Good morning,

This month, we will be focusing on psychiatric emergencies. Our patients with psychiatric emergencies often refuse to allow care or transport to the hospital. There are two situations when EMS providers are allowed to care for patients against their will: patients who lack medical decision-making capacity and patients who have been pink-slipped. While last week we reviewed medical decision-making capacity, this week we will review pink slips.

Why do we need Pink Slips? Can’t we just assess for capacity?

The question we need to be asking ourselves is if a suicidal patient has capacity. Let’s say we have a patient who reports that he plans to use a gun to shoot himself in the head and is requesting that EMS leave him alone. Four components of capacity:

1. Consistent communication of a choice: the patient communicates he does not want to go to the ED.

2. Understanding of the underlying medical issues at hand: the patient reports he understands he is depressed, and the depression is making him suicidal.

3. Understanding of the consequences, risks/benefits, and pros/cons of each choice: the patient reports that if he is not transported, he will shoot himself in the head and likely die.

4. Ability to reason through the decision in a linear, rational way:  the patient clearly explains his intent to shoot himself and is not being coerced by anyone to do this.  

As you can see, despite this patient being of imminent risk to himself, he still has the capacity to refuse. This is where the pink slip comes in.  

What is a Pink Slip?

The pink slip is a form created by ORC 5122 that allows emergency responders to force a patient believed to be having a psychiatric emergency to be evaluated in the hospital even if they have capacity. There must be sufficient evidence to believe that the mentally ill person represents a substantial risk of physical harm to self or others if allowed to remain at liberty pending psychiatric evaluation. It is important to note that hallucinations or suicidal ideation in itself does not meet the criteria for a pink slip. These symptoms would only meet the criteria if they represented a substantial risk of harm. It is also important to understand that pink slips are based on Ohio law. They do not exist in other states; however, other states have similar legislature to meet this need, but they go by different names and may be different in how they function.

Who is allowed to write a pink slip?

The list of people who can write a pink slip is:

• Psychiatrist

• Licensed physician

• Licensed clinical psychologist

• A health officer

• A parole officer

• A police officer

• A sheriff

• Clinical nurse specialist who is certified as a psychiatric-mental health CNS by the American Nurses Credential Center

• A certified nurse practitioner who is certified as a psychiatric-mental health NP by the American Nurses Credential Center

You can see that EMS providers are not listed. If you are on scene with a patient who you believe is having a psychiatric emergency and meets the criteria for a pink slip, you should request law enforcement to the scene to write one or call medical control. If a patient is willing to go to the hospital for assessment, but there are grounds for a pink slip, we should request one be written before transport. The reason is that without a pink slip, the patient can request to be let out of the ambulance before arriving at the hospital if they change their mind regarding going to the hospital. In this situation, you would be legally obligated to allow the patient to leave if no pink slip had been written. It would also be true for an IFT trip from an ER to a psychiatric facility.

What does the pink slip do once in the hospital?

The pink slip that is written outside the hospital forces the patients to be evaluated by a physician at a hospital. The hospital has 24 hours from the time of receiving the patient to evaluate the patient and decide between the following choices:

1. Not a substantial risk: Discharge the patient.

2. Poses substantial risk: Issue a hospital-based pink slip. The hospital-based pink slip extends the hold to not more than 3 court days. Court days do not include weekends or holidays, so it can be longer than 3 days, depending on when the pink slip is written.

Once the hospital writes a pink slip, the patient will likely be admitted to a psychiatric facility until it is determined that he/she no longer represents a substantial risk of physical harm to themselves or others.

Pink slips give EMS providers the right to transport patients having psychiatric emergencies to the hospital against their will if it is clearly in their best interest. Understanding this law is important for EMS personnel since it helps us navigate these difficult situations.

Be safe and keep up the awesome work!



Dr. Singer

Good morning,

This month we will be focusing on psychiatric emergencies. Our patients with psychiatric emergencies often refuse to allow us to care for them or transport them to the hospital. Once it is determined that they will need transport, either via lack of capacity or pink slip, they are still refusing, leading us to sedate the patient to transport him/her safely. It is not just to protect EMS providers but, more importantly, to protect the patients. This week, we will discuss the use of ketamine.

How does ketamine work as a sedative?

At high doses, ketamine is a dissociative anesthetic. The goal is to fully dissociate the patient, which creates a situation where “the lights are on, but no one is home.” The patient will be calm, relaxed, and stare off into space. They will effectively have a GCS of 3 but will have preserved airway reflexes, preserved respiratory rate, and stable hemodynamics. The patient will also have no memory of the time while sedated with ketamine. It is important to note that patients who are agitated enough to require ketamine are experiencing a sympathetic surge. While ketamine itself does not drop the heart rate or blood pressure, its sedating effect will remove the sympathetic surge. This removal of the sympathetic surge is likely to lead to a drop in the patient’s heart rate and blood pressure, so be prepared for this.

Who should get ketamine?

Ketamine should be rapidly administered to any patient who meets the following criteria:

1. Profound and violent agitation. It can be from a psychiatric or medical cause.

2. The patient is at imminent risk of harm to self or others. It includes situations where the patient prevents treatment of potentially life-threatening illness/injury.

Patients who meet the above criteria are often experiencing a syndrome known as hyperactive delirium with severe agitation. It is a syndrome where the patient is experiencing 6 or more of the following:

1. Pain tolerance

2. Tachypnea

3. Sweating

4. Agitation

5. Tactile/measured hyperthermia

6. Non-compliance with emergency personnel

7. Lack of tiring

8. Unusual strength

9. Inappropriately clothed

10. Mirror/glass attraction

While these patients are clearly a danger to others (such as EMS providers), the profound agitation leads to the build-up of metabolic derangements, including lactic acidosis, hypercapnia, hyperkalemia, dehydration, hypoxia, rhabdomyolysis, and renal failure. The net result of this is sudden cardiac arrest. Rapid control of the patient’s agitation halts the build-up of these derangements and allows EMS responders to rapidly treat the patient’s underlying medical issue. Ketamine is the drug of choice for these patients since it can be given IM and will often control their agitation in under a couple of minutes. 

How do we administer ketamine?

Our protocol utilizes standard doses for all patients as opposed to other protocols, which utilize weight-based dosing.

Adult: 250mg IM

• May re-dose with 250mg IM in 5m if there is no response.

• Max total dose: 500mg IM

Pediatric: 2mg/kg IM

• May re-dose with 1mg/kg IM in 5m if there is no response.

• Max total dose: 250mg IMOnly if ≥16 & >50kg

If ketamine is administered, we must fully assess the patient once they are calm. It includes pulse ox, cardiac monitor, ETCO2, full vitals every 5 minutes, and capillary glucose level. We also should have airway equipment ready in case the patient shows signs of losing his/her airway. We also should have suction ready since a known side effect of ketamine is hypersalivation.

Ketamine is a critical medication that can be lifesaving in treating profound and violent agitation. It is important to realize that this medication has been politicized due to situations where it has been inappropriately used or its use was misunderstood. For this reason, our post-treatment monitoring and evaluation, as well as our documentation, needs to be flawless so that this critical intervention is not taken away from us by EMS responders by politicians.

Be safe and keep up the awesome work!

Dr. Singer

Good morning,

This month, we will be focusing on psychiatric emergencies. Our patients with psychiatric emergencies often refuse to allow us to care for them or transport them to the hospital. Once it is determined that they will need transport, either via lack of capacity or pink slip (but are still refusing)we will need to sedate the patient to transport him/her safely. It is not just to protect EMS providers but, more importantly, to protect the patients. This week, we will discuss the sedatives we carry and how to select the optimal one.

The patient is mildly agitated but not combative in any way.

This is the patient who seems on edge, and you have the concern that, at any second, they could become combative. It also applies to the patient who is not combative but is starting to ramp up in intensity. In these situations, we have the following two options:

1) Midazolam. It is the drug of choice if the patient most likely has a medical cause for his/her agitation. It can include substance use, alcohol withdrawal, or being post-ictal.

• Dose: 2.5mg IV or 5mg IM

• Can re-dose q5m up to 10mg total

2) Olanzapine. It is the drug of choice if the patient most likely has a psychiatric cause of his/her agitation.

• Dose: 10mg ODT

• One total dose

The purpose of treating these patients with a sedative at this stage is to prevent them from progressing to a higher degree of agitation that could be dangerous for EMS as well as the patient.

The patient is agitated and combative but not violent.

This is the patient who is combative and potentially dangerous but has not yet reached the state of hyperactive delirium with severe agitation described last week. In these situations, we have the following options:

1) Midazolam. It is the drug of choice if the patient most likely has a medical cause for his/her agitation.

a. Dose: 2.5mg IV or 5mg IM

b. Can re-dose q5m up to 10mg total

2) Haloperidol + midazolam. It would be the combination of choice if the patient most likely has a psychiatric cause of his/her agitation. IM haloperidol often takes too long to start to work to be effective as monotherapy in the setting of significant agitation. For this reason, it is combined with midazolam to ensure the patient can be safely calmed to allow the haloperidol to work.

c. Haloperidol

 i.     5mg IM (if ≤65yo)

 ii.    2.5mg IM if (>65yo)

d. Midazolam

 i.     Dose: 2.5mg IV or 5mg IM

ii.    Can re-dose q5m up to 10mg total

Understanding the options for sedation helps us determine what the best option is for the patient we have in front of us. There is no one size fits all. At the end of the day, our goal is to safely transport these patients to the hospital to get the care they need.

Be safe and keep up the awesome work!

Dr. Singer