Neurological

Acute psychotic episode with self-harm risk at outdoor music festival

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Adult · 35yr · female

Patient Information

Dispatch	You are called to the medical tent at Wavecrest Music Festival. A 35YO female (Sarah Drummond) has been brought in by security after being found alone behind the main stage, talking to herself and pulling at her own hair.
Patient	Sarah Drummond — 35yr (65kg)
Incident History	Security staff report pt was found pacing erratically behind the main stage approximately 20 minutes ago. She was shouting and appeared to be responding to voices. She has become increasingly agitated since being brought to the FAP and has attempted to scratch her forearms. Festival goers nearby reported she arrived alone.
Emergency Contact	Karen Drummond (Mother) — 0412 774 381

Initial Rapid Assessment

Response	Alert
Airway	Patent. No obstructions. No stridor. Patient talking continuously — airway not at immediate risk.
Breathing	Breathing rapid and shallow. No audible wheeze or crackles. Able to speak in full sentences.
Circulation	Radial pulse rapid and strong. Skin warm and flushed. Superficial linear scratch marks to bilateral forearms — minor bleeding only, haemorrhage not life-threatening.
Disability	GCS 15 (E4V5M6). Not oriented to place or time. Responding to internal stimuli. Agitated. RASS +3.
Exposure	Bilateral forearm scratch marks, superficial — self-inflicted. No other visible injuries. No rashes. No medical alert jewellery. Phone found in pocket.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	98% (RA)	Mild	22	114	138/88	<2s	15	5 5 ++	37.4	5.4 mmol/L	3
10 mins	98% (RA)	Mild	20	108	132/84	<2s	15	5 5 ++	37.4	5.4 mmol/L	2

History Taking

Treatment Response

Diagnosis

This patient is suffering from an acute exacerbation of psychosis, precipitated by non-compliance with antipsychotic medication (olanzapine not taken for 3 days), presenting with auditory hallucinations, disorganised behaviour, agitation (RASS +3), and active self-harm risk.

Facilitator Triggers — if trainees miss a critical step

! (If trainees do not perform BGL within the first 3 minutes — patient begins to rock back and forth and repeatedly states 'they are coming for me'; facilitator prompts: 'Have you excluded an organic cause for this behaviour?')
! (If trainees do not remove sharp objects and potential ligatures from the immediate environment — patient picks up a nearby pen and begins pressing it against her forearm; facilitator states: 'She is escalating — what environmental controls have you implemented?')
! (If trainees leave patient alone at any point — patient attempts to stand and run from the FAP shouting; facilitator prompts: 'She is attempting to leave — what is your safety plan?')
! (If trainees do not contact SOC/CSP for advice — patient escalates to RASS +4, becoming physically combative; facilitator prompts: 'You are now dealing with a RASS +4 patient. Who should you be contacting right now?')
! (If trainees attempt to administer sedative medications themselves — facilitator intervenes: 'What is your scope of practice for sedation at EHS Primary Care level? Sedation is outside your authority — what are your escalation options?')
! (If medication history is not obtained — facilitator prompts: 'She has a phone in her pocket. Her mother's number is in it. What information might her family be able to give you?')

Treatment Objectives

1. Ensure scene safety BEFORE approaching — confirm FAP environment is clear of sharps, ligatures, and other items the patient could use to harm herself or others
2. Call for relevant assistance through State Operations Centre early — request Police if scene safety cannot be maintained and consider urgent backup
3. Do NOT approach alone — ensure a crewmate or security officer is present at all times
4. Perform Primary Survey — airway patent, breathing adequate, circulation intact; note superficial self-inflicted scratch marks to bilateral forearms
5. Perform BGL — result 5.4 mmol/L; exclude hypoglycaemia as organic cause
6. Perform Vital Sign Survey including SpO2 and temperature — all within normal limits; tachycardia consistent with agitation
7. Attempt de-escalation using calm, non-confrontational, non-threatening verbal technique — use patient's name, lower body language, avoid sudden movements
8. Do NOT leave patient alone at any point — suicidal/self-harm ideation is present
9. Carefully remove or have security remove dangerous objects from the patient's immediate environment (pens, lanyards, sharps, bottles)
10. Contact emergency contact (mother, Karen Drummond, 0412 774 381) to confirm medication history — olanzapine 10mg daily, not taken for 3 days
11. Contact SOC Clinical Support Paramedic (CSP) to advise of presentation, seek guidance, and arrange Priority 1 ambulance transport
12. Apply Richmond Agitation Sedation Scale (RASS) score — document as RASS +3 after meaningful de-escalation effort; agree and document RASS score with crewmate
13. Do NOT administer sedative medications — sedation (olanzapine oral dispersible, droperidol, ketamine) is outside EHS Primary Care scope and requires Advanced Care clinician authority
14. Dress superficial forearm scratch wounds with non-adherent dressings and crepe bandage as per Minor Wound Management — haemorrhage is controlled
15. Monitor patient persistently — repeat vital signs every 10 minutes; monitor for escalation in RASS score, emerging organic causes, or respiratory compromise if restraint becomes necessary
16. If physical restraint becomes necessary — use minimum force necessary, DO NOT restrain prone, DO NOT allow patient to be handcuffed to stretcher, monitor airway and breathing continuously during restraint
17. Document RASS score, all de-escalation attempts, restraint decisions, and clinical rationale thoroughly on ePCR
18. Scenario ends on arrival of ambulance and IMISTAMBO handover
19. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Disturbed & Abnormal Behaviour · Minor Wound Management · Blood Glucose Monitor · Primary Survey · Secondary & CNS Survey

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Signs/Symptoms	Patient intermittently shouting at people who 'are not there', pulling at her own hair, scratching forearms. Reports hearing voices telling her she is in danger. Intermittent periods of relative calm between episodes of agitation.
Allergies	NKDA
Medications	Olanzapine 10mg oral daily — not taken for 3 days. No other regular medications.
Pertinent History	Known diagnosis of schizophrenia. Usually managed well on antipsychotic medication. Mother (emergency contact) states pt ran out of olanzapine 3 days ago and has not been to pharmacy. No recent substance use confirmed — pt denies alcohol or drugs today.
Last Oral Intake	Water approximately 2 hours ago. Food approximately 5 hours ago.
Events Leading	Pt attended the music festival alone. Friends and family were unaware she had attended. Pt had not slept the previous night according to mother on phone.
Treatment Prior	Nil treatment prior to EHS arrival. Security attempted verbal de-escalation with limited success.

Onset	Festival security staff state pt has been behaving unusually for approximately 45 minutes. Onset insidious — no witnessed acute collapse or injury.
Pain	Reports scratches on arms are sore — 3/10. Denies any other pain.
Quality	Frightened, disorganised thought, responding to auditory hallucinations.
Radiates	Nil
Severity	RASS +3 on initial assessment. Pt is a significant safety risk to herself and potentially others.