When should paramedics be called in a psychiatric outpatient office?

When to Call Paramedics in a Psychiatric Outpatient Office

Call paramedics immediately when a patient presents with imminent risk of harm to self or others, active suicidal intent with plan and means, acute psychosis with agitation, severe behavioral dyscontrol requiring physical restraint, or medical instability requiring emergency transport to a hospital. 1

Immediate Paramedic Activation Required For:

High-Risk Suicidal Presentations

• Active suicidal intent with specific plan and access to lethal means - this represents imminent danger requiring emergency transport 1, 2
• Persistent desire to die with inability to engage in safety planning - these patients cannot be safely managed in an outpatient setting 1
• Recent high-lethality suicide attempt (e.g., gunshot, hanging, jumping) or attempt with clear expectation of death 1, 2
• Severe hopelessness combined with psychotic symptoms - this combination dramatically increases immediate risk 1
• Patient refuses voluntary transport but meets criteria for involuntary hospitalization 1, 3

Homicidal or Violence Risk

• Specific homicidal ideation with identified victim and plan - this triggers both clinical and legal duty to protect 4, 3, 5
• Acute agitation with threats of violence that cannot be verbally de-escalated 1, 6, 3
• Physical aggression toward staff or others in the office setting 6, 3

Acute Psychiatric Decompensation

• Florid psychosis with severe agitation - particularly with paranoia, command hallucinations, or confusion 6, 3
• Severe mania with marked behavioral dyscontrol - especially with psychotic features, aggressive behavior, or inability to maintain basic self-care 6
• Acute delirium or altered mental status requiring medical evaluation 1
• Severe intoxication or overdose requiring emergency medical intervention 1

Logistical and Safety Considerations

• Patient lacks adequate support system to safely transport them to emergency department 1
• Family unable or unwilling to ensure safe transport to psychiatric facility 1, 2
• Patient requires involuntary hold and refuses to cooperate with voluntary transport 1, 3
• Concern for elopement risk during transport if not accompanied by emergency personnel 7, 5

When Paramedics May NOT Be Needed:

Lower-Risk Scenarios Manageable Without Emergency Transport

• Passive suicidal ideation without intent or plan in patient with responsive family who can ensure same-day mental health evaluation 1, 2
• Patient agrees to voluntary transport by family to emergency department and family is capable of safe supervision 1, 2
• Mild-moderate distress that responds to verbal de-escalation with ability to contract for safety 4, 8

Critical Actions While Awaiting Paramedics:

Immediate Safety Measures

• Place patient in safe environment - remove access to medical equipment, sharps, medications, and potential weapons 1
• Maintain continuous 1:1 observation - never leave high-risk patient alone 7, 5
• Search patient and belongings if suicide risk identified 1
• Have patient change into hospital attire if available to remove potential means 1

Documentation and Communication

• Document specific statements about intent, plan, and means 1, 4
• Obtain collateral information from family members about recent behavior and access to lethal means 1
• Notify receiving facility about patient's presentation and risk level 5
• Prepare involuntary hold paperwork if patient meets criteria and refuses voluntary treatment 1, 3

Common Pitfalls to Avoid:

• Do not rely on "no-suicide contracts" - these have not been proven effective in preventing suicide and provide false reassurance 1, 2
• Do not underestimate risk based on low medical lethality of attempt - intent matters more than actual lethality, as patients often misjudge lethality of their methods 1, 2
• Do not accept family reassurance alone when patient has high-risk features - families often underestimate risk and overestimate their ability to supervise 1
• Do not delay transport for extensive outpatient evaluation when immediate risk is present 7, 3, 5
• Do not allow patient to leave if they meet involuntary hold criteria, even if they promise to go voluntarily 1, 3

Legal Considerations:

• Involuntary hospitalization criteria typically require mental disorder plus imminent risk of harm to self or others 1, 6
• Duty to protect applies when patient makes specific threats against identified individuals 4, 3
• Physicians can initiate psychiatric holds for brief periods (typically up to 72 hours, varying by state) when criteria are met 1, 6
• Breaking confidentiality is justified when there are significant concerns about imminent harm to patient or others 1