chest pain or a tightening in the chest

Next, look for the emotional signs:

• Severe anxiety/paranoia/panic
• Increased agitation, frustration and aggression
• Hypervigilance
• Visual and/or auditory hallucinations

Finally, look for the potential serious physical consequences of overamp, including:

• “Hyperthermia” (overheating)
• Seizures
• Stroke
• Cardiac arrest

What to do in case of overamp

Watch out for the most obvious signs of its most dangerous outcomes such as:

Hyperthermia*

• Agitated movement.
• High temperature.
• Hot dry skin.
• Acting confused or hostile.

*Note: hyperthermia is the opposite of hypothermia, which is what happens when people freeze to death.

Seizure

• Twitching and jerking.
• Frothing at the mouth.
• Sudden stiffening of the body.
• Sudden falling.

Stroke

• Sudden, severe, headache with no obvious cause.
• Sudden numbness or weakness in the face, arms, or legs, especially on one side of the body.
• Sudden confusion, trouble speaking, or difficulty understanding speech.
• Sudden trouble seeing out of one or both eyes.
• Sudden trouble walking, dizziness, loss of balance, or lack of coordination.

Cardiac Arrest

• Pressure, tightness, pain, or a squeezing or aching sensation in the chest or arms that may spread to the neck, jaw or back.
• Nausea, indigestion, heartburn or abdominal pain.
• Erratic pulse.
• Shortness of breath.
• Cold sweat.
• Lightheadedness or sudden dizziness.
• The person may appear pale or ashen.

What to do:

Hyperthermia

• Try to get the person to sit as still as possible.
• Get them to drink water or electrolyte drinks like Gatorade.
• Cool the environment by opening a window or putting on a fan or air conditioner.
• Place cold, wet cloths on their neck and face or anywhere over an artery to help cool the blood.
• If they become confused or agitated, call 911 immediately as this can be a sign that they are close to death.

Seizure

• Stay with the person until the seizure is over.
• Make sure the person is in a safe position—on one side is optimal.
• Move anything hard or sharp from around them.
• Remove any extraneous clothing like ties, scarves, or eyewear.
• Put something soft under the person’s head, such as a pillow or rolled up jacket.
• Call 911 if:
  • It is the person’s first seizure
  • The seizure lasts more than 5 minutes
  • They have multiple seizures in a short period of time
  • The person has difficulty breathing.

Stroke

• First double check your observation:
  • Ask them to smile, does one side of their mouth droop?
  • Ask them to raise both arms, does one drift down?
  • Is their speech impaired?
  • If you note any of these symptoms call 911 immediately!
• Note what time you notice symptoms started, medical staff need this information for treatment.
• Do not allow the person to go to sleep.
• Do not allow the person to drive.
• If possible, wait for emergency services, but even if the person insists, make sure they do not drive under any circumstances.

Cardiac Arrest

• Call 911 immediately and/or go to an emergency room right away BEFORE a person’s heart stops.
• If the person loses consciousness or their heart stops, perform CPR (100-120 chest compressions per minute) or use a portable defibrillator where available.

Your protocol for dealing with overdose will vary depending on the physical layout of your site and variables like how far you are from the nearest hospital.

However, the general steps are the same for any overdose event and include first identifying the signs of opioid overdose. When experiencing OD:

• People will sometimes have labored, strangled breathing (frequently called “the death rattle”), if any breath at all.
• In lighter skinned folks, people will exhibit “cyanosis”, in which they will appear pale and their skin, especially their lips and fingernails, may be bluish.
• Cyanosis often causes darker skinned people to appear ashen and their lips and fingernails may appear grey or whitish.
• People may also be cool or clammy to the touch.
• They will be unresponsive and may lose consciousness.
• People may lose muscle control and appear slack.
• People’s pulse may be slow or erratic.
• People’s pupils will be constricted or “pinned”. NOTE: this is always an effect of opioids, but if someone suspects OD and the person’s pupils are not “pinned,” they may be having another kind of medical crisis such as a heart attack or stroke and emergency care must be sought immediately.

After the signs of opioid overdose have been identified, staff and volunteers should contact appropriate emergency medical services.

• Ideally call 911 as soon you recognize the signs of overdose and perform rescue breathing until help arrives.
• Be advised that, owing to the realities of police involvement in overdose situations, there are a variety of things to do to minimize possible conflicts that might interfere with the victim’s treatment while still getting someone help. For instance:
• When calling 911, try to remain as calm as possible and minimize chaos in the environment to minimize the likelihood of the police accompanying emergency medical services.
• Tell the 911 dispatcher that “someone has stopped breathing” and avoid sharing that someone has overdosed to minimize the likelihood that the police will be sent with emergency medical personnel. Emergency medical personnel routinely have and use naloxone for anyone who has stopped breathing when there is not an obvious mechanical cause (such as a drowning victim).

Next, provide rescue breathing:

• Rescue breathing is sometimes called mouth-to-mouth and is used to help provide oxygen to people who have stopped breathing.
• Chest compressions, known as CPR, are for people whose heart has stopped and are not necessary for folks who’ve OD’ed.
• Start rescue breathing as soon as you realize someone has stopped breathing or is breathing erratically.
• First make sure the person’s airway is clear by looking in their mouth and clearing anything that might be in the way such as their tongue or vomit. Occasionally this will be enough to allow the person to breathe without rescue breathing.
• Hold the person’s nose and cover the person’s whole mouth with yours, OR cover their whole nose and mouth with your mouth and exhale into their lungs.
• You can be sure it is working if you feel their chest rise and fall, so it is good to keep a hand lightly placed on the person’s chest during rescue breathing so you can sense that effect.
• Rescue breaths should be provided every 5-6 seconds.
• Slow-but-steady rescue breaths are preferable because, even in the absence of naloxone, you can save someone if you keep breathing for them for as long as they are not breathing, or until emergency services arrive, which may take some time.
• If you have naloxone, administer it after starting rescue breathing.

Next, administer naloxone:

• First, alert the person that you are going to administer naloxone by speaking to them loudly.
• Next, shake them and rub their sternum or under their nose with your knuckles—the pain may arouse them.
• Tell them again you will be administering naloxone.

(Choose which of the following is appropriate based on current inventory and explain)

How to administer naloxone intranasally:

• Make sure that the person is on their back with their head tilted back and remove the cover from the naloxone.
• Place the tip of the nasal administrator in the person’s nostril.
• Grip the nasal administrator with three fingers and squeeze releasing the aerosol naloxone.

OR

How to administer naloxone intramuscularly:

• Get out the naloxone vial(s) and muscle syringes.
• Inject air into the naloxone vial with the syringe.
• Draw up to 6ccs of naloxone into the syringe OR however much is in the vial.
• Choose a large muscle group such as the upper arm, thigh or buttocks.
• Clean the skin if possible, though naloxone needles can go through fabric.
• Inject 1cc at a time, up to a total of 6ccs. If it is in one syringe, simply depress out 1cc at a time. Otherwise, use a new syringe for each additional cc or refill the syringe if necessary.

Note:

• Naloxone works by pushing the opioids off the receptor sites which can make people go into withdrawal, which is why you want to administer it slowly/use as little as possible.
• If people do start breathing naturally and are feeling like they are ill or “dope sick”, that they should be advised they will begin to feel “well” again within about an hour and that they should not use opioids again because the naloxone may not work a second time if they use more opioids.
• Naloxone metabolizes—that is, gets processed—out of the body faster than opioids do, which is why people get well without using again.
• Finally, you must wait with the person at least two hours after administering naloxone to make sure they do not go back into OD again when the naloxone wears off.
• If the person does go back into OD, administer more naloxone and/or perform rescue breathing as necessary.

The decision as to whether or not you are able to continue services during an escalated event is incredibly important and should be given thought before such an event takes place.

Try to develop a list of “If, then” scenarios to determine in advance how you might respond. Be forewarned that most likely your exact scenarios will never happen and certainly not exactly as planned. However, leaders shared that the exercise of thinking through these issues will better position you to respond effectively when events do escalate.

Mental health first aid is a set of techniques developed by mental health providers in Australia in the early 2000s. They developed this methodology as a way of diffusing basic mental healthcare techniques to the general population so that they could be better equipped to respond to emotional problems—especially depression, anxiety, and suicidality. Mental health first aid has a number of steps that include the following, which can be used in any order.

A – Approach, assess for risk of suicide or harm. Try to find a suitable time or place to start the conversation with the person, keeping their privacy and confidentiality in mind. If the person does not want to confide in you, encourage them to talk to someone they trust.

L – Listen non-judgmentally. Many people experiencing a challenge or distress want to be heard first, so let the person share without interrupting them. Try to have empathy for their situation. You can get the conversation started by saying something like, “I noticed that …” Try to be accepting, even if you don’t agree with what they are saying.

G – Give reassurance and information. After someone has shared their experiences and emotions with you, be ready to provide hope and useful facts.

E – Encourage appropriate professional help. The earlier someone gets help, the better their chances of recovery. So, it’s important to offer to help this person learn more about the options available to them.

E – Encourage self-help and other support strategies. This includes helping them identify their support network, programs within the community, and creating a personalized emotional and physical self-care plan.

Because participants experiencing psychosis aren’t in touch with consensual reality, they may be easily confused and frightened. For this reason, it is important to be as concrete and clear with the participant as possible.

Do not attempt to dissuade the person from their delusions or use logic to argue. Rhetoric will only confuse them and create the potential for further conflict. Likewise, humor is not the best tool to use with people experiencing psychosis because they may believe you are laughing at them, which will exacerbate negative feelings. Instead emphasize or “lean on” the ways in which the participant’s chaotic reality may intersect with consensual reality to keep the conversation focused, and use concrete suggestions to meet their needs.

What is a bathroom blockade? That’s when somebody refuses to leave the restroom. Bathroom blockades happen for many different reasons, mostly because people become agitated and confused and/or they are in desperate need of privacy.

Harm reduction OGs caution that though you can prepare for the possibility of bathroom blockades, you cannot prevent them entirely. They are inevitable. The only way you can deal with them is to patiently wait them out while reminding people consistently of the inconvenience they are causing others. Experienced harm reductionists caution against personalizing these events or getting too emotionally invested.