Treat and Release protocol for alcohol withdrawl seizures

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medic3

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Just wondering if anybody out there works for a service that has a standing treat and release protocol for known alcoholic withdrawl seizures. We're currently trying to set up a policy to treat these pt's in the field and with online medical control, not have to transport them to a hospital. We are finding that our "regular pt's" are being brought to the hospital after seizing, then sitting in the hallway with an EMS crew for hours before seeing a doctor. In many instances Doctors aren't even ordering bloodwork or prescribing any sort of medications for these people.
 
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Wow! I hope your malpractice is paid up. I don't know of any EMS that is treating and releasing seizure activity especially alcohol induced and possible D.T's that could be fatal.

I am curious how your treating the seizures? Are you giving Benzo's ? As well, any postictal level event or post benzo's; could be misconstrued as "not having full faculties enough to make a rationale decision". Are you giving folic acid, thiamine in your treatment or a Rally Pack? Again, if not can you assure that a recurrent seizure is not going to occur immediately? (since ETOH seizures are multi faceted in etiology from electrolyte to alcohol at a cellular level).

I suggest instead of circumventing the problem, that your medical director meet with ER Director and address the problems. These patients are at a high risk, and should be triaged appropriately. As well, once the EMS arrive at ER; report should be given appropriately and then EMS should be discharged, it the ER's responsibility after they have received the patient.

R/r 911
 
Ems waiting in hallways with pt's is a part of a bigger problem in Canada of underfunded healthcare. While I understand your concerns with what we are trying to do, the fact of the matter is that most of the time, these pt's do not want any sort of transport to a hospital (and that is after their postictal period.) I'm refering to our large homeless population, and more importantly a select few "frequent flyer" pt's. In Canada it takes up to 4 years to become a critical care paramedic, and thusly our ability to assess and make proper clinical judgements for our pt's along side medical control is well recieved by ER doc's. We are trying to come with a solution to a problem that is obviously multi facetted. Our goal in the end is to provide the absolute best care, and best solution to the problem.
 
My protocols say 100mg IV of Thiamine for EtOH withdrawl. What are yours?
 
We only have a protocol for these pt's when they are seizing. What we're trying to determine is if there are safe and effective treatments for these people that we can do for them in the field, which would allow us to not transport them to hospital. We do have a small population of people that we are bringing to hospital every single day for these seizures. Obviously this ties up a lot of resources every single day!
 
Sorry, did not realize you were from up North. You have a different type of system. The bad is the over crowding due to "all access" the good is lower litigation's.

I again suggest to discuss with medical director and try to solve at management level. If not, they still need to develop a protocol for releasing in those specific conditions.

If the patients do not want treatment, and are alert and orientated. The general criteria here is to inform them of the risks, and offer treatment and transport. Some may obtain FSBS for additional physical and document well. We never transport against wishes. Document as refused against medical advice and if possible witnesses stating the fact.

Good luck!
R/r 911
 
Here in Illinois we would get spanked big time for not transporting a post-ictal delirium tremens patient. By our protocol's definitions, they are not A/O and hence are transported, even if against their wishes and with the help of LE. There is a patient in our area he who is picked up at least 3 times a week when found passed out in a parking lot or park. He doesnt want to go to ER (where they put him in a special needs room and tx as needed) but he always goes even if he has to do so in restraints.
 
If someone is truly having seizures from withdrawals, then one round of benzos and 100 of Thiamine ain't gonna cut it. Most of these chronics will have a low mag and their K will be off. Might as well check an ammonia level while we're at it. Their blood doesn't clot well and they don't protect themselves well when they fall--which is a lot--and are at higher risk for subdurals. No offense, but unless the guy is herniating, you aren't going to pick that up during a field exam no matter where you went to school.

But, if you're bent on releasing them, your options would seem to be limited to:

1: Increase their blood alcohol content or
2: Run in a banana bag, perform a WAS, give them a script for Librium and arrange for follow up...and hope that you haven't missed the big bleed.

Obviously this is a systems problem, but I just don't think that putting people at risk is the right solution.

Good Luck!
 
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