You are working your last night shift of the tour. Not much has been happening and you have dosed off in the chair while studying. You are awakened by dispatch at 0230 hours. You are to respond to a private residence in the upscale area of town. It is an unknown problem but dispatch tells you it sounds like some sort of domestic dispute. A female who states her son is threatening her husband initiated the call. She reports a knife is involved.Police have been dispatched as well.

Ten minutes later you arrive at a large house in a nice neighborhood. You notice most of the lights are on in the house and two police cruisers are in the driveway. Dispatch informs you police have notified them it is safe for you to approach

A middle-aged female meets you at the doorway. She has been crying and appears anxious but in control. She tells you her son is in the kitchen with police. Her husband is sitting in the living room with his head in his hands. He is obviously crying quietly. He does not appear physically traumatized. The female tells you her husband has not been hurt,but her son needs medical attention.

As you enter the kitchen you find a 17-year-old male patient sitting at the kitchen table. Police are watching him closely and trying to calm him down. He appears to not be listening to them but is talking quickly and anxiously and occasionally he shouts incoherently. He is jiggling his legs up and down and moving his head about. A towel is wrapped around his right wrist. The police officers report that when they entered the house the patient was threatening his father at knife-point. He had put his fist through a glass door in the dining room and has sustained some lacerations on his wrist and arm. Police officers diverted him away from his father and he calmed down considerably. They removed the knife and have kept him in control in the kitchen. They also report the father is unharmed.

The patient’s mother tells you they have had concerns about their son for the past year. He has become withdrawn from family and friends and has had a noticeable change in behavior. He has been arrested several times for shoplifting.He has been drifting from job to job aimlessly and has been fired from several positions. He seems unconcerned about his behavior and personal appearance and seems to have lost any ability to react emotionally. He has begun taking a keen interest in religion and the occult. His parents have, been concerned about drug use but have found no evidence of any such behavior. She reports that tonight his father waited up for him to return home to confront him about his behavior. At that point her son became aggressive and starting yelling about the devil, god and other incoherent mes­sages. He put his fist through the glass door and when his father tried to touch him he pulled a knife on him. At that point she called police. To her knowledge he is not on any medications and has no pertinent medical history.

Primary and secondary surveys reveal he is conscious and awake but has an altered sense of person, place, time and events. He continues to mumble and speak as though he speaking to someone but he does not answer your questions or seem very aware of your presence. The only evidence of trauma appears to be several minor lacerations and one deep cut to the right forearm and wrist area. The bleeding is controlled with a pressure bandage but will require suturing. There is no evidence of any drug use. He accepts transport willingly and seems undisturbed by the police presence.

1. The most likely explanation for this patient’s behavior and history is: A. head trauma B. poor parenting C. depression D. schizophrenia  

2. Asking this patient if he is hearing voices is likely to cause him to become extremely violent and is not recommended. A. True B. False  

3. Schizophrenia is: A. caused by childhood trauma B. more prevalent in lower socioeconomic families C. a biochemical disorder D. all of the above  

4. Schizophrenia: A. involves a change in ability B. always causes violent behavior C. involves a personality change D. all of the above E. A and C are correct. 

5. Prior to a schizophrenic crisis, the person is likely to: A. Seek comfort from family and friends B. become socially withdrawn C. avoid alcohol and  drugs D. all of the above E. A and C are correct  

6. People with schizophrenia may: A. show very little emotion B. lack motivation C. hear voices that aren’t there D. all of the above  

7. If the patient in the scenario doesn’t appear to be listening to your questions you should: A. rephrase the question B. repeat the question C. hold his shoulders and maintain eye contact while you question him D. threaten violence  

8. Prior to arrival you should alert the attending hospital to prepare: A. a quiet room B.  the E.C.T. machine C.  a trauma room D. for evacuation of the waiting room  

9. Schizophrenia cannot be treated or cured. A. True B.  False  

10. This patient should be transported with lights and siren. A. True B.  False  

11. An intravenous: A. should be large bore anticubital B.  should be run at T.K.V.O. rates C.  is not necessary D. A and B are correct  

12. Signs and symptoms of a schizophrenic crisis include: A. auditory hallucinations B.  Visual hallucinations C.  Delusions D. all of the above E.  A and C only  

13. The onset of schizophrenia usually occurs: A. under age 14 B.  between ages 16 and 30 C.  over age 35 D. during a full moon  

14. Treatment for schizophrenia may include: A. surgery B.  E.C.T. C.  Medications D. all of the above E.  B and C only  

15. When assessing this patient you should: A. position yourself so exits are blocked B.  stand above the patient to establish dominance C.  maintain his personal space D. hold his hands behind his back  

16. Medications likely to be prescribed for schizophrenia include: A. Demerol B.  Morphine C.  Thorazine D. Motrin  

17. To ensure a more comfortable and compliant patient you should sedate this patient for transport. A. True B.  False  

18. Newer anti-psychotic drugs used for schizophrenic patients may include: A. Risperdal B.  Clozaril C.  Zprexa D. All of the above  

19. In order to get a comprehensive history you should ask the police officer en route what he found out about the patient. A. True B.  False  

20. You should attempt full primary and secondary assessments on this patient. A. True B.  False  

21.Schizophrenia may be caused by: A. disturbances in neurotransmitters B.  viral infections C.  birth trauma D. all of the above E.  A and C  

22. En route the patient tells you he knows you are part of the alien force sent to abduct him. This thinking is: A. an hallucination B.  an example of a delusion C.  part of the feeling of persecution D. none of the above E.  B and C are correct  

23. You should respond to the comment in question by: A. agreeing B.  arguing strongly against this giving lots of reasons C.  attempting to distract him or divert his thinking D. refusing to enter any further conversation  

24. You can increase your effectiveness on psychiatric calls by: A. researching psychiatric conditions B.  talking to mental health professionals C.  investigating resources in your community D. all of the above  

The answers to these questions are to industry standards and may not necessarily be correct according to local protocol. If there is any discrepancy between these answers and local protocol, please follow the protocol for your area as set out by your Medical Director.

Heather MacKenzie-Carey is a paramedic with over 17 years EMS experience in Nova Scotia and Alberta. She has a Bachelor of Science Degree in Health Education from Dalhousie University, a diploma in Paramedicine from the Northern Alberta Institute of Technology, and a Certificate in Social Work from the University of Waterloo. Heather is an instructor for the Paramedic Program at the Southern Alberta Institute of Technology. She can be reached at: mailto:geomac@cadvision. comor http://www.turningpointgroup.com/

Canadian Emergency News and the author of this quiz grant permission for readers to copy it for personal and departmental educational purposes. All other reproduction and re-publication without written consent is prohibited.

This Article is reprinted by permission from the author (Heather MacKenzie-Carey) and the Canadian Emergency News.