Professional standards, training and membership.
Professional standards, training and membership.
Ethics in IEMT Practice: Lesson 4.5
Risk, Self-Harm and Crisis
Welcome
Some clients will come to you in distress, and a few will be in crisis. IEMT is not a crisis service, and you are not expected to manage a crisis alone. You are expected to recognise when someone needs urgent help, to stop what you are doing, and to get that help quickly. This lesson covers screening for risk, recognising warning signs, what to do in a mental-health or medical emergency, how to stay safe yourself, and what to tell clients at the start.
Learning Objectives
By the end of this lesson, you will be able to:
- Explain why IEMT is not a crisis service, and what that means for you.
- Recognise warning signs of suicide risk, self-harm, psychosis, medical emergency and violence.
- Follow a clear sequence of steps in a crisis, and know which services to contact.
- Set expectations with clients about contact between sessions.
- Keep yourself and your clients safe, and record and report what happens.
It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.
Florence Nightingale, Notes on Hospitals (1863)
IEMT is not a crisis service
The Association’s policies are plain on this point:
IEMT is not a crisis service.
The Association for IEMT Practitioners, Scope of Practice Policy, section 5
A crisis is not managed through IEMT or by an Association email.
The Association for IEMT Practitioners, Safeguarding Policy, section 5
The Scope of Practice Policy tells you not to begin or continue an IEMT procedure when immediate safety, urgent medical assessment or emergency mental-health support is the priority. Complexity does not rule out all future IEMT work, but it may mean a different practitioner, coordination with the person’s existing care, extra supervision, postponement or a refusal.
Screening before you start
Risk work begins before the first session. Ask about the person’s goals, medical and mental-health history, current care, medication, recent distress or instability, substance use, thoughts of self-harm, and safeguarding concerns, and keep asking when circumstances change (Scope of Practice Policy, section 5). The Pre-Session Assessment Guidelines list the conditions in which IEMT should not go ahead, or should only go ahead after medical advice. They treat a history of psychotic illness as a specific exclusion unless you have the training and experience to work with it, or are working under suitable direct supervision. Read them and follow them. This lesson is not a substitute for them.
If someone is receiving medical or psychiatric care, IEMT must not replace, delay or contradict it. You do not have to contact everyone’s healthcare team, but you must not go ahead if essential information cannot be obtained and you cannot work safely within your scope. If a client refuses to let you coordinate with their care and you need to, postpone or decline.
Recognising warning signs
| Area | Possible warning signs |
|---|---|
| Suicide or self-harm | Talking about wanting to die, being a burden or having no reason to live; hopelessness; a plan, the means or a date; giving away belongings; a recent loss or crisis; increased drinking or drug use; self-harm that is new, worse or more dangerous. |
| Psychosis or severe disturbance | Hearing or seeing things others do not; strongly held, unusual beliefs that seem frightening or controlling; confusion; speech that is hard to follow; marked agitation; catatonia. |
| Acute distress during a session | Panic, dissociation, disorientation, intense or rapidly escalating emotion, being unable to respond or to stay in the room. |
| Medical emergency | Chest pain, a seizure, a diabetic emergency, severe breathing difficulty, collapse, new visual or neurological symptoms, severe dizziness, or injury. |
| Violence or threat | Threats to you or to others, aggressive behaviour, intimidation. |
Do not be afraid to ask directly. Research does not show that asking someone about suicide makes it more likely. Ask plainly and kindly: “Are you having thoughts of ending your life?” Listen to the answer, and stay calm. If the answer is yes, ask about whether they have a plan, the means to carry it out and a time in mind. Do not promise secrecy.
What to do in a crisis
- Stop IEMT. Pause the procedure straight away, and do not restart it until safety has been dealt with.
- Stay calm and stay with the person. Speak slowly and clearly, listen without judgement, and do not leave them alone if you think they may act on a plan.
- Assess how urgent it is. Is there immediate danger, a plan, the means and a time? Is anyone else at risk?
- Get help. If there is immediate danger or a medical emergency, call 999 and stay on the line. If the risk is serious but not immediate, arrange urgent help: the person’s GP the same day, NHS 111 (choose the mental health option), the local mental-health crisis team, or A&E. With the person’s agreement, involve someone they trust. If they refuse help but you believe their life is at risk, call 999: the law allows you to share information to protect life.
- Do not try to manage it alone, and do not rely on promises the person makes. Do not give advice outside your competence.
- Protect children and adults at risk. If the person is under 18, or an adult at risk, follow the safeguarding steps in Lesson 3.1.
- Record, be candid and report. Write a factual record while it is fresh. Tell the person what you did and why, report an adverse event (Lesson 4.4), tell your insurer if required, and take it to supervision.
Services you can use
| Service | When to use it |
|---|---|
| 999 | Immediate danger to life, a medical emergency, or a crime in progress. |
| NHS 111 (choose the mental health option) | Urgent mental-health help and advice that is not an emergency, in England. |
| The person’s GP, or the local crisis team | Same-day assessment and ongoing care. |
| Samaritans: 116 123 (free, 24 hours) | Anyone who needs to talk, including about suicidal thoughts. |
| Shout: text SHOUT to 85258 (free, 24 hours) | Anyone who prefers to text. |
| Childline: 0800 1111 (free, for under-19s) | Young people who need support. |
| NSPCC helpline: 0808 800 5000 | Adults who are worried about a child. Check its opening hours. |
Medical emergencies
The Scope of Practice Policy (section 5) says that you must not begin or continue an IEMT procedure when urgent medical assessment is the priority. In any practice that sees enough clients, a medical emergency is likely to happen sooner or later. The most likely are diabetes, epilepsy, asthma or other breathing problems, and chest pain. The Association’s Medical Crisis Guidelines add practical expectations, and the Pre-Session Assessment Guidelines list the conditions that need medical advice before IEMT. In summary:
- Keep your first-aid training up to date, and know the basics of those conditions.
- Ask about medical and surgical history, current care and medication before you begin, and ask clients with unstable conditions to bring their medication, such as an inhaler.
- If you work in a new setting, or remotely, make sure you know the client’s full address so that you can call an ambulance.
- If you are worried that a medical problem could arise and you are not trained to deal with it, do not take the client on, or ask for medical advice first.
Treat chest pain as potentially life-threatening, every time: the Medical Crisis Guidelines are firm on this point. Stop, call 999 and stay with the person. Your legal responsibilities are the same as anyone else’s: if you are worried about a client’s welfare, call for emergency help without delay.
Your own safety
Violence and threats have no place in practice. Think about safety before there is a problem:
- Do a simple risk assessment of your premises: medication kept on site, working alone, the layout of the room and easy exit, and objects that could be used as weapons.
- Tell someone where you are and when you expect to finish, if you work alone.
- If you feel threatened, do not try to control the situation or ask the person to leave. Leave if you can, create a safe distance and call for help.
- Report any actual assault to the police, and take advice from your insurer and your supervisor.
- Disclosures to the police or to relevant legal and medical agencies about a violent or threatening client can sometimes be justified, but must be limited to what is necessary and recorded. Do not disclose to the public. See Lesson 2.3 and the Breaking Confidentiality Without Consent Policy.
What to tell clients at the start
Many problems come from unclear expectations. At the first session, tell every client, in writing as well as aloud, that you are not a crisis or emergency service, how and when you can be contacted, and who to call out of hours. The Safeguarding Policy says you must not provide informal crisis management by private message. For example:
“I’m not an emergency or crisis service, and I’m not able to respond to messages out of hours. If you ever feel unsafe or in crisis between sessions, please call 999 if it’s an emergency, or NHS 111 and choose the mental health option, or call Samaritans on 116 123 at any time. You can message me to book sessions, and I’ll reply on working days.”
Worked examples
| Situation | What to do |
|---|---|
| During a session a client says they don’t see the point of going on, and that they have thought about how. | Stop the procedure. Ask directly about plan, means and timing. Stay with them. If there is immediate danger, call 999. Otherwise help them to get same-day urgent help (GP, NHS 111 mental health option, crisis team), with a trusted person if they agree. Record, report, supervision. |
| A client has chest pain and feels faint. | Stop at once, call 999, and stay with them. Do not wait to see if it passes. Follow any first-aid training you have, and record what happened. |
| A client seems confused and disconnected, and does not respond when you speak to them. | Stop the procedure, stay calm, and make sure they are safe. Orient them gently. If they do not recover quickly or you are worried, call 999 or arrange urgent medical help. Report it as an adverse event. |
| A client sends a message at 11 pm saying they cannot cope. | Do not try to manage it by text. Reply briefly with the out-of-hours numbers and 999, and say you will follow up on the next working day. If the message suggests immediate danger, call 999 or the emergency number for their location. |
| A client voices strong paranoid beliefs about you. | Stay calm and do not argue with the belief. Keep a safe distance and an exit. Pause or end the session, and arrange help through the client’s GP or the local mental-health service. Take advice from your supervisor, and consider whether IEMT is suitable. |
The service names differ across the UK. In Scotland, NHS 24 on 111 provides urgent help. In Wales, use NHS 111 Wales. In Northern Ireland, the Lifeline helpline (0808 808 8000) offers support. 999 works across the UK. Samaritans (116 123) and Shout (85258) are UK-wide. Outside the UK, find the local emergency number and urgent mental-health route for your client’s location before you start work, particularly for remote clients (Lesson 4.6).
Self-Reflection Exercise
Prepare now, before you need it:
- If a client told you they planned to end their life, what would you do in the first five minutes?
- Do you have first-aid training, and the number of the local crisis team and the client’s GP saved?
- What do you tell clients, in writing, about contact between sessions?
Write a one-page crisis plan for your practice, and review it with your supervisor.
Key Takeaways
- IEMT is not a crisis service. Stop the procedure and get urgent help.
- Screen for risk before you start, and follow the Scope of Practice Policy and Pre-Session Assessment Guidelines.
- Ask directly about suicide, stay with the person, and call 999 if there is immediate danger.
- Treat chest pain as potentially life-threatening, and call 999.
- Keep yourself safe, set clear expectations with clients, and record, report and use supervision.
Next Steps
Lesson 4.6 looks at remote practice: what the Association’s policies say, the risks, and what to do if you work with clients online.