Intoxication at Home, AMS?

[Detroit]

I work for a 20 some unit private ambulance company running 911's and some private-line transports returning from ER visits and such. I also work nights in a college city in PA.

Dispatched for the possible alcohol poisoning, AOS to find male standing upright by own power, CAOx4 with a GCS of 15, but visibly and admittedly intoxicated. Wife wants him TNX for possible alcohol poisioning, because he vomitted x1. I attempted to explain to this female that although it can be, it can be just being drunk, in which case a ER bed isn't the place he needs, he needs to sleep it off just like You, I and 99 million others do every weekend.

My question lies in this drunk male. So He did not call 911, there fore did not request an ambulance. The wife requested the ambulance without telling the husband. He was "Fine". He was intoxicated, therefore AMS by the book. If he's AMS he cannot sign a refusal. But how far do you go? I mean its 120% legal to get as drunk as you want in your own home.

I'm sure the book says transport for intoxication, possible alcohol poisoning, ALS assessment at least, etc etc etc but I'm standing by my judgement as a human being that there is no reason a Intoxicated individual can be CAOx4 with a GCS of 15 thus negative for AMS, thus able to sign refusal or just "False Call" as the male had no idea we were even coming, wanted to EMS attention and was in his own home.

Thoughts?

 

[luke_31]

You can be as drunk as you want and be left alone, especially if you are in a safe place like at home. Where the issue of can you leave him there is if he is truly altered, being intoxicated doesn't equal being altered. If he is unable to answer whatever questions you have to determine capacity or not then the patient would be considered altered.

 

[Detroit]

You can be as drunk as you want and be left alone, especially if you are in a safe place like at home. Where the issue of can you leave him there is if he is truly altered, being intoxicated doesn't equal being altered. If he is unable to answer whatever questions you have to determine capacity or not then the patient would be considered altered.

Okay so you cannot sign a refusal if you are intoxicated. Now what?

 

[luke_31]

Okay so you cannot sign a refusal if you are intoxicated. Now what?

A blanket policy of intoxicated can't sign a refusal is interesting as I said before intoxicated isn't a determinant of capacity and makes your job harder. From what scenario you described it sounds like you also thought the patient should be fine staying at home.
If your protocol says that they can't sign a refusal if they are intoxicated I would contact medical control and get them to sign off on that. If they want the patient brought in then use whatever resources you have available. Each system is different, in mine certain patients have no ability to refuse without a MD saying so, while other patients can refuse all day long for anything and all we can do is try to convince them.

 

[exodus]

Explain how being drunk is AMS. Show me your protocol where if your patient has had any amount of alcohol they cannot be AMA'd. Being intoxicated but AOx4 and walking / standing on their own power, is not a medical complaint and if the person says they have no complaints, then they are not a patient. Correct?

Worst case scenario, ama the patient for n/v and consult with base.

 

[CANMAN]

I would be curious to hear other provider's weigh in on this as well. Obviously it's going to be largely protocol based, however I would likely attempt to talk the wife into putting the man to bed, and if she refuses then get L.E. involved to back me up and CYA. Around where I work L.E. is not going to make someone who is legally intoxicated in their own home go to the hospital, and neither am I. Same goes for if I was the same in my own residence. We could also get away with calling this a "No Patient" in my area. A patient needs to have a complaint or medical issue, and I don't view standard intoxication as a medical issue.

Each state will vary, but where I work this patient would be completely covered if he asked you to leave his property, and shut the door. The police have no right/reason to get a warrant, therefore it's time to pack up and go home. Just my 0.02 cents, I am sure there will be a large variation in opinions on this one.

 

[46Young]

Our guidelines have language that refers to decisional capacity. The patient can be under the influence of ETOH or perscription drugs, but if they demonstrate adequate decisional capacity, they can refuse tx/txp. If you're unsure about their capacity, you can always phone OLMC or request a supervisor and put it on them. Another option is, of the record, to tell them that if they leave the scene that you can't restrain them or follow them. Advise that the pt. refused all and left the scene, and then go in-service. Easier report to write than a refusal. I've used that tactic with people that had some ETOH and didn't need a hospital.

I'm not going to get them stuck with an expensive ED bill, and waste resources treating them in the ED for nothing, when they could simply go walk around the corner, which gets them out of having to be transported, and also makes you not responsible if they get hurt later on by tripping and falling or something. It's reasonable not to pursue and restrain a patient that advises that they do not want EMS services, and then leaves. That's pretty much assault and battery. Whatever happens to them afterwards is on them. Same thing with going into their bedroom, shutting the door, and telling you to leave.

 

[Detroit]

A blanket policy of intoxicated can't sign a refusal is interesting as I said before intoxicated isn't a determinant of capacity and makes your job harder. From what scenario you described it sounds like you also thought the patient should be fine staying at home.
If your protocol says that they can't sign a refusal if they are intoxicated I would contact medical control and get them to sign off on that. If they want the patient brought in then use whatever resources you have available. Each system is different, in mine certain patients have no ability to refuse without a MD saying so, while other patients can refuse all day long for anything and all we can do is try to convince them.

Yes, in my mind, I felt that the patient would have been fine at home. A MC contact would have been a good idea, as for some reason that did not dawn upon me. I'm actually going to give my Command Doc a call this week and see what his general idea is.

Explain how being drunk is AMS. Show me your protocol where if your patient has had any amount of alcohol they cannot be AMA'd. Being intoxicated but AOx4 and walking / standing on their own power, is not a medical complaint and if the person says they have no complaints, then they are not a patient. Correct?

Worst case scenario, ama the patient for n/v and consult with base.

As much as I'd like to agree with you, I'm constantly transporting "Patients" whom are intoxicated but have zero complaint, and no true wishes to visit a ER, but because LEO's give them the "Ambulance or Jail" choice.

I would be curious to hear other provider's weigh in on this as well. Obviously it's going to be largely protocol based, however I would likely attempt to talk the wife into putting the man to bed, and if she refuses then get L.E. involved to back me up and CYA. Around where I work L.E. is not going to make someone who is legally intoxicated in their own home go to the hospital, and neither am I. Same goes for if I was the same in my own residence. We could also get away with calling this a "No Patient" in my area. A patient needs to have a complaint or medical issue, and I don't view standard intoxication as a medical issue.

Each state will vary, but where I work this patient would be completely covered if he asked you to leave his property, and shut the door. The police have no right/reason to get a warrant, therefore it's time to pack up and go home. Just my 0.02 cents, I am sure there will be a large variation in opinions on this one.

Yes, this is more so of a discussion then a direct question, I too would like to see where everyone's training, areas and protocols vary in this situation.

Our guidelines have language that refers to decisional capacity. The patient can be under the influence of ETOH or perscription drugs, but if they demonstrate adequate decisional capacity, they can refuse tx/txp. If you're unsure about their capacity, you can always phone OLMC or request a supervisor and put it on them. Another option is, of the record, to tell them that if they leave the scene that you can't restrain them or follow them. Advise that the pt. refused all and left the scene, and then go in-service. Easier report to write than a refusal. I've used that tactic with people that had some ETOH and didn't need a hospital.

I'm not going to get them stuck with an expensive ED bill, and waste resources treating them in the ED for nothing, when they could simply go walk around the corner, which gets them out of having to be transported, and also makes you not responsible if they get hurt later on by tripping and falling or something. It's reasonable not to pursue and restrain a patient that advises that they do not want EMS services, and then leaves. That's pretty much assault and battery. Whatever happens to them afterwards is on them. Same thing with going into their bedroom, shutting the door, and telling you to leave.

I always try to explain to my bosses who are all "everyone goes", as most management is in a private for-profit service, that I am not in the game of kidnapping. I can't make anyone go unless their dead or damn near close. Police and LEO's love making people go to the ER via ambulance, I prefer to give options, which I believe builds trust between patrons on scene as well as you said above, ER's are NOT cheap.

 

[Tigger]

I'd like to just say "no patient found," but I'm not sure if I could get away with that give that he's vomited and the wife is "concerned," this is unfortunate. If I wanted to go the refusal route, my first move would be to try and educate the wife, and then have her sign the refusal. If she won't, I'd see about releasing the patient to another sober party (friend, neighbor, etc). Maybe the patient walks away while trying to arrange this.

We can refuse people who are intoxicated so long as they meet the "decisionality" component of our release of care and nothing untoward is found during the mental status exam. I got the idea that this was not an option in this scenario. Someone puking drunk may be a bit a too altered to understand the refusal process, but I'll certainly try.

 

[CALEMT]

Explain how being drunk is AMS. Show me your protocol where if your patient has had any amount of alcohol they cannot be AMA'd. Being intoxicated but AOx4 and walking / standing on their own power, is not a medical complaint and if the person says they have no complaints, then they are not a patient. Correct?

Worst case scenario, ama the patient for n/v and consult with base.

This. Work a weekend at Coachella fest and you'll AMA plenty of drunk people who are A/O x4.

 

[Detroit]

This. Work a weekend at Coachella fest and you'll AMA plenty of drunk people who are A/O x4.

So long as your agency / protocols allow this.

 

[46Young]

On a few occasions, if an intox lives close by, when the police run the "jail or ED" line, I may offer to take them home, provided that they are not severely drunk. I change the call to a public service. In the CAD notes, for the dispatcher to see, I advise that there is no patient, and that we're going to give a citizen a ride home for their safety.

Much easier report to write, it takes less time than an ED transfer, and bears no cost to the patient or the healthcare system.

All of these needless transports, just because the employer wants to maximize billing, is part of the reason why my medical insurance premiums are so expensive.

Edit: In my PCR I will write that the individual on-scene (don't call them a patient) refused EMS care and transport, but requested a ride to their home.

 

[46Young]

Severely intox will go to the ED. With my luck, if I drop them off home, they'll choke on their vomit while sleeping, perhaps lose blood flow to a limb if they fall asleep in the wrong place and compress the tissue, or maybe they trip and fall.

 

[CALEMT]

So long as your agency / protocols allow this.

Pretty much any EMS system in the country allows you to AMA a EtOH pt IF they're A&Ox4. If they're A&Ox4 and refusing transport and you transport them you could be charged with battery and "kidnapping".

 

[ERDoc]

I realize that I work in a much different environment that you guys but being drunk is not a medical problem. We have plenty of "concerned citizens" who see someone drunk sleeping outside and call 911. If they can walk, talk and tolerate PO then they are good to go (assuming no other medical problems). I'm not sure why society has decided that being drunk is a medical problem. I've had cops bring in pts for being drunk with no complaints. They are not happy when we tell them that the drunk is being discharged as there is no medical problems and tell us that the jail will not accept them. Sorry, officer, I feel for you but they don't need to be here and they are taking up a bed for someone who actually needs it. You came here for medical clearance, not a babysitter.

 

[Carlos Danger]

Okay so you cannot sign a refusal if you are intoxicated. Now what?

Why does the patient have to sign a refusal anyway?

If I never even asked for help and you show up without my request or consent, I'll politely decline your assistance but I'm not signing anything, drunk or sober. And you have no moral (and probably no legal) basis for trying to force me to do so.

 

[CALEMT]

Why does the patient have to sign a refusal anyway?

If I never even asked for help and you show up without my request or consent, I'll politely decline your assistance but I'm not signing anything, drunk or sober. And you have no moral (and probably no legal) basis for trying to force me to do so.

Dispatch ambulance X available no medical aid needed.

 

[exodus]

As much as I'd like to agree with you, I'm constantly transporting "Patients" whom are intoxicated but have zero complaint, and no true wishes to visit a ER, but because LEO's give them the "Ambulance or Jail" choice.

Eh, this points a little different, at least out here. When we get patients like this they aren't just borderline drunk. Our PD only really calls us for ETOH if they actually are altered, or if they are 5150 in some way. And if someone already has PD interaction, it usually means they have done something wrong that they probably wouldn't have done sober which can show limited mental capacity at the time. The person is also ALLOWING and AGREEING you to transport him without force by you. When you call it in, you can state they have no complaint other than being drunk.


It's odd though, it seems a lot of people are being taught to be afraid of AMA'ing people who were drinking. I don't understand it. If we're taught AOx4 and ambulatory like normal, then why is it all thrown out the window once the party has had a drink?

 

[exodus]

This. Work a weekend at Coachella fest and you'll AMA plenty of drunk people who are A/O x4.

I love our guidelines at coachella.

Alone: Can you walk and are able to say what you're going to do? - Good to go.

With friends: Do you wake up with a trap pinch and are your friends sober enough / competent enough to take care of you? - Good to go.

 

[Chewy20]

Only reason we transport drunk people is if they can not walk and have no other means of getting home (their friends always seem to disappear, everytime). If you can't answer my AO questions I can force them to the hospital. But I would rather get them in a cab or have PD deal with it.