792 Summer St — psych eval

Location: Bravo post

Time: 09:44 Wednesday

Conditions: Clear and warm

Equipmentfully stocked



It’s the week after Thanksgiving, and you’re pretty sure there’s still a couple of drumsticks and a wing meditating in your belly. And yet, back to work, same as ever. You sigh philosophically.

It’s been a slow wakeup, and only about six words have been exchanged between you and Steve by the time the radio crackles… (click for audio)

[Ambulance 61, priority 1 to 792 Summer St in Lexington. 6-1, mutual aid into Lexington, 7-9-2 Summer St — that’s the continuation of 2A, just over the line. Cross of… between Haskell and Reed St. That’s to meet the police for a psych eval; Lexington Fire is responding. Time out 9:44. A61?]

Click to expand



“Uh… huh. Is Lexington exporting its crazy people now?”

Lexington isn’t a bad town, although small; their fire department runs two ambulances, and occasionally needs mutual aid when they run dry. The address looks like it’s barely over the line, so it’s no huge effort.

Steve runs you up Summer St, hugging the center divide to avoid rush hour traffic, and gets you there in nine minutes. You see a one-story home in a decent-looking complex, with an engine and two cruisers out front. Although you’re pretty sure you have a channel on your UHF radio for LFD, per protocol, you simply call off with your dispatch — they’ll notify Lexington via landline.

You travel light, bringing the stretcher and first-in bag. As you roll up to the front door, you find it open, with quite a commotion inside.



In the background, you see a middle-aged woman who seems to be struggling to hold a male child — perhaps five or six years old — who’s yelling incoherently and flailing his arms. His activity seems to be vigorous but not particularly effective. Firefighters are milling around, appearing mildly bemused but very much disinclined to get too close.

A Lexington police officer meets you at the door, saying: “Kid’s out of control. Some kind of psychiatric thing. Ma’am, can you fill in the paramedics?”

A younger woman you hadn’t noticed comes to the door, looking frazzled. “He’s just… I can’t control him. He just got back from University Hospital, but it didn’t help; I don’t know what to do. He won’t listen. I don’t know what to do.”





Looking past her, you watch as the child calms momentarily, seemingly distracted by something, and then comes unwound again.

To the woman, you say, “Sorry — you’re his mother?”


“What’s his name?”


“Okay, I’m Sam; and what’s your name?”

“Isabelle.” You shake.

“So Trevor was just recently in the hospital?”

“Yes, he got out yesterday. Clements Unit.” Clements is the pediatric psych wing at JUMC.

“What for?”

“For… this. He’s been getting worse and worse. I don’t know what to do. They didn’t do anything.”

“Well, what did they say? Was there a diagnosis?”


“Did they start him on any medication?”

“On Ritalin… but I don’t think it’s enough. It’s not helping. He wouldn’t even take it today. Since he got back he’s been even worse. The social worker is here to help but she can’t handle him either.”

“All of this just started recently?”

“A few months ago.”

“Does he have any other medical issues?”


“Taking any other medications?”

“No… I do give him cough syrup when he gets sick.”

“How old is he?”


“Okay. So what do you want to do? Shall we bring him back to University Hospital and they can try again to sort things out?”

“I don’t know what to do.”

Well, that makes two of you. You enter the home and approach Trevor, moving slowly and calmly. You kneel down beside him and try to make eye contact. He appears to be a physically well 8-year-old, breathing vigorously, with unremarkable skin and pupils.

“Hi Trevor. I’m Sam. How’s it going?” You address him directly, speaking in a simple, quiet tone.

He responds, if you can call it that, by squirming and turning around to look at a wall.

“Hey, what’s the matter, Trevor? You seem like you’re pretty upset.”

He tosses out one arm like he’s throwing a frisbee, and almost catches the social worker on the chin.

“Trevor, we’re kinda worried about you. Can you come with us so the doctor can take a look at you? We’ll give you a nice easy ride in the ambulance, it’ll be fun.”

At this point, he tries to dash away in the other direction, and is barely restrained. He starts hollering.

Well, this is productive. You stand and look back. A couple of SPD officers are still around, and fire is starting to edge toward the door. Steve has the stretcher nearby.





You wave over Steve and meet him at the door. “Let’s bring over the stretcher, get everything ready, and try to talk him onto it. If it comes to it, we may have to wrestle a little or four-point him, but…”

He grimaces. “Yeah.”

Pulling the stretcher over to the door, he drops it to kid height, lowers the rail, and releases the straps. Then he takes a big blanket and opens it in preparation to “burrito” little Trevor — a fairly benign tactic that forms the lowest level on your personal continuum of physical restraint.

Returning to Isabelle’s side, you tell her, “All right, it does look like we should probably bring Trevor in — we can just bring him back to Clements at University and they can follow-up and take another crack at addressing this. Does that sound okay to you?”

“Yes, okay.” She looks relieved that somebody has come up with a solution — one that doesn’t require her to keep wrestling fruitlessly with her kid.

“The next challenge is going to be getting him to come willingly, though. I’d rather not end up having to fight him; that won’t be fun for anyone. Can you help us try and convince him to come along?”

“Yes, of course.”

Together, you approach Trevor. But first, you turn and catch the attention of the lingering fire and police folks. “Can you guys hang around for a bit? We’re going to try and get him to cooperate, but if that doesn’t go so well we may need some hands.”

“You got it,” replies the fire lieutenant.

Isabelle is crouching down with her son. “Honey, you’re going to take a ride to the doctor. Want to take a ride? Come on, it’ll be fun.”

He looks uncertain.

“Come on, Trev.” Standing, she takes his hands and gently pulls him upward. He immediately yanks his arms free and pulls away.

“Don’t touch me!”


You join her. “Hey Trevor… I’m not going to touch you, but don’t you want to take a ride? We’re going to go in the ambulance. Have you ever been in the ambulance? I bet you haven’t.”

Pausing, after a moment he shakes his head.

“Hey, you’re going to love this, then. We’ll pop over and visit the doctor. Remember when you were there? Just a few days ago.”

He shakes his head again.

“Yeah you do,” his mother interjects, sounding annoyed.

Ignoring her, you try somewhat tenuously to hold his gaze. “So whaddya say?”

“How long?” he asks, biting one of his thumbs.

“Just real quick, real quick,” his mother assures him. “We’ll come right back.”

You cringe a little. Although you try never to lie to patients, at times like this a few fibs are sometimes the lesser evil.

“You can sit in the ambulance!” Isabelle tells him glowingly. “With the flashing lights! Don’t you want to see the lights?”

Finally, grudgingly, Trevor nods.

“All right, buddy. Come on over here.” You step over to the stretcher, and with a bit of encouragement, Trevor follows. After copious logorrhea of: “Here, just right here, have a seat, right over here,” he plops himself onto the stretcher and pulls his feet up.

You promptly flip up the rail, and together you and Steve wrap the blanket around him, transforming him into a well-bundled burrito. You start to buckle him in. As the chest strap is clicking home, he gives a spasm and tosses it away, ending up with both shoulder straps over one side.

“Hey, hey!” his mother scolds him. “Stop that, you said you wanted to go, remember? Settle down.”

He gives another little toss. “I don’t want it.”

“I’m sorry, buddy, we have to give you some seatbelts, just so you don’t go flying off. It’s just for a few minutes.”

He seems temporarily sated, so you quickly boost the stretcher up and load it into the 61.

“Can I come along?” asks his mother.

“Yes, please.” You hop into the back, sit yourself in the tech seat behind Trevor, and have Isabelle seatbelt herself onto the bench where Trevor can see her.

Poking his head into the side door, one of the cops asks, “You’re going to Jefferson?”


“Need somebody to ride along?”

You eyeball the kid. At this point, things are rolling inevitably, and if it comes down to it, you can probably handle an eight-year-old. Probably.

“Nah, we’re good. Thanks.”

Steve appears in the rear doors, catches your eye, and you jerk your thumb in a “let’s boogie” motion. He closes you in and hops into the driver seat.

“Let’s just go,” you tell him through the connector. He pulls out, lights flashing.

You’ve made it a few blocks before Trevor starts struggling restlessly, and before you know it has unbuckled his chest strap. Leaning over, you resecure it gently, buckling it upside down so it’s a little tougher to find the button. “You gotta keep this on for me, okay? It’s so you don’t fall off.”

A minute later, he’s unbuckled it again. As you reach over to resecure it, he tosses the straps away, annoyed, and starts to flail a little. His mother shushes him and lightly holds him down, but that just makes him thrash harder. Soon he’s pulled his legs out from the bottom strap, and is held only at the hips. The burrito was a complete failure.

He’s crabbing sideways and squirming all over the place, and it’s all you can do to hold him by the wrists and keep him relatively seated. His mother is doing her best to settle him down, but he’s yelling at her “DON’T TELL ME WHAT TO DO” and she seems to be losing steam.

Poking your head up front, you tell Steve, “Look, he’s going to dive out the back or something, we need to restrain him.”

Steve is burning up the road, and as you gaze out the windshield you realize how fast he’s actually moving you without throwing anybody around. Good old Steve. “We’re almost there,” he tells you, and he’s actually right. You were thinking about diverting to a closer facility, but at this point if you can hold the line for a couple more minutes you’ll make it.

“Yeah, okay.”

“Want me to call them?” Steve asks.

“Yes, please.”

He switches the UHF radio in the cab from the fire channel to the hospital notification channel and hails JUMC, giving a brief head’s-up and asking them to have security meet you. Meanwhile, you get back to wrestling with Trevor, with moderate success, although the straps are a lost cause.

Soon you’re backing into the bay, and as Steve opens the rear doors you jump down. A couple of the security officers are waiting. He hauls the stretcher out, and miraculously, Trevor slows his roll somewhat, seemingly entranced by the new surroundings. You take the opportunity to buckle his chest strap, and briskly roll him into the ED. A nurse waves you into one of the pediatric rooms, and you let his mother scoop him up and deposit him on the bed, then shamelessly escape. Buttonholing the nurse outside, you give this report (click for audio)…

[Okay, this is Trevor, 8 years old… past couple months he’s been acting increasingly defiant and uncontrollable, tantrums, fighting, yelling, you name it. He was actually here this past week in Clements, discharged yesterday with a diagnosis of ADHD, started on Ritalin, but mom says it hasn’t helped. Been just as bad or worse since then and she can’t deal with it, so she called us. He was fighting everyone on scene, we managed to talk him onto the stretcher, but he came unhinged again on the way, and just settled down again when we got here — very up and down, waxing and waning. Seems very distractible, very defiant, doesn’t want to be told what to do. Gonna be a handful; make sure you keep an eye on him. No other history or meds. You’re gonna have to get more info from the mother. Have fun!]

She sighs and thanks you, sounding world-weary. You step back into the room, where Trevor is running around in circles.

You shake Isabelle’s hand and say, “Hey, we’re gonna get out of here. Good luck with everything.”

To Trevor, you wave and say good-bye. He responds by knocking a box of gauze onto the ground.

Well, that’s your cue. You escape into the hall, and the nurse slides the door shut.

Out in the bay, you find Steve ruminating over the steering wheel.

“That,” he tells you, “is why I don’t have kids.”



Diagnosis: ODD (Oppositional Defiant Disorder) in the setting of ADHD (Attention Deficit Hyperactivity Disorder)

The business of psychiatric diagnosis is complex as well as controversial, and involving kids doesn’t make it any easier. But unlike other complicated subjects, such as brain surgery, we tend to think we “understand” it due to intuition and pop psychology. Don’t fall into that trap — these are real medical disorders with subtle diagnostic differentiations and challenging treatment pathways. (Thus, it’s best to maintain some continuity of care, as in transporting Trevor to the same facility he just left; that way they can figure out what’s not working and tweak it.)

More generally, the problem of transporting combative or uncooperative patients, by hook or by crook, is not uncommon. While in some cases, such as clearly incompetent individuals, those with legally ordered psychiatric holds, or (as in this case) an unemancipated minor, we have authority to physically (or in some instances, chemically) restrain them, it should always be a last resort. It’s dangerous to everyone, changes the patient-provider relationship, and brings you down a road you can’t return from. Many seemingly intractable patients can eventually be “talked down,” if only by wearing away their patience until they’re sick of listening to you.

If it does become physical, the safest approach is “many hands make light work”: overwhelm them with personnel, each tasked with something specific (i.e. control the left arm, control the head) until they’re fully secured with the devices and techniques available to you. Children may be physically easier to control, but don’t underestimate them; this call could have gone much worse if Trevor had been more violent and poor Sam was stuck in back with him, essentially alone.


  1. I’d love to get ALS coming, just in case the kid needs to be sedated. Also, I wouldn’t mind having them take him; he seems like a handful.

    He’s ok for now physically, with no obvious life threats at the moment, so I’d like to work on getting history from the family first, with a focus on exploring what seems to be an ongoing issue.

    Why was he at University? What did the doc(s) decide was wrong? Why was he sent home if he’s still this bad? Is he on any meds? Have they changed his meds recently, and have their been any changes in his behavior since then? Is he taking his meds when he should? Any possibility of overdosing on those meds?

    I’d preferably like to have this discussion out of earshot of the kid, so as to avoid setting him off. Once I’ve got everything I can from the mother, I’m going to calmly and quietly approach the kid and try to calm him down as much as possible. I’d like to clear as many nonessential people (i.e, the firefighters) from the scene as I can to try to calm down the whole situation. Hopefully, we can persuade him to come quietly to the ambulance, where we can do a nice slow, quiet transport to University. I’d like to avoid restraining him unless it’s absolutely necessary, since I feel like it would make him worse off overall.

    • Good thoughts. Sedation for agitated/combative/uncooperative patients is a tricky subject, though. Any idea of your local protocols?

      • I’m not 100% sure of the details, since I’m part of a BLS-only service and so everything I’m getting is just from reading the ALS protocols.

        It looks like ALS can do physical restraint and then must contact medical control afterwards to advise them of the situation, or can do 5 mg Haldol IV or IM, then contact med control. After that, they can do Benadryl 50 mg IV or IM in the event of a dystonic reaction. Additionally, they can do 5 mg of Versed IV or IM, repeated as needed up to 3 times, but only with orders from medical control.

        I think this will probably change slightly since all of our regional ALS protocols are being revised soon.

        • I actually believe it’s often the safest method, but it has some negative connotations and can be abused, so it’s a little loaded. In my state (MA) it’s not permitted at all, which I think is a shame.

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