Neurological

Acute psychotic episode with agitation and self-harm risk

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Adult · 35yr · male

Patient Information

Dispatch	You are called to the spectator concourse at Optus Stadium during an AFL match. Security have a 35YO male (Daniel Marsh) who is acting erratically, talking to himself and refusing to leave the area. A bystander states he has been increasingly distressed for the past 20 minutes.
Patient	Daniel Marsh — 35yr (80kg)
Incident History	Pt is pacing rapidly, speaking loudly to himself, appearing frightened and suspicious of bystanders. Security staff report he arrived alone and has been escalating. No known injury. Bystander states pt's partner mentioned he stopped his medication 3 days ago.
Emergency Contact	Karen Marsh (Partner) — 0412 558 743

Initial Rapid Assessment

Response	Alert
Airway	Patent. No obstruction, no stridor, speaking in full sentences (though disorganised).
Breathing	Rapid and shallow. No wheeze or stridor. Increased respiratory rate consistent with agitation.
Circulation	Radial pulse rapid and strong. Skin flushed and diaphoretic. No visible bleeding.
Disability	GCS 14 (E4V4M6). Disoriented to place and situation. Responding to internal stimuli — appears to be responding to auditory hallucinations. Not oriented to time, place or person.
Exposure	No visible injuries or rashes. No signs of trauma. Pt is wearing civilian clothing, no weapons visible. No medic alert bracelet observed.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	97% (RA)	Mild	22	112	148/94	<2s	14	4 4 ++	37.4	5.4 mmol/L	–
10 mins	96% (RA)	Moderate	26	124	155/98	<2s	13	4 4 ++	37.6	5.4 mmol/L	–

History Taking

Treatment Response

Diagnosis

This patient is suffering from an acute psychotic episode secondary to antipsychotic medication cessation (risperidone stopped 3 days ago), presenting with auditory hallucinations, paranoid ideation, and escalating agitation with a RASS score of +3 progressing toward +4, placing him at risk of self-harm and harm to others.

Facilitator Triggers — if trainees miss a critical step

! (If trainees do not establish scene safety or request Police assistance early — patient suddenly lunges toward the barrier railing at the concourse edge, shouting 'They're coming for me!' Facilitator states: 'Daniel moves rapidly toward the stadium railing approximately 1 metre away — what do you do?')
! (If trainees do not contact SOC / CSP within the first 5 minutes — patient begins striking his own head with his fist, escalating to RASS +4. Facilitator states: 'Daniel is now hitting himself and screaming. RASS is now +4. How are you managing this?')
! (If BGL is not checked — facilitator prompts: 'You have not excluded an organic cause for the behavioural disturbance. What investigations are you performing?')
! (If trainees attempt physical restraint without Police or sufficient personnel present — facilitator states: 'You are alone with one other EHS officer. Daniel is 80kg and actively resisting. Is this safe and appropriate right now?')
! (If trainees do not identify medication cessation as the likely precipitant — facilitator prompts: 'Karen, Daniel's partner, is calling back on the phone. She says he stopped taking something 3 days ago. What do you ask her?')
! (If suicidal ideation / self-harm risk is not explicitly addressed — facilitator states: 'Daniel shouts: I just want it all to stop. I can't do this anymore.' What specific action do you take now?')

Treatment Objectives

1. Ensure scene safety — confirm no immediate environmental hazards (railing proximity, crowd, restricted areas). Do not approach until scene is safe.
2. Call for Police assistance via State Operations Centre (000) early given RASS +3/+4, risk of self-harm, and escalating behaviour.
3. Maintain a safe distance initially. Adopt non-confrontational body language — no sudden movements, calm tone, open posture.
4. Attempt verbal de-escalation — introduce yourself calmly, use patient's first name ('Daniel'), speak slowly in short sentences. Avoid arguing with delusional content.
5. Contact SOC CSP as soon as practicable to advise of presentation and obtain clinical support — document time of contact.
6. Complete Vital Sign Survey including BGL (mandatory — must exclude organic causes: hypoglycaemia, hypoxia, TBI). BGL 5.4 mmol/L — hypoglycaemia excluded.
7. Perform primary survey — confirm GCS 14, SpO2 97% (RA), RR 22. Organic causes (hypoxia, hypoglycaemia, TBI, CVA) must be considered and excluded before attributing presentation to primary psychiatric cause.
8. Identify and document RASS score — initial RASS +3. Reassess after meaningful de-escalation attempts before any sedation is considered.
9. Explicitly address self-harm risk — if patient expresses suicidal ideation ('I want it all to stop'), do not leave patient unattended. Remove or have bystanders remove any dangerous objects in the immediate environment.
10. Contact Karen (partner) via phone to confirm medication history — risperidone ceased 3 days ago, known schizophrenia, previous similar episodes. Document this history.
11. Do NOT administer sedative medications — sedation (Olanzapine, Droperidol, Ketamine) is Advanced Care scope only and is not authorised for EHS officers.
12. Do NOT physically restrain unless essential to protect patient or others from immediate harm, and only with sufficient personnel and Police present. Use minimum force necessary.
13. Do NOT transport patient prone or handcuffed to stretcher under any circumstances.
14. Repeat vital signs every 10 minutes — at 10 minutes GCS 13, RR 26, HR 124, BP 155/98 — document clinical deterioration and escalate to SOC CSP.
15. Maintain continuous reassurance and verbal de-escalation throughout. Monitor for signs of positional asphyxia if any physical restraint is applied.
16. Prepare for handover to Police and higher-scope clinicians (ILS/ALS) — document RASS scores, timeline of escalation, medication history, and all interventions attempted.
17. Scenario ends on arrival of ambulance and Police, and IMISTAMBO handover.
18. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Disturbed & Abnormal Behaviour · Hypoglycaemia · Unconsciousness

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Signs/Symptoms	Auditory hallucinations, paranoid ideation, disorganised speech, pacing, increasing agitation, diaphoresis.
Allergies	NKDA — confirmed via partner Karen.
Medications	Risperidone (antipsychotic) — last taken 3 days ago. No other regular medications.
Pertinent History	Known diagnosis of schizophrenia. Managed on regular risperidone. Partner reports this is consistent with previous decompensation episodes when medication is ceased. One prior involuntary admission to psychiatric inpatient unit.
Last Oral Intake	Unknown — partner uncertain, possibly not eaten today.
Events Leading	Pt attended the AFL match alone. Security first noticed him approximately 30 minutes ago pacing on the concourse and talking to himself. Behaviour escalated with pt becoming suspicious of security staff and attempting to move toward restricted areas.
Treatment Prior	Nil prehospital treatment. Security have been attempting verbal de-escalation for approximately 20 minutes prior to EHS arrival.

Onset	Escalating over the past 20–30 minutes at the event. Partner (via phone) reports gradual deterioration over 3 days since stopping medication.
Pain	Nil reported. Pt not engaging with pain assessment.
Quality	Acutely agitated and distressed. Intermittently shouting, not responding to redirection.
Radiates	Nil
Severity	RASS +3 (very agitated — aggressive behaviour, unreasonable) on initial assessment, escalating toward RASS +4.