Emergency Response for the Mentally Ill

The blinds separated, leaving an inch of blackness between them. Somewhere in the darkness two eyes peered out; they saw me, I couldn’t see them.

“Rescue 1 to fire alarm, do you have a callback number?”

“Stand by.”

We stood on the snow-covered doorstep. No sounds came from inside. I knocked again. Nothing.

“Rescue 1?” my portable radio cracked the silence.

“Go ahead.”

“The person should be opening the door, I’ve got her on the phone.”

“Roger, the door is opening.”

A disheveled, intoxicated thirty-year-old female opened the door widely, begging us to come in and shut the door. The place was in shambles. Dirty dishes, laundry, spent cigarette butts; animal waste and cockroaches had taken over. The patient scurried about, pretending to tidy up the place but in actuality couldn’t have tied her shoes at this point, she was too far gone.

“Rescue 1, do you need the police?” the radio blared.

“No police!” screamed the patient, “I’m sick, not a criminal!”

And so it goes.

The fire department is called for a variety of reasons. Nestled among the building fires, chest pain, intoxicated persons, building collapses, car accidents and other emergencies are a surprising number of calls for psychologically unstable patients. The labels vary, Emotional, Change of Mental Status, Anxious, Suicidal, but all are potentially dangerous.

Society is filled with people suffering from emotional and psychological problems. Many of these folks lead productive lives once helped by remarkably effective treatments; therapy and medication produce tangible results in the mentally ill. Some patients have given up on treatment, choosing to make their own way in the world unimpeded by modern medicine. Most are not successful. Many have no access to the healthcare system. Whether that is their own decision or beyond their control is irrelevant, what matters is there are a lot of untreated mentally ill people living among us.

When crisis occurs, and if they are able to recognize the warning signals their damaged minds send out, a good resource is the 911 system. Highly trained personnel are waiting to take care of these patients, get them the help they so desperately need. Or are they?

Those in the field of EMS (emergency medical services) are given rudimentary training regarding the mentally ill. They cannot solve their problems, nor do they have the qualifications to try. The best they can do is to keep the patient calm and get them to the help they so desperately need. Sound simple? It’s not.

When a person decides to call for help, they are at the end of a long, downward spiral. Making that cry for help is a courageous step, fraught with uncertainty. They wait by the phone, wondering if they did the right thing by calling. From the time the initial call is made to the time help arrives a lot can happen. They change their mind. They hear voices. They begin to see their rescuers as threats to their independence. At times violent struggles ensue. Sometimes the situation is diffused with care and compassion, often, force must be used. But whose responsibility is it to use force?

The majority of calls for help concerning the mentally ill are handled by the fire department EMS, not the police. Family members and friends who call for help want to avoid a confrontation. They are at the end of their rope, helpless and afraid. They look to EMS as saviors when they arrive to take their loved one to a hospital or psychiatric facility, only to find their options limited by law and lack of training.

Patients who make the call of their own accord don’t see themselves as a threat. What lucidity remained when they called for help is often gone when help arrives. These emotionally charged situations often lead to violent confrontations with would-be rescuers.

Mental health care professionals call 911from their facilities looking for an “ambulance” to take a problem patient off their hands. EMT’s are then expected to put that volatile patient into a four x eight-foot space filled with glass and needles. It is a recipe for disaster.

EMS professionals cannot restrain, subdue or abduct. Doing so is a violation of a persons civil rights. There are no “men in the white coats.” They don’t carry straitjackets. All they have is common sense, compassion and a willingness to help a person in need. Often, it is not enough.

In the tragic aftermath of one such recent call in Pawtucket a mentally ill man was shot and killed. The police solved the crisis the only way they could at the time. The officer justifiably felt his life in danger and responded accordingly. Would the result have been different if the fire department had been called, or would there be a dead EMT in the patient’s place? We will never know.

A rapid intervention team consisting of a psychiatrist with power to commit a patient, a law enforcement officer with power to restrain a person against their will and a pair of EMT’s to provide support and transportation in a safe environment is what is needed on these type of calls. Until that happens we are sending under trained, unarmed and overwhelmed people into dangerous situations. There needs to be a definitive approach to handling the mentally ill who call for help. The lack of a system currently used is a time bomb. You can hear it ticking if you care to listen.

“No police,” I said as softly as possible. “Get your things and come with us. We’ll get you some help.” I looked around for potential weapons, kitchen knives especially. A caseworker was stabbed in the neck on Broad Street a few years ago by an emotional patient, bled to death in the doorway, leaving a wife and two small children.

After fifteen minutes of negotiations, crying, laughing, and a temper tantrum or two we left the woman’s apartment, from the looks of things for a long time.


  • brendan says:

    Excellent piece Mike. Out of everything the state has changed over the last two years, the one thing they haven’t given us is one of the things we need the most- a restraint protocol. That said, I have called and gotten Medical Control permission to restrain a patient. I explained to the doctor that I had an elderly dementia patient with whatever her medical condition was that required transport, but that given her combativeness on my first attempt, and the dementia preventing anyone from reasoning with her, I felt that I would be unable to safely effect transport without restraining her. “So, are you asking for chemical or mechanical restraint?” “Welp, the company doesn’t give us anything to use for chemical, so it’ll have to be mechanical. “Ok, do whatever you need to do to safely transport her.”I then had to fashion limb restraints out of towels and tape. She managed to wriggle out of one enroute, but I was able to hold that arm down for the rest of the trip. She got five of Haldol on our arrival.

  • Anonymous says:

    This type of call is all over the news again. East Providence is now under the microscope for this exact type of run.

  • Chrysalis Angel says:

    As Brendan said – excellent, excellent post, Michael!!Here we would have to use the police. They went with us, don’t know if that’s still the case today, but they were the only resource we had to use restraints for the protection of the crew.When frightened and confused they can lash out, and everyone has to be on their toes. A pen can be a weapon.

  • Anonymous says:

    a firefighter is so use to running in to rescue or put out a fire…but as an emt i recall being taught is the scene safe for me to go inside…if not we called police before entering no matter what…your life comes first. i wholeheartedly agree that it is incredibly unsafe transporting these individuals in such a small space by yourself in the back….someday there may be a law requiring all police to escort mentally ill people to their destination or train all emts as cops

  • PFDSpitfire says:

    It’s sad that people don’t understand that things must be done to protect not only the EMTs, but the PATIENTS from hurting themselves. My grandmother had dementia. When I admitted her to the nursing home, I had to sign a permission slip authorizing the nursing home to restrain her and/or drug her if she became combative or uncontrollable. It was one of the most horrible things I ever had to do, but I signed that paper, knowing that should the situation arise, it would be the best thing for all concerned. People live in their own little worlds of right and wrong. They don’t look at the big picture.

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