# When do you transport "EtOH" patients?



## RedAirplane (Nov 24, 2015)

I put "EtOH" in quotes because it's a diagnosis of last resort, I know. Be suspicious of hypo/hyperthermia, stroke, hypo/hyperglycemia, and the whole kitchen sink. 

We were dealing with a special event this past weekend and "patients" tend to straddle that line between competent to refuse and just go home and rest, and altered enough to require a full EMS workup and transport. (For this example there's no third option).

Some people say that any EtOH onboard removes decision making capability. That doesn't make any sense because then EMS would just transport the entire local pub to the hospital. 

Some people say to use the A&Ox4 questions. But what if the patient can answer these questions while sitting, but is visibly "out of it" and can't stand/walk without assistance? (And doesn't want to go with you, but you can't very well leave him on the chair/ground alone...)

It's a good option to leave someone with a responsible parent/friend/sister. But what if their family member or friend is equally altered and planning to drive both of them home? What are your duties ethically, legally, etc?

If it's an open secret that other pharmaceuticals are involved at the event, how might that change your decision making process? How long do you have to be with a patient to know that they aren't going to crash?


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## BlueJayMedic (Nov 24, 2015)

We have an Aid to Capacity form that you must fill out each time we do a sign off, if the patient doesn't meet the criteria then they go to the hospital either willingly or under a form with police. CAOx3, understands risks, "responsible" adult on scene, over age 16 (unless substitute decision maker is signing) and ability to reactivate if necessary. I have no problem signing off ETOH patients that are able to care for themselves or have a competent companion for the night. This is where experience and judgement come in. If someone in front of me is alert to person, place and time and can't stand or is continuously barfing all over themselves then I am going to get the police or a supervisor involved to explore other options. You also need to use that feeling for the friend or family member they are staying with. Nine times out of ten when someone wants to sign off (regardless of complaint) I will look them in the eye and say "if you do not come with us tonight there is always a chance you will die." Even if I know that it would take a super extreme scenario for them to die, at least i have done my due diligence in explaining the risks involved with refusal. Personally, from a legal standpoint, I try to transport anyone who dials 911. The larger problem lies in the people who did not want us there in the first place and a bystander or third party activates us. 

As far as other pharmaceuticals are concerned, that changes the CC from ETOH intoxication to substance misuse/toxicology and is a different beast altogether. Again, in any of these situations regardless of ETOH, drug abuse, general medical or otherwise if that gut feeling is even slightly off I will always involve a higher authority or the police as different avenues to either transport or collaboratively agree to leave the patient as-is. This is not meant to pass the responsibility off to someone else but to find a way to talk the patient into transport.


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## johnrsemt (Dec 1, 2015)

You would only transport the entire pub if someone called about them all needing an ambulance.

That is always an interesting question though:  When is drunk to drunk to make decision of refuse or not?


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## RedAirplane (Dec 1, 2015)

johnrsemt said:


> You would only transport the entire pub if someone called about them all needing an ambulance.
> 
> That is always an interesting question though:  When is drunk to drunk to make decision of refuse or not?



Usually some bystander reports an unconscious guy yelling at people (???) way over there and we go investigate.


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## COmedic17 (Dec 1, 2015)

Our county has a detox bigger then the actual jail. No exaggeration. 

We take a pulse, spo2, BP, BGL, and if they can walk assisted, PD takes them to detox. 
It's pretty fantastic. But there's a massive homeless population here that enjoys drinking anything they can get their hands on ( mouth wash, vanilla extract, you name it) and we house a huge "party school".......so it's very much needed. We rarely transport someone who has no other complaints then Being wasted.


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## Ensihoitaja (Dec 1, 2015)

For us, if they're A&O x4, with clear speech, and a steady gait then they have decision-making capacity and they can refuse. If they don't meet all those criteria, then we need to make sure they're taken care of. 

If they're clinically intoxicated and they have a complaint or injury then they're going to the hospital. 

If they don't have any complaints or injuries, then we have a few options. If they have a sober person with them , we can release them to a responsible party. If the other person isn't clinically sober, then we can't release them. We release people to responsible parties a lot at special events. 

If there's no one to release them to, they can go to detox. We have a detox van that will pick people up from us, or the police or sheriff's deputies can transport them. We don't transport to detox with the ambulance. Detox candidates have to be able to walk with "minimal assistance," have normal vital signs, and no complaints or signs of injury. 

To summarize, have decision-making capacity? Great, not my problem.
No decision-making capacity and a complaint/injury or can't walk? Hospital. 
No decision-making capacity and no complaint/injury? Detox or responsible party.


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## MS Medic (Dec 2, 2015)

There is a difference between someone who is legally intoxicated and so drunk they are medically incompetent. If they are drunk but meet AOx4 criteria, they have the right to refuse. On the other hand I've had a pt who was just off and I wasn't comfortable obtaining a refusal on them. I solved this by contacting med control and explaining the situation. I then let the doctor talk to the pt and once he got the same feel for the pt I did I was able to get orders to force transport. I'm not a fan of calling and passing the buck but in my state we have to get verbal orders to force transport and by calling and expressing your concerns, you meet requirements of your doing your due diligence.


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## RedAirplane (Dec 2, 2015)

Let's say your patient can answer all of the A&O questions, but he isn't "alert" per se--you have to prod him to get him to talk. His only companion is slurring her speech and walking with a wobble and wanting to drive them both home. You ask the pt to remember three words and five minutes later he doesn't know what they were. You have no alternate destinations besides Emergency Room. Would that be where you end up?


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## MS Medic (Dec 2, 2015)

Then that would be responsive to painful stimuli and not A&O. Unless LEO wants to take him that would be a trip to the ED where I'm from.


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## RedAirplane (Dec 2, 2015)

Not actually prod... I meant it figuratively. 

You have to keep saying "Hey! Pay attention!"


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## Tigger (Dec 2, 2015)

Ensihoitaja said:


> For us, if they're A&O x4, with clear speech, and a steady gait then they have decision-making capacity and they can refuse. If they don't meet all those criteria, then we need to make sure they're taken care of.
> 
> If they're clinically intoxicated and they have a complaint or injury then they're going to the hospital.
> 
> ...


This is how we do it in the springs as well. Ambulances will transport to detox as well if the detox van is not available, we don't have enough have enough beds to put ambulatory drunks in the EDs unless they have a complaint of some sort.

My full time place west of the springs will transport detox patients with a single provider in an SUV, detox is a regional resource (though I wish we had one in our county, it's a long drive).


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## MS Medic (Dec 3, 2015)

RedAirplane said:


> Not actually prod... I meant it figuratively.
> 
> You have to keep saying "Hey! Pay attention!"



Ok so would you classify as him as responsive to verbal stimuli then? If so then would you classify that as A&O?


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## RedAirplane (Dec 3, 2015)

MS Medic said:


> Ok so would you classify as him as responsive to verbal stimuli then? If so then would you classify that as A&O?



Good point. I always thought of verbal stimulus as the pt grunting or something, not talking appropriately. But what you're saying makes sense.


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