Wow... Loaded question.
As a College EMS Agency Lieutenant, this is a huge issue for my service. We use the PBT reading that the police have obtained to help guide our assessments... but the root of the refusal is determining that the patient is CAOx4 and able to understand the risks of refusal. If they are alert, oriented, and understand the risks... then they can refuse.
Sometimes we involve OLMC in the decision tree, sometimes we don't. I've had some folks that blow greater than a 0.2 that I let refuse, and I've had folks less than 0.08 that have been told they need to go by the ED doc.
If they aren't CAOx4 and can't understand the risks of refusal... then it gets interesting.
Jon
I also struggle with this greatly, and is has been the discussion of many hours of meetings with our Medical Director.
The assessment of a patient who has consumed alcohol and is a candidate for a refusal MUST include questions/history of:
-- Number of drinks (1/2 is very different than 10/12)
-- Size of Drinks (shot, solo cup, bottle, etc)
-- Type of drink (Champagne is absorbed very differently than beer, or vodka) Mixed?
-- Time of first drink (as precise as possible)
-- Time of LAST drink (as precise as possible)
-- Last Oral Intake
-- Presence of other substances (Prescribed or other drugs)
-- Location of consumption, methods of locomotion, accompaniment with friends.
-- History of slips, trips and falls while intoxicated.
-- Any other trauma (full physical exam)
The assessment cannot be hinged on measures such as "odor of alcoholic beverage about person", or merely the number of drinks consumed.
The reason we are so obsessed with timing is because of the BAC curve. BAC and Absorption (and decay) within the body is impacted not only by physiological factors (sex, weight, etc), how regularly the patient consumes alcohol, by food in stomach, medications, presence or absence of carbonation in beverage, proof of beverage, volume of beverage, and most importantly the rate of consumption.
In a smaller woman, drinking 8 oz over an hour will spike the BAC to 0.15 or so, and it can take up to 8 hours to drop back down to 0. Drinking those same 8oz in 2oz increments over 4 hours will make the BAC peak at .10 or so.
There really isn't a fool-proof way of calculating BAC, because it has so many variables.
In a fasting state, >50% of EtOH will be absorbed within 15 minutes, with peak at about 20 minutes, and 80-90% of complete absorption will be achieved after 30-60 minutes.
Although the alcohol concentration initially lags behind that in the blood, CSF concentrations remain high, however, even after BAC begins to drop. While it's absorbed effeciently, it is not metabolized or eliminated as well. Clinically significant BAC levels are reached rather quickly (30-60 minutes), BUT THE BAC CONTINUES TO RISE UP TO AN HOUR AFTER THE CESSATION OF DRINKING.
In your assessment, you must also be aware of other diseases that mimic intoxication, such as other medications (Rx or otherwise), hypoglycemia, head trauma, seizure, infection, hypoxia, electrolyte imbalances, nearly any psychiatric condition, etc.
Your disposition decision must include an assessment of the patient's capacity to ambulate (assisted or unassisted, what would they do if there were a fire in the building), capacity to get to a bed and sleep it off, presence of friends or responsible party (sober), vitals (alcohol is a diuretic, can lead to dehydration), perhaps including BGL, history, physical exam, continued airway protection, etc.
Ultimately, you also have to look at, or for treatment. Most intoxicated patients at the hospital simply receive a bag of saline, and the ability to sleep off their intoxication. If the patient is of reasonably sound mind, and has people to take care of them, sometimes the best solution is to release them in the care of the responsible party.
With all of the above said, I will admit, I do allow for alcohol refusals, fairly often. I work on a college campus, and frankly, students sometimes call unnecessarily. Many of my patients don't need an ALS ride to the ER and a bag of fluid, but simply to go to sleep.
