Competence and alcohol

[Veneficus]

I saw this post in another thread and rather than hijack it, I figured I would start a new discussion.

Technically he meets S.D. protocol to back board since he was ETOH + and competing pain. On the other hand if your assessment was thorough and he refused treatment then you are fine. I would just make sure he didn't smell of ETOH, no impairment in LOC or sign of intoxication which can distort pain. Make sure he didn't hear any cracking or popping when hitting the snow. I would have asked if the snow was powder, compact or icy and if their were any hard objects underneath.

For many years in EMS, it has been taught and advocated that ETOH not only conceals pain and injury, it also automatically disqualifies a person from being a reliable historian or self determination.

But does it?

Most people I associate with can have a drink or two with no appreciable impairment at all. (Some I would say it even helps their judgement)

The amount an alcoholic needs to drink is usually appreciable more than the average person to become inebriated. Severe alcoholism requires a certain level of alcohol in the body to function properly.

Many nations, excluding the US unless something has changed, do allow for "clinically drunk" in their determination of whether a person is intoxicated.

Let's consider an example...

What if I was at a bar and I had a drink? Suppose for a second that I fall off the bar stool while doing a double take of an attractive lady who just entered. So I fall down, spill some alcohol on myself, and some off duty EMT in the bar complete in whacker gear, runs over and decides to call 911 and hold c-spine...

What if I refuse this good samaritan's help? Am I competent to make that decision? If I refuse and he maintains I am not competent, he could find himself in serious legal trouble, depending on how forgiving I am feeling.

Especially if I go get a blood test done that shows I am well within the legal BAC for operating a motor vehicle.

Now that EMS arrives, are they going to automatically decide I need spinal precautions and transport? That I am distracted or inebriated?

What if they restrain me against my will and drive me to the hospital?

What happens if after a brief chat with the ED doc he decides I do not meet the criteria for involuntary commitment?

Who is going to pay the bill for all of that? (I can assure you it won't be me)

Because everyone who touched me against my will is going to be on the hook for it. As well as my best efforts to press charges for assault, battery, kidnapping, and wrongful imprisonment because it will help me bolster my civil case for damages. (don't think I won't be able to find a lawyer for it, because I personally know a handful who would be more than willing to take that case on consignment) I wouldn't even have to be belligerent about it, I might even say "thank you" as you left me at the hospital.

The drunk bounce...

If you haven't yet seen it, most intoxicated people can survive, in many cases completely without serious injury, some very extreme mechanisms. Simply put, they don't tense up and flexibility better absorbs impact.

Drunk people aren't more likely to be seriously injured, they are less likely.

But what constitutes drunk? In Whom? What constitutes too drunk to understand and make informed decisions?

Does it only apply to alcohol? A depressant which is available without a prescription? Does it extend to other mind altering substances like diphenhydramine? (aka Benadryl) Other prescription or nonprescription medications?

How much? When?

Now from the "do no harm" standpoint, you are going to force an iatrogenic treatment on me against my will, drive me to the hospital where I will be subject to further economic insult, and you are ok with that?

Perhaps you will invite a police officer to "persuade me" and add abuse of process or malicious prosecution to your list of misdeeds, drawing this poor officer into a very unfortunate situation?

Now suppose your patient is not as informed as I am. Does it make it ok to violate the rights of people who know less because they don't know?

That seems like gross misuse of the position of trust a healthcare provider is given.

I would suggest if you find yourself in a situation where a person's ability of self determination is in question, you not simply follow the wrote protocol and make a call to medical control? Especially before you restrain somebody.

 

[RocketMedic]

I'd like to think that it was always this simple, but from my new-guy perspective, I really don't know what my own employment future would hold were I to go and start calling the best medical controls I could and following their dictates, or even practicing evidence-based assessment-driven medicine, as opposed to Mandatory Cookbook-ocols. For many paramedics, especially those in Kool-Aid Socials, I suspect that this holds true.

Then again, I already get weird looks for "free thinking" and at least one Kool-Aid Mixmaster doesn't particularly want to partner with me. I have, however, attracted a small cloud of fellow free-thinkers.

 

[shfd739]

Then again, I already get weird looks for "free thinking" and at least one Kool-Aid Mixmaster doesn't particularly want to partner with me. I have, however, attracted a small cloud of fellow free-thinkers.

You too? lol. After refresher class last friday more of my coworkers dislike me and the FTO likes me more. Apparently mentioning studies/evidence instead of "tradition" is finally in my favor.

My approach to these patients is if you can answer the questions and hold a conversation with us, your speech isnt slurred, and you can walk/move in a normal appearing fashion then you arent intoxicated. Amount consumed and smell doesnt matter.

The only question I have to answer regarding this on a refusal is "Does the patient appear intoxicated?" If you meet the above then Im marking "no" and explaining out my findings in the report.

For the bar example with no complaints of pain: Ill tell the ricky rescue thanks for the help, sit you up, talk some more and probably get a refusal if thats what you want. In the process ricky rescue will get his feelings hurt and thats fine with me.

 

[mycrofft]

LEO can declare you a 5150 (threat to self and others) and then its "off to the races".

Worked detox for six years, and did some booking interviews off and on over 22 years. I saw people fresh off the street drunk, I saw them after days without alcohol but on tapering benzos, I've seen them without any ETOH or benzos later on. Also saw them on the street as an EMT.

People can have little motor impairment but still have affected inhibition.

Folks can have nothing going on acutely but be experiencing the long-term effects like Korsakov's encephalopathy, other malnutrition and hepatic issues, and repeated closed and other type injuries to head and other systems, which can affect their decision making etc.

As for "drunk bounce" for MVA's, I seemed to see that alcohol-intoxicated people either seemingly came out better, or were dead because they got themselves into an unsurviveable situation. Kind of cut out the "bell" of the "bell curve". I don't recall a similar "drunk bounce" for non-MVA's (fights, falls, lacs) , and nowadays cars have so much survivability gear built in that the difference is trending toward asymptotic.

 

[nwhitney]

Here in my neck of the woods. LEO or a small number of EMT's can put people on a civil hold if they are not able to care for themselves and are inebriated. If they do then the person is taken to the drunk tank. Even if they blow above 0.08 they can still legally refuse medical treatment. For that matter regardless of the drug(s) they are on they can refuse medical.

 

[Rano Pano]

All this from a guy falling off a stool after one drink, huh?

I get the point everyone's trying to make, BUT if you're anyone of the responders involved in the scenario you were probably going to yourself sued at some point in time.

 

[Veneficus]

All this from a guy falling off a stool after one drink, huh?

I get the point everyone's trying to make, BUT if you're anyone of the responders involved in the scenario you were probably going to yourself sued at some point in time.

Fine, 3 drinks. 5 drinks, it doesn't matter...

The smell or admission of ETOH use, does not preclude somebody from being able to understand and make a reasonable decision.

Besides, everyone knows the drunks only ever have 2 drinks.

 

[VFlutter]

When I fell off a barstool I got the whole work up...but then again I was way over the legal limit and lost consciousness for a period of time. That being said, when I did regain consciousness in the ER I requested that they take the C collar off and said I did not want a CT. Should they have honored my requests? Probably not since my competency was pretty questionable. But if they did it would have saved me $25k in bills.

 

[Veneficus]

Probably not since my competency was pretty questionable.

I think questionable competency is another matter.

 

[EpiEMS]

Does somebody having a drink or two (or, heck, 5) preclude them from being considered competent? No.

I apply similar standards for intoxication as I do to other sorts of AMS. I like taking parts from the mini-mental status (though not in the same exact way its scored), such as time and location orientation specificity (in that there is a difference between saying "It's nighttime" versus "It's about 5:15 pm on Monday, January 21st, 2013." Affect and appearance are good assessment tools: do they appear well-kept and is their mood appropriate? Are they putting themselves in danger, or are they displaying reasonable judgement?

People can be drinking without being drunk. Likewise, they can be drinking and have alcohol on board without being incompetent to make decisions. Will I be more willing to board a trauma patient that's intoxicated? Yes. But will I still be ok with ruling out the need for immobilization just like I would with any other patient? Yes.

 

[mycrofft]

Fine, 3 drinks. 5 drinks, it doesn't matter...

The smell or admission of ETOH use, does not preclude somebody from being able to understand and make a reasonable decision.

Besides, everyone knows the drunks only ever have 2 drinks.

That's 2 BEERS. "All I drink is beer, officer!".

 

[WTEngel]

As far as I am concerned, if they do not appear altered, have intact neuro, and are not displaying behavior that appears to be a threat to themselves or anyone around them, then the decision is their own to make, ETOH or not. In fact, an officer who pulls over a person, smells alcohol, administers a field sobriety test and has the person blow with the result being less than 0.08%, will almost certainly allow that person to proceed down the road, even if they smell of ETOH.

I know we are not doing field sobriety tests or administering breathalyzers, however the snap judgement that many make when they smell ETOH on the patient is not appropriate in the absence of other supporting evidence that the patient should not be allowed to make their own medical decisions.

If they are displaying questionable behavior and I feel like leaving them is a bad decision, yet they are not altered, I will get police involved, and they can make the call as to whether they want to put the person in custody or not. Even though they are not doing anything illegal necessarily, if they are displaying behavior that is irrational, up to and including not seeking medical treatment when an otherwise non-altered person would seek treatment, then the police where I work were normally pretty good about giving us the assistance we need to make sure things are legal.

Where I am from, EMS professionals are not allowed to take a patient against their will unless life or limb is clearly at risk. Consent is implied at this point, because it is assumed that a rational person would make the decision to seek medical treatment when life or limb is at risk, and the patient in question is displaying a decision making pattern that is not consistent with being fully alert and oriented.

Even with all of this, you may still find yourself defending your actions in court. I would much rather explain my actions related to taking a person who appeared to be about to die (and you better believe the chart will reflect this!) as opposed to defending why I left a patient who was most likely altered to die in their home.

Which situation do you think the jury will find sympathy for the EMS provider in?

 

[mycrofft]

BTW, the accepted legalese statement is that an "alcohol-like odor" was present.

 

[EpiEMS]

BTW, the accepted legalese statement is that an "alcohol-like odor" was present.

Is there alternative phrasing that's acceptable if the patient denies alcohol use? I would think that mentioning odor, normal BGL, presence of empty bottles, that sort of thing?

 

[ToyotaTruck]

I dislike drunks. I had a drunk guy punch through a window w/big bloody lac on his arm. I get to him and he starts spitting blood at me. Screw that, scene safety. PD puts a spit mask on him. Get him packaged and in the back and he the vomits all over the back of my rig. Took me 2 hours over my graveyard shift to clean my unit. I don't like drunks. Medics threw a tourniquet on him I wonder if he lost his arm.

 

[EMDispatch]

Working at a college, I learned to never, ever trust an intoxicated person as "competent" at initial presentation. I've known many blackout drunk, binge drinking students that could appear sober and of sound mind even while extremely intoxicated.
A critical factor to consider is you have no clue how much they have had to drink for sure, and how long ago. In 5 years I watched well over 100 people go from slightly buzzed to sloppy drunk of the course of a short conversation. They often neglect to mention the "2 beers" were four hours ago, and they had 4 jagerbombs shortly before I walked up. That being said, I've also watched sloppy drunks quickly sober up.
It boils down to a matter of trust for me. Do you trust a pilot who had few drinks before flying your plane, or a surgeon that just came out of a bar to perform a surgey?

 

[Tigger]

Working at a college, I learned to never, ever trust an intoxicated person as "competent" at initial presentation. I've known many blackout drunk, binge drinking students that could appear sober and of sound mind even while extremely intoxicated.
A critical factor to consider is you have no clue how much they have had to drink for sure, and how long ago. In 5 years I watched well over 100 people go from slightly buzzed to sloppy drunk of the course of a short conversation. They often neglect to mention the "2 beers" were four hours ago, and they had 4 jagerbombs shortly before I walked up. That being said, I've also watched sloppy drunks quickly sober up.
It boils down to a matter of trust for me. Do you trust a pilot who had few drinks before flying your plane, or a surgeon that just came out of a bar to perform a surgey?

If I "appear" to be sound of mind, than am I not of sound mind? If you ask me questions and I provide appropriate answers to them, then what? Are you going to tell me that I can't refuse because you suspect I have had a lot to drink? How can you tell when someone has the tolerance to handle quite a bit of alcohol, and someone that does not?

The college kid is not flying a plane, they just want to walk home and go to sleep.

 

[EMDispatch]

If I "appear" to be sound of mind, than am I not of sound mind? If you ask me questions and I provide appropriate answers to them, then what? Are you going to tell me that I can't refuse because you suspect I have had a lot to drink? How can you tell when someone has the tolerance to handle quite a bit of alcohol, and someone that does not?

The college kid is not flying a plane, they just want to walk home and go to sleep.

The problem is the College Kid who has failed to have all the ETOH enter the blood stream. Oe occasion remember in particular, the individual we were dealing with went from full complete sentences and and fully alert to incoherrent babble 20 minutes later followed by vomiting and all the other fun that comes along with alcohol posioning. I went through many events simlar between the college and working at a Casino.

I understand what people are saying about a few drinks, but my ability to accept a statement like that at face value has been ruined by experience. I guess in my mind, the question is are you really competent in those minutes before your BAC shoots through the roof.

 

[mycrofft]

Is there alternative phrasing that's acceptable if the patient denies alcohol use? I would think that mentioning odor, normal BGL, presence of empty bottles, that sort of thing?

You can't say "the smell of alcohol" because then the defender asks if you are a chemist; did you know that many people in early ketoacidosis or suffering from inhaled aromatic toxins have been thought to be drinking alcohol and sometimes died in custody; with objective measurements around how come you're using the odor of someone's breath?

You say and document "an alcohol-like odor" so that has raised your suspicion that the pt needs help and might, might have imbibed. OR something else. EIther way, they get help and their alteraton of consciousness is "decriminalized" until LE steps in and does their thing.

Hey, why not have a breathalyzer for ALS units? Of any clinical help? (I'd think....no).

 

[Meursault]

Hey, why not have a breathalyzer for ALS units? Of any clinical help? (I'd think....no).

Probably not, given the small number of zebras you'd catch, but it would be fun. Boston Medical Center has a breathalyzer at triage, though.