# Legality of Assessment of a "ETOH" (drunk) Patient



## rmyers3458 (Dec 11, 2008)

This is a good one.. read till the end.. 

Have an issue.. Were dispatched to a ETOH patient laying on the lawn of a residence.  PT didn't know how he got their, little lathargic, and admited that he had been drinking.. PD on scene.  Gave PT 3 options, go home, have PD arrest the PT or we take him to the hospital. PT stated that he couldnt make it home.

Squad took vitals, once to the hospital released to Hospital and placed in Triage.

This is the kicker.... 

5 hours later PD called and stated they recieved a call from the Hospital stating that the PT had a *bullet hole *in the back of his head.  

PT never stated that he was posible shot.. No apparrient DCAP BTLS... Hospital placed PT in Triage and found it 4 hours later.

Now my question is, by the law of EMT BLS, where we obligated do perform a complete full body assessment.  Or was the Assessment completed when asking him questions and he stated that he had been drinking and coulndt make it home.  PT was answering basic questions and never complained of pain..


----------



## Noctis Lucis Caelum (Dec 11, 2008)

I was taught to do a FULL complete assessment weather its a medical or trauma. We ran a lot of scenarios on medical and it'll turn out to be trauma and vice versa.  Just because the patient doesn't tell you whats going on doesn't mean you don't need to check.  They could have all sort of things on them.  So i believe we are obligated to do a full body assessment.  Check kill zones, flanks, etc.  It'll make you a better EMT also when you deliver and present the patient to the hospital. Because when the hospital finds out something else on the patient where you didn't on your assessment.  They're going to remember who you are.  I'm not talking about things outside our scope of practice.  Just full visualization and palpation of the patient on what we were taught.

Patient also told you he didn't know how he got there. AVPU, AN04, AEIOU TIPS, you ruled out ETOH, but down the list there's also Trauma.


----------



## VentMedic (Dec 11, 2008)

There are 3 types of patients that you may automatically make wrong assumptions and assessments even in your best efforts not to.  A lot will depend on the company you keep (partner with attitude) and your education in medicine.

Substance abusers (alcohol or drugs)
Patients with mental illness (assumed or professionally diagnosed)
COPD patients


----------



## Ridryder911 (Dec 11, 2008)

I don't know about them your Honor? ... But, I was always taught ( as was every other EMT) to assess all my patients. Also that part regarding assessment on their PCR can be considered false documentation.


----------



## BossyCow (Dec 11, 2008)

I recall a case that was toned out as belly pain. It wasn't until a block away from the hospital that the sweet 70 something little old lady, bedridden x3 days with belly pain, slight fever etc happened to mention in passing that she had been shot in the belly with a 22 by her husband. 

How many of us would have caught that one? The GSW was only visible upon close inspection. Sort of in a fold in her belly. Wouldn't have been found without the patient's pointing it out.


----------



## traumateam1 (Dec 11, 2008)

If they are lethargic or ETOH than how can you obtain an appropriate history? If they are in a state where you know, as a medical professional, that the answers (or lack of) could either be wrong, or a lie. I don't know about you, but I do a rapid trauma assessment on all DLOC or ETOH patients.

I dunno how this is going to hold up, but it sounds as if the crew that was attending this scene didn't do their job properly. Unfortunately we all get sick and tired of the ETOH calls and just wanna get rid of them as soon as possible, but the way this patient presented, I would have done a rapid trauma assessment.

Hopefully everything works out okay for the attending crew.


----------



## fma08 (Dec 11, 2008)

ETOH, drugs, none, or both, if you are called to check on a guy just laying outside for no reason, a full once over should be given.


----------



## Code 3 (Dec 11, 2008)

Ridryder911 said:


> I don't know about them your Honor? ... But, I was always taught ( as was every other EMT) to assess all my patients. Also that part regarding assessment on their PCR can be considered false documentation.



I was kind of waiting for something like this and surprised it wasn't mentioned by Vent.



> Or was the Assessment completed when asking him questions and he stated that he had been drinking



Assessments are more than just asking questions and they should not be stop based on a given answer. As Vent stated, you should be weary and not quick to make assumptions with patients presenting with ETOH abuse. In fact, I would approach all ETOH patients with a high index of suspicion for secondary injuries.



> ETOH patient laying on the lawn of a residence. PT didn't know how he got their



This should have been a major red flag. Was he thrown, pushed, fell off the roof, etc? You can't assume that he simply walked outside and then gently slumped to the ground because he was intoxicated.



> PT was answering basic questions and never complained of pain..



I would give this statement little weight simply because any intoxicated patient is going to have a skewed perception of pain.


----------



## BossyCow (Dec 11, 2008)

For me the big indicator is PD on scene. Anytime law enforcement is involved, someone is going to end up in some kind of a legal wrestling match. Everything that happens from then on takes a whole different tone. You have to CYA because if you don't, people will be lining up to take turns whuppin' on ya.


----------



## boingo (Dec 11, 2008)

I guess I'll play Devils Advocate on this one.  Assessment should be complaint oriented.  Not every patient gets a full head to toe assessment, in the ambulance or in the ED.  If you go to the hospital with a complaint of a sore throat, you'll get your temp, hr and bp taken, a visual exam of ears, nose and throat, and a quick auscultation of breath sounds.  Now, a guy lying on the ground with alcohol on board should get a brief PE, which in this case probably should have included the head/neck/back, however, with no complaints I won't throw them to the wolves, after all, the hospital triage nurse ( I assume it was a nurse) directed them to the waiting room for 4 hrs.

Oh, and I'll second Bossy's observation, the cops will always get you in trouble.  LOL


----------



## TomB (Dec 11, 2008)

This story illustrates the danger of labeling anyone an "ETOH patient". It's stigmatizing and it tends to preclude the caregiver from seeking other causes of altered level of consciousness. The David Rosenbaum case comes to mind.


----------



## Hastings (Dec 11, 2008)

You, my friend, are lucky if you avoid having serious action taken against your license. That's a pretty inexcusable mistake, and one there is no defense to. ETOH patients don't get a physical assessment because they're drunk? Your questions are really disturbing to me.

You better hope that patient was REALLY drunk, because that is an incredibly good way to get you fired and the patient a ton of money. At least, over here it is.


----------



## austinmedic77 (Dec 11, 2008)

anyone unable to demonstrate present mental capacity (ie recall, recognition, orientation), not just caox3 as most drunks regardless of level of intoxication can spout of year, president, name, social secuirty # with out a problem, get full assessment no exceptions.  I hate to point out the obvious but this is what we get paid to do and if they don't have present mental capacity and a clear concise complaint then the focused exam does not apply.


----------



## Ridryder911 (Dec 11, 2008)

boingo said:


> I guess I'll play Devils Advocate on this one.  Assessment should be complaint oriented.  Not every patient gets a full head to toe assessment, in the ambulance or in the ED.  If you go to the hospital with a complaint of a sore throat, you'll get your temp, hr and bp taken, a visual exam of ears, nose and throat, and a quick auscultation of breath sounds.  Now, a guy lying on the ground with alcohol on board should get a brief PE, which in this case probably should have included the head/neck/back, however, with no complaints I won't throw them to the wolves, after all, the hospital triage nurse ( I assume it was a nurse) directed them to the waiting room for 4 hrs.
> 
> Oh, and I'll second Bossy's observation, the cops will always get you in trouble.  LOL



I realize you are attempting to see another side, when in fact its not Devil''s advocate when in fact its negligence. No where, in any curriculum, studies, that a "focused assessment" is in place for an assessment. Are we not taught head to toe? 

Alike any physician is taught the same. The best physicians are ones that do and perform their job. Case in point, when I was in nursing school; I had a young teenage boy that had AML Leukemia. It was diagnosed by his physician .... a *Dermatologist!* Yep, when he was checking the boy's acne, he did the usual physical examination and noted spleenmegaly. If was not for a good physical examination this would had been missed. In consequence a early diagnosis and treatment was made. Again, one of the reasons all health care providers are taught to perform a thorough examination, especially on a unknown patient. 

I do wonder what one would chart then? Examination not performed due to ..... ? 

In regards to the nurse, yes it is shameful. She trusted the EMT's... I bet she won't do that again!... Yeah, we accomplished something alright. 



R/r 911


----------



## Foxbat (Dec 11, 2008)

Ridryder911 said:


> No where, in any curriculum, studies, that a "focused assessment" is in place for an assessment. Are we not taught head to toe?



A quote from my EMT book:

_After of while gathering this information, you should be performing the rapid assessment, which is a head-to-toe examination of the patient. The focused history and physical examination of medical patients is guided by the patient's chief complaint. *It is often unnecessary to assess a patient from head to toe, when he or she has a medical problem *(Mosby's EMT-Basic Textbook, 2d Edition, 2007, p. 198)._


Obviously, in the case described, head-to-toe exam should have been made due to the loss of consciousness.


----------



## Ridryder911 (Dec 11, 2008)

Foxbat said:


> A quote from my EMT book:
> 
> _After of while gathering this information, you should be performing the rapid assessment, which is a head-to-toe examination of the patient. The focused history and physical examination of medical patients is guided by the patient's chief complaint. *It is often unnecessary to assess a patient from head to toe, when he or she has a medical problem *(Mosby's EMT-Basic Textbook, 2d Edition, 2007, p. 198)._
> 
> ...



Sorry, they are discussing prioritizing a problem not saying NOT to assess. This a whole different discussion and systematic assessment. If one fails to assess then one will and should be held accountable as they will be. 

Let's be realistic, you miss something you will be held responsible. 

R/r 911


----------



## medicdan (Dec 11, 2008)

It is my personal preference and my company's protocol when we encounter a patient who we suspect is intoxicated on the ground or with dirt on their body-- and does not remember how they got where they are, we assume larger injuries, and will immobilize their spine if we feel there is potential MOI.
You really need to fully asses your patients, not always on scene, but certainly in the ambulance, or let the triage nurse know if you didnt have a chance to fully asses.


----------



## reaper (Dec 11, 2008)

Ok, A complete assessment should have been done on this pt, period!

That said. It may not have been an obvious wound and may not have been detectable with palpation. I had a pt with a GSW from a .32 in the head. No bleeding, no pain, and no visible entrance wound.

I happen to find it on accident. The bullet went in on the left side, followed the scalp and lodged above right ear. I did not feel it, while palpating the scalp. I found it while placing pt on a NC. I happen to notice a slight bump above the ear. Nothing more.

I advised the Dr. of the bump and he blew it off as nothing. They had ordered a CT for LOC and it showed up on the image. They figured that it never penetrated the skull and just followed the scalp up and over to the other side.

So, This may have been something similar, with no obvious signs of a GSW and the hospital may not have found it till a CT was done or the pt sobered up enough to feel the pain of it and complained.

Just remember that not everything is black and white in this line of work!


----------



## Foxbat (Dec 12, 2008)

Ridryder911 said:


> Sorry, they are discussing prioritizing a problem not saying NOT to assess. This a whole different discussion and systematic assessment.


I am not sure what you mean by prioritizing a problem.
Would you make a head-to-toe assessment of, say, pt. with an epistaxis, GI bleed, or asthma attack (conscious and alert, no history of trauma), or you would only make a focused physical exam?


----------



## rmyers3458 (Dec 12, 2008)

Well thank god this is not me... I am posting this in concerns of a co-worker.. This morning we came into work and got the "hey did you hear what happend to ... "  

Any ways.. I was taught that you begin your assessment with the tones going off.. Once continuing your assessment with the PT you split from medical or trauma... If the PT is not A&OX3 then you may want to rule out Trauma.. But if the PT is speaking to you, tells you that he had been drinking, walks to the ambulance, complains of no pain and no visible blood or DCAP.. That it should be treated as a medical and there for no Head to toe would be necisarry.. 

Now I know old school was almost everybody go the good ol' head to toe..   I am asking legally was he in the wrong..   Did he not follow BLS protocal and is there possible problems down the road...


----------



## traumateam1 (Dec 12, 2008)

rmyers3458 said:


> Well thank god this is not me... I am posting this in concerns of a co-worker.. This morning we came into work and got the "hey did you hear what happend to ... "
> 
> Any ways.. I was taught that you begin your assessment with the tones going off.. Once continuing your assessment with the PT you split from medical or trauma... If the PT is not A&OX3 then you may want to rule out Trauma.. But if the PT is speaking to you, tells you that he had been drinking, walks to the ambulance, complains of no pain and no visible blood or DCAP.. That it should be treated as a medical and there for no Head to toe would be necisarry..
> 
> Now I know old school was almost everybody go the good ol' head to toe..   I am asking legally was he in the wrong..   Did he not follow BLS protocal and is there possible problems down the road...



By *not* doing the head to toe or rapid trauma assessment than yes, he will be held responsible. Is that not neglect? He failed to do his job properly due to the nature of the call. Not a good excuse that would hold up in court.

Marriam-Webster defines neglect as:


> synonyms neglect , disregard , ignore , overlook , slight , forget mean to pass over without giving due attention. neglect implies giving insufficient attention to something that merits one's attention <habitually neglected his studies>. disregard suggests voluntary inattention <disregarded the wishes of his family>. ignore implies a failure to regard something obvious <ignored the snide remark>. overlook suggests disregarding or ignoring through haste or lack of care <in my rush I overlooked a key example>. slight implies contemptuous or disdainful disregarding or omitting <slighted several major authors in her survey>. forget may suggest either a willful ignoring or a failure to impress something on one's mind <forget what others say>.


----------



## boingo (Dec 12, 2008)

So for arguements sake, what constitutes an appropriate exam?  Does removal of all clothing, i.e trauma assessment happen for all patients?  Do you do a GU exam on all patients?  See the thread on EMT's molesting patients.  I think you might have a problem if you were to cut off or remove a 20yo college girsl (boys) clothes to do a "full" assessment because they have some etoh on board, yet have no complaint.  I do realize in the OP senario,that this patient would have had an exam done of the head/neck/back at the least, but no one should be doing a gyn exam in the truck on a drunk lady with a headache.  Just my opinion.  Thoughts?

I think there is a big difference between focused medical assessment and a complete physical exam.  One is complaint oriented, the other is generally done to establish a baseline in an outpatient setting.  At least thats how I see it.


----------



## traumateam1 (Dec 12, 2008)

boingo said:


> So for arguements sake, what constitutes an appropriate exam?  Does removal of all clothing, i.e trauma assessment happen for all patients?  Do you do a GU exam on all patients?  See the thread on EMT's molesting patients.  I think you might have a problem if you were to cut off or remove a 20yo college girsl (boys) clothes to do a "full" assessment because they have some etoh on board, yet have no complaint.  I do realize in the OP senario,that this patient would have had an exam done of the head/neck/back at the least, but no one should be doing a gyn exam in the truck on a drunk lady with a headache.  Just my opinion.  Thoughts?
> 
> I think there is a big difference between focused medical assessment and a complete physical exam.  One is complaint oriented, the other is generally done to establish a baseline in an outpatient setting.  At least thats how I see it.



*No where did I say I would start removing all of my patients clothes unless it was warranted!!* Yes a patient with ETOH on board and in that state, than I am going to be doing a rapid body survey to check this patient out, with leaving clothes *on* unless it was a hoodie or something. Then after the RBS and my primary is done, and we get the pt in the ambo, I am going to do a head to toe assessment on my patient to make sure I didn't miss anything. Again, leaving the clothes on unless I think that they need to be taken off.

Side story: called by police code 3 to a unresponsive patient. We arrive on scene to find a 16 y/o ish unresponsive and ETOH+++. So based on his presentation, we decide to clam shell him with hard collar and the works. The medic I was with decided to cut off all of his clothes because he had become incontinent of urine and was very very cold. So we cut everything off but his undies. Loaded him up in the ambo after doing an RBS, and once in the ambo I did a full head to toe to make sure we weren't missing anything. His GCS was something like 5 or 6. So yes, I will take my patients clothes off if I feel it is needed. I am not gonna hold back thinking "oh my, this guy/girl might wake up in the ambo next to naked and decided to sue me!" If I end up getting called to court all I have to do it present my case and tell them why I decided to take off their clothes. "My patient was hypothermic, incontinent of urine. I needed to take off his clothes so he could warm up in the back of the ambulance."



> I think there is a big difference between focused medical assessment and a complete physical exam.  One is complaint oriented, the other is generally done to establish a baseline in an outpatient setting.  At least thats how I see it



If your patient is GCS of 15 or A&Ox3 and they have a c/c of chest pain, or abdominal pain, or a bad headache with no history of a fall or anything, than of course you aren't going to start touching every part of their body doing a full head to toe. 
But if you have a patient with a GCS of 13 and they say something about a sore head, than you should make sure you give the head a good assessment, because you can't be sure that there is no trauma involved.


----------



## boingo (Dec 12, 2008)

I agree, unless warranted.  Now the million dollar question is "what is warranted?"  Did the OP's patient warrant it?  He ambulates to the truck, denies injury, admits to etoh.  What if his injury were to his flank?  I am not defending them for missing the head injury, just looking to generate discussion on what constitutes an appropriate physical exam.  I am not questioning anyones motives, just opening the topic of exam up for discussion.


----------



## BossyCow (Dec 12, 2008)

What technically is an ETOH patient. I am not aware of any treatment for 'drunk'. There is possible alcohol poisoning. But other than that, the pt would on my report be described as unconscious pt, unknown cause.

I have been called many times for a law enforcement assist. Often requested as "Clear for incarceration" This means that Law Enforcement wants me to assume the liability for putting this pt in jail where he may be unmonitored for several hours up to overnight. 

How many of your unconscious pts would you be willing to leave unattended for that long? I've found all kinds of trauma on drunk pts. Drunk people are clumsy and do not exercise due caution or a high degree of fine motor skill or physical coordination. A full head to toe would be done on any pt in my rig on the ride in. Of course my 30 minute transports give me the time to be thorough!


----------



## John E (Dec 12, 2008)

*Interesting that...*

it took the trauma center 4 hours to find the gunshot wound, according to the original post. 

John E.


----------



## el Murpharino (Dec 12, 2008)

It states the hospital put the pt. in triage first and found the would 4 hours later, not just found it 4 hours later.  I don't know if triage is the same everywhere, but that just means a nurse evaluated the patient, and placed them in the waiting room pending a bed - if it were a busy night, it could be something as simple as the nurse saying "what do you have", and the EMT saying "another drunk kid".


----------



## traumateam1 (Dec 12, 2008)

boingo said:


> I agree, unless warranted.  Now the million dollar question is "what is warranted?"  Did the OP's patient warrant it?  He ambulates to the truck, denies injury, admits to etoh.  What if his injury were to his flank?  I am not defending them for missing the head injury, just looking to generate discussion on what constitutes an appropriate physical exam.  I am not questioning anyones motives, just opening the topic of exam up for discussion.



Well we could sit here for hours and hours listing what is and isn't warranted. This is where your critical skills as a medic has to come into play. The excuse "oh he's just drunk" is *not* a good excuse/reason to not do an assessment.

"Oh well he was drunk and not speaking clearly, just a typical drunk. That's why we didn't further evaluate him your honor." Yeah not so much. lol


----------



## Ridryder911 (Dec 12, 2008)

Hence the reason one is supposed to obtain an accurate history and physical. If one does not act accordingly on the basis, one can be found negligent. 

As well, if you only base upon your examination of what the patient tells or does not tell you then you are asking to be negligent. For example a patient denies anything, or will not tell you.... so you don't examine? Within reason to examine can be described to be able to fulfill the examiners reasonably to obtain an accurate examination.

Sorry, nowhere in any EMS education one is taught what a alcohol patient is. Let me ask ..Does alcohol have a smell?... Actually no. 

It comes down to this. If you miss an injury due to lousy assessment technique (not assessing) and due to this failed actions to treat, one can expect to be held accountable. Critical thinking skills, for example when to expose the patient (MOI, very potential injuries) an not, is weighted and used. 

R/r 911


----------



## marineman (Dec 13, 2008)

Ridryder911 said:


> Sorry, nowhere in any EMS education one is taught what a alcohol patient is. Let me ask ..Does alcohol have a smell?... Actually no.



Come on, you didn't even give me a chance to answer. I could have finally gotten one right.


----------



## fma08 (Dec 13, 2008)

The simple fact that he had been drinking and did not remember ending up where he did should warrant at least a quick head to toe. Not saying a strip naked now, and finger up the butt, but still check for general trauma, esp. to the head since he wasn't remembering things.


----------



## TomB (Dec 13, 2008)

I don't know about "head to toe" but I think we can all agree on "head".


----------



## mycrofft (Dec 14, 2008)

*When you were told it was an ETOH you were offered a lay diagnosis.*

Many GSW victims who come in are also ETOH. Ketoacidotic patients can also be ETOH, they used to die regularly in jail drunk tanks.
The banter about being troubled and such is troubling to me in that that turns the dicussion from the case to personalities, and when we start micturation contests logic goes out the window.

Bean counters _start_ at that point. Here's what used to be their solution: long spineboard anyone who isn't up and walking. Do we want to go to that extreme (again)? Throw out professional judgement and training in favor of blind criteria?

_If you start a focused eval with the pronouncment "He's drunk", you are then focused on the whole pt because you don't have a credible history._  Cut to the chase.

PS: I worked detox for six years after my street time, and while some drunks are so obtunded they don't feel pain (which needs hospitalization because they are approaching toxicity), many others are hysterical or grandiose about their "wounds".

PPS: No one wondered why a scalp related wound wasn't pooling blood everywhere? I saw a sort of similar wound ( two .38 slugs in the upper forehead, one went in, the other slid along between cranium and scalp), and the bleeding was contained under the scalp.


----------

