This document discusses the management of behavioral emergencies in psychiatry. It covers creating a safe environment, assessing agitation levels, pharmacological interventions including benzodiazepines and antipsychotics, and physical restraint as a last resort with proper training and personnel. The goal is rapid control of agitation while prioritizing patient and staff safety.
2. EMERGENCY PSYCHIATRY
THE PHYSICIAN DEALS WITH SITUATIONS FOR WHICH
IMMEDIATE THERAPEUTIC INTERVENTION FREQUENTLY
NECESSARY.
3. PSYCOMOTOR AGITATION
PSYCHOMOTOR AGITATION IS DEFINED AS A STATE OF MARKED
MENTAL EXCITATION ACCOMPANIED BY PURPOSELESS MOTOR
ACTIVITY, WHICH MAY VARY FROM SLIGHT RESTLESSNESS TO
VIGOROUS UNCOORDINATED MOVEMENTS.
6. IMPORTANT EVALUATIONS
LETHALITY
SUICIDAL AND HOMICIDAL IDEATION,INTENT,ATTEMT
LEGAL RIGHT(CONSEQUENCES OF CIVIL COMMITMENTS)
FACTORS TRIGGERING HOSPITALISATION
NEED FOR CHEMICAL/PHYSICAL RESTRAINS
7. DESIRED FORTITUDE FOR
CLINICIANS
INTINCTS FOR DANGER
TOLERANCE
EMPATHY NOT SYMPATHY
SELF ASSERTION
HONESTY
RESOURSEFULLNESS AND NETWORKING
CREATIVITY
ENDURANCE
HUMOR
PRAGMATISM
8. SAFE ENVIRONMENT
SPECIAL INTERVIEW ROOM: TWO EXIT DOORS,NO
WIRES/TUBES,CEILING NOT
REACHABLE,NONREMOVABLE MATERIALS,FIVE
STAFFS,VISUAL MONITORING,BOLTED DOWN
FURNITURE,ISOLATION ROOM,RESTRAINS MATERIALS.
SCRENING WEAPONS
PANIC BUTTONS
CODING SYSTEM
SECURITY STAFFS NEAR ENTRANCE
9. INTERVIEW
ASSESS THE SCENE
BE PREPARE TO SPEND EXTRA TIME
SAFE DISTANCE,SITTING ON 45 DEG ANGLE
CALM ,HONEST
METHODICAL(SHOW INTEREST IN PT’S STORY)
NONJUDGEMENTAL
RAPPORT
10. OPEN ENDED QUESTIONS
AVOIDING DIRECT EYE CONTACT,AVOID FRIGHTENING
EXCLUDE DISRUPTIVE PEOPLE
ENCOURAGE PURPOSEFUL MOVEMENTS
AVOIDING CHALLEGING
DEVELOP A PLAN OF ACTION.
ONCE THE PLAN IS SET, ALLOW THE PATIENT TO EXERCISE
SOME CONTROL
11. INTERVIEW COURSE
GENERAL QUESTIONS
ASSESSMENT OF DELIRIUM
SUICIDAL IDEATIONS
MEDICAL ILLNESS
PRESENT MEDICATIONS
H/O POISONING
PAST/FAMILY HISTORY/SOCIAL SUPPORT/COLLATERAL
INFORMATIONS
MSE
13. MSE
THOUGHT
IS THE PATIENT MAKING
SENSE?
MEMORY
RECENT
REMOTE
IMMEDIATE
AFFECT AND MOOD
DO THE INNER FEELINGS
SEEM APPROPRIATE?
PERCEPTION
“DO YOU HEAR THINGS
OTHERS CAN’T?”
14. SECONDARY ASSESSMENT
In examining the
extremities, check for:
Needle tracks
Tremors
Unilateral weakness or
loss of sensation
OBTAIN VITAL SIGNS.
EXAMINE SKIN
TEMPERATURE AND
MOISTURE.
INSPECT THE HEAD AND
PUPILS.
NOTE UNUSUAL ODORS ON
THE BREATH.
15. ASSESSING AGITATION
SHOULDN’T BE RESTRAINED OR MEDICATED IMMEDIATELY.
DETERMINE THE PT’S “RISK OF ESCALATION.”
FOUR STAGES OF AGITATION
STAGE 1: THE AGITATION IS MODIFIED BY VERBAL CUES, WITHOUT
LIMITS OR BOUNDARIES BEING INVOKED.
STAGE 2: THE AGITATION IS CONTAINED VERBALLY THROUGH LIMIT-
SETTING, BUT IT PERSISTS NONETHELESS.
STAGE 3: THE AGITATION SUBSIDES DURING TRANSIENT PHYSICAL
RESTRAINT.
STAGE 4: THE AGITATION REQUIRES PHARMACOTHERAPY. IT IS
OTHERWISE INTRACTABLE.
OFTEN STAGES 3 AND 4 ARE CONFLATED.
16. ALWAYS HAVE AN EXIT STRATEGY, AND ENSURE THAT
OTHERS CAN QUICKLY COME TO YOUR ASSISTANCE,
IN CASE THAT’S REQUIRED.
NEVER PLAY HERO(INE) AND TAKE THINGS INTO YOUR
OWN HANDS!
17. CRITERIA FOR HOSPITALISATION
DANGER TO SELF/OTHER
POOR SELF CARE/BREAKDOWN OF SUPPORT SYSTEM
EXTREME DISTRESS OR CRISIS
EXACERBATION OF PSYCHIAYTRIC ILLNESS
CLARIFICATION OF DIAGNOSIS
POOR INSIGHT/JUDGEMENT
INTOXICATION
REPEATED TREATMENT FAILURE
FOR ECT
18. IT IS IMPORTANT TO FORMULATE A TENTATIVE
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS TO GUIDE
TREATMENT.
19. MEDICAL CONDITIONS
ACUTE ONSET
FIRST EPISODE
GERIATRIC AGE
CURRENT MEDICAL ILLNESS OR INJURY
SIGNIFICANT SUBSTANCE ABUSE
NON-AUDITORY DISTURBANCES OF PERCEPTION
NEUROLOGICAL SYMPTOMS
COGNITIVE DYSFUNCTION
CONSTRUCTIONAL APRAXIA
22. IMPORTANT CONSIDERATIONS IN
DIAGNOSIS OF A VIOLENT BEHAVIOR IN
PATIENT
1. PATIENT’S PREMORBID PERSONALITY
2. PAST HISTORY
3. THE UNDERLYING DISORDER
4. THE SOCIAL SETTING
23. PHYSICAL AND PSYCHOLOGICAL CONDITIONS
THAT PRESENT WITH ALTERED MOOD.
PHYSICAL
ALCOHOL INTOXICATION
ANTIHYPERTENSIVE
MEDICATION (E.G.,
METHYLDOPA, PROPRANOLOL,
RESERPINE TOXICITY)
ANTIDEPRESSANT
MEDICATION
BENZODIAZEPINE
INTOXICATION
CARCINOMA OF PANCREAS
CEREBRAL TUBERCULOSIS
CEREBROVASCULAR SYPHILIS
CESSATION OF AMPHETAMINE OR
COCAINE USE
CIRRHOSIS OF THE LIVER
CORTICOSTEROID TOXICITY
DEGENERATIVE DISEASES OF THE
CENTRAL NERVOUS SYSTEM (E.G.,
ALZHEIMER’S DISEASE,
HUNTINGTON’S CHOREA, PICK’S
DISEASE)
DIABETES
ENCEPHALITIS
36. DRUGS
BENZODIAZEPINES CATIONS
LORAZEPAM 1 OR 2
MG,PO/IM/IV
FAST ACTING,
EASY,DOSING,ABSORPTIO
N
NO ACTIVE METABOLITES
NO GLUCURONIDATION
COPD
SLEEP APNEA
37. ANTIPSYCHOTICS
HALOPERIDOL DROPERIDOL
TYPICAL
HIGH POTENCY
CAN BE COMBINED
LORAZEPAM
TO AVOID S/E:COMBINE
WITH
TRIHEXYPHENIDRYL/BENZ
TROPINE/DIPHENHYDRAM
INE
SEDATION MORE RAPID
PROLONG QT INTERVAL
40. PHYSICAL RESTRAINT
IMPROVISED OR COMMERCIALLY MADE DEVICES
BE FAMILIAR WITH RESTRAINTS USED BY YOUR AGENCY
MAKE SURE YOU HAVE SUFFICIENT PERSONNEL
MINIMUM OF FIVE TRAINED, ABLE-BODIED PEOPLE
DISCUSS THE PLAN OF ACTION BEFORE YOU BEGIN
INCLUDE LAW ENFORCEMENT
USE THE MINIMUM FORCE NECESSARY
DON’T IMMEDIATELY MOVE TOWARD THE PATIENT
41. DO NOT
TIE ANKLES AND WRISTS TOGETHER
HOBBLE TIE
PLACE A PATIENT FACEDOWN IN A REEVES STRETCHER
42. ONCE IN PLACE
DON’T REMOVE RESTRAINTS.
DON’T NEGOTIATE OR MAKE DEALS.
PLACE A MASK OVER THE FACE OF A SPITTING PATIENT.
43. CONTINUOUSLY MONITOR
THE PATIENT.
NEVER PLACE YOUR PATIENT
FACE DOWN.
CHECK PERIPHERAL
CIRCULATION EVERY FEW
MINUTES.
44. ADVERSE EFFECT CAN PRESENT
WITH AGITATION
SEROTONIN SYNDROME NEUROLEPTIC MALIGNANT
SYNDROME
CAUSES-SSRI,SNRI,COMBINATIONS
OF MULTIDRUGS
DIARRHEA/CONFUSION/DELIRIUM
/COMA/INSTABLE
ANS/TREMOR/RIGITY/MYOCLONU
S/AKI/DIC/ARDS/SEIZURE
RFT/LFT/CPK/ECG/CBC/INR
RX:DISCONTINUE
DRUGS/IVF/BDZ/ICU
ANTIPSYCHOTICS
HTN/DIAPHORESIS/TACHYCARDIA/
LIVER
FAILURE/AKI/MYOCLONUS/CONFU
SION/TREMOR/RIGIDITY/ATAXIA
SEROLOGIC MARKERS INCLUDE
ELEVATED CK, DEMONSTRATING
RHABDOMYOLYSIS; METABOLIC
ACIDOSIS; AND LEUKOCYTOSIS
RX:DISCONTINUATION/IVF/DANTR
OLENE/BROMOCRIPTINE/AMANTI
DINE/LEVODOPA/BENZTROPINE/C
LONAZEPAM/ECT
45. LITHIUM
TOXICITY
ASSOCIATED WITH NAUSEA, VOMITING, DIARRHEA,
WEAKNESS, FATIGUE, LETHARGY, CONFUSION, SEIZURE,
AND POTENTIALLY COMA
TOXICITY NOT ENTIRELY CORRELATED WITH SERUM
LITHIUM LEVEL; TOXICITY MAY DEVELOP AT DIFFERENT
LEVELS FOR DIFFERENT PEOPLE
OBTAIN SERUM LITHIUM LEVEL, AND EKG
ENCOURAGE HYDRATION; CONSIDER HEMODIALYSIS IN
EXTREME CASES
47. Suicide Risk Factors
PREVIOUS ATTEMPTS
DEPRESSION
AGE
15–24 OR OVER 40
ALCOHOL OR DRUG ABUSE
DIVORCED OR WIDOWED
GIVING AWAY BELONGINGS
LIVING ALONE OR IN
ISOLATION
PRESENCE OF PSYCHOSIS WITH
DEPRESSION
MANIA
F20
HOMOSEXUALITY
HIV STATUS
MAJOR SEPARATION
TRAUMA
MAJOR PHYSICAL STRESSES
LOSS OF INDEPENDENCE
LACK OF GOALS AND PLAN
FOR THE FUTURE
SUICIDE OF SAME-SEXED
PARENT
EXPRESSION OF A PLAN
FOR SUICIDE
POSSESSION OF THE
MECHANISM FOR SUICIDE
48. SUICIDAL IDEATION
ASSESSMENT
EVERY DEPRESSED PATIENT MUST BE EVALUATED FOR
SUICIDE RISK.
MOST PATIENTS ARE RELIEVED WHEN THE TOPIC IS
BROUGHT UP.
BROACH THE SUBJECT IN A STEPWISE FASHION.
DIAGNOSE HIGHER-RISK PATIENTS
49.
50. DON’TS
DON’T LECTURE, BLAME OR PREACH
DON’T CRITICIZE CLIENT
DON’T DEBATE THE PROS AND CONS OF SUICIDE
DON’T BE MISLED BY CLIENT’S TELLING YOU THE CRISIS HAS
PASSED
DON’T DENY THE CLIENT’S SUICIDAL IDEAS
DON’T TRY TO CHALLENGE
51. DON’T LEAVE CLIENT ISOLATED, UNOBSERVED OR DISCONNECTED
DON’T DIAGNOSE AND ANALYZE BEHAVIOR OR CONFRONT PERSON
WITH INTERPRETATIONS DURING ACUTE PHASE
DON’T BE PASSIVE
DON’T OVER REACT
DON’T KEEP CLIENT’S SUICIDAL RISK A SECRET
DON’T GET SIDE TRACKED ON EXTERNAL ISSUES OR PERSONS
DON’T GLAMORIZE, MARTYRIZE, GLORIFY OR DEFY SUICIDAL
BEHAVIOR IN OTHERS, PAST OR PRESENT
DON’T FORGET TO TREAT THE PSYCHIATRIC ILLNESS
DON’T FORGET TO FOLLOW UP
52. HOMICIDALITY
RISK FACTORS:
HISTORY OF VIOLENCE;
AGGRESSION
IMPULSIVITY; INTOXICATION
SINCERE PLAN
COMMON ETIOLOGIES
INCLUDE:
PSYCHOSIS (COMMAND
AHS); AFFECTIVE
DISORDERS; PERSONALITY
VULNERABILITIES;
SUBSTANCE INTOXICATION
OR WITHDRAWAL
MANAGEMENTS
CLARIFY THREAT TO OTHER(S)
IF THREAT IS DEEMED SERIOUS
NOTIFY POLICE
MAKE EFFORTS TO WARN
INDIVIDUAL(S) (TARASOFF
RULING)
ADMIT PT UNTIL THREAT
SUBSIDES
DON’T HESITATE TO ADMIT
INVOLUNTARILY EVEN IF PRECISE
PSYCHIATRIC DIAGNOSIS REMAINS
ELUSIVE IN THE END
53. AGITATED DELIRIUM
FLUCTUATING SENSORIUM
SUICIDAL AND HOMICIDAL
RISK
COGNITIVE CLOUDING
VISUAL, TACTILE, AND
AUDITORY HALLUCINATIONS
PARANOIA
EVALUATE ALL POTENTIAL
CONTRIBUTING FACTORS AND
TREAT EACH ACCORDINGLY
REASSURANCE, STRUCTURE,
CLUES TO ORIENTATION
BENZODIAZEPINES
HIGH-POTENCY
ANTIPSYCHOTICS MUST BE
USED WITH EXTREME CARE
BECAUSE OF THEIR POTENTIAL
TO ACT PARADOXICALLY AND
INCREASE AGITATION
54. ALCOHOL DEPENDENCE AND
DELIRIUM
CONFUSION,
DISORIENTATION,
FLUCTUATING
CONSCIOUSNESS AND
PERCEPTION, AUTONOMIC
HYPERACTIVITY; MAY BE
FATAL
BDZ
THIAMINE
MET
ANTICRAVING
55. GERIATRIC BEHAVIORAL PROBLEMS
DISTRESS AND PAIN MAY BE
CAUSED BY:
EXPOSURE TO NEW
EXPERIENCES
ALTERATIONS TO
ROUTINES
ANXIETY AND DEPRESSION
ARE TOO OFTEN
CONSIDERED A “NORMAL
PART OF AGING.”
AGEISM:
DISCRIMINATION
AGAINST OLDER PEOPLE
56. PEDIATRIC BEHAVIORAL PROBLEMS
50% OF CHILDHOOD
MENTAL ILLNESSES WILL
PRESENT BY AGE 14
YEARS.
MORE LIKELY TO HAVE
COEXISTING PROBLEMS
DIFFICULT TO DIAGNOSE
MENTAL STATUS
ASSESSMENT IS SIMILAR TO
THAT OF AN ADULT.
EXCEPTION: CONSIDER
DEVELOPMENTAL LEVEL.
ABNORMAL FINDINGS ARE
OFTEN RELATED TO
ADJUSTMENT DISORDERS
AND STRESS.
57. MANAGEMENT
AVOID SEPARATING YOUNG
CHILDREN FROM THEIR
PARENT.
PREVENT CHILDREN FROM
SEEING THINGS THAT WILL
INCREASE THEIR DISTRESS.
MAKE ALL EXPLANATIONS
BRIEF AND SIMPLE.
BE CALM AND SPEAK SLOWLY.
IDENTIFY YOURSELF.
BE TRUTHFUL WITH CHILDREN.
ENCOURAGE CHILDREN TO
HELP WITH THEIR CARE
REASSURE CHILDREN BY
CARRYING OUT ALL
INTERVENTIONS GENTLY.
DO NOT DISCOURAGE
CHILDREN FROM CRYING OR
SHOWING EMOTIONS.
IF YOU WILL BE SEPARATED
FROM CHILDREN, INTRODUCE
THE NEXT PERSON WHO WILL
ASSUME THEIR CARE.
ALLOW CHILDREN TO KEEP A
FAVORITE BLANKET OR TOY.
DO NOT LEAVE CHILDREN
ALONE.
58. ABUSE OF CHILD OR ADULT
SIGNS OF PHYSICAL
TRAUMA
MANAGEMENT OF
MEDICAL PROBLEMS
59. ADOLESCENT CRISES
SUICIDAL ATTEMPTS AND
IDEATION
SUBSTANCE ABUSE
TRUANCY, TROUBLE WITH
LAW
PREGNANCY
RUNNING AWAY
EATING DISORDERS
PSYCHOSIS
EVALUATION OF SUICIDAL
POTENTIAL
EXTENT OF SUBSTANCE
ABUSE
FAMILY DYNAMICS
CRISIS-ORIENTED
FAMILY AND INDIVIDUAL
THERAPY
HOSPITALIZATION IF
NECESSARY
CONSULTATION WITH
APPROPRIATE
EXTRAFAMILIAL
AUTHORITIES
60. BORDERLINE PERSONALITY
DISORDER
SUICIDAL IDEATION AND
GESTURES
HOMICIDAL IDEATIONS
AND GESTURES
SUBSTANCE ABUSE
MICRO PSYCHOTIC
EPISODES
BURNS, CUT MARKS ON
BODY
SUICIDAL AND HOMICIDAL
EVALUATION (IF GREAT,
HOSPITALIZATION)
SMALL DOSAGES OF
ANTIPSYCHOTICS
CLEAR FOLLOW-UP PLAN
61. BRIEF PSYCHOTIC DISORDER
EMOTIONAL TURMOIL
EXTREME LABILITY
ACUTELY IMPAIRED
REALITY TESTING AFTER
OBVIOUS PSYCHOSOCIAL
STRESS
HOSPITALIZATION OFTEN
NECESSARY
LOW DOSAGE OF
ANTIPSYCHOTICS MAY BE
NECESSARY BUT OFTEN
RESOLVES SPONTANEOUSLY
62. CATATONIC SCHIZOPHRENIA
MARKED PSYCHOMOTOR
DISTURBANCE (EITHER
EXCITEMENT OR STUPOR)
EXHAUSTION
CAN BE FATAL
RAPID TRANQUILIZATION
WITH ANTIPSYCHOTICS
MONITOR VITAL SIGNS
AMOBARBITAL MAY
RELEASE PATIENT FROM
CATATONIC MUTISM
STUPOR BUT CAN
PRECIPITATE VIOLENT
BEHAVIOR
LORAZEPAM CAN BE USED
63. DELUSIONAL DISORDER
MOST OFTEN BROUGHT IN
TO EMERGENCY ROOM
INVOLUNTARILY; THREATS
DIRECTED TOWARD OTHERS
ANTIPSYCHOTICS IF PATIENT
WILL COMPLY (IM IF
NECESSARY)
INTENSIVE FAMILY
INTERVENTION
HOSPITALIZATION IF
NECESSARY
64. DEMENTIA
UNABLE TO CARE FOR SELF
VIOLENT OUTBURSTS
PSYCHOSIS
DEPRESSION AND SUICIDAL
IDEATION
CONFUSION
SMALL DOSAGES OF HIGH-
POTENCY ANTIPSYCHOTICS
CLUES TO ORIENTATION
ORGANIC EVALUATION,
INCLUDING MEDICATION
USE
FAMILY INTERVENTION
65. DEPRESSIVE DISORDERS
SUICIDAL IDEATION AND
ATTEMPTS
SELF-NEGLECT
SUBSTANCE ABUSE
ASSESSMENT OF DANGER
TO SELF
HOSPITALIZATION IF
NECESSARY
NONPSYCHIATRIC CAUSES
OF DEPRESSION MUST BE
EVALUATED
66. Panic disorder
PANIC, TERROR; ACUTE
ONSET
MUST DIFFERENTIATE
FROM OTHER ANXIETY-
PRODUCING DISORDERS,
BOTH MEDICAL AND
PSYCHIATRIC; ECG TO RULE
OUT MITRAL VALVE
PROLAPSE
ALPRAZOLAM (0.25 TO 2.0
MG); LONG-TERM
MANAGEMENT MAY
INCLUDE AN
ANTIDEPRESSANT
67. HOMOSEXUAL PANIC
ADAMANTLY DENY
HAVING ANY
HOMOEROTIC IMPULSES
AROUSED BY TALK, A
PHYSICAL OVERTURE
PLAY AMONG SAME-SEX
FRIENDS
PANICKED PERSON SEES
OTHERS AS SEXUALLY
INTERESTED IN HIM
VENTILATION,
ENVIRONMENTAL
STRUCTURING
BDZ/ ANTIPSYCHOTICS MAY
BE REQUIRED
OPPOSITE-SEX CLINICIAN
SHOULD EVALUATE THE
PATIENT WHENEVER POSSIBLE
69. RAPE AND SEXUAL ASSAULT
AN UNEXPECTED AND VIOLENT THREAT ON ONE’S LIFE.
IT IS A LOSS, VIOLATION AND INSTANT DEMORALIZATION.
TYPICAL REACTIONS INCLUDE SHAME, HUMILIATION,
ANXIETY, CONFUSION AND OUT RAGE.
70. MANAGEMENT
1. STAY WITH THE PATIENT THE ENTIRE TIME IN THE E.R.
2.EXPLANATIONS FOR SPECIFIC DATA THAT IS NEEDED.
3. CONSENT FOR EXAMINATION AND SPECIMEN COLLECTION
4. PATIENT AND CONSIDERATE. NEVER PRESS OR HARASS THE
PATIENT FOR ANSWERS.
5.ANSWER THE PATIENT’S QUESTIONS AND FREQUENT
REASSURANCE THAT THE PATIENT IS IN A SAFE PLACE.
6.THE PATIENT MUST BE GIVEN TIME AND DATE TO MAKE HER
OWN DECISION ABOUT THE LEGAL PROCESS.
71. 7. EDUCATE THE PATIENT ABOUT THE RAPE TRAUMA
SYNDROME.
8. CALL THE PATIENT 48HOURS LATER AND THEN WEEKLY FOR
FOLLOW UP.
9. ON LATER STAGES, PROVIDE COUNSELING WITH REALISTIC
ISSUES SUCH AS WORK, HOME, LEGAL DIFFICULTIES, SHARING
OF EMOTION, FUTURE REHABILITATION.
72. CRISIS INTERVENTION
UNEXPECTED SERIES OF EVENT
DANGER OR OPPORTUNITY
PHYSICAL,PSYCHOLOGICAL,INTERPERSONAL
DEVELOPMENTAL,SITUATIONAL
74. DEATH AND DYING
DENIAL AND ISOLATION
ANGER
BARGAINING
DEPRESSION
ACCEPTANCE
75. LEGAL ISSUES IN EMERGENCY
PSYCHIATRY
CONFIDENTIALITY
DUTY TO WARN
COMPETENCY
INFORMED CONSENT
INVOLUNTARY COMMITMENT
76. BEHAVIORAL EMERGENCIES CAN PRESENT UNIQUE
CHALLENGES IN PATIENT MANAGEMENT. FOCUS ON
REDUCING THE PATIENT’S STRESS WITHOUT
EXPOSING OWNSELF TO UNNECESSARY RISKS.
77. OUR GREATEST WEAKNESS LIES IN GIVING UP. THE
MOST CERTAIN WAY TO SUCCEED IS ALWAYS TO TRY
JUST
ONE MORE TIME.
-THOMAS EDISON
78. REFERENCES
Kaplan & sadock's comprehensive textbook of
psychiatry, 9th edition
Emergency psychiatry by Hani raoul khouzam,Doris
tiu tan,Tirath sing gill