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

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rmyers3458

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This is a good one.. read till the end..

Have an issue.. Were dispatched to a ETOH patient laying on the lawn of a residence. PT didn't know how he got their, little lathargic, and admited that he had been drinking.. PD on scene. Gave PT 3 options, go home, have PD arrest the PT or we take him to the hospital. PT stated that he couldnt make it home.

Squad took vitals, once to the hospital released to Hospital and placed in Triage.

This is the kicker....

5 hours later PD called and stated they recieved a call from the Hospital stating that the PT had a bullet hole in the back of his head.

PT never stated that he was posible shot.. No apparrient DCAP BTLS... Hospital placed PT in Triage and found it 4 hours later.

Now my question is, by the law of EMT BLS, where we obligated do perform a complete full body assessment. Or was the Assessment completed when asking him questions and he stated that he had been drinking and coulndt make it home. PT was answering basic questions and never complained of pain..
 
I was taught to do a FULL complete assessment weather its a medical or trauma. We ran a lot of scenarios on medical and it'll turn out to be trauma and vice versa. Just because the patient doesn't tell you whats going on doesn't mean you don't need to check. They could have all sort of things on them. So i believe we are obligated to do a full body assessment. Check kill zones, flanks, etc. It'll make you a better EMT also when you deliver and present the patient to the hospital. Because when the hospital finds out something else on the patient where you didn't on your assessment. They're going to remember who you are. I'm not talking about things outside our scope of practice. Just full visualization and palpation of the patient on what we were taught.

Patient also told you he didn't know how he got there. AVPU, AN04, AEIOU TIPS, you ruled out ETOH, but down the list there's also Trauma.
 
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There are 3 types of patients that you may automatically make wrong assumptions and assessments even in your best efforts not to. A lot will depend on the company you keep (partner with attitude) and your education in medicine.

Substance abusers (alcohol or drugs)
Patients with mental illness (assumed or professionally diagnosed)
COPD patients
 
I don't know about them your Honor? ... But, I was always taught ( as was every other EMT) to assess all my patients. Also that part regarding assessment on their PCR can be considered false documentation.
 
I recall a case that was toned out as belly pain. It wasn't until a block away from the hospital that the sweet 70 something little old lady, bedridden x3 days with belly pain, slight fever etc happened to mention in passing that she had been shot in the belly with a 22 by her husband.

How many of us would have caught that one? The GSW was only visible upon close inspection. Sort of in a fold in her belly. Wouldn't have been found without the patient's pointing it out.
 
If they are lethargic or ETOH than how can you obtain an appropriate history? If they are in a state where you know, as a medical professional, that the answers (or lack of) could either be wrong, or a lie. I don't know about you, but I do a rapid trauma assessment on all DLOC or ETOH patients.

I dunno how this is going to hold up, but it sounds as if the crew that was attending this scene didn't do their job properly. Unfortunately we all get sick and tired of the ETOH calls and just wanna get rid of them as soon as possible, but the way this patient presented, I would have done a rapid trauma assessment.

Hopefully everything works out okay for the attending crew.
 
ETOH, drugs, none, or both, if you are called to check on a guy just laying outside for no reason, a full once over should be given.
 
Ridryder911 said:
I don't know about them your Honor? ... But, I was always taught ( as was every other EMT) to assess all my patients. Also that part regarding assessment on their PCR can be considered false documentation.
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I was kind of waiting for something like this and surprised it wasn't mentioned by Vent.

Or was the Assessment completed when asking him questions and he stated that he had been drinking
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Assessments are more than just asking questions and they should not be stop based on a given answer. As Vent stated, you should be weary and not quick to make assumptions with patients presenting with ETOH abuse. In fact, I would approach all ETOH patients with a high index of suspicion for secondary injuries.

ETOH patient laying on the lawn of a residence. PT didn't know how he got their
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This should have been a major red flag. Was he thrown, pushed, fell off the roof, etc? You can't assume that he simply walked outside and then gently slumped to the ground because he was intoxicated.

PT was answering basic questions and never complained of pain..
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I would give this statement little weight simply because any intoxicated patient is going to have a skewed perception of pain.
 
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For me the big indicator is PD on scene. Anytime law enforcement is involved, someone is going to end up in some kind of a legal wrestling match. Everything that happens from then on takes a whole different tone. You have to CYA because if you don't, people will be lining up to take turns whuppin' on ya.
 
I guess I'll play Devils Advocate on this one. Assessment should be complaint oriented. Not every patient gets a full head to toe assessment, in the ambulance or in the ED. If you go to the hospital with a complaint of a sore throat, you'll get your temp, hr and bp taken, a visual exam of ears, nose and throat, and a quick auscultation of breath sounds. Now, a guy lying on the ground with alcohol on board should get a brief PE, which in this case probably should have included the head/neck/back, however, with no complaints I won't throw them to the wolves, after all, the hospital triage nurse ( I assume it was a nurse) directed them to the waiting room for 4 hrs.

Oh, and I'll second Bossy's observation, the cops will always get you in trouble. LOL
 
This story illustrates the danger of labeling anyone an "ETOH patient". It's stigmatizing and it tends to preclude the caregiver from seeking other causes of altered level of consciousness. The David Rosenbaum case comes to mind.
 
You, my friend, are lucky if you avoid having serious action taken against your license. That's a pretty inexcusable mistake, and one there is no defense to. ETOH patients don't get a physical assessment because they're drunk? Your questions are really disturbing to me.

You better hope that patient was REALLY drunk, because that is an incredibly good way to get you fired and the patient a ton of money. At least, over here it is.
 
anyone unable to demonstrate present mental capacity (ie recall, recognition, orientation), not just caox3 as most drunks regardless of level of intoxication can spout of year, president, name, social secuirty # with out a problem, get full assessment no exceptions. I hate to point out the obvious but this is what we get paid to do and if they don't have present mental capacity and a clear concise complaint then the focused exam does not apply.
 
boingo said:
I guess I'll play Devils Advocate on this one. Assessment should be complaint oriented. Not every patient gets a full head to toe assessment, in the ambulance or in the ED. If you go to the hospital with a complaint of a sore throat, you'll get your temp, hr and bp taken, a visual exam of ears, nose and throat, and a quick auscultation of breath sounds. Now, a guy lying on the ground with alcohol on board should get a brief PE, which in this case probably should have included the head/neck/back, however, with no complaints I won't throw them to the wolves, after all, the hospital triage nurse ( I assume it was a nurse) directed them to the waiting room for 4 hrs.

Oh, and I'll second Bossy's observation, the cops will always get you in trouble. LOL
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I realize you are attempting to see another side, when in fact its not Devil''s advocate when in fact its negligence. No where, in any curriculum, studies, that a "focused assessment" is in place for an assessment. Are we not taught head to toe?

Alike any physician is taught the same. The best physicians are ones that do and perform their job. Case in point, when I was in nursing school; I had a young teenage boy that had AML Leukemia. It was diagnosed by his physician .... a Dermatologist! Yep, when he was checking the boy's acne, he did the usual physical examination and noted spleenmegaly. If was not for a good physical examination this would had been missed. In consequence a early diagnosis and treatment was made. Again, one of the reasons all health care providers are taught to perform a thorough examination, especially on a unknown patient.

I do wonder what one would chart then? Examination not performed due to ..... ?

In regards to the nurse, yes it is shameful. She trusted the EMT's... I bet she won't do that again!... Yeah, we accomplished something alright.



R/r 911
 
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Ridryder911 said:
No where, in any curriculum, studies, that a "focused assessment" is in place for an assessment. Are we not taught head to toe?
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A quote from my EMT book:

After of while gathering this information, you should be performing the rapid assessment, which is a head-to-toe examination of the patient. The focused history and physical examination of medical patients is guided by the patient's chief complaint. It is often unnecessary to assess a patient from head to toe, when he or she has a medical problem (Mosby's EMT-Basic Textbook, 2d Edition, 2007, p. 198).


Obviously, in the case described, head-to-toe exam should have been made due to the loss of consciousness.
 
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Foxbat said:
A quote from my EMT book:

After of while gathering this information, you should be performing the rapid assessment, which is a head-to-toe examination of the patient. The focused history and physical examination of medical patients is guided by the patient's chief complaint. It is often unnecessary to assess a patient from head to toe, when he or she has a medical problem (Mosby's EMT-Basic Textbook, 2d Edition, 2007, p. 198).


Obviously, in the case described, head-to-toe exam should have been made due to the loss of consciousness.
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Sorry, they are discussing prioritizing a problem not saying NOT to assess. This a whole different discussion and systematic assessment. If one fails to assess then one will and should be held accountable as they will be.

Let's be realistic, you miss something you will be held responsible.

R/r 911
 
It is my personal preference and my company's protocol when we encounter a patient who we suspect is intoxicated on the ground or with dirt on their body-- and does not remember how they got where they are, we assume larger injuries, and will immobilize their spine if we feel there is potential MOI.
You really need to fully asses your patients, not always on scene, but certainly in the ambulance, or let the triage nurse know if you didnt have a chance to fully asses.
 
Ok, A complete assessment should have been done on this pt, period!

That said. It may not have been an obvious wound and may not have been detectable with palpation. I had a pt with a GSW from a .32 in the head. No bleeding, no pain, and no visible entrance wound.

I happen to find it on accident. The bullet went in on the left side, followed the scalp and lodged above right ear. I did not feel it, while palpating the scalp. I found it while placing pt on a NC. I happen to notice a slight bump above the ear. Nothing more.

I advised the Dr. of the bump and he blew it off as nothing. They had ordered a CT for LOC and it showed up on the image. They figured that it never penetrated the skull and just followed the scalp up and over to the other side.

So, This may have been something similar, with no obvious signs of a GSW and the hospital may not have found it till a CT was done or the pt sobered up enough to feel the pain of it and complained.

Just remember that not everything is black and white in this line of work!
 
Ridryder911 said:
Sorry, they are discussing prioritizing a problem not saying NOT to assess. This a whole different discussion and systematic assessment.
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I am not sure what you mean by prioritizing a problem.
Would you make a head-to-toe assessment of, say, pt. with an epistaxis, GI bleed, or asthma attack (conscious and alert, no history of trauma), or you would only make a focused physical exam?
 
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...
 
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