Urine Drug Screen in Trauma

[DeadCactus]

Curious if anyone has any insights on this.

A urine drug screen seems to be a routine part of most trauma order sets. (I've been told previously it's a way to meet the ACS Level 1 requirement to screen for and treat substance abuse though it seems nothing is ever really done with the results.)

All the medical issues with using a urine drug screen for anything, the legal aspect of this is interesting to me. There are a lot of potential legal ramifications for patients: driving while impaired, violating employer drug policies, losing workers compensation coverage. What specifically interests me:

1. It seems like a patient could make the argument that they never consented to a urine drug screen and (in most cases) argue against it being covered under implied consent because it really has no role in the emergent treatment of their traumatic injury. I'm surprised the practice has been allowed to stand; the hoops you used to have to jump through for HIV testing provides a sharp contrast.

2. How do these results have any role in a legal case without a chain of custody? Even if you don't exclude them from evidence, it would seem so easy to just throw out but that doesn't seem to be how things play out

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[Raryn]

Every lab test I'm aware of is covered under a general consent for treatment - whether signed or implied - except for specific ones that have a legal carveout. HIV in some - but not all - states has that requirement for explicit consent. Historically it used to be quite onerous - many states requires explicit forms - but these days most states have gotten rid of it. I think certain genetic tests need similar consents. Anything else can just be done.

The other parts of the legal stuff, I don't know. I would *hope* a regular garden-variety UDS wouldn't be enough to sustain a legal issue - they'd likely need to do a confirmatory mass-spec - but I don't know for sure.

 

[MechEDoc]

I don't believe it's a level 1 requirement (level I that I trained at stopped doing UDS's reflexively).

It's of almost no utility.

 

[Apollyon]

UDS not by law enforcement is invalid for legal proceedings. As stated above, chain of custody is just one part. As I would tell the pts, I was in a separate rail car, and the UDS with the State Police was another car.

Likewise, there would have to be a separate, legal blood draw for LE.

 

[AlmostAnMD]

I'm surprised the practice has been allowed to stand; the hoops you used to have to jump through for HIV testing provides a sharp contrast.

First of all, I agree and feel badly about the UDS. Lots of roofers have fallen from a roof and lost their jobs because half of them have cocaine in their system. Not only do they have numerous fractures from a massive fall but they leave the hospital without a job.

To the point I quoted, this is something that is often misunderstood, at least in Ohio. In Ohio, ED docs do not have ANY DUTY to f/u on HIV testing. You just order the test. You can DC the patient if stable. The department of health f/u on ALL HIV tests. They explicitly tell us we don't have to worry about it. Still, many docs don't believe this which is a huge barrier for testing here. One of the ID docs in charge of this personally reviews each and every HIV test on a weekly basis for her region in Ohio and they get like a SWAT team to track this person down if positive.

 

[BoardingDoc]

UDS not by law enforcement is invalid for legal proceedings. As stated above, chain of custody is just one part. As I would tell the pts, I was in a separate rail car, and the UDS with the State Police was another car.

Likewise, there would have to be a separate, legal blood draw for LE.

Is this true for blood EtOH as well? I'm sure it's state dependent to a degree. I've definitely had LEOs ask me if I drew an EtOH lvl on some drunk who just crashed his car, so I can only assume that it's somehow admissible?

I generally order a blood EtOH on patients who come in with MVCs, altered and I suspect are drunk. I justify drawing it as identifying their etiology for AMS so I don't have to worry about life threatening causes, though my main reason is that I'm hopeful that some judge will ultimately see the lvl I drew because screw drunk drivers.

 

[clibby]

Is this true for blood EtOH as well? I'm sure it's state dependent to a degree. I've definitely had LEOs ask me if I drew an EtOH lvl on some drunk who just crashed his car, so I can only assume that it's somehow admissible?

I generally order a blood EtOH on patients who come in with MVCs, altered and I suspect are drunk. I justify drawing it as identifying their etiology for AMS so I don't have to worry about life threatening causes, though my main reason is that I'm hopeful that some judge will ultimately see the lvl I drew because screw drunk drivers.

Anything is admissible, but any half decent lawyer should be able to get it tossed. LEO needs to come and draw their own EtOH if they are going to charge the patient. To me, a hospital is supposed to be a safe place for patients, not law enforcement and even if we wanted it to be, any lawyer could get our lab work tossed. The only people likely to be charged using our labs are those who can’t afford a lawyer, not the entitled @$$****s. Unless I need the alcohol level to prove AMS etiology, I don’t get it as it only increases LOS waiting for it to come down. If they say they are drunk or high and the picture fits, I believe them.

I also don’t order UDS often as it doesn’t tell me anything useful. In trauma, all it is likely to do is get WC cancelled resulting in the patient getting an unpayable bill and nobody else getting paid all because marijuana was positive. Unless the patient is altered from an unknown cause, a UDS rarely helps.

 

[AlmostAnMD]

Random story:

I've only seen one LEO blood draw.

Apparently our hospital has an agreement that they can use our mothership for them.

We don't actually see the patient. They just dragged this guy, kicking and screaming with like 12 cops on him, into a conference room in the ED. The pinned him down and had a phlebotomist take the blood which was then given to LEO. They then dragged him out of the ED. caused a huge ruckus since he was screaming, fighting, biting and resisting the whole way.

But, didn't need to staff him so all is well.

 

[DeadCactus]

Every lab test I'm aware of is covered under a general consent for treatment - whether signed or implied - except for specific ones that have a legal carveout. HIV in some - but not all - states has that requirement for explicit consent. Historically it used to be quite onerous - many states requires explicit forms - but these days most states have gotten rid of it. I think certain genetic tests need similar consents. Anything else can just be done.

The other parts of the legal stuff, I don't know. I would *hope* a regular garden-variety UDS wouldn't be enough to sustain a legal issue - they'd likely need to do a confirmatory mass-spec - but I don't know for sure.

Sure we have patients sign those consents (or use implied consent if the can't sign) but it seems odd to me that a blank check holds up when a test is ordered that has no real bearing on the complaint they came in for and then has significant downstream ramifications for them. And then even with GC-MS confirmation, there's no chain of custody but the results still seem to be frequently used in courtroom.

I just find it asinine. You go to a hospital for help, they order a test you would never consent to, maybe even use an expensive confirmatory test that benefits you in no way, they charge you for it, there is no chain of custody, the QA process is geared at medical decisions and not forensic work, and then your results get subpoenaed by a third parties to try screw you out of workers comp or your job. To be clear, I don't have any problem with the legal system collecting forensic quality samples for criminal cases and can understand indicated tests finding their way into the civil courts.

I don't believe it's a level 1 requirement (level I that I trained at stopped doing UDS's reflexively).

It's of almost no utility.

The UDS isn't a requirement but they list "Program for substance abuse screening and patient intervention" as an element of a level 1 trauma center. Routine UDS seems to be a lazy way of addressing this by many centers.

 

[n2b8me]

I have no idea about the legal aspect of the law or workplace ramifications of the UDS.
But from a clinical perspective it can help the patient and providers start a discussion about substance abuse if the test is positive. Maybe not in the ER, but maybe.

 

[pkwraith]

I have no idea about the legal aspect of the law or workplace ramifications of the UDS.
But from a clinical perspective it can help the patient and providers start a discussion about substance abuse if the test is positive. Maybe not in the ER, but maybe.

Maybe. But due to the flawed nature of the ED UDS and the false positive/negative rate of the drugs not THC/Cocaine, likely to generate trust issues with the patient and result in false understanding of what the patient may or may not have actually used.

 

[Birdstrike]

*Disclaimer: I used to do EM. Post-fellowship, I now practice Pain Medicine, mostly interventional, but I do prescribed some.

I used to order in-office urine-dip drug screens, like the ones you guys do in the ED and hospitals, and also send out an LC-mass spec confirmed sample on every patient that was on opiates. I had to stop doing the urine-dip drug screens because they were so damn inaccurate, with, I'd guess, a 25-30% false positive/negative rate. And I know this for sure, because I'd get a confirmed sample 5 days later on every single one.

I'd have little old ladies test positive for PCP, then have the confirmed sample come back negative. I'd have people test positive for every single drug on the strip, then have the confirmed come back negative. There were false negatives, too. They're really bad. (The cocaine results seemed to be most accurate, for some reason).

So, I just stopped doing the dip-UDS's and now just send out the LC-mass spec. They're not practical for ED use, since they're very expensive and usually require a special off-site lab.

 

[MechEDoc]

I hate to say this, but the UDS almost never is indicated. However *some* colleagues might order them to potentially undermine a difficult patient. I have known of threats to fall apart due to positive drug screens (they were high in methamphetamines and cocaine!).

 

[RoyBasch]

Curious if anyone has any insights on this.

A urine drug screen seems to be a routine part of most trauma order sets. (I've been told previously it's a way to meet the ACS Level 1 requirement to screen for and treat substance abuse though it seems nothing is ever really done with the results.)

All the medical issues with using a urine drug screen for anything, the legal aspect of this is interesting to me. There are a lot of potential legal ramifications for patients: driving while impaired, violating employer drug policies, losing workers compensation coverage. What specifically interests me:

1. It seems like a patient could make the argument that they never consented to a urine drug screen and (in most cases) argue against it being covered under implied consent because it really has no role in the emergent treatment of their traumatic injury. I'm surprised the practice has been allowed to stand; the hoops you used to have to jump through for HIV testing provides a sharp contrast.

2. How do these results have any role in a legal case without a chain of custody? Even if you don't exclude them from evidence, it would seem so easy to just throw out but that doesn't seem to be how things play out

The standard hospital UDS has no role in legal or occupational consequences for exactly the reasons you just stated in #2. There is no chain of custody, there is no a forensic standard applied (much higher than clinical standard) in obtaining the sample, therefore it is not admissible in court. Employers cannot legally use the results to enforce occupational consequences. They might, but this is technically challengeable by the patient and their representatives.

Working at a trauma center if DUI is suspected, we get our own serum EtOH and UDS (whatever). If law enforcement or occupational safety officers are present, they have some legal process where they "consent" the patient (I think they can refuse, but there is some substantial consequence like they lose their license or job or something) with a collection kit. They will "supervise" one of our nurses or lab techs or whoever and then take the sample directly from their hands into their evidence collection box with the tamper-proof tape and then take it to the city crime lab for processing. (Supposedly) Meticulous chain of possession of the evidence with signed hand offs then ensue. My (very) limited legal understanding however is that errors on the part of law enforcement in this process is a very frequent bone of contention that defense attorneys attack liberally.

Personally I try to stay out of this process completely. In this situation I'm a physician, not a judge, cop, moral arbiter, etc.

 

[Raryn]

(The cocaine results seemed to be most accurate, for some reason).

This is well supported in the literature. Nothing shows up as cocaine on a UDS except cocaine (you can argue about coca tea - but that has cocaine in it). Nothing shows up as cannabinoids except cannabinoids (& one HIV HAART drug, but I can never remember which).

But all kinds of wackadoodle stuff can show up as amphetamines, including NSAIDs in some people.

 

[RoyBasch]

This is well supported in the literature. Nothing shows up as cocaine on a UDS except cocaine (you can argue about coca tea - but that has cocaine in it). Nothing shows up as cannabinoids except cannabinoids (& one HIV HAART drug, but I can never remember which).

But all kinds of wackadoodle stuff can show up as amphetamines, including NSAIDs in some people.

the cocaine assay on the UDS is also helpful because of a relatively short half life. It's not a level, but if they pop positive on cocaine, not only is it very likely truly representative of cocaine use, but recent use. The assay is usually negative again with 72 hours.

Agains if someone used marijuana 3 weeks ago, that is rarely going to inform the present clinical situation in a meaningful way.

Agree, the amphetamine and PCP assays have A LOT of false positives that react to a whole host of common prescription and over the counter medications.

 

[dadaddadaBATMAN]

The only real argument for a uds is for an inpatient team caring for the patient afterwards. It’s good to know the reason your patient is losing their mind is that they were able to tolerate an etoh of 300+ and be awake, or that they may be withdrawing from multiple substances.

Having said that, I agree it’s a crappy test even for this purpose, it has no ed use, but I can see an argument for the inpt team. It also might provide a better starting point for the team to discuss rehab (which is of questionable utility as well). I don’t think it has to be argumentative if it’s a routine thing.

“We get these on every trauma pt. Yours was + for x and y. The test isn’t perfect, but would you be interested in resources.” In residency, that’s how I phrased it. Neutral tone, no judgement. No one was upset. About 1/3-1/2 said sure.

If they asked I usually told them police could subpoena results but they generally got thrown out.

 

[southerndoc]

the cocaine assay on the UDS is also helpful because of a relatively short half life. It's not a level, but if they pop positive on cocaine, not only is it very likely truly representative of cocaine use, but recent use. The assay is usually negative again with 72 hours.

Agains if someone used marijuana 3 weeks ago, that is rarely going to inform the present clinical situation in a meaningful way.

Agree, the amphetamine and PCP assays have A LOT of false positives that react to a whole host of common prescription and over the counter medications.

Cocaine XR will last >72 hours.

We have a frequent flier who says "doc, I haven't used that cocaine in a month." Surprisingly, when a resident checks the UDS, it's always positive.

 

[thegenius]

I hate to say this, but the UDS almost never is indicated. However *some* colleagues might order them to potentially undermine a difficult patient. I have known of threats to fall apart due to positive drug screens (they were high in methamphetamines and cocaine!).

Yes i've heard that lawyers don't like picking up malpractice cases if the plantiff has + UDS in their chart

 

[docB]

Very interesting discussion. I understand the negative ramifications to patients of all this and try not to order UDS/EtOH unnecessarily. However I think the idea that an employer might misuse the results represents a problem with the employer/insurance system rather than the ED process. I do think there is some value in getting a UDS in trauma. Is the tachycardia impending shock due to an occult bleed or is it the drug response? It's not perfect but it's an additional piece of info and it can guide a clinician away from more imaging or obs admissions in certain settings.

When I was first out I never got EtOH levels. But we started having a problem with patients challenging their bills when diagnosed with alcohol intoxication without a level. So we had to start getting them.

I'd rephrase the part about using a UDS to undermine a difficult patient. I'd say that I was looking for a cause for their behavior and to further justify my use of restraints and sedation. I'd argue it was for their benefit. If their behavior was drug induced I'll let them sober up and leave. If they're like that without being intoxicated they're likely to wind up on a legal hold. I know we're talking about different patients on a spectrum of "difficult" but we all have to do these on a case by case basis.

 

[Mushdoc]

Sometimes you get the alcohol back on the patient you presumed was intoxicated and it’s undetectable and then you go hmmmm

 

[docB]

Sometimes you get the alcohol back on the patient you presumed was intoxicated and it’s undetectable and then you go hmmmm

I tell the students that I get the alcohol level to make sure it's there rather than see how high it is.

This is more for the the undifferentiated AMS rather than the trauma patients who the OP was referring to.

 

[GeneralVeers]

I do love how the patients found "altered" in a nightclub on the strip while visiting from Minnesota always claim someone "put something in my drink" rather than admit to copious alcohol use. BTW if you are a 40 year-old, fat, diabetic from the midwest, no one is putting anything in your drink......

 

[RustedFox]

I do love how the patients found "altered" in a nightclub on the strip while visiting from Minnesota always claim someone "put something in my drink" rather than admit to copious alcohol use. BTW if you are a 40 year-old, fat, diabetic from the midwest, no one is putting anything in your drink......

Same here in FL.
The midwesterners that come down here are near-universally obese and irresponsible.
We call them "fried butter" when they're sunburnt because "they won't be out in the sun for that long."

 

[docB]

Same here in FL.
The midwesterners that come down here are near-universally obese and irresponsible.
We call them "fried butter" when they're sunburnt because "they won't be out in the sun for that long."

Yeah. In Vegas we have the cocaine fairy who sprinkles doses of a very expensive drug in drinks out of the goodness of his heart. That's clearly what's happening as no tourist ever did a bunch of blow and raged until EMS had to sedate them.