Columns, Patient Care

Safely Treating Patients with Schizophrenia

Issue 9 and Volume 41.

“Ugh, not another drunk teenager—it’s only 10:00 in the morning,” your partner whines as you start up the ambulance. It’s a short drive to the house where an anxious mother meets you at the door.

She ushers you into her home and tells you she’s very concerned about her daughter, who has seemed withdrawn recently. She was “acting weird” this morning, which the mom initially thought was her daughter just being a teenager, but now something is really wrong.

You find Amanda, an 18-year-old female, sitting in the corner of her room clutching a stuffed toy elephant. She doesn’t initially acknowledge you when you enter and call her name. As you approach she slowly looks up and says, “They told me you were coming.”

You ask who informed her of your arrival. After a period of silence, she says, “Shhh, I don’t want them to know you’re here.” Amanda begins whispering the date over and over, “6/16/16, 6/16/16.” Between her references to “them,” she mutters made-up words.

Her mother begins to cry and says, “This is what I was talking about.” She says Amanda has never acted like this before and has no diagnosed medical history. Amanda’s grades have been dropping, she’s stopped going out with her friends and she usually won’t come out of her room.

Amanda isn’t combative and allows you and your partner to take vital signs. Pulse is 84, blood pressure is 116/78 and respirations are 11 and uncompromised. Her pulse oximetry reading is 99% on room air and blood glucose level is 110 mg/dL. There’s no odor of alcohol on her breath or clothes and there are no obvious signs of drug use. A physical assessment reveals no bruising to the head or arms and her mother denies any knowledge of recent traumatic events.

Guided, Amanda stands and sits on the stretcher. You continue to reassess her during transport with no significant changes in her vital signs. She does, however, appear to be having a conversation with someone who’s not there. You transfer care to the ED physician and return to service.

Hospital Course

When you return to the ED with another patient a couple hours later, you ask the physician for an update on Amanda. He shares that she was admitted for a psychiatric evaluation after the ED ruled out acute life-threatening causes. The ED physician believes Amanda was presenting with schizophrenia.

Discussion

Schizophrenia is a psychiatric disorder with an onset affecting persons in their late teens or early 20s. Common symptoms include hallucinations that can be auditory, visual or somatic. This means that patients with schizophrenia can hear voices, see lights or people and, in some cases, feel as though they’re being touched. Schizophrenia can also present with the sensation of tastes or smells.1

Patients may also have delusions or false beliefs. These delusions may be implausible where, for example, the patient describes alien occupation of their home or body. They may also have plausible delusions as in the case when a patient tells you the bank is going to repossess their home and car.

Patients experiencing delusions may believe they’re someone of extreme importance or that someone is out to get them. They may also believe they’re being communicated with through messages in radio or television ads or in written articles found online or in magazines. Disorganized speech, rambling tangents and making up words is also commonly seen with these patients.

With all of the symptoms associated with schizophrenia, patients can experience difficulties with personal relationships and at work. Occasionally this can result in the lack of a support network.

After being diagnosed, schizophrenia can be treated with medications such as thiothixene (Navane) or fluphenazine (Prolixin). Nonetheless, according to the World Health Organization, there are over 21 million people worldwide affected by schizophrenia, and more than 50% of these patients aren’t receiving treatment.1

EMS Considerations

Patients with schizophrenia aren’t commonly combative but may be difficult to manage if they believe someone is after them. These patients may not be willing to trust EMS providers or may not want to leave their home. They may present with a flat affect or without emotion, and communication may be difficult. Don’t attempt to alter their beliefs or tell them that their beliefs or hallucinations aren’t real, because to them they’re real.2

It’s important to consider all other possible causes for the patient’s symptoms such as strokes, tumors or blood glucose levels. Restraints may be necessary if the patient is at risk of running or jumping out of the moving ambulance.

Be supportive and work to keep the patient safe.

References

1. World Health Organization. (April 2016.) Schizophrenia. Retrieved July 20, 2016, from www.who.int/mediacentre/factsheets/fs397/en/.

2. Fischer BA, Buchanan RW. (March 24, 2016.) Schizophrenia: Clinical manifestations, course, assessment, and diagnosis. UpToDate. Retrieved July 20, 2016, from www.uptodate.com/contents/schizophrenia-clinical-manifestations-course-assessment-and-diagnosis.