Not geting Blood Alcohol and UDS for fear of not getting paid

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Im an intern in my 2nd month. Last night we had a pt in a MVC come in who was alert w/ suspected alcohol intox. I wanted to get a blood alcohol level and uds on the guy but my upper level said not to b/c if insurance found out they my not pay the hospital for his injuries. I was told that we already had clinical suspecion of alcohol and it would not change the management. I thought that was a crapy answer since every other non-trauma pt gets at least a uds. I had never heard of this. Is this common practice in hospitals everywhere? Can ins companies really refuse to pay the hospital?

 

[BADMD]

Im an intern in my 2nd month. Last night we had a pt in a MVC come in who was alert w/ suspected alcohol intox. I wanted to get a blood alcohol level and uds on the guy but my upper level said not to b/c if insurance found out they my not pay the hospital for his injuries. I was told that we already had clinical suspecion of alcohol and it would not change the management. I thought that was a crapy answer since every other non-trauma pt gets at least a uds. I had never heard of this. Is this common practice in hospitals everywhere? Can ins companies really refuse to pay the hospital?

Some insurance policies won't pay if alcohol/drugs are related.

Here is another question: You already suspect the guy is intoxicated. While there are some cases were it is useful to prove the patient is intoxicated, would anything have changed based on the results of the ethanol and the UDS.

While ethanol may change what you do if it is stone cold negative, the results of the UDS are very unlikely to change anything. If a test won't change what you are going to do, why order it?

 

[SoCuteMD]

Sorry - you say that every other non-trauma patient gets a UDS? Why on earth would you do that?

 

[DoctorMedic]

it was a MVC, car insurance companies don't pay for the driver if the driver was DWI simple as that. Some health insurance companies will pick up the tab but that is per plan. Most car insurance companies won't.

 

[Rendar5]

Not to mention that ordering a test just to have more data that will not change any management or change any differentials is just a waste of money. If it's a drunk driving case and they need alcohol for prosecutorial reasons, the cops can get that themselves.

 

[GeneralVeers]

I rarely order alcohol levels. Clinical suspicion is usually enough.

They are ordered on psych patients as part of the "medical screening" exam, and on obtunded patients in order to help predict when they should wake up, or on admitted patients.

If a patient has a minor injury, family is at bedside and they are probably going to go home I don't even order it.

 

[rxfudd]

I routinely order alcohol levels on drunk patients nowadays, especially if I'm sending someone home.

Here's my logic: I write that the patient was clinically sober and could walk/talk/dance/etc, and discharge them. They then go and immediately get re-tanked upon discharge, and get flattened by a truck while walking home (or worse, get in a car and kill a family of four). The post-mortem or legal BAC comes back at 450. I have absolutely no evidence to back me up that the patient was sober when they left my ER. All I have is my clinical judgement, and the defense will just say that my judgement was clearly wrong because the level that is now on record was through the roof. If I had gotten a level, my claim that they were sober on discharge holds a whole lot more water (assuming they weren't drinking in the ER).

As much as that scenario sounds improbable, how many times have you sent a drunk out when he was clinically sober, only to have him bounce back a few hours later tanked again? It just seems like it would be hard to defend yourself if something bad happened in the meanwhile.

Does it suck to keep them around until they can get a ride or are below legal limits? I suppose. I just let them sleep in the corner and pee themselves.

If I know for sure that they have a ride (meaning that person is at the bedside with the patient on arrival), and that person will be able to get them into their house, I don't order it.

 

[Septo Shock]

I routinely order alcohol levels on drunk patients nowadays, especially if I'm sending someone home.

Here's my logic: I write that the patient was clinically sober and could walk/talk/dance/etc, and discharge them. They then go and immediately get re-tanked upon discharge, and get flattened by a truck while walking home (or worse, get in a car and kill a family of four). The post-mortem or legal BAC comes back at 450. I have absolutely no evidence to back me up that the patient was sober when they left my ER. All I have is my clinical judgement, and the defense will just say that my judgement was clearly wrong because the level that is now on record was through the roof. If I had gotten a level, my claim that they were sober on discharge holds a whole lot more water (assuming they weren't drinking in the ER).

As much as that scenario sounds improbable, how many times have you sent a drunk out when he was clinically sober, only to have him bounce back a few hours later tanked again? It just seems like it would be hard to defend yourself if something bad happened in the meanwhile.

Does it suck to keep them around until they can get a ride or are below legal limits? I suppose. I just let them sleep in the corner and pee themselves.

If I know for sure that they have a ride (meaning that person is at the bedside with the patient on arrival), and that person will be able to get them into their house, I don't order it.

That's what happened at the hospital I used to work at. Friends brought one of their buddies in after drinking too much and passed out. Guy wakes up and starts acting all fine upon admission. Then he was discharged on grounds that he was now clinically sober. 15 mins later paramedics brings him back in dead. Turned out that he had crossed the street across the hospital without looking and a car struck him and killed him. Now the hospital mandates that all alcohol related pts must have a blood alcohol done and that they keep them over night before discharge. Seems like alcohol testing would be an extra precaution for liability? Besides Obama will be paying for it

 

[AmoryBlaine]

It's certainly an annoying conversation to have with people who are still drunk but not completely out of it. They demand to leave, promise to sue you and everyone, tell you how important they are.

Look ace, I don't care if you're the secretary of state, you're staying her until your level says you are sober. It's just another way that the culture of liability has created a culture of insanity -- we are responsible for what drunk people do when they leave the ER.

 

[shortbread9]

This is interesting.....so you have to base everything on an etoh level....a number!? I was taught to not get an etoh level unless you are clinically suspicious that something else is going on and want to clarify their level, or of course if knowing would change their management.. Otherwise most drunks we see live at 200...and can walk, talk coherently. if i wait until they have that magic sober number they will be in DT's. I think we need to be careful about this b/c for most chronic alcoholics waiting may actually be a bad thing. If we are talking about getting levels for the intoxicated patient new to our dept ...maybe i would keep them around a bit longer until someone comes to pick them up but i would still like to think using and documenting our clinical judgement should somehow hold up in court. otherwise we will end up keeping a bunch of patients with multiple complaints way to long to ensure absolutely nothing will happen...even the remote possibility of getting hit by a car.

 

[Rendar5]

That's what happened at the hospital I used to work at. Friends brought one of their buddies in after drinking too much and passed out. Guy wakes up and starts acting all fine upon admission. Then he was discharged on grounds that he was now clinically sober. 15 mins later paramedics brings him back in dead. Turned out that he had crossed the street across the hospital without looking and a car struck him and killed him. Now the hospital mandates that all alcohol related pts must have a blood alcohol done and that they keep them over night before discharge. Seems like alcohol testing would be an extra precaution for liability? Besides Obama will be paying for it

umm...was the hospital actually sued or something? Cause otherwise, it's a strange response. Either go the full 9 yards and get a crossing guard cause you don't trust patients to (previously drunk or not) not kill themselves or let it be.

 

[Septo Shock]

umm...was the hospital actually sued or something? Cause otherwise, it's a strange response. Either go the full 9 yards and get a crossing guard cause you don't trust patients to (previously drunk or not) not kill themselves or let it be.

Yeah there was a lawsuit involved filed by the parents. Not exactly sure the details of it. This was a few years ago but I agree!

 

[rxfudd]

Trust me, I hear you. I was taught the same thing in residency that you were. Maybe it's easier for me because for some reason, a large number of my drunks have people they can call for a ride home.

The problem is that documentation of clinical judgment will only get you so far in certain cases. In this particular scenario, your clinical judgment (they were sober when they left, I swear!) has the potential to directly conflict with a cold hard number. If you say they were sober but their postmortem or legal level was super high (greater than 400, for example), the lawyers will just eat it up. They'll say that the patient couldn't have possibly been sober with the level they had, and you either must not have even examined them or you blew them off and pushed them out the door. Whether this is true or not, this is what they'll say, and I just don't see how you can defend yourself in that unfortunate position. You're sort of stuck. And it's pretty damn hard for them to suggest that you are to blame if the level in the ER was 200 and legal/postmortem level later on was 310.

I'm not saying at all that this is standard of care, just that you should recognize that you're putting faith in a patient that they will not do something stupid like drink more and get killed (or kill others, which is what I'm really worried about). I may be the only one who practices like this, but I'd just rather not put my license in the hands of a drunk.

So do I get a level on all of our chronic drunks or people who are not obviously drunk but have "had a few"? In truth, not every single time (it depends on the person and the situation) - but I totally recognize that I'm slightly rolling the dice when I don't.

This is interesting.....so you have to base everything on an etoh level....a number!? I was taught to not get an etoh level unless you are clinically suspicious that something else is going on and want to clarify their level, or of course if knowing would change their management.. Otherwise most drunks we see live at 200...and can walk, talk coherently. if i wait until they have that magic sober number they will be in DT's. I think we need to be careful about this b/c for most chronic alcoholics waiting may actually be a bad thing. If we are talking about getting levels for the intoxicated patient new to our dept ...maybe i would keep them around a bit longer until someone comes to pick them up but i would still like to think using and documenting our clinical judgement should somehow hold up in court. otherwise we will end up keeping a bunch of patients with multiple complaints way to long to ensure absolutely nothing will happen...even the remote possibility of getting hit by a car.

 

[docB]

rxfudd makes a really good point. To be honest it's one I hadn't really considered in terms of the specific scenario he's talking about. I probably won't start doing etohs on everyone as it would be pretty onerous where I am. I think it will make me document better and make sure that the nurse's note also documents clinical sobriety as well. I think having some corroborating input could help, but certainly not eliminate, the danger with this situation.

 

[txterp98]

On a similar note, I learned in residency from a hand surgeon that replantations don't get compensated in worker's comp injuries if there are drugs or alcohol on board. He made sure that I didn't order a UDS.

A quick look into worker's comp laws (though they vary from state-to-state) validates what the hand surgeon told me. Worker's comp injuries don't pay out if the patient is under the influence of alcohol or has any drugs in their system (including MJ).

Rarely, though, a patient can win a petition saying the accident would've occurred regardless of intoxication/drug use.

I'll also echo SoCute....why are so many of your non-trauma patients getting a UDS. And BadMD is right....why order a test if the results won't change your management?

RxFudd....nice points. I never thought about it that way. I think you and DocB's point about having nursing documentation corroborate your own documentation is key.

 

[SLUser11]

Adding my two cents as a trauma surgery chief resident currently:


For MVCs, or really any situation that can land you with a c-collar, the patient needs an EtOH level if you have clinical suspicion. I'm sure you are all familiar with the NEXUS criteria. Bottom line: You can't clear a c-collar if a patient is intoxicated.


As for the UDS, I was always taught to only get it if it was going to change my management of the patient, for the above-mentioned reasons. I remember specifically a patient who was horribly burned in an explosion at work, has permanent disability and a life of constant pain, and he lost a lot of his workman's comp because his UDS came back positive for marijuana.

That being said, there are papers coming out now that early intervention by social work, specifically while the patient is still in the hospital detoxing from whatever drug, has shown to have a decent success rate in helping the patient to quit.....so a lot of centers, especially the urban ones that don't get reimbursed much by their patients regardless, are starting to routinely test for drugs so they can "get help" for their patients......


I haven't necessarily bought into that yet......

 

[Jeff698]

For MVCs, or really any situation that can land you with a c-collar, the patient needs an EtOH level if you have clinical suspicion. I'm sure you are all familiar with the NEXUS criteria. Bottom line: You can't clear a c-collar if a patient is intoxicated.

But the determination of intoxication (clinically) isn't correlated to a specific EtOH level. NEXUS is describing a condition, not a level. We've all seen patients with an EtOH level that would make us snore but are at their baseline mental capacity. The criteria say imaging is required if intoxicated. EtOH level is not required (which would be silly since that's not the only intoxicating substance). It can be helpful but isn't required.

If you have clinical suspicion for a c-spine injury then NEXUS doesn't apply and you will need to do imaging, regardless of EtOH level. If you think they're intoxicated but their EtOH level is 0, they're still intoxicated. You just haven't found the substance/condition yet.

It would never cross my mind to depend on an EtOH level (which takes, approximately, forever to come back at my place) to make a clinical decision. If there is any doubt, you're done. Move on to imaging.

This isn't to say that there is no role for levels in trauma, I just don't think that blanket statements that might be misinterpreted to imply that you can't clear a c-spine without a documented EtOH level are not helpful. I suspect that's not what you meant but I just wanted to clarify.

Take care,
Jeff

 

[tkim]

Had a patient who was in rollover MVC, clinically intoxicated, but after negative trauma workup had persistent tachycardia. Didn't get the UDS until we considered giving b-blockers for the tachycardia to rule out cocaine use. Nurse warned us about getting the UDS because insurance wouldn't pay if he tested positive, but since he was going to jail for attempted murder, I doubt we were going to get much anyway.

 

[docB]

This is an interesting discussion. Nexus doesn't require an etoh level. It says that if the patient is intoxicated (or you have suspicion based on ALOC) then you have to image. Nexus doesn't say what you do when you have negative imaging and an intoxicated patient. Clearing the neck after negative imaging is a pretty controversial subject.

To be honest I image if intoxicated and if negative I reexamine and if clinically sober and negative exam I let it go. I know that others are more conservative. I fear the inevetable DTs in my population should they ever approach numerical sobriety.

 

[GeneralVeers]

This is an interesting discussion. Nexus doesn't require an etoh level. It says that if the patient is intoxicated (or you have suspicion based on ALOC) then you have to image. Nexus doesn't say what you do when you have negative imaging and an intoxicated patient. Clearing the neck after negative imaging is a pretty controversial subject.

To be honest I image if intoxicated and if negative I reexamine and if clinically sober and negative exam I let it go. I know that others are more conservative. I fear the inevetable DTs in my population should they ever approach numerical sobriety.

Too many drunk people in Vegas to be holding all of them in the ER for repeat alcohol levels and imaging everyone with a positive ETOH (by labs).

If they are clinically sober, or have family at bedside they are going home, sans ETOH level.

 

[SLUser11]

But the determination of intoxication (clinically) isn't correlated to a specific EtOH level. NEXUS is describing a condition, not a level.

It would never cross my mind to depend on an EtOH level (which takes, approximately, forever to come back at my place) to make a clinical decision. If there is any doubt, you're done. Move on to imaging.

Take care,
Jeff

Absolutely, I think that "intoxication" is relative. Still, I tend to practice defensive medicine in the trauma population since despite receiving free care, they will sue at the drop of a hat. For that reason, I have to prove that a patient is not intoxicated with an objective measurement. I get the EtOH level so I don't have 20 patients laying around waiting for their c-spines to be cleared.

As for imaging, even if a patient has a negative CT scan, I still can't clear their collar until they're "sober," so I don't base imaging decisions on whether or not they're intoxicated.

This is an interesting discussion. Nexus doesn't require an etoh level. It says that if the patient is intoxicated (or you have suspicion based on ALOC) then you have to image. Nexus doesn't say what you do when you have negative imaging and an intoxicated patient. Clearing the neck after negative imaging is a pretty controversial subject.

I just can't do it. They could hypothetically have ligamentous injury despite a negative CT, and be too drunk to appreciate it. I obviously think that 99% of people could just get their collars off and be done with it, but unfortunately I feel stuck, as I'm sure you guys do, spending extra money/time proving it.

I still do flexion/extension x-rays for people with c-spine tenderness and negative CTs, but a lot of people are jumping straight to MRI, which is a pricey decision.....

 

[GiJoe]

for those who routinely get etoh levels... does that mean u get 1 level when they come in drunk and then another level when you 'think' they're sober? what if your repeat level is 150? 120? does that mean you wait to get a THIRD level before you send them home?

my practice is to get it if i dont know whats going on....or if t hey look really obtunded and i wanna know how long they're gonna be in my ER so when i sign out, the next doc has an idea when the drunk is gonna wake up

i will usually head ct them too.

 

[Speed Racer]

how many times have you sent a drunk out when he was clinically sober, only to have him bounce back a few hours later tanked again?

16 or so....

 

[docB]

Lets make sure we're all talking about the same things here because I think we're falling prey to a pitfall of the medium and discussing different things at the same time.

First there is the issue of intoxicated patients without trauma and wheter or not we need to draw an etoh before we can dispo those patients.

Second there is the issue of how you clear the c-spine in an intoxicated patient. Unless you would argue that every intoxicated patient needs a c-spine xray these are seperate issues ( no one is imaging the neck of the drunk guy who comes in conscious due to vomiting are they?).

 

[GeneralVeers]

Lets make sure we're all talking about the same things here because I think we're falling prey to a pitfall of the medium and discussing different things at the same time.

First there is the issue of intoxicated patients without trauma and wheter or not we need to draw an etoh before we can dispo those patients.

Second there is the issue of how you clear the c-spine in an intoxicated patient. Unless you would argue that every intoxicated patient needs a c-spine xray these are seperate issues ( no one is imaging the neck of the drunk guy who comes in conscious due to vomiting are they?).

CLINICALLY intoxicated + head trauma = CT c-spine, and c-collar. Can clear when clinically sober without ETOH

Obtunded with possible ETOH = get ETOH level

head trauma + Alcohol on board but no evidence of intoxication = Can clear without ETOH or imaging.

I think some of you guys are saying that if I have 1 beer (about 1/10 of what it takes to make me "clinically intoxicated") and have head trauma I have to have a CT of my neck, and an alcohol level to clear me. That's a bit high on the insane defensive medicine scale if you ask me.

 

[kungfufishing]

The nursing notes issue mention here is a great point. If I think you are not intoxicated and the nurse thinks you are not intoxicated and thus I feel you can make decisions and interpret pain, I'll call my exam good. Otherwise if you are traumatized you probably get lots of scans.

I think the best question that has come out of this discussion is "what are you doing with your intox and negative Cspine CT?"

For me this is where mechanism most often comes into play. What do the rest of you do?

 

[Rendar5]

Absolutely, I think that "intoxication" is relative. Still, I tend to practice defensive medicine in the trauma population since despite receiving free care, they will sue at the drop of a hat. For that reason, I have to prove that a patient is not intoxicated with an objective measurement. I get the EtOH level so I don't have 20 patients laying around waiting for their c-spines to be cleared.

As for imaging, even if a patient has a negative CT scan, I still can't clear their collar until they're "sober," so I don't base imaging decisions on whether or not they're intoxicated.



I just can't do it. They could hypothetically have ligamentous injury despite a negative CT, and be too drunk to appreciate it. I obviously think that 99% of people could just get their collars off and be done with it, but unfortunately I feel stuck, as I'm sure you guys do, spending extra money/time proving it.

I still do flexion/extension x-rays for people with c-spine tenderness and negative CTs, but a lot of people are jumping straight to MRI, which is a pricey decision.....

MRI to detect ligamentous injury? Umm...I don't have much experience at all with this, but is mild ligamentous injury something that even needs diagnosing?

 

[BADMD]

MRI to detect ligamentous injury? Umm...I don't have much experience at all with this, but is mild ligamentous injury something that even needs diagnosing?

We aren't talking whiplash ligamentous injury. This is more "unstable, can't prevent spinal subluxation" ligamentous injury.

I've really only seen MRIs used to clear persistently obtunded inpatients. On the rare occasions when they still have pain, I usually flex/ex and if neg, put them in a Philly collar and have them see neurosurg in a week or two.

 

[jbar]

Can't you use your clinical exam to determine if the patient is reliable for exam? Ie if they admit ETOH, but their mini mental is perfect and they can distinguish shrp/ dull touch, proprioception, vibration sense etc. then I would think that they could be counted on to report spinal tenderness.

Also the ED at our school uses brethalyzers. It would seem to be a lot easier and cheaper than sending BALs.

 

[tkim]

Can't you use your clinical exam to determine if the patient is reliable for exam? Ie if they admit ETOH, but their mini mental is perfect and they can distinguish shrp/ dull touch, proprioception, vibration sense etc. then I would think that they could be counted on to report spinal tenderness.

Also the ED at our school uses brethalyzers. It would seem to be a lot easier and cheaper than sending BALs.

Very inaccurate.

 

[SLUser11]

for those who routinely get etoh levels... does that mean u get 1 level when they come in drunk and then another level when you 'think' they're sober? what if your repeat level is 150? 120? does that mean you wait to get a THIRD level before you send them home?

For me, once I have an EtOH level that is elevated, I know that I can't clear their c-collar. I leave their collar on, admit them to the hospital, and wait for an appropriate amount of time, based on common sense, to clear them. I don't get a follow up EtOH level to prove they're sober.

head trauma + Alcohol on board but no evidence of intoxication = Can clear without ETOH or imaging.

I think some of you guys are saying that if I have 1 beer (about 1/10 of what it takes to make me "clinically intoxicated") and have head trauma I have to have a CT of my neck, and an alcohol level to clear me. That's a bit high on the insane defensive medicine scale if you ask me.

While I don't necessarily disagree with you in theory, the bolded sentence is very ballsy.

We all know from experience that most patients will state that they've had "two beers," regardless of how intoxicated they truly are. I don't think it's insane defensive medicine to be skeptical of their truthfulness.

Just like Meckel's Diverticulum, Trauma has its own rule of 2's:
---The patient has had 2 beers.
---They were beat up by 2 dudes (nobody has ever confessed to losing a 1 on 1 fight in my experience)
---They will come in at 2am every night.
---Tattoo to tooth ratio of 2
---Say F- you 2 times, and you get intubated.....
----etc etc etc

We aren't talking whiplash ligamentous injury. This is more "unstable, can't prevent spinal subluxation" ligamentous injury.

I've really only seen MRIs used to clear persistently obtunded inpatients. On the rare occasions when they still have pain, I usually flex/ex and if neg, put them in a Philly collar and have them see neurosurg in a week or two.

That's great, but you haven't actually cleared their c-spine. You've just found somebody else to address the problem. MRIs play a larger role in the inpatient setting when you are stuck with the patient.

 

[BADMD]

You've just found somebody else to address the problem. MRIs play a larger role in the inpatient setting when you are stuck with the patient.

I haven't claimed to clear the neck of those few patients that fall into this category. I've risk stratified them to higher or lower risk and then act appropriately. Time will work almost as well as a few thousand dollar MRI and the patient neither occupies a bed in the hospital nor sits in my ED waiting for it.

In fact, Nexus, Canadian C-spine, and all the imaging in the world doesn't really "clear" a neck. They are all tools for risk stratification.

 

[SLUser11]

I haven't claimed to clear the neck of those few patients that fall into this category. I've risk stratified them to higher or lower risk and then act appropriately. Time will work almost as well as a few thousand dollar MRI and the patient neither occupies a bed in the hospital nor sits in my ED waiting for it.

In fact, Nexus, Canadian C-spine, and all the imaging in the world doesn't really "clear" a neck. They are all tools for risk stratification.

That's why I said "that's fine." I don't disagree with your reasoning or your methods, but I find myself in a different position when the patients are admitted to my service and they're tougher to turf.

Still, for the vast majority of trauma patients, at least at my facility, no more than 20% or so would be compliant with wearing a collar for any length of time without a real diagnosis.....that being said, I'm usually content to d/c their c-collar if the flex-ex is negative.....based on risk stratification.

 

[zinjanthropus]

Im an intern in my 2nd month. Last night we had a pt in a MVC come in who was alert w/ suspected alcohol intox. I wanted to get a blood alcohol level and uds on the guy but my upper level said not to b/c if insurance found out they my not pay the hospital for his injuries. I was told that we already had clinical suspecion of alcohol and it would not change the management. I thought that was a crapy answer since every other non-trauma pt gets at least a uds. I had never heard of this. Is this common practice in hospitals everywhere? Can ins companies really refuse to pay the hospital?

the real question is - what could a UDS and BAL add to the medical mgmt of this patient? as a matter of fact, when does a UDS change what you are actually doing for the pt in the ER? BAL i will give b/c i can calculate time to clinical sobriety...only a handful of scenarios where UDS matters

and for the person who asked, no - you don't have to repeat the BAL, just watch clinically and do the math

 

[GeneralVeers]

While I don't necessarily disagree with you in theory, the bolded sentence is very ballsy.

We all know from experience that most patients will state that they've had "two beers," regardless of how intoxicated they truly are. I don't think it's insane defensive medicine to be skeptical of their truthfulness.

I never said you had to believe the patient. I never believe anything patients tell me when alcohol is concerned. But if they have alcohol on board, have GCS 15 with no slurring of words, normal finger to nose, and normal neuro exam I don't think you need to do imaging, unless they're actually having neck pain.

 

[SLUser11]

I don't think you need to do imaging, unless they're actually having neck pain....

Or they have the mechanism for an injury and are too drunk to say one way or the other. I have to admit that for adults, the majority of the time that I get a head CT for trauma, I also get a neck CT. High impact MVC, or MCC, or fall from height......

I have to say, I enjoy this forum...this same topic in the surgery forums would have taken a week to get this many responses and different opinions. The majority of threads in there are "what are my chances" and "I really enjoy surgery but hate working hard...what should I do?"

 

[DoctorMedic]

i'm guessing the MRI is to look for transverse ligament damage, but in all honestly, what is the likelyhood of that without some sort of C1/C2 damage that would be found by XRay and def CT?

 

[dpmd]

This is interesting, since we have this argument routinely for our trauma patients. I can understand that the ED folks say the Utox and BAL doesn't affect their management, but as it turns out sometimes it affects mine as the trauma resident. We have come to a peaceful solution. The ED pretty much never orders BAL or Utox (the initial trauma orders at our institution are written by the ED resident: labs, films, etc). If I have a situation where I want the info, I write the order myself.

Some examples:

Patient is acting like a jackass, yelling and cursing at everyone after a moderate mechanism (could be associated with badness, or could be fine), Persistently tachycardic despite fluids, but normal-high BP, minimal obvious trauma. If the Utox comes back normal I am going to pan scan and likely admit for serial exams/labs, if it comes back meth, he might still get scanned, but he's probably going home in 6 hrs.

Pt comes in comatose after major trauma, unable to obtain much history. If BAL is high, or Utox is positive, it makes a lot more sense to me when I am having trouble keeping him sedated with fentanyl/versed in the ICU, and when he's extubated and going nuts, its easier to figure out what is going on (and I can work on avoiding it before it happens)

I don't order either test that frequently, but I have taken care of admitted patients that I wished had gotten one (are they withdrawing or having a complication?)

As for the insurance issue, most of our patients have none, so it doesn't matter. Also I wonder if writing down that you smell etoh, or suspect intoxication is enough to make them not pay (if so would you not put it in the chart, and is that fraud). If the patient clearly caused the trauma due to their drunkenness, would you be more willing to assist the loss of their workman's comp (esp. if it's state funded)?

 

[Rendar5]

As for the insurance issue, most of our patients have none, so it doesn't matter.

It's actually automotive insurance and not health insurance that pays for MVA healthcare for some reason. Don't ask me why, I think it's kind of silly, but I'm sure there's a good explanation somewhere.

 

[DoctorMedic]

yeah how else could they charge personal injury in their premiums. They know a majority of MVA's are fender benders and make out like bandits.

 

[dpmd]

It's actually automotive insurance and not health insurance that pays for MVA healthcare for some reason. Don't ask me why, I think it's kind of silly, but I'm sure there's a good explanation somewhere.

Oh, I know its usually auto insurance, and I know it's mandatory in our state, but I stand by my statement that most our patients don't have any.

 

[Rendar5]

Oh, I know its usually auto insurance, and I know it's mandatory in our state, but I stand by my statement that most our patients don't have any.

ah ok, call me ignorant on the issue then.😳

 

[EM2BE]

Oh, I know its usually auto insurance, and I know it's mandatory in our state, but I stand by my statement that most our patients don't have any.

My state is like this as well. I know many people just get the insurance for the one month they need it to get their tag done (if they even update their tags) and then let it expire.

 

[DoctorMedic]

My state is like this as well. I know many people just get the insurance for the one month they need it to get their tag done (if they even update their tags) and then let it expire.

in NY if your insurance expires or lapses they notify DMV, DMV then suspends the license and removes registration from the registered owner. serious offense in NY

 

[EM2BE]

in NY if your insurance expires or lapses they notify DMV, DMV then suspends the license and removes registration from the registered owner. serious offense in NY

For us it's a ticket and possible jail time (depends if it's your first offense or not). But that's if you get pulled over for something else first.

 

[Apollyon]

Just like Meckel's Diverticulum, Trauma has its own rule of 2's:
---The patient has had 2 beers.
---They were beat up by 2 dudes (nobody has ever confessed to losing a 1 on 1 fight in my experience)
---They will come in at 2am every night.
---Tattoo to tooth ratio of 2
---Say F- you 2 times, and you get intubated.....
----etc etc etc

Hey brother, welcome! You're right on target, and we've been saying the same thing for years here. Just search for "SOCMOB" - the most dangerous job in America. Forget commercial fisherman, lumberjack, firefighter, or astronaut - it's "standing on the street corner minding your own business", when "those two dudes" (closely related to "that bitch") beat me up for "no reason" (as one other person can shoot or stab you, but, unarmed combat? Two dudes). And you got the tattoo/tooth ratio correct, too! Very early on in the "Things I Learn From My Patients" thread, DocB mentioned about a guy with the negative T/T ratio, who was hit with a 2X4, and was dead, and how he kept looking for something else, because that just is NOT enough to kill one of those guys. They're like cockroaches - they won't die.

 

[BADMD]

Just search for "SOCMOB" - the most dangerous job in America. Forget commercial fisherman, lumberjack, firefighter, or astronaut - it's "standing on the street corner minding your own business", when "those two dudes" (closely related to "that bitch") beat me up for "no reason" (as one other person can shoot or stab you, but, unarmed combat? Two dudes).

I've also noted that they always seem to reading their bible right before it happens.

 

[predodoc]

Sorry - you say that every other non-trauma patient gets a UDS? Why on earth would you do that?

Wow, lots of responses. Its been about a week since Ive read SDN.
Sorry I didnt clarify myself when I said every other person gets a uds,, Im not a EM resident but a transitional year at an unopposed FM program. When we admit for Medicine its probably close to 50% who have a uds by the time we get to them since we admit alot of AMS, CP, N/V ect. But when we get trauma admits(esp. MCV's) I dont see many alcohol levels or uds. Doesnt matter if its a head injury, or C-coller pt. Thats what made me wonder if all hospitals do this....(Although a few nights ago I did see a BA on a guy who was drunk and got hit in the head with a pipe during a fight).

By reading all the responses I get the feeling that most people:
-Get BA/UDS for obtunded or worse pts
-Sometimes get one for C-collar pts depending on hospital/ case by case basis.
-And dont get one for pretty much all other traumas

 

[Apollyon]

I've also noted that they always seem to reading their bible right before it happens.

On the porch with Grandma, or walking to or from church/a prayer meeting!

 

[SoCuteMD]

Wow, lots of responses. Its been about a week since Ive read SDN.
Sorry I didnt clarify myself when I said every other person gets a uds,, Im not a EM resident but a transitional year at an unopposed FM program. When we admit for Medicine its probably close to 50% who have a uds by the time we get to them since we admit alot of AMS, CP, N/V ect. But when we get trauma admits(esp. MCV's) I dont see many alcohol levels or uds. Doesnt matter if its a head injury, or C-coller pt. Thats what made me wonder if all hospitals do this....(Although a few nights ago I did see a BA on a guy who was drunk and got hit in the head with a pipe during a fight).

By reading all the responses I get the feeling that most people:
-Get BA/UDS for obtunded or worse pts
-Sometimes get one for C-collar pts depending on hospital/ case by case basis.
-And dont get one for pretty much all other traumas

I can sort of understand a UTox for AMS (sort of), but CP? N/V? Really?

It sounds like the place you are working is a bit UTox happy.