Drunk & Combative Patient in Low-to-Medium Risk MVC

[Angry Birds]

I had a patient the other day who was skunk drunk in a high speed MVC without any obvious major injuries on initial inspection, aside from abrasions/road rash. She had been ambulatory, and arrived by EMS highly combative. They came to my facility due to their reasonable fear that she would literally jump out of the ambulance if they took her to the farther away trauma center.

The patient is verbally abusive to my staff and I, and refuses any interventions. What would you do in this scenario?

I figured that it was a high speed MVC and that she couldn't walk out like this (her blood alcohol ended up being >400) even though my suspicion for injury was only low-to-medium. I sedated her, and then ended up having to tube her. I scanned her head to toe, all negative, extubated her, and eventually discharged her.

Would you have done differently? What are they doing nowadays at academic trauma centers with regard to this scenario?

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[goodoldalky]

I’m at a level 1 trauma center and would have done the same thing.

 

[deleted480308]

That’s what I believe my attending would do. Sedation is safer than restraints if you can’t know they aren’t injured yet and you can’t let a patient without capacity leave AMA

 

[rbnsafsadgf]

Yep, would have done 5 and 2 then probably tubed if really combative.

 

[Zebra Hunter]

What’d you use for sedation? In a drunk trauma patient, the best answer is probably some IM ketamine.

 

[Janders]

High speed MVC?
Visible marks of trauma?
Can't get a solid exam.

Tube, then tube of truth. Sure you can try 5&2 or IM Ketamine, but odds are solid you are going to ETT. Which I think is completely reasonable.

 

[Groove]

I had a patient the other day who was skunk drunk in a high speed MVC without any obvious major injuries on initial inspection, aside from abrasions/road rash. She had been ambulatory, and arrived by EMS highly combative. They came to my facility due to their reasonable fear that she would literally jump out of the ambulance if they took her to the farther away trauma center.

The patient is verbally abusive to my staff and I, and refuses any interventions. What would you do in this scenario?

I figured that it was a high speed MVC and that she couldn't walk out like this (her blood alcohol ended up being >400) even though my suspicion for injury was only low-to-medium. I sedated her, and then ended up having to tube her. I scanned her head to toe, all negative, extubated her, and eventually discharged her.

Would you have done differently? What are they doing nowadays at academic trauma centers with regard to this scenario?

I like your style. Management sounds completely reasonable.

 

[deleted859535]

My work and my life is too important to jeopardize for some obnoxiously drunk person hiding their high-grade splenic laceration or head bleed because they're too drunk to care about themselves.

Sedate. Intubate if need be. Trauma evaluation. Dispo pending that. Period. Same at my level 1 or my regional facilities.

 

[bravotwozero]

Yup you did just fine. Too bad the police weren’t looking for him, otherwise I’d try to let them know their suspect is here and can be discharged into their custody. Note - only do this if the cops are aware and ask, otherwise obviously it’ll become a hipaa issue.


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[shoal007]

I would have done the same, but would have left her intubated and admitted.

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[TooMuchResearch]

What’d you use for sedation? In a drunk trauma patient, the best answer is probably some IM ketamine.

In an agitated drunk patient, I go for 10 of Haldol. No benzo. Usually enough to either get the workup or let them sober up and determine no workup is needed.

 

[alpinism]

350 IM ketamine.

Puts em down in less than a minute.

Shouldn't need to intubate either just closely monitor their respiratory status.

 

[WilcoWorld]

I agree with the above posters that ketamine or haldol might have allowed the workup while avoiding the intubation, but I don't think that what you did was wrong.

This patient needs a workup and is not competent to refuse. Assess the situation and proceed in whatever way you decide is safest - if that involves an endotracheal tube, so be it.

 

[Interpolfanclub]

Samesies. I love these cases, ketamine and tube. I like most people better on a vent.

 

[GeneralVeers]

I would try Ketamine first. 90% of the time I can get the scans/tests I need with that. If i have to intubate, then I'm going to just admit them overnight to the hospital. I don't have time to try managing an intubated patient and extubating them.

 

[Brigade4Radiant]

If I need to intubate the patient they will be transferred/admitted because if I intubate an alcoholic with a BAL of 400 I would play it as severe alcohol intoxication needing airway protection. I would do Haldol 10 IM or 3mg per kg of ketamine for the patient.

 

[Birdstrike]

I had a patient the other day who was skunk drunk in a high speed MVC without any obvious major injuries on initial inspection, aside from abrasions/road rash. She had been ambulatory, and arrived by EMS highly combative. They came to my facility due to their reasonable fear that she would literally jump out of the ambulance if they took her to the farther away trauma center.

The patient is verbally abusive to my staff and I, and refuses any interventions. What would you do in this scenario?

I figured that it was a high speed MVC and that she couldn't walk out like this (her blood alcohol ended up being >400) even though my suspicion for injury was only low-to-medium. I sedated her, and then ended up having to tube her. I scanned her head to toe, all negative, extubated her, and eventually discharged her.

Would you have done differently? What are they doing nowadays at academic trauma centers with regard to this scenario?

Based on what you're telling us, it seems your means of restraint was out of genuine concern for patient safety and that you determined it was the best and safest form of restraint for that patient, at that time. Hard to question that, assuming the outcome was good.

Some other thoughts: In 10 years in the ED, I didn't do this that often for combative drunks (sedate and intubate simply as a means to restrain). I'm not saying it's wrong; sometimes you need to. But I had partners where it seemed to be their go-to method for handling drunks that were acting wild with even the slightest hint of any trauma or illness. With an ETOH >400, often you can physically restrain that person for a few minutes, at least long enough to forget why they were pissed off and for them to pass out. There can be more than 1 way to get this done. If had intubated every combative drunk that might have something wrong with him on every night shift, I'd have had an ED full of wasted ICU players clogging up my ED and ICU. And generally, I'm much less worried un-diagnosed injury in a combative, angry drunk, than one overly sedate one, that won't arouse.

But if you're truly concerned about some severe trauma or bleed, sure you can do it. You've got to do something to get your evaluation in a patient that clearly is altered enough they can't give informed refusal. But I've also seen it done seemingly more out of anger and irritation towards the combative drunk person going berserk & making a scene in the ED at 3 am while generally being a pain in the buttocks, than out of concern for patient injury or illness. Just act in the patient's best interests and document it, and it should be fine.

 

[gamerEMdoc]

I like ketamine in situations like this. Lets you avoid the tube.

Also, shockingly, sometimes calling the police or threatening to do so calms these situations down.

“Sir, I know you are angry, but the law says we cant let you go with your level of intoxication. I dont want to have to call the police to keep you safe, but thats what we’ll have to do if you try to leave. I’d rather you just try and sober up here and go home in a bit when you are sober enough to safely leave. Id really rather not get the cops involved for your sake.”

Not saying this works for everyone, but it does for some.

These cases make me miss my days in the military. I made more than one drunk young marine cry by simply asking “Im calling your command, who is your sergeant?”.

 

[dchristismi]

I ninja-tubed someone like that once... he was walkie/sweary, but hypoxic as hell and clearly not mentating... but was going to get violent.

Nurse who he'd tolerated walked in (he was pacing at this point) pushed some etomidate, we caught him as he fell and tubed him. First (and only) time I've entered the room with blade and tube in hand.

I'd also try to talk them down as Gamer described. Sometimes having a different doc come in makes the difference. "Whoa, whoa whoa... let start over. How can I help you..." sometimes goes a long way. But yeah, I'm all for a big slug of ketamine to gain control of the situation.

 

[TooMuchResearch]

I like ketamine in situations like this. Lets you avoid the tube.

Also, shockingly, sometimes calling the police or threatening to do so calms these situations down.

“Sir, I know you are angry, but the law says we cant let you go with your level of intoxication. I dont want to have to call the police to keep you safe, but thats what we’ll have to do if you try to leave. I’d rather you just try and sober up here and go home in a bit when you are sober enough to safely leave. Id really rather not get the cops involved for your sake.”

Not saying this works for everyone, but it does for some.

These cases make me miss my days in the military. I made more than one drunk young marine cry by simply asking “Im calling your command, who is your sergeant?”.

What law prevents you from discharging a drunk person?

 

[edmadison]

Tort law

-Ed

 

[Angry Birds]

Thanks from great feedback. I did not use Ketamine and maybe that's something I could've done. That's a good idea.

FYI, the reason for this thread was that the nurses were royally annoyed by me tubing the patient and insisting on the pan-scan (even though I'm known as the minimalist compared to my non-EM trained colleagues, many of whom CT scan aggressively and also order lots of tests in general).

 

[deleted109597]

Tort law

-Ed

Discharging them? Maybe. Letting them leave AMA? Case law says you're not responsible.

 

[deleted859535]

... FYI, the reason for this thread was that the nurses were royally annoyed by me tubing the patient and insisting on the pan-scan...

Good thing the nurses will be there at the deposition for the missed visceral trauma or head bleed because you didn't do the medically safer thing in a high-energy MVC.

Oh, wait.

 

[gamerEMdoc]

What law prevents you from discharging a drunk person?

Public intoxication. Its illegal to be drunk and combative in public. Its my duty as a concerned citizen to let that happen. Lol.

And you not only are liable for missed injury, you can also be liable if that person is so intoxicated they go walk into traffic.

 

[TooMuchResearch]

Public intoxication. Its illegal to be drunk and combative in public. Its my duty as a concerned citizen to let that happen. Lol.

And you not only are liable for missed injury, you can also be liable if that person is so intoxicated they go walk into traffic.

Ah, we don't have that. If you can walk and talk, you are eligible for discharge regardless of BAC.

 

[gamerEMdoc]

I don't rely on the BAC. It's a question of whether the patient can display appropriate decision making capacity. If a patient can get up, safely walk a straight line without falling down, and isn't slurring their speech, and can explain the consequences of their decisions, their BAC is irrelevant. They display decision making capacity, and can therefore leave AMA. It just so happens, most drunk beligerent people can't do those things.

 

[WilcoWorld]

Public intoxication. Its illegal to be drunk and combative in public. Its my duty as a concerned citizen to let that happen. Lol.

And you not only are liable for missed injury, you can also be liable if that person is so intoxicated they go walk into traffic.

I believe that there was a tort decision (in NY?) that found the provider NOT to be liable for an intoxicated patient's behavior after leaving AMA.

 

[Vandalia]

I believe that there was a tort decision (in NY?) that found the provider NOT to be liable for an intoxicated patient's behavior after leaving AMA.

True, but as I am sure you know (this is for the students) that only applies in NY. If there is no binding precedent in your own state, the court might be persuaded by the reasoning of another state's highest court. That might work in Texas, but probably not in Chicago.

 

[BoardingDoc]

I believe that there was a tort decision (in NY?) that found the provider NOT to be liable for an intoxicated patient's behavior after leaving AMA.

New York's High Court Rules Hospital Is Not Liable for Failure to Retain an Intoxicated Patient | 2013-10-01 | AHC Media: Continuing Medical Education Publishing

TL;DR: guy was drunk, showed up wanting detox. Stayed in the ED 4 hours then eloped. Told a RN as he was leaving that a friend was going to drive him home. Wandered into traffic instead and wound up a quad. Sued and lost.

 

[goodoldalky]

Discharging them? Maybe. Letting them leave AMA? Case law says you're not responsible.

Untrue. I am aware of a current intoxication/AMA trauma case in Texas which is going to result in a seven figure payout.

Never say never, each case is different, and there can be payable liability even in an AMA case such as this.

 

[gamerEMdoc]

Yeah, I think it would be very up in the air in terms of how the jury would side in these cases. In the end, if you legitimately do what is in the best interest of the patient to rule out anything emergent, and document well why you had to sedate them, then I think it would be hard to find fault for having to do a chemical takedown on a beligerent intoxicated person. Much easier to find fault in someone blowing them off because they didn't want to deal with them.

 

[BoardingDoc]

Untrue. I am aware of a current intoxication/AMA trauma case in Texas which is going to result in a seven figure payout.

Never say never, each case is different, and there can be payable liability even in an AMA case such as this.

Agree. While the case I linked above worked out well for the doc, my practice is:
-if you are clinically sober, you can leave. BAL is irrelevant as someone who doesn't drink can be wasted at .08, and a hardcore boozer can be stone cold sober at .30. I just document that they appeared sober and were independently ambulatory and steady on their feet at time of DC.
-if you are not clinically sober, you're staying in the ED until you are, one way or another (or until a sober, responsible person comes to get you).

 

[Perfect Hair Day]

Agree. While the case I linked above worked out well for the doc, my practice is:
-if you are clinically sober, you can leave. BAL is irrelevant as someone who doesn't drink can be wasted at .08, and a hardcore boozer can be stone cold sober at .30. I just document that they appeared sober and were independently ambulatory and steady on their feet at time of DC.
-if you are not clinically sober, you're staying in the ED until you are, one way or another (or until a sober, responsible person comes to get you).

I remember when I was in college, my fraternity brothers called 911 because I was, erm, lets call it "difficult to arouse" (like, I was drunk and tired I just wanted to sleep lol), so when EMS came I had to go to great lengths to justify that I was okay - I took them through an ACLS megacode, fraternity brothers were dumbfounded, EMS was like lulz, and I got to go back to sleep - but I was honestly drunk as hell haha.

 

[gamerEMdoc]

Agree. While the case I linked above worked out well for the doc, my practice is:
-if you are clinically sober, you can leave. BAL is irrelevant as someone who doesn't drink can be wasted at .08, and a hardcore boozer can be stone cold sober at .30. I just document that they appeared sober and were independently ambulatory and steady on their feet at time of DC.
-if you are not clinically sober, you're staying in the ED until you are, one way or another (or until a sober, responsible person comes to get you).

This is exactly what I do. Pretty much what's recommended by the risk manamement monthly folks, if you listen to their CME.

My documentation regarding these folks if they are leaving AMA says something like "The patient shows no signs of clinical intoxication, was visualized ambulating without any signs of ataxia, was not slurring their speech, and was fully conversant and understood and explained back to me the discussion we had about the consequences of their decision to leave AMA. They appear to exhibit decision making capacity at this time."

 

[DocEspana]

I was reading this and baffled at how many of you are intubating people. Not thst I'm against it. But in residency I 5 and 4'd (prefer versed) people with >400 alcohol multiple times a day*. Never intubated one in 3 years. He'll sometimes they'd get the 5 of haldol, 4 of versed, 2 of ativan.... another 2 of ativan.

No one ever needed anything more than a nasal cannula, an occasional sternal rub and (for the 5 and 4 and 2 and 2 peeps) an nasal trumpet. When they were awake enough to pull it out they were awake enough to no longer need it.

What the hell are you guys putting in your B52s? Is it the fact thst I don't use benadryl? Maybe it's that?

My actual addition to this thread is that for agitated people I'd find thst the 5 and 2 only calmed them but testing was still a pain.... used etomidate in the ct tube with a bag valve handy to solve that agitation issue for exactly how long a CT whole body would take. 10mg given and then start the CT sort of deal.

*we were an alcohol intox and PCP (but not at the same time) center of excellence.

 

[gamerEMdoc]

*we were an alcohol intox and PCP (but not at the same time) center of excellence.

Never at the same time. That would be uncivilized.

 

[DocEspana]

Never at the same time. That would be uncivilized.

Dont mix uppers and downers. That's just classless

 

[Angry Birds]

I was reading this and baffled at how many of you are intubating people. Not thst I'm against it. But in residency I 5 and 4'd (prefer versed) people with >400 alcohol multiple times a day*. Never intubated one in 3 years. He'll sometimes they'd get the 5 of haldol, 4 of versed, 2 of ativan.... another 2 of ativan.

No one ever needed anything more than a nasal cannula, an occasional sternal rub and (for the 5 and 4 and 2 and 2 peeps) an nasal trumpet. When they were awake enough to pull it out they were awake enough to no longer need it.

What the hell are you guys putting in your B52s? Is it the fact thst I don't use benadryl? Maybe it's that?

My actual addition to this thread is that for agitated people I'd find thst the 5 and 2 only calmed them but testing was still a pain.... used etomidate in the ct tube with a bag valve handy to solve that agitation issue for exactly how long a CT whole body would take. 10mg given and then start the CT sort of deal.

*we were an alcohol intox and PCP (but not at the same time) center of excellence.

I did not expect the patient to require intubation when I sedated her, but she did. Shrug.

I don't willy-nilly intubate people. This was a specific case in which I need to due to her specific response to the sedation.

 

[TooMuchResearch]

I was reading this and baffled at how many of you are intubating people. Not thst I'm against it. But in residency I 5 and 4'd (prefer versed) people with >400 alcohol multiple times a day*. Never intubated one in 3 years. He'll sometimes they'd get the 5 of haldol, 4 of versed, 2 of ativan.... another 2 of ativan.

No one ever needed anything more than a nasal cannula, an occasional sternal rub and (for the 5 and 4 and 2 and 2 peeps) an nasal trumpet. When they were awake enough to pull it out they were awake enough to no longer need it.

What the hell are you guys putting in your B52s? Is it the fact thst I don't use benadryl? Maybe it's that?

My actual addition to this thread is that for agitated people I'd find thst the 5 and 2 only calmed them but testing was still a pain.... used etomidate in the ct tube with a bag valve handy to solve that agitation issue for exactly how long a CT whole body would take. 10mg given and then start the CT sort of deal.

*we were an alcohol intox and PCP (but not at the same time) center of excellence.

Almost every agitated drunk patient who needed to sleep it off during residency did great with 10 of Haldol and no benzo. I work in the same town as my residency and now realize the police and medics selectively dumped the drunk patients to our residency hospital...

 

[deleted109597]

It's like ketofol. No data to say the combo is better than each individually. But worse outcomes due to overdosing on a particular agent. In the people with EtOH on board, they don't need more BZDs. Their GABA is already saturated. Just stop the crazy and let them breathe on their own.

 

[dchristismi]

...assuming they aren't so combative that they'll hurt you, your staff or themselves.

I had a guy in residency so combative that it was all we could do to get access - he sat up bolt upright in the middle of his CXR and smashed his head on the portable.
He was a trauma patient though, and, well, this was, um, 14 years ago, when ketamine wasn't quite the hot drug it is today. And he had a basilar skull fracture. But the bottom line is that he was a danger, so we tubed him. That he stands out in my mind from over a decade ago makes me relatively certain that it really isn't something we do frequently.

I see some of the same degree of agitation with some of the K2 blends that are out there. While I think most of us try to avoid it, sometimes it's the safest option.

 

[UKEMdoc]

CYA

In court drunk and aggressive becomes cerebrally irritated from the tiny haemorrhagic contusion. Restraints won't help the ICP and sedating someone with an unprotected airway and a stomach full of Jack Daniels mixed with McDonalds is pretty sporting.

Extubate the second the scan's finished and if they as much as swear at a nurse post recovery then get them prosecuted for Breach of the Peace/equivalent.

 

[UKEMdoc]

I'm sure that if there was the smallest bit of intracereberal blood an ambulance chasing lawyer would be able to claim that it was your fault they will be unemployed for the rest of their life...

 

[DocEspana]

...assuming they aren't so combative that they'll hurt you, your staff or themselves.

I had a guy in residency so combative that it was all we could do to get access - he sat up bolt upright in the middle of his CXR and smashed his head on the portable.
He was a trauma patient though, and, well, this was, um, 14 years ago, when ketamine wasn't quite the hot drug it is today. And he had a basilar skull fracture. But the bottom line is that he was a danger, so we tubed him. That he stands out in my mind from over a decade ago makes me relatively certain that it really isn't something we do frequently.

I see some of the same degree of agitation with some of the K2 blends that are out there. While I think most of us try to avoid it, sometimes it's the safest option.

I left NYC and actually miss K2. It was fun to see the toxidrome change every 2 or 3 weeks. You'd get really good at one blend (blue iPhone, toasted, black ninja) with some known mix of agitation and sedation and then the next one would present with pharmaceutical resistant bradycardia and transaminitis.

Starting to see flakka in South Florida. So that's filled a little bit of the hole in my heart, but I'm told they're always just crazy agitated. So it's more like PCP and less like the mystery that was k2.

In Hindsight it's a miracle I didn't tube any k2 people.

 

[TooMuchResearch]

CYA

In court drunk and aggressive becomes cerebrally irritated from the tiny haemorrhagic contusion. Restraints won't help the ICP and sedating someone with an unprotected airway and a stomach full of Jack Daniels mixed with McDonalds is pretty sporting.

Extubate the second the scan's finished and if they as much as swear at a nurse post recovery then get them prosecuted for Breach of the Peace/equivalent.

Using Haldol to calm the agitated drunk without an invasive procedure is defensible practice.

 

[deleted109597]

...assuming they aren't so combative that they'll hurt you, your staff or themselves.

I had a guy in residency so combative that it was all we could do to get access - he sat up bolt upright in the middle of his CXR and smashed his head on the portable.
He was a trauma patient though, and, well, this was, um, 14 years ago, when ketamine wasn't quite the hot drug it is today. And he had a basilar skull fracture. But the bottom line is that he was a danger, so we tubed him. That he stands out in my mind from over a decade ago makes me relatively certain that it really isn't something we do frequently.

I see some of the same degree of agitation with some of the K2 blends that are out there. While I think most of us try to avoid it, sometimes it's the safest option.

I don't disagree, but you can knock down most wildebeest with enough Haldol or Geodon (or ketamine today if your shop lets you). BZDs are not my favorite class of drug. They can stop people breathing even without coingestion. They can have paradoxical effects in spectrum people.
At the end of the day, if you have to tube them it's not the end of the world. I'm just trying to offer non-tube suggestions. Everything isn't a nail, and intubation isn't a hammer. I saw a guy get a cric because someone made the decision to tube them for agitation, and it turns out they had no other injury. I've read about people dying from failed tubes.

 

[BoardingDoc]

This is exactly what I do. Pretty much what's recommended by the risk manamement monthly folks, if you listen to their CME.

My documentation regarding these folks if they are leaving AMA says something like "The patient shows no signs of clinical intoxication, was visualized ambulating without any signs of ataxia, was not slurring their speech, and was fully conversant and understood and explained back to me the discussion we had about the consequences of their decision to leave AMA. They appear to exhibit decision making capacity at this time."

This is the part where I'm having a disconnect though. Who are these people leaving AMA? In my decision tree you're either drunk and can't leave at all, or you're clinically sober and discharged. Why would there be an AMA involved?

 

[gamerEMdoc]

This is the part where I'm having a disconnect though. Who are these people leaving AMA? In my decision tree you're either drunk and can't leave at all, or you're clinically sober and discharged. Why would there be an AMA involved?

I think you need tests after an MVC, the drunk person doesn't think they need tests. That's the AMA.

 

[DocEspana]

I think you need tests after an MVC, the drunk person doesn't think they need tests. That's the AMA.

I think boarding docs argument falls into the spectrum of how I feel.

There is pretty good anecdotal evidence that unless a (capacitated) person makes a completely indefensible medical decision, that AMA discharge raises your risk of loss in court not lowers*. This is compared to taking thst same patient and doing a thoroughly written shared decision making commentary. You're allowed to discharge someone and say that you disagree with them, as long as you can document that they understood your reasoning and declined everything you offered.**

* I believe Greg Henry referred to AMA documents as the fastest way to turn a bad outcome into your lawyer settling. It basically makes you seem like a doctor who didn't care to listen to the patient or work with the patient to find a middle ground. Medicine doesnt always *have* a middle ground, but thats irrelevant when this appearance colors a court case against you in those subjective ways that make your lawyer want to settle.

** there are people who will then argue that your informed consent is just an AMA without the negative stigma - but that your hospital will freak out because they feel the provisions they want in the AMA for their defense aren't in there. My residency would yell at us for every single AMA regardless of reason as AMA was an administrative metric, but they yell even louder if they found out that we educated and discharged someone where we openly acknowledged they refused necessary treatment because we didn't use the legal forms they liked. They begged us to find some third way, which obviously didn't exist. Point being - I never AMA someone unless they're making a completely terrible decision or the rare "I want to be admittred but I have to drive my family home first/walk the dog first" since that guy is my problem if he doesn't come back. But shared decision making is just a different way of doing it that is better for the doctor unless your admin makes it worse for you