alcohol test by EMT

[chaz90]

Or you could just use your brain instead of wasting time with a cheap breathalyzer. If they don't smell of booze, and the scene is not indicitive of them sipping the apple juice, more than likely they are not drunk enough to be unconcious.

Well, that's a touch insulting. I never said to use it alone without any kind of critical thinking. Like any other tool we use, this would only be useful in conjunction with a physical examination and as an additional piece of information to help us. All data we acquire needs to be interpreted and put into context and this would be no different.

To mention the glucometer analogy again that seemed to get everyone riled up, isn't this the same as arriving to find an unconscious, diaphoretic, known type I diabetic? We've run him before, we know he often forgets to eat after taking insulin, and we expect to find him to be hypoglycemic. We could simply assume he is and treat him with D50, and that would be a fair assumption. Sometimes though, that assumption is wrong and could be with our suspected ETOHers as well.

Look, either way we all agree that the treatment doesn't need to change, the number is relative and subject to interpretation, and that either way the patient should be treated the same and transported to the hospital. I don't understand the opposition to a simple POC test though that is non-invasive and could give us a diagnostic clue as a rule out for pure intoxication in someone that might otherwise be suspicious for the same. 99% of what we do is trying to get the ball rolling for the ED and accomplishing some of the early tasks to put them a couple steps of where they would be otherwise. Isn't this a small, small extension to that same goal?

 

[chaz90]

As some are saying, having a BAC would help you recognize wether the behavior is ETOH or a possible head injury, as someone said...but if someone has a high enough BAC you can most def smell it. And if someone was in a car accident and is incoherent, does the fact they are ETOH rule out a head injury? No. All it means is its a drunk person with a possible head injury as opposed to a sober person with a possible head injury. Both might have a head injury. Both should be treated as they have a possible head injury.


If there's a potential mechanism of injury, treat it as such. If you pull up to a alley and a patient is rolling around in his urine and vomit with colt 45 cans everywhere, then you really don't need a breathilizer.

As I mentioned, I wouldn't be excluding patients with positive values from having other injuries or causes. The most significant subset of patients would be those who aren't intoxicated and therefore have another cause of AMS that needs to be investigated. I agree that most of these patients with positive values will be highly obvious. It's the ones who aren't obviously drunk that can now be attached to a quantifiable number that says "yeah, they're not drunk" that would mean something to EMS and the ED.

 

[COmedic17]

As I mentioned, I wouldn't be excluding patients with positive values from having other injuries or causes. The most significant subset of patients would be those who aren't intoxicated and therefore have another cause of AMS that needs to be investigated. I agree that most of these patients with positive values will be highly obvious. It's the ones who aren't obviously drunk that can now be attached to a quantifiable number that says "yeah, they're not drunk" that would mean something to EMS and the ED.

How would it mean anything to EMS wether they are not noticeably drunk, but have a low BAC? Its not. People who are ETOH or have alcohol poisoning will not need a breathilizer to recognize it. If someone, as you said, "not obviously drunk" but has a low BAC, why is it imperative to my treatment? The only thing I'm going to think about someone who's been drinking is they are going to clotslower. But it's not like I'm going to treat someone with a BAC of .04 complaining of abdominal pain any different then im going to treat someone with a BAC of 0.0 for abdominal pain.

 

[COmedic17]

And have you ever seen a cop trying to get an overly drunk person to take a breathilizer?? It goes something like this -

Cop- "blow here sir"
ETOH pt - " I have something for you to blow"
Cop-" sir you need to blow or you will go to jail"
ETOH a pt-" Obama/George Washington/ Ben affleck is my brother. I am suing you all"


Granted not all ETOH a patients are combative, but patients with no other complaint then being blitzed are typically not very pleasant. And you def don't need a breathilizer to tell.

 

[chaz90]

How would it mean anything to EMS wether they are not noticeably drunk, but have a low BAC? Its not. People who are ETOH or have alcohol poisoning will not need a breathilizer to recognize it. If someone, as you said, "not obviously drunk" but has a low BAC, why is it imperative to my treatment? The only thing I'm going to think about someone who's been drinking is they are going to clotslower. But it's not like I'm going to treat someone with a BAC of .04 complaining of abdominal pain any different then im going to treat someone with a BAC of 0.0 for abdominal pain.

I might not be making my point clearly enough. For what I'm envisioning, the BAC would only matter in patients who are altered or have some kind of neurological type symptoms that may appear to come from alcohol but in fact come from something else entirely.

It wouldn't matter at all for the clearly intoxicated person in a pool of their own blue curaçao vomit with empty glasses around them. It wouldn't matter in the slightest for the drunk chest pains, the drunk abdominal pains, the emotional drunks, or the drunk people who are just cold and want to go to the hospital. It wouldn't matter for any positive value, because like you said, it doesn't rule anything more severe out simply because the person is drunk.

The useful information I could get from this device pre-hospitally are negative values where I'm not certain what caused the patient's current condition. By ruling out intoxication as the sole cause of AMS, those patients who have a more acute process causing their condition without the presence of alcohol can more easily be up triaged as they are already determined to have something other than the obvious as their primary complaint. All other "obvious" patients that have elevated BACs with potentially drunk/neurological symptoms that are unable to be differentiated because of their elevated BACs are simply treated the same as today. We'd continue to assume they could have something else going on and simply report all findings to the hospital, including the BGL and BAC we obtained.

This is the same as happens in every hospital ED daily. EMS brings in an altered 22 year old from the street after a party night. ED runs diagnostic tests as necessary, including a BAC, and treats the patient as indicated. If all tests and exams seem to rule out other causes for AMS besides the alcohol, the patient sleeps it off. If the obviously altered patient has a BAC of 0.00 it would absolutely get their attention and make them continue to look for other causes, just like it should for us.

Is anyone understanding me or am I talking circles around myself here?

 

[chaz90]

And have you ever seen a cop trying to get an overly drunk person to take a breathilizer?? It goes something like this -

Cop- "blow here sir"
ETOH pt - " I have something for you to blow"
Cop-" sir you need to blow or you will go to jail"
ETOH a pt-" Obama/George Washington/ Ben affleck is my brother. I am suing you all"


Granted not all ETOH a patients are combative, but patients with no other complaint then being blitzed are typically not very pleasant. And you def don't need a breathilizer to tell.

As I mentioned to Desert earlier, I'm envisioning a glucometer like device that doesn't exist as this is a very real concern.

 

[COmedic17]

I might not be making my point clearly enough. For what I'm envisioning, the BAC would only matter in patients who are altered or have some kind of neurological type symptoms that may appear to come from alcohol but in fact come from something else entirely.

It wouldn't matter at all for the clearly intoxicated person in a pool of their own blue curaçao vomit with empty glasses around them. It wouldn't matter in the slightest for the drunk chest pains, the drunk abdominal pains, the emotional drunks, or the drunk people who are just cold and want to go to the hospital. It wouldn't matter for any positive value, because like you said, it doesn't rule anything more severe out simply because the person is drunk.

The useful information I could get from this device pre-hospitally are negative values where I'm not certain what caused the patient's current condition. By ruling out intoxication as the sole cause of AMS, those patients who have a more acute process causing their condition without the presence of alcohol can more easily be up triaged as they are already determined to have something other than the obvious as their primary complaint. All other "obvious" patients that have elevated BACs with potentially drunk/neurological symptoms that are unable to be differentiated because of their elevated BACs are simply treated the same as today. We'd continue to assume they could have something else going on and simply report all findings to the hospital, including the BGL and BAC we obtained.

This is the same as happens in every hospital ED daily. EMS brings in an altered 22 year old from the street after a party night. ED runs diagnostic tests as necessary, including a BAC, and treats the patient as indicated. If all tests and exams seem to rule out other causes for AMS besides the alcohol, the patient sleeps it off. If the obviously altered patient has a BAC of 0.00 it would absolutely get their attention and make them continue to look for other causes, just like it should for us.

Is anyone understanding me or am I talking circles around myself here?

I understand what your trying to say, but a BAC isn't going to rule anything out for someone with a AMS who isn't obviously drunk. A cat scan to rule out head traumas, blood glucose, electrolyte/blood levels, toxicology for drugs, and cardiac tests will rule out other reasons for an AMS. If they aren't "noticeably" drunk as you say, I don't care what there BAC is. And me knowing what their BAC is won't rule anything out. You knowing their BAC won't do anything for you. And the hospitals will test it when they do blood draws regardless. You pulling a BAC is irrelevant and a waste of time.

 

[chaz90]

I understand what your trying to say, but a BAC isn't going to rule anything out for someone with a AMS who isn't obviously drunk. A cat scan to rule out head traumas, blood glucose, electrolyte/blood levels, toxicology for drugs, and cardiac tests will rule out other reasons for an AMS. If they aren't "noticeably" drunk as you say, I don't care what there BAC is. And me knowing what their BAC is won't rule anything out. You knowing their BAC won't do anything for you. And the hospitals will test it when they do blood draws regardless. You pulling a BAC is irrelevant and a waste of time.

It absolutely would rule out intoxication if it is a low value in the same way a verified glucometer reading of 200 mg/dL rules out hypoglycemia. If intoxication is on your list of differential diagnoses for why someone is acting like they are and their BAC is found to be 0, then ETOH intoxication is ruled out. I can then move on to other causes, and more importantly, advise the hospital that their expected normal patient has something more severe going on.

 

[Tigger]

Is anyone understanding me or am I talking circles around myself here?

I understand completely. I don't understand why people are so opposed to gaining more information regarding their patients.

I think it's awesome that we can breathalyze and drug test our patients as it most certainly effects our transport decisions. If they are over [a value I can't remember] BAC, we have to transport them to the hospital or detox. If we take them to a mental health facility they will get kicked out when the facility breathalyzes them, which just adds another bill. We also cannot take patients who test positive for stimulants to such facilities, they need to go to the hospital.

I also have no issues getting most of my patients that are not hammered drunk to comply with the breathalyzer instructions.

 

[Chewy20]

I understand completely. I don't understand why people are so opposed to gaining more information regarding their patients.

I think it's awesome that we can breathalyze and drug test our patients as it most certainly effects our transport decisions. If they are over [a value I can't remember] BAC, we have to transport them to the hospital or detox. If we take them to a mental health facility they will get kicked out when the facility breathalyzes them, which just adds another bill. We also cannot take patients who test positive for stimulants to such facilities, they need to go to the hospital.

I also have no issues getting most of my patients that are not hammered drunk to comply with the breathalyzer instructions.

Ok, well if you have to make transport decisons off of it, then sure I see a point. Other than that. Nope. Just my opinion which isnt worth much so it doesnt matter.

 

[COmedic17]

But if they have an AMS with a possible mechanism of injury ( like a car accident as Chaz said earlier), wouldn't they need to be medically cleared before going to detox?


And the noticeable ETOH patients who are just laying down surrounded by colt 45s with no possible mech of injury, dont the police take them to detox? Unless hypothermia is a concern, etc.

 

[Handsome Robb]

Maybe it's just the city I work in but I've had plenty of patents in car accidents that smell drunk, are acting drunk but actually had a .000 BAC. Why do they smell drunk? Because the whole damn car smells drunk because everyone else in it is. Like a few have said a positive finding doesn't change your treatment however a negative finding in someone who may be deemed as intoxicated is a significant finding. Another thing to consider is that patient that you find down on the sidewalk with no outward signs of trauma, normal vital signs, ataxia, ALOC, slurred speech and isn't "rolling around in their urine with colt 45 cans everywhere" (or however it was put earlier), sure we can infer that they are drunk but a PBT can confirm that or rule it out so again...why not? We ask LE for PBTs all the time if they have the capability and reason enough to do it.

I'm going to ask the same question that Chaz did. Why are people so afraid of a non-invasive POC test? Ever noticed that when you bring a certain subset of patients to the hospital one of the first things they do is get a PBT on them or order labs to test for the same? What is so wrong with have a quantitative assessment tool to add one more piece of information to our report and our documentation? With that logic agencies that have iSTAT capabilities shouldn't even check a CBC because if they can't hang blood who cares if their H&H is low? ...

 

[Ewok Jerky]

I'm going to ask the same question that Chaz did. Why are people so afraid of a non-invasive POC test? Ever noticed that when you bring a certain subset of patients to the hospital one of the first things they do is get a PBT on them or order labs to test for the same? What is so wrong with have a quantitative assessment tool to add one more piece of information to our report and our documentation? With that logic agencies that have iSTAT capabilities shouldn't even check a CBC because if they can't hang blood who cares if their H&H is low? ...

An on going debate in many areas of medicine is why order a test if you aren't going to do anything with the information you get from the test. Some providers are more comfortable with more information regardless, others like to make judicious decisions based on the preponderance of evidence and don't feel the need for extraneous information. There is no "right or wrong answer" as long as your treatment is correct and you don't kill someone. For example 24 y/o F who take birth control has CP after flying home from Europe: some would order a D-Dimer, some would say its a PE we don't need a D-Dimer. (caveat: this isn't a discussion about the specificity of D-Dimer tests for PE).

In the case of EMS using breathalyzers, I don't know what the right answer is. Personally I don't think it would change my treatment if I knew someone was drunk/not drunk. I would like to think that I would treat a suspected head injury or stroke in a drunk person with the same urgency that I would a not drunk person. For me, I don't see it being a useful tool on the ambulance. If it was there and my partner was teching the call and wanted it, no problem, I wouldn't fault them for it.

 

[akflightmedic]

I see no value in it. We all agree it does not change treatment, it might change destination in some individual's circles but this is more the exception than the rule.

If a magical device which does not exist could tell me a BAC, fine I will incorporate it into my BGL/IV start routine. However, as stated, if we are using a breathalyzer....I would not do it and do not support it.

1. On a good day and with a competent user and a compliant patient, you are looking at on average 5 minutes to perform the test properly. You have to switch it on, let it self test, explain instructions to the patient, do the test, repeat the test...all while coaching the patient, etc.

2. In this discussion we are talking about using it on AMS patients. Take that time and add unknown amount of minutes to process...anyone disagree it most likely will always take longer?
*Additionally, an earlier post mentioned using this on unresponsive or semi-conscious or something like that...really?

3. What about AMS patients with underlying respiratory issues or what if the issue is present at same time? Gonna make them blow hard several times and exacerbate the condition?

4. Potential for abuse. While in the perfect world, we are all professionals...there are going to be douche bag medics who abuse this and under treat a patient or flat out miss obvious issues simply by being tunnel visioned and "hardened" by the 'just a drunk' mentality. Yes, you can say those people should not be in our profession and will weed themselves out, but we all know this is not the case.

5. Legality. Suddenly the police are calling EMS to perform a medical diagnostic more frequently. Yes, we all work together, same cause koombahyah....but again I see more abuse. We get a high reading...we legally should NOT share that data with the police but we do. Now the police either use our result or repeat the test officially with their equipment so it is all legit. Who is liable?

I can go on and on...but like I said, it is great in theory, however actual implementation is bad juju.

 

[chaz90]

4. Potential for abuse. While in the perfect world, we are all professionals...there are going to be douche bag medics who abuse this and under treat a patient or flat out miss obvious issues simply by being tunnel visioned and "hardened" by the 'just a drunk' mentality. Yes, you can say those people should not be in our profession and will weed themselves out, but we all know this is not the case.

5. Legality. Suddenly the police are calling EMS to perform a medical diagnostic more frequently. Yes, we all work together, same cause koombahyah....but again I see more abuse. We get a high reading...we legally should NOT share that data with the police but we do. Now the police either use our result or repeat the test officially with their equipment so it is all legit. Who is liable?

I can go on and on...but like I said, it is great in theory, however actual implementation is bad juju.

I see a lot of validity in these two points. Your other points make sense as well from the real world breathalyzer standpoint, but since this is a theoretical discussion for me anyway I'm imagining I have a BACometer available to me that magically spits out an accurate and reliable reading in 10 seconds. Assuming that is the case, I'll focus on 4-5, but 1-3 are absolutely valid and I have no way of getting around that in real life.

I don't think there's any getting around point 4. There would undoubtedly be medics who downplayed patient's complaints after seeing a high number, but wouldn't those same patients be treated the same by the same medics anyway without having a number as the tunnel vision medic suspects them of being drunk? Even those who find themselves doing this to drunk patients might find themselves focusing in a little more on the relevant population who appear drunk at first blush but are revealed by the BACometer to be free of ETOH intoxication. In these patients, I imagine the attitudes of even the most jaded and drunk intolerant amongst us have nowhere to go but up.

For point 5, let's imagine LE have these super awesome tools as well. We can't bring anything to their table in regards to testing a BAC that they can't already acquire for themselves, so why call us for that? If the patient already has a complaint, legit or not, we're going to get called anyway and transport them. This wouldn't change from how it operates now, and we've already all agreed that showing up and finding the abdominal pain in PD custody has a BAC of 0.3 certainly doesn't preclude him from treatment by EMS.

 

[akflightmedic]

For point 5, let's imagine LE have these super awesome tools as well. We can't bring anything to their table in regards to testing a BAC that they can't already acquire for themselves, so why call us for that? If the patient already has a complaint, legit or not, we're going to get called anyway and transport them. This wouldn't change from how it operates now, and we've already all agreed that showing up and finding the abdominal pain in PD custody has a BAC of 0.3 certainly doesn't preclude him from treatment by EMS.

Because it comes down to the legalities with the cops...them deploying a BACometer comes with far more legal scrutiny and possibly documentation than if EMS is doing it to determine medical issues. Even though we should not share the info with them, a simple wink wink indicating they should go ahead and use their machine to test may occur. Anything which saves them a hassle will occur and abuse of EMS will continue...after all, whats the big deal since we are all on same team, right? (sarcasm)

I am sure a lawyer would have a field day over a BACometer being used. Start getting into self incrimination--since the patient is AMS...he does not have the right to consent nor would he understand his rights. So then this would be illegal search, etc. Lot of potential rights violations...but the escape clause, call the medics and see what they get first. Then they have a slam dunk case more or less.

 

[Benja99]

I think everyone is being too narrow minded. Obviously, using breathalyzers in a rural EMS situation would most likely be useless, but when considering the inclusion of a skill to the scope of practice of EMS professionals, you should take into account the multitude of environments where EMS functions. For example, there are 200+ college-based EMS agencies, one of which I am president. The amount of calls within our jurisdiction, and the surrounding city, that are ultimately related to EtOH are numerous. Therefore, a question often arises: is a pt who has EtOH intoxication and refusing transport mentally competent? Should they be able to refuse treatment? And don't lie- protocols surrounding this are super iffy, I know because I helped write ours; which are based on our local EMS' protocols.

Therefore, no- the breathalyzer would be a great tool for EMS in urban jurisdictions that have frequent calls involving inebriated pt's who commonly refuse transport. The breathalyzer will bring an objective and evidence-based test into our arsenal, rather than running AVPU, AOx4, and GCS. All of which have not been proven to be effective in determining the awareness of intoxicated patients.

Also important, by preventing unnecessary BLS/ALS transport of inebriated pt's solely because they are intoxicated would free up more local resources, reduce healthcare costs for the pt, and reduce our operational costs on all of those EtOH runs to the ED. Same for ED.

 

[PotatoMedic]

I think everyone is being too narrow minded. Obviously, using breathalyzers in a rural EMS situation would most likely be useless, but when considering the inclusion of a skill to the scope of practice of EMS professionals, you should take into account the multitude of environments where EMS functions. For example, there are 200+ college-based EMS agencies, one of which I am president. The amount of calls within our jurisdiction, and the surrounding city, that are ultimately related to EtOH are numerous. Therefore, a question often arises: is a pt who has EtOH intoxication and refusing transport mentally competent? Should they be able to refuse treatment? And don't lie- protocols surrounding this are super iffy, I know because I helped write ours; which are based on our local EMS' protocols.

Therefore, no- the breathalyzer would be a great tool for EMS in urban jurisdictions that have frequent calls involving inebriated pt's who commonly refuse transport. The breathalyzer will bring an objective and evidence-based test into our arsenal, rather than running AVPU, AOx4, and GCS. All of which have not been proven to be effective in determining the awareness of intoxicated patients.

Also important, by preventing unnecessary BLS/ALS transport of inebriated pt's solely because they are intoxicated would free up more local resources, reduce healthcare costs for the pt, and reduce our operational costs on all of those EtOH runs to the ED. Same for ED.

So here is my question to you. At what breath alcohol level is someone considered too intoxicated to make their own decisions? I'm also interested in knowing what studies show that orientation and capacity assessments are ineffective at "determining the awareness of intoxicated patients."

 

[Benja99]

Great questions! It's really up to your agency's medical director and general counsel. There are correlations between breath alcohol level to the blood alcohol level, backed by research. Those are widespread and their are studies that show blood alcohol level for acute pt's does correlate to altered mental status. There is also research that shows that physicians have a difficult time determining alcohol intoxication level among ED patients, and the blood alcohol concentrations had better associations.

This means, from a medico-legal perspective, paramedics, more so EMT's, may not be able to fully determine mental competency among intoxicated patients. So once again, the breathalyzer provides an objective measure. Most studies about mental competency and EtOH intoxication use breathalyzer readings as objective comparisons to the assessment or population in question. Even an article by AMR testing the efficacy of EMS personnel diverting intoxicated pt's from the ED included the use of a breathalyzer.

 

[PotatoMedic]

I have done a bit of googling, heck I even logged into my school's academic journal database and have yet to find anything that says at what specific blood alcohol level is someone no longer competent to make their own medical decisions. If you have some of the research you are using to make your case I'd love to read it.

I did find one journal published in cureus in 2018 that says that "none of the clinical exams are sensitive or specific for determining breath EtOH levels and degree of intoxication."

To me, if I interpret that correctly, says that I could pass a field sobriety test and still have an elevated breath EtOH level. I could also fail the exam and have no breath EtOH.

Heck a study published in 2014 in the annuals of emergency medicine states in their conclusion "Blood alcohol concentration was not correlated with capacity." That sentence really puts a hole in your argument.

The doi so you can look that last one up is: 10.1016/j.annemergmed.2014.09.027

But research changes so again. I'd love to read what you have.