Competence and alcohol

[Tigger]

The problem is the College Kid who has failed to have all the ETOH enter the blood stream. Oe occasion remember in particular, the individual we were dealing with went from full complete sentences and and fully alert to incoherrent babble 20 minutes later followed by vomiting and all the other fun that comes along with alcohol posioning. I went through many events simlar between the college and working at a Casino.

I understand what people are saying about a few drinks, but my ability to accept a statement like that at face value has been ruined by experience. I guess in my mind, the question is are you really competent in those minutes before your BAC shoots through the roof.

If a person is providing appropriate answers to questions at the time of interview, they are competent. You can't just unilaterally declare somewhat unfit to refuse treatment just because you suspect that they might become altered an incompetent at a later time. If they are able to properly refuse treatment at the time of patient contact, the patient contact is then closed.

 

[EMDispatch]

If a person is providing appropriate answers to questions at the time of interview, they are competent. You can't just unilaterally declare somewhat unfit to refuse treatment just because you suspect that they might become altered an incompetent at a later time. If they are able to properly refuse treatment at the time of patient contact, the patient contact is then closed.

I apologize, as my statements were not particularly clear. I was speaking more towards a general caution when dealing with a patient or individual with ETOH in their system, particularly underage and binge drinkers. I have just observed many EMS providers right off an individual as OK to refuse after a cursory chat. They have been unable to shake the impression of the patients initial presentation to see the sometimes gradual decrease in mental status before having them sign forms.

You can't hold them based upon suspicion, but keep a high level of suspicion about their intoxication level and how it is fluctating over the course of your interaction.

 

[Anonymous]

This forum confuses my newbieness.

In one thread I read how if medics want respect they need to start acting as professionals rather than technicians who follow "cook-book" style medicine.

Then in the next thread the thought of a medic using his/her own "clinical judgement" (if you will) to make a determination is met with the idea of criminal and civil charges.

perhaps my level of inexperience has caused me to misread or wrogfully interpret things?

on a side note, a lawyer once told me it is easier to defend an action than it is to defend negligence... just some food for thought.

 

[Veneficus]

This forum confuses my newbieness.

In one thread I read how if medics want respect they need to start acting as professionals rather than technicians who follow "cook-book" style medicine.

Then in the next thread the thought of a medic using his/her own "clinical judgement" (if you will) to make a determination is met with the idea of criminal and civil charges.

perhaps my level of inexperience has caused me to misread or wrogfully interpret things?

on a side note, a lawyer once told me it is easier to defend an action than it is to defend negligence... just some food for thought.

I think you misread the post.

It outlines the idea that follow a cookbook and not using clinical judgement can get you into a lot of trouble.

Ask a lawyer if "just following orders" is an affirmative defense and how often it works.

 

[Handsome Robb]

BTW, the accepted legalese statement is that an "alcohol-like odor" was present.

"Patient has an odor about them and emanating from their mouth consistent with alcohol containing drinks" is my standard line.

As far as c-spine. If you were to follow my clearance protocol verbatim any ETOH or drugs onboard would make them ineligible for clearance from spinal motion restriction. With that said, you need to use good judgement and take the entire picture into account. As usalsfyre would say: "clinical correlation!"

I wont parrot what others have already said since it has been covered pretty well.

 

[EMDispatch]

Until your action is deemed negligent...

That's why cook-book style is the norm, and will realistically remain the norm for well into a forseeable future. When the lawyers and investigators come after you, having a simple and safe approved algorithim that you follow will save you.

 

[Handsome Robb]

I'd love to see a number of how many EMS providers are sued annually. I'd be willing to bet it's a LOT lower than most think.

There's a reason malpractice insurance for Paramedics isn't all that expensive.

We aren't the ones with the money, lawyers know that. They don't go after the provider they go after the agency.

 

[EMDispatch]

I'd love to see a number of how many EMS providers are sued annually. I'd be willing to bet it's a LOT lower than most think.

There's a reason malpractice insurance for Paramedics isn't all that expensive.

We aren't the ones with the money, lawyers know that. They don't go after the provider they go after the agency.

Agreed that it's probably low, but your employers would rather not risk it. Beyond the number sued , is the even lower number that actually loose.

The biggest problem is that when a public safety profession gets sued, legit or not, it's gonna probably be front page news with you and your agency named everywhere imaginable

 

[Handsome Robb]

For the sake of keeping this on topic. Does anyone's agency have a set number for patients who get PBTed by PD that's the defining line of "no matter what they're 'too drunk'" despite their actions and decision making?

Agreed that it's probably low, but your employers would rather not risk it. Beyond the number sued , is the even lower number that actually loose.

The biggest problem is that when a public safety profession gets sued, legit or not, it's gonna probably be front page news with you and your agency named everywhere imaginable

I'm in no way advocating blatantly violating your protocols. Even if you follow them to a "T" doesn't mean your agency isn't going to get sued by a patient or family who thinks you did it wrong because they or their loved one had a poor outcome. They don't know if you violated or followed your protocols, hell the majority don't even know how EMS operates outside of showing up with disco lights and noisemakers, putting people in the back and driving them to the hospital. It's not uncommon for people, including those in healthcare professions, that are amazed at how much we can actually do.

 

[Veneficus]

When the lawyers and investigators come after you, having a simple and safe approved algorithim that you follow will save you.

Keep telling yourself that.

As in my last post, "I was just following orders" basically never works and is not reliable.

The reason most cookbook protocols exist is to try to do the least amount of harm for the most people.

They are not meant for every patient you encounter.

You cannot infringe upon people's rights under the guise of "medical care" or "medical protocol." I wouldn't doubt they fail to mention that in EMT school.

Especially instructors who are convinced that as long as you do follow the protocol you will miraculously be saved from litigation.

It has no more realistic effect than sacrificing a goat to ward off evil spirits. Which is then reinforced as true because when nothing happenes there is a perception it works.

Competent people have the right to refuse medical treatment, regardless of what we believe is best or the consequences.

In order to determine if a patient is competent, the use of alcohol or other substance is not an automatic disqualifier. It is the same as a chronic pain or cancer patient on opioid therapy. The same as a post operative patient who refuses more care. The same as a religious person who refuses a life saving abortion or blood product.

If you perfrm any treatment or transport on a person who is capable of making their own informed decisions against their will and try to cover yourself with a treatment protocol, you could find yourself with a very serious problem.

an EMT hold no authority, they operate on consent, sometimes implied consent, which requires certain parameters to be met.

"Because my protocol says..." is not one of them.

This thread is not about people who are obviously not capable to make an informed decision. It is about people who are capable to do so. Even if they have had a drink or a few.

If this is the first you have heard of this, you should probably think much less of the person who "taught" you and educate yourself.

If you are teaching ETOH is an automatic disqualifier, you need more education before you teach others.

That is why I suggested a call to medical control, because obviously from some of the replies here, the tecnician level is not capable of making such complex decisions.

 

[EMDispatch]

Protocols will not prevent a lawsuit, but will prevent a loss. But I digress off that issue because I'm too tired to and way too off topic to dscuss torts.

A person with a drink or 2 in their system should be competent. That being said, I've watched many EMS providers fail to appropriately address a patient's level of intoxication Perhaps it's just the fact they they were tired of transport drunk college kids on a Friday night, but it was just stupid and dangerous.

I'm just curious though at what point do you feel they loose their competency? Is it a specific BAC (obviosusly higher for alcoholics) or the way they present? I had several residents in college who were heavy binge drinkers, and could "hold it toghether" very well. You'd assume they'd had 2 beers, and would blackout with no recollection of the night prior. We're they competent to refuse medical treatment the night before?

 

[Veneficus]

Protocols will not prevent a lawsuit, but will prevent a loss. But I digress off that issue because I'm too tired to and way too off topic to dscuss torts.

If it actually prevented losses, all medicine would be protocol driven and nobody would ever win or settle a suit.

A person with a drink or 2 in their system should be competent. That being said, I've watched many EMS providers fail to appropriately address a patient's level of intoxication Perhaps it's just the fact they they were tired of transport drunk college kids on a Friday night, but it was just stupid and dangerous.

I wouldn't base it off the number of drinks. One of my lawyer friends probably weighs 95lbs soaking wet. She can outdrink anyone I know, and out drink me by a very wide margin. On the otherhand, my wife (weight withheld for modesty) is ready to pass out after a pint of Guiness and even with a 1/2 pint needs some guidance.

I have seen several doctors fail to address the potential seriousness of patient complaints all the time, it doesn't mean we hold everyone against their will on "what if." People sign out AMA all the time. They refuse reasonable diagnostics and care all the time. I am here to help those that want help, I am not here to save the world from stupidity. That disease in incurable, supportive care only.

I'm just curious though at what point do you feel they loose their competency? Is it a specific BAC (obviosusly higher for alcoholics) or the way they present?

In most cases it is how they present. Some institutions I have seen have a threshold of BAC they use, usually between 200-300, but it is often modified for the alcoholics that are theraputic in that range.

I had several residents in college who were heavy binge drinkers, and could "hold it toghether" very well. You'd assume they'd had 2 beers, and would blackout with no recollection of the night prior. We're they competent to refuse medical treatment the night before?

The stupidity of a decision is not your responsibility. (nor mine for that matter) if they were able to "hold it together" while they were being interviewed, potential subsequent events, no matter how realistically probable, don't change the fact they are capable to refuse at that moment.

Somebody is free to call you back if their condition deteriorates. If they are unconscious, they are not competent to make decisions, and fall under the realm of implied consent.

It would be a good idea to ask a responsible person to stay with them if possible and to give them instructions. Similar is done with diabetics and head injury patients who either refuse or are discharged from the ED. (including AMA)

 

[DrParasite]

Especially instructors who are convinced that as long as you do follow the protocol you will miraculously be saved from litigation.

I don't think anyone thinks following protocols will save you from litigation... however, if you follow your protocols the bulk of the liability will be on the agency, instead of being on the individual.

If you deviate from your approved protocols, and a lawsuit arises, don't be surprised if your agency hangs you out to dry, because you deviated from what they "approved" you to do.

as for alcohol use, Rutgers University has a policy: any underage student that has consumed ANY alcohol must be transported to the ER for evaluation. This policy is enforced by the Rutgers police, and applies to the 24/7 career Rutgers University EMS system, as well as the municipal 911 services that cover the areas.

 

[Tigger]

as for alcohol use, Rutgers University has a policy: any underage student that has consumed ANY alcohol must be transported to the ER for evaluation. This policy is enforced by the Rutgers police, and applies to the 24/7 career Rutgers University EMS system, as well as the municipal 911 services that cover the areas.

Ugh that is miserable.

What if they are not on university property? Does simply being a student mean you have to go to the ER?

If so, that is a great way to get kids to avoid calling EMS at all possible costs until it is actually too late.

Where I am, we are a "wet campus." If you're just gone, campus safety can choose to take you to campus health, or call 911 on you behalf. If the the ambulance shows up and you can competently refuse, then you can. Being taken to campus health after midnight means EMS is coming anyways, at which point the campus LEO is probably involved so then refusing gets harder.

 

[rescue1]

We had a policy at college where students would not be subject to disciplinary action if they called 911 for a friend who was drunk, in order to prevent the culture of not calling because you didn't want to get in trouble. There was no policy in place for refusals, but I allowed a few students to refuse if they were alert/oriented, not currently puking their brains out, and had someone to stay with them.

If I had 911 called on me and I was only 4-5 beers deep, I would be all kinds of furious if they tried to force transport.

 

[DrParasite]

Ugh that is miserable.

yes, it is....

What if they are not on university property? Does simply being a student mean you have to go to the ER?

no. As I said, the policy is enforced by campus PD. The city cops don't care (and for the record, neither did we). So as long as no one calls campus PD, the policy isn't enforced. But if campus PD is driving down the city street, and get involved (or requested city city pd).....

PD has an old habit of telling drunk people they have two options: go to jail in handcuffs or go to the ER. On campus, security used to say go to the ER or go to judicial affairs, where you can be suspended or expelled from the university. More often than not the patients were in the back of the truck before we were.

 

[Veneficus]

I don't think anyone thinks following protocols will save you from litigation... however, if you follow your protocols the bulk of the liability will be on the agency, instead of being on the individual.

Genally, personal injury lawyers only sue people who have money. If I was a lawyer, I would not sue a paramedic, I would always sue the agency and medical director naming the EMT as an agent or officer of.

Most EMS providers I know do not carry private malpractice insurance, even if they did, there is no incentive to settle. Which means a lot of work for potentially nothing or actually very little.

Garnishing 15% of future wages of a laborer is chump change. Seizing a home in the current environment is probably more trouble than it is worth and certainly not a big payout.

I hate to break it to you, but EMS providers are small fish, and while you may think 100% of everything you own is substantial, A percentage of an insurance policy payouot is much better. Especially if they settle without a fight.

If you deviate from your approved protocols, and a lawsuit arises, don't be surprised if your agency hangs you out to dry, because you deviated from what they "approved" you to do.

Generally if you get sued at all expect your agency to hang you out to dry. One of the most successful ways to avoid a judgement is to deflect blame onto somebody else. Additionally, most organizations are proved council to act on their behalf, not that of the employee. If you don't have your own lawyer, you don't have one at all. That cost is likely all yours too.

 

[cruiseforever]

Just finished a CE class today. The company has made a decsion to make no load pts. a care goal for the year. The medical directors want us to contact med. control on any pt. that is refusing transport after drinking alcohol. Be it one drink or 10 drinks.

They made it very clear that you do not use a PBT reading to decide if the pt. is at risk.

As other's have stated they want us to use very detailed documentation on pt.'s apperance, understanding of what we are telling them to cover our butts.

The most intresting thing to watch should be what happens when the PD wants to take the pt. to jail and Med. Control wants the pt. transported. We have been told to give the phone to police officer and med. control will discuss the issue with the officer.

 

[Veneficus]

The most intresting thing to watch should be what happens when the PD wants to take the pt. to jail and Med. Control wants the pt. transported. We have been told to give the phone to police officer and med. control will discuss the issue with the officer.

Why would that be interesting to watch?

I know most EDs do not like drunk patients, but it doesn't change the fact being drunk is really a poisoning.

I don't know any LEOs who wouldn't happily turf a drunk to the ED over taking them.

Unless you got some LEOs who are a bit overzealous about "getting the bad guy" or some other megalomaniac disorder...

 

[Sandog]

Alcoholics having a high tolerance depends on the length of time (In years) that an alcoholic has been drinking. Once the liver is the size of a football, that persons liver can no longer detoxify properly, subsequently 1 or 2 drinks is all it takes to put that individual in a drunken stupor.

To detain someone on the suspicion of excessive alcohol consumption is a slippery slope indeed.