Alcoholic with head injury

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msgsk

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I had an interesting scenario last night and wanted to get y'alls thoughts on how you would have approached:

Clearly intoxicated (ie smelling of EtOH and slurring words) HOWEVER oriented x3 and ambulating with a mostly-steady gait, presents after swerving off the road and hitting a light pole. He has some abrasions on his face and thinks he blacked out, but adamantly refuses to get any imaging. He understands the risks of having a head bleed but says 'just let me go to jail'. He is accompanied by a police officer, who brought him in for 'medical clearance'.

What do you do:
A - let him go without imaging
B - give him some meds and get the images anyway (ativan or what not)
C - make him stay until he is more clearly sober then allow him to refuse

There's problems with all of these choices.

Normally 'obs to sober' for me anyway, means a/ox3 and ambulating with a steady gait. He can smell of EtOH as much as he wants. So you could argue this guy has capacity and can refuse. As long as you document it well, you should be legally protected.

In reality what happened was the officer told him he had to, and he then consented. But, what if the officer didn't say that. What if there was no officer. Do you let him walk?

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CT. He doesn't have medical decision making capacity just because you document that he does. He just crashed a car into a light pole while drunk and you're telling me this guy somehow can now make a complex medical decision based on multiple factors and arrive at a logical coherent decision based on their own wishes and values.

Yeah, no.
 
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CT. He doesn't have medical decision making capacity just because you document that he does. He just crashed a car into a light pole while drunk and you're telling me this guy somehow can now make a complex medical decision based on multiple factors and arrive at a logical coherent decision based on their own wishes and values.

Yeah, no.


He refuses - that's the point of the while scenario. Of course you WANT to image him. Questiom is how can you force him? Restrain him? Chemically sedate him? Are you legally allowed to do any of those things? Does the act of being intoxicated alone nullify capacity? If so how do you define intoxicated? Because he smells of alcohol? He is oriented, ambulatory, and able to convey what you want him to do and his refusal to do it. That's the definition of possessing capacity.
 
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Slurring words = he is intoxicated.

Hypoxia, intoxication, hypoglycemia... If ya let someone sign out AMA, you are ranked in court.

Prove the intoxication with a BAL or breathalyzer. It helps take someone the emotional component off the table - the part where you try to rationalize that the guy really isn't drunk. Then he either stays till sober or gets scanned, depending on your gestalt.

This guy in particular is either going to sit in jail ignored overnight or going to be checked and released. No good scenario if he's the drunk with a head bleed and delayed decompensation.
 
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He's in police custody so you can chemically restrain him. If he wasn't I would pink slip him because he is clearly a danger to himself and possibly others and then chemically restrain him. This is of course if persuasion fails. Usually you can convince these people of anything using Doctor Jedi mind tricks.
 
Which is likelier:
- The low-speed single car MVC has a serious injury.
- The "chemical sedation" of an intoxicated and combative person goes poorly and results in complications.

... and even if all goes well, forcibly restraining someone and making them submit to harmful testing (radiation, financial costs) by any means is a hell of a can of worms to open in a legal sense, as well.
 
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Smells of EtOH doesn't exactly directly lead to dysarthria. Maybe he *just* cracked the beer and the MVC spilled it all over him... and the dysarthria is a bleed.

That said, I feel your pain. This is a toughie... I don't like the "may have blacked out" part.

Without it, obs in ED until clearly sober then document capacity to decline. With well-recorded reevals showing a clear trend to sobriety.

With the possible LOC, I'm gonna want numbers (EtOH level) then follow above strategy OR just scan the dude. If the Jedi mind tricks don't work, then I'd sedate & scan.

Drunks aren't worth losing my livelihood over... and if he complains when sober, well, being in police custody they can consent for him.

Document, document, document.

-d
 
I'm not a BAL checker.

This is a judgement call and we are paid to make decisions like this one. Either you think he's clinically sober and has capacity to refuse, or you don't and he can either stay and get CT later, or get CT now.

Whether the potential harm of sedating a patient outweighs the harms of not doing a CT factor into whether it is appropriate to sedate and CT.

If he's clearly intoxicated and refusing something that's medically indicated, he's getting sedated.

Patients in custody have the same right to refuse aspects of clinical care as patients not in custody. I discharged a patient in custody last week with a broken arm who refused care for it.

I generally let people decline aspects of care right and left. I just document these discussions.
 
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I'm not usually a BAL checker either. But just yesterday saw a "drunk guy" who was a little more unkempt than usual. And had a lump on his head. I didn't recognize him to be one of our regulars. (Even though his last 3 visits were all EtOH related.)

BAL <10.
SDH with small SAH.

I am a big fan of doctor Jedi mind tricks. I can usually work on people enough to smooth things out and do what needs to be done.
And just because you're intoxicated/crazy/combative does not mean you aren't sick.
 
I'm not a BAL checker provided they are alert and oriented. If they are in police custody it's fairly easy to get testing. If not in police custody then I try to get family or someone to show up. If they don't have family, and are intoxicated, but refusing scan they are going to be hanging out in your ED pending sobriety anyway, so it's easier just to watch them until they are sober and scan them at that time (or not scan them if your concern is minimal)

I'm firmly against sedating/restraining noncompliant patients who are A&Ox3 without a psych complaint.
 
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I had an interesting scenario last night and wanted to get y'alls thoughts on how you would have approached:

Clearly intoxicated (ie smelling of EtOH and slurring words) HOWEVER oriented x3 and ambulating with a mostly-steady gait, presents after swerving off the road and hitting a light pole. He has some abrasions on his face and thinks he blacked out, but adamantly refuses to get any imaging. He understands the risks of having a head bleed but says 'just let me go to jail'. He is accompanied by a police officer, who brought him in for 'medical clearance'.

What do you do:
A - let him go without imaging
B - give him some meds and get the images anyway (ativan or what not)
C - make him stay until he is more clearly sober then allow him to refuse

There's problems with all of these choices.

Normally 'obs to sober' for me anyway, means a/ox3 and ambulating with a steady gait. He can smell of EtOH as much as he wants. So you could argue this guy has capacity and can refuse. As long as you document it well, you should be legally protected.

In reality what happened was the officer told him he had to, and he then consented. But, what if the officer didn't say that. What if there was no officer. Do you let him walk?

I would scan him, even if I needed to chemically restrain him to do it. Here is my ethical argument:

Capacity isn't always an all or nothing kinda thing, but rather a spectrum. A medical condition can make a patient have the capacity to make some decisions, but not others. The greater the risk of the decision the greater threshold they have to meet to be able to consent or refuse treatment. That is the standard that is used for consent of people with mild mental ******ation or psychiatric conditions (http://www.medscape.com/viewarticle/748996_6). So a person with mild mental ******ation may be deemed able refuse to consent for a cholecystectomy for his biliary colic but may not be deemed able to refuse consent for cath for his STEMI.

I think alcohol intoxication can be thought of as a temporary mental ******ation. A patient who is mildly intoxicated but steady on his feet and no other injuries may have the capacity to make some decisions that are low risk. For example, he can refuse to have an IV placed (as long as he is not hypotensive and I as his treating physician consider the risk of not having IV access in his case to be low) by simply arguing "I don't want to because it hurts". However, if I suspect the possibility of a life threatening condition, that is much higher risk and requires him to pass a reasoning threshold he may not be able to until he sobers up. If it's something I think can wait a few hours (lung cancer), then obviously we wait. But if it's a time sensitive condition, it would be ethically wrong for me to wait for him to sober up.
 
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I'd rather be in court defending my position on restraining this guy, then be there defending the missed ICH.
Neither is a good position, but I'd sedate and scan if I couldn't convince otherwise.
Maybe if the guy consents to a BAL and it's below 80 do I let him pass on the scan.
Even then, I'd try to get him to stay in the ED for observation.
 
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I'd rather be in court defending my position on restraining this guy, then be there defending the missed ICH.
Neither is a good position, but I'd sedate and scan if I couldn't convince otherwise.
Maybe if the guy consents to a BAL and it's below 80 do I let him pass on the scan.
Even then, I'd try to get him to stay in the ED for observation.

Having a BAL <80 would make me more worried, actually. Because now I don't have as convincing an explanation of why he is "clearly intoxicated" and slurring his speech.
 
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Having a BAL <80 would make me more worried, actually. Because now I don't have as convincing an explanation of why he is "clearly intoxicated" and slurring his speech.
I wasn't talking specifically about this case, just in general.

In that case, I would be worried.
Also, deciding if someone is intoxicated is very complex.
Maybe etoh is 0, but you think they took K2.
No test to show that. At least no test that is useful in the ED.

We have all seen cases of the "intoxicated guy" that is something else.
 
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Just because someone is drunk doesn't mean they don't have capacity to make medical decisions. If they are alert and oriented to person, place, and time and do not appear to have difficulty with their conversation with you, then you can't force someone to do something against their will. To do so is an assault.

Generally jurors have erred on the side of physician judgement, but there was a case within the last 5 years that awarded a plaintiff money for a procedure he refused. The physician thought he couldn't refuse a life saving procedure if he was intoxicated.

Just because someone is in police custody doesn't mean they lose their rights. They are not convincted and incarcerated yet. They have been arrested, but they still have their rights.

Unfortunately this is always a tricky situation, and it's one to where only you can determine if they have capacity to make decisions. Perhaps a colleague could also document his/her interpretation of their medical decision making capacity.
 
I'm not a BAL checker provided they are alert and oriented. If they are in police custody it's fairly easy to get testing. If not in police custody then I try to get family or someone to show up. If they don't have family, and are intoxicated, but refusing scan they are going to be hanging out in your ED pending sobriety anyway, so it's easier just to watch them until they are sober and scan them at that time (or not scan them if your concern is minimal)

I'm firmly against sedating/restraining noncompliant patients who are A&Ox3 without a psych complaint.
Just curious, what is your move if he tries to walk out? Somewhat intoxicated but oriented and ambulatory, refusing care, do you restrain if they try to leave or just let them go?
 
Just curious, what is your move if he tries to walk out? Somewhat intoxicated but oriented and ambulatory, refusing care, do you restrain if they try to leave or just let them go?

http://www.wilsonelser.com/news_and...ew_yorks_highest_court_finds_er_physician_and

I'm sure many on this board will be familiar with this legal case from New York state, 2007 - the key point is that the law permits detention, but only in situations when the the patient is truly at risk of imminent harm.

If you assume the patient actually has X, Y, or Z injury, they may still be able to refuse care for it if they have decision making capacity.

The key is documentation - you need to document the status of the patient, the conversation with them, their ability to verbalize understanding of risk, etc.

I see several intoxicated patients per shift, of all varieties. The rule of thumb I use is that if the person is too inappropriate or weird that I think a civilian is likely to call 911 when this patient is walking down the street outside the ED - I don't discharge those patients. They have to be able to be calm. They have to be willing to engage in a conversation with me in order for me to determine if they have capacity to leave. Detaining all these patients makes you feel like a jailor, and that's not what we went into medicine for.

There are 2 principles that the law will usually support

1. That a physician attempted to act in the best interest of a patient.
And
2. That you acted with respect for a person's autonomy and right to choose what they do and don't want.

If your documentation reflects these 2 principles, you will likely be supported.

As for police or judge-mandated body cavity searches or anything else - my ED group had a lengthy discussion about this. It comes back to the same 2 principles. Both may be violated in doing it.

What we discussed as they way out is - you stall. If the "court order" is requesting something that isn't medically indicated, and it doesn't have your actual name on it, don't do it. Even if it did have your name on it, you need to check with your department chief, the hospital ethics committee, etc. Tell the police you're not refusing, you just can't do it at this time. Admit the patient if you need to. Don't do something you don't think is medically appropriate.
 
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Just curious, what is your move if he tries to walk out? Somewhat intoxicated but oriented and ambulatory, refusing care, do you restrain if they try to leave or just let them go?

I would yell "Please stop, don't go!" However I don't every physically touch or restrain anyone. I also instruct nurses not to. I inform hospital security and police and let them deal with it. I will never risk injury to myself or other staff in order to prevent a patient from leaving.
 
Chemically restrain someone who smells of alcohol? Really?

Document A&O x 3, clear of thought, understands refusal. NO CT.

Sorry, if I had to force anyone who smells of alcohol to do tests, I would restrain half my drunks. I would think if you were said Pt who drank 3 beers and smells of alcohol, came to the ED in an MVA, and I wanted to CT head, CXR, pan lab, foley, rectal exam you would think differently.

If you are A&O x 3, you have no right to force a workup on them or keep them in the ED against their will.

I let pts leave all the time who smells of etoh if they are A&Ox3 and not a danger to themselves. I don't check etoh levels.

Imagine the homeless alcoholic who came to the ED smelling of alcohol. We all know his level is way above 0.1

What do you do? Draw an etoh level and find out that its 350, keep in the ED for 12 hrs and he goes into DTs? Or do you let him leave clinically sober? Pick #1 and your ED is full of drunks going into DTs.
 
Good luck convincing a jury that someone who is drunk, slurring their speech, crashed their car into a pole after swerving off the road, and hit their head hard enough to get knocked out is "clinically sober" to make good decisions.

Write your chart to reflect that this person displays no regard for their wellbeing or capability of reasonable thought and has physical evidence of a head injury. Document they don't display an adequate understanding of risk and consequences. Then restrain them and do what you need to do.

In my opinion, if you're going to be unlucky enough to have a bad outcome, I'd rather it happen within a narrative that makes sense. Lawyers can argue any side of any position so either way you're screwed. I'd prefer to be defending a position that makes the most sense.

Implement Occam's razor of medical decision making and stop rationalizing yourself out of a reasonable decision.
 
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Good luck convincing a jury that someone who is drunk, slurring their speech, crashed their car into a pole after swerving off the road, and hit their head hard enough to get knocked out is "clinically sober" to make good decisions.

Write your chart to reflect that this person displays no regard for their wellbeing or capability of reasonable thought and has physical evidence of a head injury. Document they don't display an adequate understanding of risk and consequences. Then restrain them and do what you need to do.

In my opinion, if you're going to be unlucky enough to have a bad outcome, I'd rather it happen within a narrative that makes sense. Lawyers can argue any side of any position so either way you're screwed. I'd prefer to be defending a position that makes the most sense.

Implement Occam's razor of medical decision making and stop rationalizing yourself out of a reasonable decision.
Case law lets us. We aren't responsible for the drunk, they are.
 
Case law lets us. We aren't responsible for the drunk, they are.

Is this the case law you're referring to? I've always wondered how decisions like this, often cited in support of one opinion on the legal risk of something, generalize to other states or situations in terms of being protective. I have no idea, would love to know if someone else can speak to the relevance of a NY State Supreme Court opinion to practicing EPs in other states.
 
If I'm so worried about a patient that I'm willing to do RSI and intubate them to get the diagnosis, then that's what I do. Otherwise, I will not stop someone from walking out. I often will refer to my other options in my MDM ("As the patient was not suicidal or homicidal, I did not have grounds to impose the risks of physical or chemical restraint, so I did not detain the patient against his will.")

If it's a big angry dude (as such patients often are) I will also mention staff safety in my MDM.
 
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I literally just had this patient a few days ago. intoxicated, reeks like etoh, belligerant toward staff. struck with beer bottleand being adament that we let him leave. I bribe him with a turkey sandwich to get a CT....the guy had prolonged LOC and somethimg didnt feel right. The scan shows frontal nondepressed skull fx....frontal subdural....and sub arachnoid blood. In an asymptomatic drunk. He tried to elope and i took his rights away and let security handle him. But it would have been way too easy to let one of our usual drunks walk out of the ED
 
The differences between which hospital the patient shows up to are interesting.

Our inner city community hospital (non trauma center): 50 something year old foul smelling likely chronic alcoholic brought in by EMS because somebody called about him passed out on the side of the road. Abrasion to his forehead. He moans words when provided a painful stimulus, withdraws to pain, so GCS is what, 8-9? He gets put somewhere, possibly the hallway depending on how busy we are, I'll probably order a head CT with any even remote sign of trauma, and he may sit there for a few hours and either be too drunk to argue about the CT, or he can be convinced to participate with the promise of a sandwich afterwards.

Our Trauma center: 50 something year old foul smelling likely chronic alcoholic brought in by EMS because somebody called about him passed out on the side of the road. Abrasion to his forehead. He moans words when provided a painful stimulus, withdraws to pain, so GCS is what, 8-9?

Our protocols deem him a trauma alert (GCS < 13 with signs of trauma), the trauma team arrives, patient starts getting poked on multiple sides with needles while other people are holding him down and cutting clothes off. Patient starts waving arms around in response to this. Our trauma surgeons, who have the patience of my 5 year old nephew on Christmas morning, order him intubated. He gets his CT scans (which of course means pan-scan) and buys himself a unit bed.
 
I literally just had this patient a few days ago. intoxicated, reeks like etoh, belligerant toward staff. struck with beer bottleand being adament that we let him leave. I bribe him with a turkey sandwich to get a CT....the guy had prolonged LOC and somethimg didnt feel right. The scan shows frontal nondepressed skull fx....frontal subdural....and sub arachnoid blood. In an asymptomatic drunk. He tried to elope and i took his rights away and let security handle him. But it would have been way too easy to let one of our usual drunks walk out of the ED

I might just point out that this may be a self limited injury... The belligerant toward staff thing would probably push most EP's to do what you did.

And while none of us would want to miss an injury such as this, the benefit of hospitalizing the patient, besides a repeat CT and maybe some dilantin, may be very little...
 
in the original case, "slurring words" and "mostly steady gait" mean that he is intoxicated and unable to have the capacity to refuse treatment.

And agree most of these people with tiny traumatic subarachnoid-whatevers would be fine no matter what we did.
 
I had an interesting scenario last night and wanted to get y'alls thoughts on how you would have approached:

Clearly intoxicated (ie smelling of EtOH and slurring words) HOWEVER oriented x3 and ambulating with a mostly-steady gait, presents after swerving off the road and hitting a light pole. He has some abrasions on his face and thinks he blacked out, but adamantly refuses to get any imaging. He understands the risks of having a head bleed but says 'just let me go to jail'. He is accompanied by a police officer, who brought him in for 'medical clearance'.

What do you do:
A - let him go without imaging
B - give him some meds and get the images anyway (ativan or what not)
C - make him stay until he is more clearly sober then allow him to refuse

There's problems with all of these choices.

Normally 'obs to sober' for me anyway, means a/ox3 and ambulating with a steady gait. He can smell of EtOH as much as he wants. So you could argue this guy has capacity and can refuse. As long as you document it well, you should be legally protected.

In reality what happened was the officer told him he had to, and he then consented. But, what if the officer didn't say that. What if there was no officer. Do you let him walk?

Do you work in Community place? CT
Do you work in Academic Center or County? CT
Trust me, radiation is the least of this guys' problems.
 
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Does law2doc still exist? I wonder if they would have any helpful comments particularly on if a New York Supreme Court case is applicable to other states. I would err on the side of caution document as many others have above and sedate and scan. Also don't forget the importance of documenting other deescalation techniques that you tried prior to resorting to chemical restraints.


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and yes Haldol and restraints are your friends.

Problem with using haldol for these players is that it's not actually FDA-approved for agitation...so when the guy goes into torsades you're hosed. I love a B52 as much as the next guy and I have no problem going off label most of the time but in border-line cases like above I try to stick with benzo IM +/- ketamine. Imagine the trial lawyer: "So doctor, your chart says my client was agitated. Please explain why you gave my client a drug that's not FDA approved for this indication and caused him harm as you also violated his rights. Do you frequently ignore expert guidelines?"

I try really hard to avoid sedating these patients and only do so if I have a very high suspicion (or obviously if they're clearly unable to string a sentence together, etc).

I think generally BALs box us in to a needless waiting game and/or cause the alcoholics to withdraw. I don't want to deal with that.

My typical approach in order for the EToH patient above who is not floridly agitated:

1) "I want to make sure you're not having a brain bleed because if you do then you're not going to jail tonight, you're being admitted to." Probably works ~20-40% of the time since most people don't like going to jail.

2) "I'd like to be able to give you something to eat and drink but I can't do that unless we get the CT and know it's safe for you to eat." Most drunk people are hungry and thirsty and will go with this.

3) Get their family to talk to them on the phone or come in.

4) If above options fail: obs till clinical sobriety in a busy/noisy hallway bed provided they're not a danger/major nuisance to others. Many will change their minds as they wait. If they're a guy I make sure to tell them about about the potential disability that can arise by delaying the scan "being in a wheel chair, not being able to have sex or again, needing to wear a diaper for the rest of your life or having to stick a tube up your penis in order to pee, blah blah blah." Then document, document, document.
 
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Does law2doc still exist? I wonder if they would have any helpful comments particularly on if a New York Supreme Court case is applicable to other states. I would err on the side of caution document as many others have above and sedate and scan. Also don't forget the importance of documenting other deescalation techniques that you tried prior to resorting to chemical restraints.


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Law2doc is absolutely useless when it comes to clinical medicine. The only thing I've ever seen that person do is say that the program is always, 100% correct when there is a problem between resident and program. And I have 14 f'n years on SDN.
 
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Law2doc is absolutely useless when it comes to clinical medicine. The only thing I've ever seen that person do is say that the program is always, 100% correct when there is a problem between resident and program. And I have 14 f'n years on SDN.

Too bad. I wish we had someone like enbastet on SERMO here for legal questions.



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and yes Haldol and restraints are your friends.

I think we should stop using haldol in these situations. Its great for your straight forward, known psych history, type agitation. Its not so great for the frequent undifferentiated agitation patient. So many cases seen on tox rotation where haldol was used and caused adverse effects. When you consider the possibility of qt prolongation, impaired heat dissipation, anticolingergic side effects, dystonic reactions, its just not worth it. Honestly, I don't even see much of a difference between ativan + haldol and ativan + ativan for these people. It seems the patients at highest risk for adverse reaction to haldol are the ones getting it. When you combine this with the lack of FDA indication, I suspect the legal implications if an adverse event occurred would be significant. My algorithm for that undifferentiated agitation patient is generally: benzo, consider reversible causes ---> benzo +/- physical restraint ---> heavy dose benzo ---> RSI
 
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maybe I am too cavalier. But if he is clinically sober (I hate BAL), Bye Bye to jail if minor mechanism/no physically concerning trauma. My documentation would Be AIR tight. A&Ox3, ambulatory, capable of making his own decision, Well appearing.

I am NOT every going to chemically restrain a Drunk for a CT unless I have High Bleed suspicion.

I would rather let him go and have a bad outcome than Chemically restrain/potentially intubate drunk and have him crash in the ED. Give me the 1 bad outcome in my career vs intubating/chemically restraining drunk 3 times a shift + having to Obs said belligerent Drunk for another 3-12 hrs while endangering my staff.

Being Drunk doesn't mean someone can force care on you. I am sure no one here would like it if a friend brought you into the ED, some Hot shot EM docs says you can't make any decisions, and then knocks you out to go to CT. Wake up potentially with a tube down your throat b/c you stopped breathing.
 
Just curious, what is your move if he tries to walk out? Somewhat intoxicated but oriented and ambulatory, refusing care, do you restrain if they try to leave or just let them go?

Dude, dont' leave or I will call the police. Dude leaves, I call the police that a drunk guy just left the ED. We have no right to Hold someone against their will just b/c they are drunk. Can you imagine going to a bar, wanting to walk or take a cab home, and the bouncer forcibly keeps you from leaving?
 
Good luck convincing a jury that someone who is drunk, slurring their speech, crashed their car into a pole after swerving off the road, and hit their head hard enough to get knocked out is "clinically sober" to make good decisions.

Write your chart to reflect that this person displays no regard for their wellbeing or capability of reasonable thought and has physical evidence of a head injury. Document they don't display an adequate understanding of risk and consequences. Then restrain them and do what you need to do.

In my opinion, if you're going to be unlucky enough to have a bad outcome, I'd rather it happen within a narrative that makes sense. Lawyers can argue any side of any position so either way you're screwed. I'd prefer to be defending a position that makes the most sense.

Implement Occam's razor of medical decision making and stop rationalizing yourself out of a reasonable decision.

I would rather try to convince a Jury that the pt was alert/oriented, had no major signs of head trauma

Vs

convince a jury that I held him against his will, gave him versed, intubated him, aspirated, and died. The family lawyer would have a Field Day with every Jury thinking what a Dufus of an EM doc and that dead guy could have been me.

Yeah good luck with that.
 
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I literally just had this patient a few days ago. intoxicated, reeks like etoh, belligerant toward staff. struck with beer bottleand being adament that we let him leave. I bribe him with a turkey sandwich to get a CT....the guy had prolonged LOC and somethimg didnt feel right. The scan shows frontal nondepressed skull fx....frontal subdural....and sub arachnoid blood. In an asymptomatic drunk. He tried to elope and i took his rights away and let security handle him. But it would have been way too easy to let one of our usual drunks walk out of the ED

We are not talking about the pt who is clearly Drunk but otherwise just acts like he is drunk. Of course I would intubate a guy if pieces of bone is coming out of his skin. This is not a gray area. The Gray area is minor head trauma in an otherwise drunk appearing guy.
 
Simple algorithm for me:
Drunk and no injury. Security. The drunk usually doesnt fight and sleeps the night away. I dont let anyone drunk leave unless into a reliable guardian.

Drunk, no injury, fights security. Haldol. I dont care about off label use and stuff. We use plenty of meds off label. A lawyer could easily say "Why doctor why would you use a benzo with risk of respiratory depression blah blah blah."

Drunk, injury. Jedi mind tricks. If not successful, Rsi.

I dont waste time with agitation. Dangerous to staff, dangerous to patient.

Now this is for my "drunks." Excited delirum is a whole another story. Usually I just RSI but sometimes IM ketamine.
 
Simple algorithm for me:
Drunk and no injury. Security. The drunk usually doesnt fight and sleeps the night away. I dont let anyone drunk leave unless into a reliable guardian.

Drunk, no injury, fights security. Haldol. I dont care about off label use and stuff. We use plenty of meds off label. A lawyer could easily say "Why doctor why would you use a benzo with risk of respiratory depression blah blah blah."

Drunk, injury. Jedi mind tricks. If not successful, Rsi.

I dont waste time with agitation. Dangerous to staff, dangerous to patient.

Now this is for my "drunks." Excited delirum is a whole another story. Usually I just RSI but sometimes IM ketamine.
Our hospital would be 89% avoidable ICU admission if we intubated our agitated delirium patients.

Some combination of Ativan, Haldol, Zyprexa, ketamine, Benadryl, physical restraint nearly always takes care of it.
 
Simple algorithm for me:
Drunk and no injury. Security. The drunk usually doesnt fight and sleeps the night away. I dont let anyone drunk leave unless into a reliable guardian.

Drunk, no injury, fights security. Haldol. I dont care about off label use and stuff. We use plenty of meds off label. A lawyer could easily say "Why doctor why would you use a benzo with risk of respiratory depression blah blah blah."

I don't see how this is legal or moral. How does being drunk take away a person's right to leave? Its not my job to be the cops and arrest for public intoxication.

So if you went out drinking, found passed out at the bar, EMS took you to my ER, you have a BAC of 300, then I have the right to keep you until you are sober? Are you really going be happy that someone is going to tie you down and shoot you up with Haldol?

I think if this happens to you , you would change your mindset.

my algorithm simply is clinically sober, you can leave. If you can find a ride you can leave. If you are clinically drunk and want to leave, I will show you the door and call the police for public intoxication.

I refuse to hold someone against their will, endanger staff to keep them in the ED. If I were a nurse, and a doctor told me to jump on the pt so another nurse with a needle can stab his thigh, I would tell the doctor to be the first to jump in there and I will follow.
 
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I don't see how this is legal or moral. How does being drunk take away a person's right to leave? Its not my job to be the cops and arrest for public intoxication.

So if you went out drinking, found passed out at the bar, EMS took you to my ER, you have a BAC of 300, then I have the right to keep you until you are sober? Are you really going be happy that someone is going to tie you down and shoot you up with Haldol?

I think if this happens to you , you would change your mindset.

my algorithm simply is clinically sober, you can leave. If you can find a ride you can leave. If you are clinically drunk and want to leave, I will show you the door and call the police for public intoxication.

I refuse to hold someone against their will, endanger staff to keep them in the ED. If I were a nurse, and a doctor told me to jump on the pt so another nurse with a needle can stab his thigh, I would tell the doctor to be the first to jump in there and I will follow.

What do you do when the police bring all of their drunks to the ed?
 
I don't see how this is legal or moral. How does being drunk take away a person's right to leave? Its not my job to be the cops and arrest for public intoxication.

So if you went out drinking, found passed out at the bar, EMS took you to my ER, you have a BAC of 300, then I have the right to keep you until you are sober? Are you really going be happy that someone is going to tie you down and shoot you up with Haldol?

I think if this happens to you , you would change your mindset.

my algorithm simply is clinically sober, you can leave. If you can find a ride you can leave. If you are clinically drunk and want to leave, I will show you the door and call the police for public intoxication.

I refuse to hold someone against their will, endanger staff to keep them in the ED. If I were a nurse, and a doctor told me to jump on the pt so another nurse with a needle can stab his thigh, I would tell the doctor to be the first to jump in there and I will follow.
If I'm not concerned about major underlying pathology and the patient is sober enough to rapidly stand and take two steps towards me in an attempt to hit me, they're sober enough to leave. (Or if they're pleasant and ambulatory.)

I prefer they have a ride or responsible party, but I'm not putting my staff at risk and penalizing the patient with chemical restraint and removal of autonomy just because no one loves them enough to pick them up.
 
What do you do when the police bring all of their drunks to the ed?

Drunk gets bought to ED ALL the time. No drunk tank in my city after some dufus died for some unknown reason.

If police brings them in and they are not under arrest, and Police leaves. I tell him that I am happy to watch u in the ED, Put an IV in for IV fluids if you want, feed you if you are cooperative, and you can leave if you get a ride. If dude is clinically drunk, and refuses to be cooperate, and he wants to leave.... I show him the exit. Call the police and report public intoxication.

Either they can't find the pt or if they do, take them to jail. If they bring them back to the ED, I will in front of the Police tell the pt that he is free to leave unless the police wants to stay with the pt and tackle him.

I have a few goals when working in the ED outside of good patient care.

1. Leave right on time or very close
2. Not get hurt or have the staff hurt.

I see way too many issues with fighting with a drunk.
 
I had one tonight! Had this thread in my head the whole time.

Luckily, security flexed a bit and he cooperated .
 
We live in a litigious society.

Drunk = no capacity. I dont order EtOH levels, if altered, cant leave. Simple.
Altered from sepsis, trauma, hypoxia, etc. all cant leave.

I dont see how that makes me a bad doctor for not allowing altered people to leave and get hit by busses
 
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