Legality of Assessment of a "ETOH" (drunk) Patient

[traumateam1]

Well thank god this is not me... I am posting this in concerns of a co-worker.. This morning we came into work and got the "hey did you hear what happend to ... "

Any ways.. I was taught that you begin your assessment with the tones going off.. Once continuing your assessment with the PT you split from medical or trauma... If the PT is not A&OX3 then you may want to rule out Trauma.. But if the PT is speaking to you, tells you that he had been drinking, walks to the ambulance, complains of no pain and no visible blood or DCAP.. That it should be treated as a medical and there for no Head to toe would be necisarry..

Now I know old school was almost everybody go the good ol' head to toe.. I am asking legally was he in the wrong.. Did he not follow BLS protocal and is there possible problems down the road...

By not doing the head to toe or rapid trauma assessment than yes, he will be held responsible. Is that not neglect? He failed to do his job properly due to the nature of the call. Not a good excuse that would hold up in court.

Marriam-Webster defines neglect as:

synonyms neglect , disregard , ignore , overlook , slight , forget mean to pass over without giving due attention. neglect implies giving insufficient attention to something that merits one's attention <habitually neglected his studies>. disregard suggests voluntary inattention <disregarded the wishes of his family>. ignore implies a failure to regard something obvious <ignored the snide remark>. overlook suggests disregarding or ignoring through haste or lack of care <in my rush I overlooked a key example>. slight implies contemptuous or disdainful disregarding or omitting <slighted several major authors in her survey>. forget may suggest either a willful ignoring or a failure to impress something on one's mind <forget what others say>.

 

[boingo]

So for arguements sake, what constitutes an appropriate exam? Does removal of all clothing, i.e trauma assessment happen for all patients? Do you do a GU exam on all patients? See the thread on EMT's molesting patients. I think you might have a problem if you were to cut off or remove a 20yo college girsl (boys) clothes to do a "full" assessment because they have some etoh on board, yet have no complaint. I do realize in the OP senario,that this patient would have had an exam done of the head/neck/back at the least, but no one should be doing a gyn exam in the truck on a drunk lady with a headache. Just my opinion. Thoughts?

I think there is a big difference between focused medical assessment and a complete physical exam. One is complaint oriented, the other is generally done to establish a baseline in an outpatient setting. At least thats how I see it.

 

[traumateam1]

So for arguements sake, what constitutes an appropriate exam? Does removal of all clothing, i.e trauma assessment happen for all patients? Do you do a GU exam on all patients? See the thread on EMT's molesting patients. I think you might have a problem if you were to cut off or remove a 20yo college girsl (boys) clothes to do a "full" assessment because they have some etoh on board, yet have no complaint. I do realize in the OP senario,that this patient would have had an exam done of the head/neck/back at the least, but no one should be doing a gyn exam in the truck on a drunk lady with a headache. Just my opinion. Thoughts?

I think there is a big difference between focused medical assessment and a complete physical exam. One is complaint oriented, the other is generally done to establish a baseline in an outpatient setting. At least thats how I see it.

No where did I say I would start removing all of my patients clothes unless it was warranted!! Yes a patient with ETOH on board and in that state, than I am going to be doing a rapid body survey to check this patient out, with leaving clothes on unless it was a hoodie or something. Then after the RBS and my primary is done, and we get the pt in the ambo, I am going to do a head to toe assessment on my patient to make sure I didn't miss anything. Again, leaving the clothes on unless I think that they need to be taken off.

Side story: called by police code 3 to a unresponsive patient. We arrive on scene to find a 16 y/o ish unresponsive and ETOH+++. So based on his presentation, we decide to clam shell him with hard collar and the works. The medic I was with decided to cut off all of his clothes because he had become incontinent of urine and was very very cold. So we cut everything off but his undies. Loaded him up in the ambo after doing an RBS, and once in the ambo I did a full head to toe to make sure we weren't missing anything. His GCS was something like 5 or 6. So yes, I will take my patients clothes off if I feel it is needed. I am not gonna hold back thinking "oh my, this guy/girl might wake up in the ambo next to naked and decided to sue me!" If I end up getting called to court all I have to do it present my case and tell them why I decided to take off their clothes. "My patient was hypothermic, incontinent of urine. I needed to take off his clothes so he could warm up in the back of the ambulance."

I think there is a big difference between focused medical assessment and a complete physical exam. One is complaint oriented, the other is generally done to establish a baseline in an outpatient setting. At least thats how I see it

If your patient is GCS of 15 or A&Ox3 and they have a c/c of chest pain, or abdominal pain, or a bad headache with no history of a fall or anything, than of course you aren't going to start touching every part of their body doing a full head to toe.
But if you have a patient with a GCS of 13 and they say something about a sore head, than you should make sure you give the head a good assessment, because you can't be sure that there is no trauma involved.

 

[boingo]

I agree, unless warranted. Now the million dollar question is "what is warranted?" Did the OP's patient warrant it? He ambulates to the truck, denies injury, admits to etoh. What if his injury were to his flank? I am not defending them for missing the head injury, just looking to generate discussion on what constitutes an appropriate physical exam. I am not questioning anyones motives, just opening the topic of exam up for discussion.

 

[BossyCow]

What technically is an ETOH patient. I am not aware of any treatment for 'drunk'. There is possible alcohol poisoning. But other than that, the pt would on my report be described as unconscious pt, unknown cause.

I have been called many times for a law enforcement assist. Often requested as "Clear for incarceration" This means that Law Enforcement wants me to assume the liability for putting this pt in jail where he may be unmonitored for several hours up to overnight.

How many of your unconscious pts would you be willing to leave unattended for that long? I've found all kinds of trauma on drunk pts. Drunk people are clumsy and do not exercise due caution or a high degree of fine motor skill or physical coordination. A full head to toe would be done on any pt in my rig on the ride in. Of course my 30 minute transports give me the time to be thorough!

 

[John E]

Interesting that...

it took the trauma center 4 hours to find the gunshot wound, according to the original post.

John E.

 

[el Murpharino]

It states the hospital put the pt. in triage first and found the would 4 hours later, not just found it 4 hours later. I don't know if triage is the same everywhere, but that just means a nurse evaluated the patient, and placed them in the waiting room pending a bed - if it were a busy night, it could be something as simple as the nurse saying "what do you have", and the EMT saying "another drunk kid".

 

[traumateam1]

I agree, unless warranted. Now the million dollar question is "what is warranted?" Did the OP's patient warrant it? He ambulates to the truck, denies injury, admits to etoh. What if his injury were to his flank? I am not defending them for missing the head injury, just looking to generate discussion on what constitutes an appropriate physical exam. I am not questioning anyones motives, just opening the topic of exam up for discussion.

Well we could sit here for hours and hours listing what is and isn't warranted. This is where your critical skills as a medic has to come into play. The excuse "oh he's just drunk" is not a good excuse/reason to not do an assessment.

"Oh well he was drunk and not speaking clearly, just a typical drunk. That's why we didn't further evaluate him your honor." Yeah not so much. lol

 

[Ridryder911]

Hence the reason one is supposed to obtain an accurate history and physical. If one does not act accordingly on the basis, one can be found negligent.

As well, if you only base upon your examination of what the patient tells or does not tell you then you are asking to be negligent. For example a patient denies anything, or will not tell you.... so you don't examine? Within reason to examine can be described to be able to fulfill the examiners reasonably to obtain an accurate examination.

Sorry, nowhere in any EMS education one is taught what a alcohol patient is. Let me ask ..Does alcohol have a smell?... Actually no.

It comes down to this. If you miss an injury due to lousy assessment technique (not assessing) and due to this failed actions to treat, one can expect to be held accountable. Critical thinking skills, for example when to expose the patient (MOI, very potential injuries) an not, is weighted and used.

R/r 911

 

[marineman]

Sorry, nowhere in any EMS education one is taught what a alcohol patient is. Let me ask ..Does alcohol have a smell?... Actually no.

Come on, you didn't even give me a chance to answer. I could have finally gotten one right.

 

[fma08]

The simple fact that he had been drinking and did not remember ending up where he did should warrant at least a quick head to toe. Not saying a strip naked now, and finger up the butt, but still check for general trauma, esp. to the head since he wasn't remembering things.

 

[TomB]

I don't know about "head to toe" but I think we can all agree on "head".

 

[mycrofft]

When you were told it was an ETOH you were offered a lay diagnosis.

Many GSW victims who come in are also ETOH. Ketoacidotic patients can also be ETOH, they used to die regularly in jail drunk tanks.
The banter about being troubled and such is troubling to me in that that turns the dicussion from the case to personalities, and when we start micturation contests logic goes out the window.

Bean counters start at that point. Here's what used to be their solution: long spineboard anyone who isn't up and walking. Do we want to go to that extreme (again)? Throw out professional judgement and training in favor of blind criteria?

If you start a focused eval with the pronouncment "He's drunk", you are then focused on the whole pt because you don't have a credible history. Cut to the chase.

PS: I worked detox for six years after my street time, and while some drunks are so obtunded they don't feel pain (which needs hospitalization because they are approaching toxicity), many others are hysterical or grandiose about their "wounds".

PPS: No one wondered why a scalp related wound wasn't pooling blood everywhere? I saw a sort of similar wound ( two .38 slugs in the upper forehead, one went in, the other slid along between cranium and scalp), and the bleeding was contained under the scalp.