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Scenario: Agitated Male — Aztec Residential

Difficulty: MODERATE Category: Behavioral / Altered LOC Generated: 2026-04-04

Dispatch

Unit 5, respond to 412 W Chaco, Aztec — behavioral complaint. Family called, reporting a 28-year-old male acting erratically, not recognizing family members. PD is en route but has not arrived. Time out: 2118.

Scene Size-Up

Single-family home, residential street. Front door open, light on inside. A woman (late 50s) meets you at the door — says it's her son. She's distressed but not injured. From the doorway you can hear shouting from a back room. No weapons mentioned. PD is 4 minutes out.

Do you enter?

Patient Presentation

You wait at the door. The mother says: - He came home from a friend's house about an hour ago acting "not right" - History of bipolar disorder, normally takes lithium and quetiapine - She doesn't know if he took his meds today - "He's never been like this — usually he's fine" - No alcohol smell that she noticed - He fell earlier in the evening (she's not sure how)

PD arrives in 3 minutes. You enter with officers. Patient is in the kitchen, pacing, shouting, and sweating heavily. He's not making coherent sentences but responds to his name.

Physical exam (once patient is calmer with PD present): - AVPU: V — responds to voice, confused, disoriented - Airway: patent, speaking (shouting) - Breathing: 22, unlabored - Circulation: HR 136, bounding. Skin: flushed, diaphoretic, hot to touch - Pupils: 6mm, equal, sluggishly reactive - Blood glucose: 44 mg/dL - SpO2: 98% - Temperature (if available): 103.1°F rectal (or axillary 102.4°F) - No obvious trauma on visual inspection — but he won't let you fully examine him

Assessment Steps
  1. Scene safety — Do NOT enter before PD. This is a behavioral complaint with an agitated patient at night. Wait for law enforcement. This is not cowardice — it is protocol and it is correct.
  2. Scene size-up — 1 patient (mother denies injury), mechanism unclear (fall earlier), behavioral/possible medical NOI.
  3. Primary assessment — Once you can safely approach: responds to voice (V on AVPU). Airway patent. Breathing adequate. Circulation: tachycardic, flushed, hot, diaphoretic.
  4. Medical cause first — His behavior looks psychiatric, but:
  5. BGL 44 mg/dL = hypoglycemia → can cause aggression, confusion, psychosis
  6. Temp 103.1 = fever → infection, heat emergency, or serotonin syndrome (check meds)
  7. Pupils dilated, sluggish → CNS involvement
  8. He fell earlier → possible occult head trauma All four findings point toward a medical cause for this behavioral presentation.
  9. History — from mother: bipolar, lithium + quetiapine, possibly missed doses, fell earlier, no known drugs/alcohol.
  10. Secondary assessment — Focused exam. Head for trauma from the fall. Neck for rigidity (meningitis). Abdomen for tenderness. Skin for track marks.
Interventions
  1. Do not restrain without cause — Verbal de-escalation with PD. One provider communicates. Calm tone, non-threatening body language, do not stand over him.
  2. Oral glucose — conditional. BGL is 44 mg/dL. He's confused but is he able to swallow? Have him demonstrate by drinking water first. If he can swallow voluntarily, oral glucose is indicated. If he won't cooperate or you cannot safely assess his ability to swallow, defer to ALS for IV dextrose.
  3. Oxygen — SpO2 98%, no immediate need. Have it available.
  4. Cooling — Temp 103.1. Remove excess clothing. Cool environment (move to unit with A/C). Wet towels if available. Do not give oral antipyretics.
  5. ALS — This patient needs IV dextrose (if won't take oral), further eval for fever source, potential chemical sedation if becomes violent (midazolam = ALS scope).
  6. Do NOT assume psychiatric — His known psychiatric history is a distractor. Treat the medical findings. If BGL and temp correct and he normalizes, the psych history becomes more relevant.
  7. Trauma screen — Once safely possible, check head and neck for injury from the fall.
Transport Decision

Priority transport to SJRMC Farmington (nearest ED with psych consult capability).

Do not transport to a psychiatric facility without medical clearance — he has: - Active hypoglycemia - Fever - Possible head injury from fall - Unknown medication compliance - Altered LOC

He needs an ER, not a behavioral health unit. ALS intercept en route on NM-516. PD may ride with you if he's a safety concern.

Key Takeaways

What this tests: Recognizing medical cause of apparent behavioral emergency + scene safety (waiting for PD) + oral glucose decision-making with a semi-cooperative patient.

Common mistakes: 1. Entering before PD — most common student error. The scene is not safe. 2. Assuming psychiatric — he has a psych history, so students anchor on it. The BGL of 44, fever of 103, and earlier fall all demand medical workup first. 3. Not checking BGL — glucometry on every AMS/behavioral patient. Always. 4. Chemical restraint without ALS — midazolam is not in EMT-B scope. You can assist with restraint under PD direction; you cannot sedate. 5. Giving oral glucose without confirming he can swallow — same trap as Scenario 2. Assess swallowing ability first.

NM protocol note: NM behavioral emergency protocol requires medical causes (hypoglycemia, hypoxia, stroke, trauma) be evaluated and treated before psychiatric disposition. EMT-B should not transport directly to a psych facility without ED clearance when medical instability is present.

behavioral-psychiatric | altered-loc | diabetic-emergencies | oral-glucose | scene-size-up | history-taking