I was just wondering what others though about this. In your region can intoxicated patients refuse treatment? Who determines what intoxicated is? Is it the state legal limit to drive? Some alcholics are still very with it at .08 or .10 and would be able to understand anything you ask them. If the person is CAOx4 but smelled slightly of booze can tehy refuse? I am saying call Med. Com. and the PD just to let them handle it and do what they say. CYA. Just wanted to see what others say.

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You have pretty much stated the obvious. I agree with that statement. We do the same. PD in case they are forced to go, and Med. Com. in case they say the patient can refuse. We have enough liability on us without making a mistake with an intoxicated patient. As long as a thorough assesment is completed to rule out any other diagnose. Document, document, document.
I know I stated the obvious. There was a recent discussion I had about this issue. The other person was convinced that an intoxicated person was not allowed to refuse under any circumstance. I just wanted to see where others stand on this issue.
CAOx4 really is a terrible matrix for deciding if a patient has capacity. It doesn't matter if the patient can recite where he is, who he is, why he's there, and the time if they can't comprehend the dangers of refusing medical control. How many psychiatric patients are transported every day who lack capacity (either through action or by legal action such as conservatorships) but are still A/Ox4? The problem with patients who have EtOH on board is that you can't really claim that someone who has had 1 beer an hour ago is incapacitated. So, at what point can a patient be considered incapacitated? You've gotta ask enough questions to determine if a patient truly understands his/her condition(s) and the warnings being issued about refusing care. Yes, consult online control, but remember the saying, "Garbage in, garbage out."
Assuming the patient has the legal right to make decisions (adult or emancipated minor) the issue is decisional capacity and informed refusal. If the patient lacks the present mental capacity to make informed choices due to intoxication, hypoglycemia, head trauma, post-ictal state, drug overdose, dementia, acute stress, whatever, then it can't be an informed refusal, and you are responsible for the patient.

Assuming the patient does have the legal right and present mental capacity to make informed choices, then it's incumbent upon you to assist the patient in understanding the risk of refusing care, including any alternatives, and it can't simply be "you might die" unless you believe that to be the situation, in which case you should explain why.

The standard for your actions will be the "reasonable and prudent" paramedic.
If I think a patient needs to go, I'll push the issue with them. If I don't, I don't push it. When it comes to pt.'s I don't think need to be treated or transported, and there's something like alcohol in the mix, I do what you said, I fall back on command. Not because I am unsure (not saying there's anything wrong with being unsure) but because that way it's documented that medical command agreed with my assessment and allowed the release. Then of course the appropriate signatures for refusal as normal. Command is always a good fall back in situations like these.
My department serves a small city (10,000) with a university population of about 7,000. We have many many intoxicated calls. All of our calls within the city and campus limits we have at least one officer on scene as a first responder, which makes it much better for us. Intoxicated patients can refuse treatment which is determined by our crew and also the suggestion of the officer. If we think that the patient has any chance of getting worse or not maintaining a patent airway we will transport. Basically it comes down to that crew and what they want to do along with the officers suggestion.
i try to persuade them into going, if it is medically necessary. We do get some issues when they have "lacerations" to their hands or face. PD usually calls just needing to get cleared before they proceed onto jail. but we have had a an intoxicated trauma pt, who we thought was just "drunk". we overlooked. the fact that he had been hit in the head. PD took him, because he initially "refused". by the time he got the medical attention necessary, it was too late.

Jose
Can the person account for themselves, their recent history and sufficiently care for themselves? If not, go to hospital.

Just becasue you are tanked,doesn't mean the ambulance owns you.

Here our PD has a guideline that determines whether or not a person in custody is safe to have ina cell. this includes review by a PD nurse or doctor. If unsafe-->ambulance.

Really, legalities like this has ruined health care. Paranoia medicine is just a dangerous as neglect.
No, defensive medicine is not dangerous. It's expensive. There's a difference.

The ambulance does not own you if you're tanked, and you'll never see paramedics walking into a bar putting people into handcuffs because they've got nothing better to do.

The issue on the table is what to do when EMS is called to the scene of a patient who has been drinking and has an altered level of consciousness.

Like it or not, in the United States (which last time I checked cares more about individual liberty than just about any other country in the history of the world), if you're an adult or an emancipated minor who can't make an informed decision about your health care, an agent of the state (edit: or your health care provider) is expected to act in your best interest (with caveats).

Dismissing a head injured patient as a drunk is clearly not acting in the patient's best interest. I'm sure we're agreed on that point, at least.

Tom

P.S. You have PD nurses and doctors? Do they come to the scene? Also, do you have access to the guidelines that determine whether or not a person who has been drinking can be in a cell? I'd like to see it, just for curiosity's sake.
It seems this issue stretches across the pond to us here in the UK too. We have a number of issues about being called out to people that are drunk. One of the biggest for us just now is that the Police have stopped responding to reports of intoxicated person in street/lay on bench/sat at bus stop etc. Instead they just activate us (EMS). Quite often once we have arrived on scene, the person has wondered off home anyway, but when they haven't it becomes a nightmare for us as we can't just prod them, wake them up and let them go. Our wonderful leaders have introduced policy that means we have to do full sets of obs on them over a 15 minute period, and then convey them to hospital regardless. We're not actually allowed to leave them, and must recommend that they go to hospital. As you can imagine, most of our intoxicated friends don't want to go to hospital, and refuse, which then means we have to call for the police to deal, as a patient that is intoxicated does not have capacity to refuse. We now have to wait anything from 10 mins to and hour or so for the police to turn up, who then do there best to put the patient in the back of the motor so that they don't have to deal. If the patient still refuses, it's down to the police officer in scene to decide if they are arisk to themselves or others. If not, they go on their way. What a perfect system !!! NOT !!!!

Downtime for Police - 10 mins.
Downtime for Paramedic Emergency Service - 90 mins.

It's annoying that the Police keep doing this, more so cause our healthcare is free to those in the UK. Well, us tax payers foot the bill. And I honestly think that 10 mins of a Police Officers time (who can also give them an £80 - $140 on the spot fine too for being intoxicated in a public place), is gonna work out much cheaper than a fully equipped paramedic vehicle for 2 hours (allowing for time in hospital) with staff, plus 8 hours in the Emergency Department taking up a bed whilst the bum sleeps it off. Its such a waste of the service.

Here in the UK over 90% of our emergency call outs are alcohol related during the hours of darkness... It's not good.
We are pretty good at the liberty thing too.........

I'll see what I can drag up on persons in custody.

Forensic Medical and Nursing Officers do attend Cells at Police and Remand centres. they ca recommned and assess suitability for cell time as opposed to ED time.

Tom Bouthillet said:
No, defensive medicine is not dangerous. It's expensive. There's a difference.

The ambulance does not own you if you're tanked, and you'll never see paramedics walking into a bar putting people into handcuffs because they've got nothing better to do.

The issue on the table is what to do when EMS is called to the scene of a patient who has been drinking and has an altered level of consciousness.

Like it or not, in the United States (which last time I checked cares more about individual liberty than just about any other country in the history of the world), if you're an adult or an emancipated minor who can't make an informed decision about your health care, an agent of the state (edit: or your health care provider) is expected to act in your best interest (with caveats).

Dismissing a head injured patient as a drunk is clearly not acting in the patient's best interest. I'm sure we're agreed on that point, at least.

Tom

P.S. You have PD nurses and doctors? Do they come to the scene? Also, do you have access to the guidelines that determine whether or not a person who has been drinking can be in a cell? I'd like to see it, just for curiosity's sake.
If you're "tanked" then by definition, you have altered mental status, which automatically gives EMS implied consent to transport in most places in the U.S. Patients with altered mental status typically do not have the present mental capacity to refuse, as Tom states. Intoxication can mask a host of other injuries, including the patient's perceptions of pain or other signs and symptoms.

Remember, just because the patient is drunk or stoned, it doesn't mean that he or she isn't injured or ill.

Ben



TheCannulator said:
Can the person account for themselves, their recent history and sufficiently care for themselves? If not, go to hospital.

Just becasue you are tanked,doesn't mean the ambulance owns you.

Here our PD has a guideline that determines whether or not a person in custody is safe to have ina cell. this includes review by a PD nurse or doctor. If unsafe-->ambulance.

Really, legalities like this has ruined health care. Paranoia medicine is just a dangerous as neglect.

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