ETOH, Intoxication, and Capacity to Refuse

[EpiEMS]

On a recent call, I had a (calm) disagreement with my partner - an early 30s female patient in custody s/p MVC (no trauma center criteria) wanted to refuse care (and law enforcement was OK with this). I was happy to oblige, given the clinical presentation:

Alert and oriented (person, place, time, events)
Ambulatory without assistance (and did not want any assistance)
GCS: 15 (4-5-6)
BP: 130/80 (by partner's manual auscultation)
HR: 80
Respirations: 16, no apparent difficulty
(Didn't get a BGL, which was a mistake on our part)

No trauma was evident, and the patient denied any complaint. She endorsed ETOH consumption, denied other drugs, and stated that she took no medications.

Fly car medic arrives, the medic says he's comfortable with the patient refusing care.

She signed a refusal, witnessed by PD, and we cleared the scene. My partner complained that we should have transported, but I stated that consuming alcohol doesn't remove competence or capacity - and if they are otherwise alert (that is, A on AVPU), I can't force them to go. Should we have contacted medical control? I'd say it couldn't hurt, but other than getting a BGL, I don't really see the call going any better, and I doubt the physician would have mandated that we transport. Furthermore, I anticipated that the likely outcome of trying to *force* the patient to be transported would be injury to the patient & LEOs, so I'm not sure that would have been great.

(On a related note, does anybody have a specific protocol for handling intoxicated patients? Or perhaps patients who are intoxicated with respect to a specific drug?)

 

[gonefishing]

On a recent call, I had a (calm) disagreement with my partner - an early 30s female patient in custody s/p MVC (no trauma center criteria) wanted to refuse care (and law enforcement was OK with this). I was happy to oblige, given the clinical presentation:

Alert and oriented (person, place, time, events)
Ambulatory without assistance (and did not want any assistance)
GCS: 15 (4-5-6)
BP: 130/80 (by partner's manual auscultation)
HR: 80
Respirations: 16, no apparent difficulty
(Didn't get a BGL, which was a mistake on our part)

No trauma was evident, and the patient denied any complaint. She endorsed ETOH consumption, denied other drugs, and stated that she took no medications.

Fly car medic arrives, the medic says he's comfortable with the patient refusing care.

She signed a refusal, witnessed by PD, and we cleared the scene. My partner complained that we should have transported, but I stated that consuming alcohol doesn't remove competence or capacity - and if they are otherwise alert (that is, A on AVPU), I can't force them to go. Should we have contacted medical control? I'd say it couldn't hurt, but other than getting a BGL, I don't really see the call going any better, and I doubt the physician would have mandated that we transport. Furthermore, I anticipated that the likely outcome of trying to *force* the patient to be transported would be injury to the patient & LEOs, so I'm not sure that would have been great.

(On a related note, does anybody have a specific protocol for handling intoxicated patients? Or perhaps patients who are intoxicated with respect to a specific drug?)

Sound of mind and no danger to self they are good to go.

 

[DesertMedic66]

I would be fine with her refusing care. Just because someone has drank or took medications does not mean they can not make their own choices. As long as she is able to understand what refusing care means and is able to take care of herself then there is no issue. I wouldn’t have done a BGL on this patient as it’s not indicated.

 

[EpiEMS]

I wouldn’t have done a BGL on this patient as it’s not indicated.

The only reason I was thinking BGL may be useful is for documentation, I agree that the patient (probably) is not hypo/hyperglycemic.

 

[mgr22]

In one of my former systems, ETOH consumption is a contraindication to refusal without medical control involvement.

 

[EpiEMS]

ETOH consumption is a contraindication to refusal without medical control involvement.

I'm picturing a really irritated physician at the other end of the radio...

 

[Bullets]

an early 30s female patient in custody

Everything you wrote after this is totally irrelevant. If she is in custody she is the sole responsibility of the arresting agency. While certainly consulting with the patient is advisable, technically it is up to PD as to the patients disposition. I would have had the cop sign as a patient representative and witness by another cop. Peace out Cub Scout

We have no specific protocol regarding intoxication. Its based solely on the patients presentation and their capacity to make decisions and understand them.

 

[Ensihoitaja]

I think there's 2 key points missing from your summary. Was she slurring her speech and was her gait ataxic? With my system/protocols those are the 2 key points for determining decision-making capacity.

Personally, I'm pretty hard pressed to refuse someone who's crashed their car and is under arrest for DUI. It's hard to argue for their capacity when they have an impaired ability to drive. Our police agencies and base hospital are fine with this too.

 

[EpiEMS]

@Ensihoitaja She wasn’t ataxic (actually had ok gross motor function) and wasn’t slurring at all

 

[mgr22]

I'm picturing a really irritated physician at the other end of the radio...

Only about 90% of the time.

 

[Carlos Danger]

Consumption of intoxicating substances does not itself make a person legally incompetent. Think about the large percentage of the population who walks around perfectly normally on a daily basis on benzos and opioids and gabapentinoids - in some cases, on all 3.

Alcohol is no different. A beer or two is not likely to make most people intoxicated. You just apply the same clinical criteria (alert, oriented, etc.) to someone whose had a few beers as you would to someone who may have suffered a head injury.

 

[VFlutter]

Personally I would probably chart something along the lines of "Patient understands and is able to verbalize risks of refusal of medical care". To me that describes a better level of comprehension and capacity than just alert and oriented.

"Ma'am, you may potentially have an injury that is masked by your consumption of alcohol. We recommend you evaluated. Refusing medical care may result in serious injury"

"Ok, go it. I understand there are risks to refusing care. I still do not want to be evaluated"

Boom, done.

 

[Tigger]

I have no issue with refusing patients provided that they can demonstrate they are alert and oriented, answer questions appropriately, have a linear and logical thought process, have no new cognition or memory deficits, and demonstrate a degree of insight into their present condition. If they are able to summarize to me the benefits of ambulance transport and why they don't want it, they can refuse. I will admit that I don't do the full "mini-mental status exam," but this is pretty close. Our AMR operation had a really excellent and qualified educator who taught a mental status/refusals class for every new hire academy and people would willingly attend it yearly. Solid stuff.

 

[EpiEMS]

Alcohol is no different. A beer or two is not likely to make most people intoxicated. You just apply the same clinical criteria (alert, oriented, etc.) to someone whose had a few beers as you would to someone who may have suffered a head injury.

Totally agree - I do think that this isn't something all field providers are aware of, though.

I will admit that I don't do the full "mini-mental status exam," but this is pretty close.

I've wanted to try doing the full one!

 

[DrParasite]

1) you said she's in custody of PD? Than she can't refuse care. The Officer, however, can refuse care on her behalf. Usually he can discuss it with the patient, but it's his call. Since you were there, if you disagreed with the officer's assessment, get a LEO supervisor to the scene. But you can't transport this person until you get approval from the arresting officer.

2) why were you there? She had no complaint. This sounds like a law enforcement matter. Take her to jail for a DUI, let her sleep it off. No need for EMS to even be involved

 

[EpiEMS]

@DrParasite

For #1, in custody...used loosely. She wasn't placed under arrest until we did our evaluation. There was a LEO supervisor on scene, a sergeant.

For #2, "uh, can you dispatch EMS to, uh *radio crackle*, check out the driver?" You know, usual cop stuff

 

[hometownmedic5]

In Ma, this is a high risk refusal requiring OLMC. Perhaps it irritates the med con docs, but I didn't write the protocols and we're paying them to do a job so eff them.

It has been my experience that they typically err on the side of caution and say they have to come in. It's a BS policy, but nobody asked me to consult on the last protocol revision.

 

[Tigger]

Totally agree - I do think that this isn't something all field providers are aware of, though.



I've wanted to try doing the full one!

I'm not really sure it's entirely necessary. The whole idea is being able to see if the patient can understand the risks and benefits of refusing further care. Memory, cognition, thought process and the like are all essential to being able to "prove" that informed consent (which I'd argue can be a refusal) exists.

 

[EpiEMS]

@Tigger, agreed that it isn't entirely necessary, just thought it might make a nice addition to documentation