# BLS transport of the ETOH patient



## chri1017 (Sep 1, 2013)

Where do people draw the line when it comes to transporting intoxicated patients BLS or ALS.


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## ATFDFF (Sep 1, 2013)

Assuming there are no other abnormal findings that would indicate the need for ALS, and alcohol is the only KNOWN problem (NO patient is ever "just drunk"), I make the determination based on how responsive/A&O the person is.  If they are able to answer questions well (maybe not perfectly, but pretty decently), are non-combative, and are able to follow commands, I'm pretty comfortable letting BLS take it.

That being said, I will ALWAYS have an officer follow us to the hospital when I'm transporting anybody who is under the influence of just about anything.


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## JPINFV (Sep 1, 2013)

Always be careful with "intoxicated" patients. We had a patient who appeared to be intoxicated with meth (scratching, pulling at lines, talking to himself, etc) and while, yes, his urine drug screen was positive for meth, his free T4 was 11 (almost 3 times the normal open limit).


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## Ewok Jerky (Sep 1, 2013)

if you are drunk enough for an ambulance ride, aren't you probable "altered mental status"?  in my old system, basics could not check a blood sugar so any drunk required an ALS assessment.

but if they are A&O, no neuro deficits, BS alright, and vitals stable I will take them...but then why are they in my ambulance in the first place?


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## JPINFV (Sep 1, 2013)

beano said:


> if you are drunk enough for an ambulance ride, aren't you probable "altered mental status"?  in my old system, basics could not check a blood sugar so any drunk required an ALS assessment.
> 
> but if they are A&O, no neuro deficits, BS alright, and vitals stable I will take them...but then why are they in my ambulance in the first place?





...because you can't say no, and that officer over there gave the "patient" the option of going to jail or going to the hospital.


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## ATFDFF (Sep 1, 2013)

beano said:


> if you are drunk enough for an ambulance ride, aren't you probable "altered mental status"?  in my old system, basics could not check a blood sugar so any drunk required an ALS assessment.
> 
> but if they are A&O, no neuro deficits, BS alright, and vitals stable I will take them...but then why are they in my ambulance in the first place?



In my area it's because several years ago law enforcement initiated a traffic stop on a possible DUI, just assumed the guy was drunk (slurring words, having a hard time staying awake, etc).  Turned out he was diabetic and was rather hypoglycemic.  Patient put in the drunk tank and wasn't given any attention until he "wouldn't wake up" 10 hours later.  

Obviously this scared the PD brass...and now virtually any drunk that is being arrested first gets a trip to the hospital.

Edited to add: I should have mentioned in my first post, EMTs in my state/system are able to check blood glucose (and are damn well expected to).


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## usalsfyre (Sep 2, 2013)

Perhaps I was stupidly gun shy...but I tended to shy away from having my Basic partner transport these patients. To me there's too much potential for airway comprise and I've only run into a couple EMTs that can manage an airway at the BLS level with any level of skill.


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## EpiEMS (Sep 2, 2013)

usalsfyre said:


> Perhaps I was stupidly gun shy...but I tended to shy away from having my Basic partner transport these patients. To me there's too much potential for airway comprise and I've only run into a couple EMTs that can manage an airway at the BLS level with any level of skill.



To this point, what constitutes an airway that can be managed in the conscious or semi-concious patient at the BLS level? Profound emesis, say, would be better suited to ALS, no?


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## teedubbyaw (Sep 2, 2013)

usalsfyre said:


> Perhaps I was stupidly gun shy...but I tended to shy away from having my Basic partner transport these patients. To me there's too much potential for airway comprise and I've only run into a couple EMTs that can manage an airway at the BLS level with any level of skill.



You don't trust your partner to log roll and suction? You're not going to be intubating an EtOH pt. with no associated illnesses.


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## chaz90 (Sep 2, 2013)

teedubbyaw said:


> You don't trust your partner to log roll and suction? You're not going to be intubating an EtOH pt. with no associated illnesses.



False. This could, and sometimes does, happen.


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## Medic Tim (Sep 2, 2013)

teedubbyaw said:


> You don't trust your partner to log roll and suction? You're not going to be intubating an EtOH pt. with no associated illnesses.



There are times that you will need to tube these pts.


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## teedubbyaw (Sep 2, 2013)

We're talking simple "intoxicated pt" per OP.


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## unleashedfury (Sep 2, 2013)

Intoxicated pt. with no other clinical findings, its a BLS call 

Being intoxicated impairs your judgment so allowing the pt. to refuse is unacceptable as they cannot express consent 

the simple just a little drunk should be transported or evaluated and cleared by an ED. Pts can appear drunk and could be hypoglycemic, having a bleed. or another medical emergency that's being masked by the "hes just drunk" 

Its a judgment call based on your findings location to the closest facility and if you can get a good assessment along with medical history on the pt.


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## chaz90 (Sep 2, 2013)

unleashedfury said:


> the simple just a little drunk should be transported or evaluated and cleared by an ED. Pts can appear drunk and could be hypoglycemic, having a bleed. or another medical emergency that's being masked by the "hes just drunk"



Oh, nonsense. Firstly, patients can absolutely refuse even if they have had something to drink. A beer passing your lips doesn't automatically take away your competence. Also, what is our purpose if we can't even tell the difference between simple hypoglycemia and intoxication? Seriously, we carry a really simple test for hypoglycemia, and it's definitive. There are some gray areas that need further investigation, but we've gone WAY too far down the EMT textbook pipeline of "No one is just drunk." In reality, no one should be looked past as "just drunk," but full evaluations can reveal that many people are. Trauma adds a different element, as does severe intoxication leading to unconsciousness or airway issues. Run of the mill drunk who has sober friends, no trauma, may or may not have puked, and has no complaints besides "alcohol?" If they wish to refuse, it isn't my place to tell them they have to go sober up in an ED bed. That's an absolute waste of everyone's time.


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## unleashedfury (Sep 2, 2013)

chaz90 said:


> Oh, nonsense. Firstly, patients can absolutely refuse even if they have had something to drink. A beer passing your lips doesn't automatically take away your competence. Also, what is our purpose if we can't even tell the difference between simple hypoglycemia and intoxication? Seriously, we carry a really simple test for hypoglycemia, and it's definitive. There are some gray areas that need further investigation, but we've gone WAY too far down the EMT textbook pipeline of "No one is just drunk." In reality, no one should be looked past as "just drunk," but full evaluations can reveal that many people are. Trauma adds a different element, as does severe intoxication leading to unconsciousness or airway issues. Run of the mill drunk who has sober friends, no trauma, may or may not have puked, and has no complaints besides "alcohol?" If they wish to refuse, it isn't my place to tell them they have to go sober up in an ED bed. That's an absolute waste of everyone's time.



Whilst I agree that if you wanna go home and sleep it off after an assessment reveals your just drunk.. and your right a beer or two with dinner dosent make you incompetent. However my medical director insists otherwise.. I think its so his ED gets its census goals.


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## teedubbyaw (Sep 2, 2013)

Taking a competent person against their will is illegal, regardless of medical direction.


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## usalsfyre (Sep 2, 2013)

unleashedfury said:


> Whilst I agree that if you wanna go home and sleep it off after an assessment reveals your just drunk.. and your right a beer or two with dinner dosent make you incompetent. However my medical director insists otherwise.. I think its so his ED gets its census goals.



Errr, your medical director or your training officer's fourth hand interpretation of what the OMD said?

You think everyone who has a beer or two gets a full body CT? Do you have any idea how potentially harmful that is? What about anyone who takes opiates on a daily basis? 

I think it would be wise to investigate this matter a bit further for your sake.


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## usalsfyre (Sep 2, 2013)

teedubbyaw said:


> You don't trust your partner to log roll and suction? You're not going to be intubating an EtOH pt. with no associated illnesses.



Frankly, no. I've run into far too many PARAMEDICS who are afraid to aggressively suction, much less EMTs.


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## DrParasite (Sep 2, 2013)

I've transported more than my share of drunks in a BLS ambulance.

Are they arousable with external stimuli?  can you wake them with minimal effort?  sure, take them BLS, esp if they are maintaining their own airway.

Now when they cross the line from drunk to alcohol posioning is when you have to think about having ALS M+T them.

The majority of our drunks will be perfectly fine once they sleep it off.  in the ER, they usually aren't tubed, they are put in a bed with an IV running (banana bag) and they are allowed to sleep it off.  

There is a rare few that will need additional interventions, but they are the vast minority of all the drunks you will ever pick up.


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## Jambi (Sep 3, 2013)

These sorts of patients and calls can run a fuzzy gray line and require good assessment and strong clinical judgement.  The problem is that protocols provide a warm fuzzy blanket of removed accountability (hyperbole I know, but it makes the point).  Many providers don't have the knowledge and experience to make consistent and reliable clinical judgements, so these get referred to ALS and to ED for evals.  All it takes is one bad outcome, preventable or not, to result in cookie-cutter one-size-fits-all policies for these situations.

I personally never approach a patient assuming he or she is drunk. I start from the point of ALOC and start investigating reasons with AEIOTIPS, and in the presence of overwhelming evidence of ETOH consumption, make a judgement that ETOH is the most likely culprit.  A former partner of mine instilled this approach in my some time ago, and he's caught a few patients that were having strokes, low BGL, etc because of it.

I don't think the problem is ever deciding a patient is drunk, but rather having it be predetermined.

I'm not sure I actually added to the thread's OP questions, and I hope I don't sound like a blathering idiot, but there you have my approach to "drunks."


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## rmabrey (Sep 3, 2013)

chri1017 said:


> Where do people draw the line when it comes to transporting intoxicated patients BLS or ALS.



As a medic student I transport them with ALS or BLS Intervention depending on how drunk or their LOC. Always with a medic in back though.

Reasoning is that EMT's cannot check a glucose in my state and im not about to get burned cause I dont feel like taking 10 mintues to write the report.


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## Ace 227 (Sep 7, 2013)

ATFDFF said:


> (NO patient is ever "just drunk")



 You don't work in a college town, lol. Lots of patients are "just drunk"


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## AmeriCare Supervisor (Sep 7, 2013)

In CA, altered is altered, which is ALS. Lots of ETOH's are shipped out BLS because they "seem to be okay." But, I've definitely seen ETOH's go completely unk/unresponsive and had to upgrade/divert.

Although, at least in CA, if they can answer your A X O questions appropriately and you put them through a Glasgow assessment and they come up as 15, then they would be considered "Alert/non-altered" and can be BLS'ed (as long as there are no other complaints that would fall outside of BLS).

When in doubt, call ALS. I'd rather have a grumpy medic and keep my license than the opposite.


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## Jambi (Sep 7, 2013)

AmeriCare Supervisor said:


> In CA, altered is altered, which is ALS. Lots of ETOH's are shipped out BLS because they "seem to be okay." But, I've definitely seen ETOH's go completely unk/unresponsive and had to upgrade/divert.
> 
> Although, at least in CA, if they can answer your A X O questions appropriately and you put them through a Glasgow assessment and they come up as 15, then they would be considered "Alert/non-altered" and can be BLS'ed (as long as there are no other complaints that would fall outside of BLS).
> 
> When in doubt, call ALS. I'd rather have a grumpy medic and keep my license than the opposite.



That's an accurate description of what does happen here in California with these sorts of patients...but the question remains: Is that was should happen. 

My contention is drunk is drunk and there is no need for ALS interventions.  The hard part is making the judgement call between drunk vs something else. The average Paramedic isn't equipped to make that knowledge let alone an EMT thus we get a colossal waste of resources.


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## NomadicMedic (Sep 7, 2013)

Jambi said:


> My contention is drunk is drunk and there is no need for ALS interventions.  The hard part is making the judgement call between drunk vs something else. The average Paramedic isn't equipped to make that knowledge let alone an EMT thus we get a colossal waste of resources.



I bed to differ. This is a true horse vs zebra call. 25 year old make comes out of a bar, no traumatic events, puking and altered. That's BLS all day long.  If he was in a fight in the bar or he can't be roused or his sugar is low or he seizures ... Then he gets a medic. But really, in most cases drunk is drunk. It's BLS.


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## Jambi (Sep 7, 2013)

DEmedic said:


> I bed to differ. This is a true horse vs zebra call. 25 year old make comes out of a bar, no traumatic events, puking and altered. That's BLS all day long.  If he was in a fight in the bar or he can't be roused or his sugar is low or he seizures ... Then he gets a medic. But really, in most cases drunk is drunk. It's BLS.



I agree with you. I didn't mean to come off so dismissive is my post. My point is that if they're drunk, barring nothing else outstanding, then BLS all the way.

I would like to refer to my previous post



> These sorts of patients and calls can run a fuzzy gray line and require good assessment and strong clinical judgement. The problem is that protocols provide a warm fuzzy blanket of removed accountability (hyperbole I know, but it makes the point). Many providers don't have the knowledge and experience to make consistent and reliable clinical judgements, so these get referred to ALS and to ED for evals. All it takes is one bad outcome, preventable or not, to result in cookie-cutter one-size-fits-all policies for these situations.
> 
> I personally never approach a patient assuming he or she is drunk. I start from the point of ALOC and start investigating reasons with AEIOTIPS, and in the presence of overwhelming evidence of ETOH consumption, make a judgement that ETOH is the most likely culprit. A former partner of mine instilled this approach in my some time ago, and he's caught a few patients that were having strokes, low BGL, etc because of it.
> 
> ...


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## NomadicMedic (Sep 7, 2013)

Jambi, I agree wholeheartedly. And we need to teach our initial responders, either BLS or ALS, this mindset and assessment pathway. Do I check a BG on drunks? Yep. Do I ask a lot of questions? You betcha. Do I have to be a paramedic to do that? Nope. Assessing a patient to determine the appropriate response is a skill that seems to be lost and is dumbed down to either "transport on a long spine board with 15 LPM of O2" or "call for ALS". Maybe I was better trained or came from a system that expected more from the basics. Either way, I learned how to reach the conclusion of probable ETOH intoxication rather than "ahh, he's just drunk"


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## Glucatron (Dec 20, 2013)

I think it depends on mentation, differential diagnosis, airway management, any other complaints. Anything cardiac, possible stroke or if the pt is unable to manage their airway and it's ALS. If they have a low blood sugar it is BLS unless D50 or oral glucose has no effect, they deteriorate, etc... But usually if there are no other complaints, they are just intoxicated we can either just hand them to PD for transport to detox (if they can walk with minimal assistance and have stable vital signs) or take them BLS to the hospital.


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## Bullets (Dec 20, 2013)

chri1017 said:


> Where do people draw the line when it comes to transporting intoxicated patients BLS or ALS.



When the medics have been grumpy all day and treating BLS like :censored::censored::censored::censored:

Altered Mental Status is ALS criteria.....MUHAHAHHHAHHAHAHHAHHA


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## medicsb (Dec 20, 2013)

chri1017 said:


> Where do people draw the line when it comes to transporting intoxicated patients BLS or ALS.



Not hypoglycemic, intact airway, adequate breathing, and without another potential cause for the change in mental status that could be treated by a paramedic.  I'd probably add a GCS component, some like a score ≥12.


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## medichopeful (Dec 20, 2013)

ATFDFF said:


> (NO patient is ever "just drunk")



:huh: Are you sure about that?


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## mycrofft (Dec 20, 2013)

*FIVE is FOUR*



chri1017 said:


> Where do people draw the line when it comes to transporting intoxicated patients BLS or ALS.



again and again and again and again…assess, follow protocols.


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## Carlos Danger (Dec 21, 2013)

ATFDFF said:


> NO patient is ever "just drunk"



I have proven that statement incorrect a few times in my life.

Then again, no one has ever had to call 911 because of it.


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## yowzer (Dec 26, 2013)

In my area, most intoxicated patients don't even get BLS transport unless they're passed out. Left at scene or sent to a sleep off center in a special van or by taxi.

If they're just drunk, they're not a patient.


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## usalsfyre (Dec 26, 2013)

yowzer said:


> If they're just drunk, they're not a patient.


You MIGHT want to check with David Rosenbaum's family about how well that attitude works in EMS systems.


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## JPINFV (Dec 26, 2013)

yowzer said:


> In my area, most intoxicated patients don't even get BLS transport unless they're passed out. Left at scene or sent to a sleep off center in a special van or by taxi.
> 
> If they're just drunk, they're not a patient.


http://emedicine.medscape.com/article/155050-overview


I think one of my admits last night had this actually... and yes, he came in as a drunk dude fall down, go boom.


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## Carlos Danger (Dec 26, 2013)

usalsfyre said:


> You MIGHT want to check with David Rosenbaum's family about how well that attitude works in EMS systems.



So someone badly screwed up an assessment. Does that mean everyone who is drunk needs full ALS and priority 1 designation?

Many cities have drunk tanks where intoxicated folks are taken to sleep off their drunk rather than to ED's. It seems to work quite well and you rarely hear about problems with people being taken to one when they should have been taken to the hospital instead. I don't think that would be the case if there were some inherent problem in under-triage of people who are simply intoxicated.


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## EpiEMS (Dec 26, 2013)

usalsfyre said:


> You MIGHT want to check with David Rosenbaum's family about how well that attitude works in EMS systems.



Here's the DC Inspector General's report: http://www.washingtonpost.com/wp-srv/metro/pdf/Rosenbaum.pdf

It's pretty damning of DC Fire and EMS.


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## yowzer (Dec 26, 2013)

usalsfyre said:


> You MIGHT want to check with David Rosenbaum's family about how well that attitude works in EMS systems.



That's that reporter who got clobbered on the head and died, right? If so, he wasn't just drunk, he had an actual complaint. That's why you assess people. That doesn't mean every person you see who's drunk needs a trauma center just in case.


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## yowzer (Dec 26, 2013)

JPINFV said:


> http://emedicine.medscape.com/article/155050-overview
> 
> 
> I think one of my admits last night had this actually... and yes, he came in as a drunk dude fall down, go boom.



Interesting. Sounds like a pretty benign condition for non-addicts.

I have been seeing a lot of people with tachycardia lately, but the drunk ones don't exactly fit the profile of that article. When your normal daily intake is enough to kill most people...


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## nwhitney (Dec 26, 2013)

Halothane said:


> So someone badly screwed up an assessment. Does that mean everyone who is drunk needs full ALS and priority 1 designation?
> 
> Many cities have drunk tanks where intoxicated folks are taken to sleep off their drunk rather than to ED's. It seems to work quite well and you rarely hear about problems with people being taken to one when they should have been taken to the hospital instead. I don't think that would be the case if there were some inherent problem in under-triage of people who are simply intoxicated.



My city has a drunk tank staffed by EMT's, an Intermediate, and two paramedics.  It's also where I work and the majority of the people are "just drunk".  We also transport folks to the drunk tank to help keep the ambulances free.


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## usalsfyre (Dec 27, 2013)

Halothane said:


> So someone badly screwed up an assessment. Does that mean everyone who is drunk needs full ALS and priority 1 designation?


No, but TO ME,  making the statement "they're not a patient" implies assessment isn't being performed and documented.  



Halothane said:


> Many cities have drunk tanks where intoxicated folks are taken to sleep off their drunk rather than to ED's. It seems to work quite well and you rarely hear about problems with people being taken to one when they should have been taken to the hospital instead. I don't think that would be the case if there were some inherent problem in under-triage of people who are simply intoxicated.



Correctional facilities usually have medical staff that boots even the slightest hint of "more than drunk" down the road to an ED, which is appropriate. I'm not saying drunk tanks are inappropriate.


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## TheLocalMedic (Dec 27, 2013)

Here's my take:  If they're too intoxicated to care for themselves and too intoxicated to go to jail (and they will typically accept REALLY intoxicated people), then they're an ALS patient.  They get an ALS assessment, BG check and airway monitoring.  Because yes, they are altered.  

But a patient has to be really really intoxicated to warrant an ambulance ride.  

If they are only mildly or moderately intoxicated but still oriented and GCS 15, then as long as they aren't causing any problems they are free to walk away.  And if they're being a problem then they go to jail.  

If the intoxicated patient can be deemed stable enough for BLS, then they are stable enough to go to jail and don't need an ambulance ride.  We don't need more drunks clogging up hospitals and wasting ambulance rides.  The jail system was designed with drunks in mind though.


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