Intoxicated Refusals

[Bernice13]

We have zero policy on this except "it depends." What are your SOG's regarding pt refusals with obvious intoxication?

[BCoFD vollie]

as long as they are CAOx3 we will let it slide, however beyond that it is an absolute no-no

[Bernice13]

How about when their answers include..

Where are you? "I'm right here. Where are you?"
What's your name? "Why? You gonna arrest me?"
What day is it? "It's today."

It was amusing, but the patient couldn't even stand on his own and all questions had to be repeated 3 times. Which of course brings up a whole different issue with crew members pulling the "I'm the paramedic, we will do as I say" card when the BLS states that they are uncomfortable with the decision. Topped with the glare over the top of the glasses and a "do you have a problem with that?"

[BCoFD vollie]

yeah the crew would get QA'ed on that one

[Medic_QT]

Yeah if it was a couple beers (by our standards, not the falling over, slurring couple of beers answer we always get) we'd tell them to either answer the questions in all seriousness and if they answer correctly, get to go about their business, or we'd take them to the ER. If they opted to resist, then we'd call the cops down and say "Ok, jail, or ER. Your pick."

Your patient was OBVIOUSLY intoxicated, so I would have called the cops and given him the option of ER or drunk tank. Either one would release when he was sober enough. Unfortuantely, it's the medic's ass if they allow the heavily intoxicated patient to sign AMA and something happens. You can make things easier for calling for SO or manpower. If something like that happens and I think someone may be combative I have someone walk away and call for an engine company and SO. Or, if they're actively trying to kick our asses, we activate a Code 99. Unfortunately we're put in uneasy, tense situations nearly every day, so we just do what we can to dissolve those situations, or at least get the help to manage them a little more safely.

[medic pathetic]

They have to answer the questions. Actually answer the questions correctly. And here, i've rarely heard a call go out for simply a drunk person. Usually it's a drunk person who fell, threatened someone, was driving, someone overheard they wanted to "go to sleep forever" or something like that. Whenever those kinds of calls go out, PD responds also, or PD requests us. If it's a fall and they looked banged up, the thinking goes along the lines of are they acting like that because they are drunk, or because when they fell/ got bit with a board or chair in the fight, it caused some kind of brain injury. If they can't answer the questions and have suffered some kind of injury, we'll recommend they come with us, or they will have to go with PD, If they already plan to take them, provided there are no broken bones, or serious injuries, we'll clean up the scrapes and send them on their way to jail, getting the police to sign that they are refusing transport of the person via ambulance. If it's no injuries, and we literally just got called because they are really drunk but can answer our questions properly, we encourage them to be transported "no less than three times", (that's protocol) get the refusal signatures, document carefully and cleanly, and leave them to their own devices.

In a nutshell, it's largely up to the medics. Our MD gives us free range of a lot of things, understanding that we aren't just putting his license on the line, but our own as well. So sig MOI/NOI, unable to maintain their own airway, potential threat to themselves or others, they are going with us or PD. Anything else really can be a refusal, or even no patient, depending.

[brandon911]

It's kinda funny to hear people say that if they are drunk they absolutly have to go to the er no question about it. But if you go out on someone that is having a heart attack and they don't wanna come they can refuse. Doesn't make a whole lot of sense. The last time I checked being drunk isn't a medical problem. It's a dumbass problem. Now if they have airway complications or something then yes they need to come in. But if they are drunk and fell..... oh well. They can't handle their liquor very well. I think it's crap that pd calls us out on every drunk that they come across. Put em in bed on their stomach and leave em alone. They need sleep. Not the er.

Just my opinions

brandon911

[PSYCtest040]

It's kinda funny to hear people say that if they are drunk they absolutly have to go to the er no question about it. But if you go out on someone that is having a heart attack and they don't wanna come they can refuse. Doesn't make a whole lot of sense. The last time I checked being drunk isn't a medical problem. It's a dumbass problem. Now if they have airway complications or something then yes they need to come in. But if they are drunk and fell..... oh well. They can't handle their liquor very well. I think it's crap that pd calls us out on every drunk that they come across. Put em in bed on their stomach and leave em alone. They need sleep. Not the er.

Just my opinions

brandon911

It is now in our protocols that intoxicated patients can not refust transport. So in a scence the medical director dose think they need and ER bed.

[emtkristin]

It's kinda funny to hear people say that if they are drunk they absolutly have to go to the er no question about it. But if you go out on someone that is having a heart attack and they don't wanna come they can refuse. Doesn't make a whole lot of sense. The last time I checked being drunk isn't a medical problem. It's a dumbass problem. Now if they have airway complications or something then yes they need to come in. But if they are drunk and fell..... oh well. They can't handle their liquor very well. I think it's crap that pd calls us out on every drunk that they come across. Put em in bed on their stomach and leave em alone. They need sleep. Not the er.

Just my opinions

brandon911
Agreed 100%...but protocol is protocol...unfortunately.

[JxGx928]

Yeah if it was a couple beers (by our standards, not the falling over, slurring couple of beers answer we always get) we'd tell them to either answer the questions in all seriousness and if they answer correctly, get to go about their business, or we'd take them to the ER. If they opted to resist, then we'd call the cops down and say "Ok, jail, or ER. Your pick."

Your patient was OBVIOUSLY intoxicated, so I would have called the cops and given him the option of ER or drunk tank. Either one would release when he was sober enough. Unfortuantely, it's the medic's ass if they allow the heavily intoxicated patient to sign AMA and something happens. You can make things easier for calling for SO or manpower. If something like that happens and I think someone may be combative I have someone walk away and call for an engine company and SO. Or, if they're actively trying to kick our asses, we activate a Code 99. Unfortunately we're put in uneasy, tense situations nearly every day, so we just do what we can to dissolve those situations, or at least get the help to manage them a little more safely.

Around here 99.9% of the drunks that we do runs on end up going to the hospital because the county jail refuses to take them if they are above a .30.
Any Resisting or fighting is automatic shiny bracelets.

[Medic_QT]

It's kinda funny to hear people say that if they are drunk they absolutly have to go to the er no question about it. But if you go out on someone that is having a heart attack and they don't wanna come they can refuse. Doesn't make a whole lot of sense. The last time I checked being drunk isn't a medical problem. It's a dumbass problem. Now if they have airway complications or something then yes they need to come in. But if they are drunk and fell..... oh well. They can't handle their liquor very well. I think it's crap that pd calls us out on every drunk that they come across. Put em in bed on their stomach and leave em alone. They need sleep. Not the er.

Just my opinions

brandon911


What do your protocols state for this situation?

If a person is heavily intoxicated, yes they do need to sleep it off. PD isn't qualified to make the judgement call though. Maybe the person is also a diabetic? My cousin was a diabetic and died because of it after a night of partying. My department ran on him, and he had a BGL of 23. Post-mortem tox came back negative except for a low ETOH level. If the cop doesn't call for EMS and they die, that's the cop's ass. Also, people toss and turn while asleep (when I'm drunk, for some reason I seem to thrash about in my sleep) and can roll over on their backs and aspirate. They're taken to the ER because there can't consciously take care of themselves. What if they smoke a cigarette and pass out with it still lit? Now you have a crispy-fried drunk, and it's your fault. They were too drunk to make decisions for themselves and now your ass is on the line. If they're being babysat, then it's harder for those things to happen.

The person having an MI on the other hand, is still A&Ox3, is still able to make their own informed decisions about their healthcare. Is it right? Nope. Tell them there is a serious chance of death, that the pain they're having is their heart tissue dying, and once it dies it's DEAD and won't come back. Call your EMS supervisor if you don't think you can convince them, maybe your super can. If that doesn't work, fill out the AMA paperwork. Your supervisor can at least vouch that yes, you did do everything possible to try and get this person to go in. Have them promise to stay with someone who can look after them. Wait til they go into cardiogenic shock, then you can take them in on implied consent.

Sucks but that's how the world goes 'round...

[anthonyt]

People who are AO*3, have a right to choose their own destiny. I don't care if they're drunk or not. I have been drunk a time or two, and if someone had pulled my cantankerous ass into the hospital, there would've been trouble. Not the, "I need security on the dock, he's a live one." sort of trouble, but the "I don't understand why I am losing my license, and being forced to answer false imprisonment, battery, and kidnapping charges," kind of trouble.

Who the Hell, do you folks think you are, that you can make a decision for someone else, when that person satisfies legal competency tests? Just as the police are not qualified to decide when a person needs to sleep it off, we are not either. In fact, the only one qualified to decide that is the person who is drunk.

What we are, however, qualified to do is, decide whether someone is alert and oriented to person, place, and time, oh, and sometimes situation. If you are oriented properly, then the only person qualified to determine whether you should go to the ER, is you. Period. If not, then you take a ride.

This is still a free country, and so long as what you are doing does not endanger another, nor infringe upon the rights of others, then you are free to continue doing it. Being drunk, is not a medical emergency. Being drunk is not a reason to strip me of my rights, and freedoms.

Oh, and your protocols, be damned. If you kidnap someone, and do so willingly, you are breaking the law. It doesn't matter that a doctor says you can, or not. Doctors are not judges, and barring medical emergencies in which you are incapacitated, have not the right to deny you freedom.

[FF/EMTP1317]

If they are CAO x3 then they have the right to refuse. However, if we feel that they are a danger to themselves or others we can request that the cops EP them which means they will either go with us to the ER or the cops will take them into custody and put them in the drunk tank. This is not to say that I want to babysit every dumbass drunk that I run but if they are trying to drive or walk out in the middle of traffic it's safer for them to be an EP.

[Medic_QT]

People who are AO*3, have a right to choose their own destiny. I don't care if they're drunk or not.

I agree. If they're able to answer questions appropriately and they're intoxicated then fine. If they're unable to stand up under their own power, are obviously intoxicated, can't tell me what's going on, etc, those are the situations I'm talking about. I've been drunk before, talking to friends and not paying attention while walking the 6 blocks home from the bar on campus and tripped and fell on a curb. Typical injured person call around here. Should I have been taken in? Hell no. I knew where I was, who I was, where I had been, where I was going, all of my info down to my DL number, what time it was, what happened, etc. If they have their wits about them, great. If they're drunk and attack someone in navy blue coming at them in a non-threatning way, you probably need to go. If I think they're able to take care of themselves, great. If there are sober people there who say they're able to take care of them, great. If not, too bad.

[strwblue]

I say bring them all and let the ER sort it out. They have better insurance and deeper pockets.

[bubbamedic]

Sorry, I'm short on time today and have not read all of the posts. I do have this to share though. If it has been said I apoligize to the original for ... Oh nevermind that.


My medical director and the majority of the area ER Docs where I worked has always stressed that it is not the compentiency of the individual, but the capability of the individual to make the choices and maintain their safety. Think if it this way, This frequent flyer has all of the basic alert and oriented questions, of ALL of the crews in the past ten years, MEMORIZED. So the crew get the response that they wanted, but the guy then falls over and starts snoring right in the middle of the alley. This person is competent per say, but not capable to keep themself safe, hence a danger to themselves... I think you can see the way this line of thinking goes.

In a college town where on a weekend night a good 80% of your calls involve a drunk, you learn to differeniate the difference quickly. I have let a good number of drunks go, but they have proven to me that they are capable of caring for themselves, even though they are intoxicated. I am a fan of CYA, so if I have the time, I will call doc and get his stamp of approval in a consult as well.

A disavantage I do have is the existance of the Alcohol Recovery Center or ARC in the county. With some interesting laws in place, we can elect to let these people go, and the police can take them to these facilities to "sleep it off" in a controlled enviroment. People that have friends or family that are willing to care for their intoxicated ass do not go, it is for those that drink alone and usually on the street. I have seen some more affluent people there too, usually the lonely drunk in the mansion on the hill that did not make it home before passing out.

I take the kidnapping charge seriously and I have actually put the burden back on the police officer that called me in the first place. Politely I remind them that I am a medical provider not a social worker. I have rules that I have to follow, just like they do. Once explained to them, the police usually accept it and will even rise in your defence on the matter. No cop wants to be accussed of a felony...

So if you are just basing your decision whether or not to force a person into the ER on the presence of alcohol on their breath, you are wrong.

Same thing applies to injured parties that have alcohol on board too.

I have developed an ability to talk these people into the ER trip when I truly believe that they need to go. If you can do this, you save the ER a great deal of trouble and they do notice, at least there they did.
Karma can be a bitch at times, but it has its rewards as well. It pays to have a little finesse and patience, rather than just using brute force.

Before you busy metro guys say that there is not enough time, think of it this way. I am not wanting the transport if the guy is capable, I want to take just enough time to give them a chance, usually they can recognize this.

Of course there are those that need to be taken down and tied down too, but it better not be because the reak of Johnny Walker, vanilla extact,or Listerine; or even cause they dropped and broke a good bottle of scotch. Justify your actions! (Breaking a good bottle of scotch, unfortunately does not qualify, but it should.)

[scribble]

What we are, however, qualified to do is, decide whether someone is alert and oriented to person, place, and time, oh, and sometimes situation. If you are oriented properly, then the only person qualified to determine whether you should go to the ER, is you. Period. If not, then you take a ride.

I've had plenty of patients tell me "I'm Jane Smith, I'm in the hospital, and it's tuesday the 29th." and then go on to tell me that they were helicoptered into the ER for a golf club sticking out of their chest and that Dr. Joyce Brothers is going to meet us at the recieving facility "because she adopted me and she's my mother AND my doctor" and that "I was kidnapped by Al Capone when I was ten and then that's when Dr. Joyce Brothers found me and adopted me and we're going to write a book about it and make it into a Major Hollywood Film. I'm a Big Hollywood Star."

Was she really A&Ox3? No. She saw her name on the hospital ID bracelet (person), there's tons of nurses running around and ambulances coming in, plus sheets that say "***** Hospital" (place), and the TV news is on in her room (time, date, who's president). Asking Name, "do you know where you are?" and "what day is it?" is not sufficient. Asking "How are you feeling?", "What's been the problem today?", and "Do you know where you're going and why?" are going to give you a more accurate picture of what's going on inside the patient's head.

[jdemaio]

How about when their answers include..

Where are you? "I'm right here. Where are you?"
What's your name? "Why? You gonna arrest me?"
What day is it? "It's today."

I believe the reply is something like: "Ok, time to go to the hospital."

[prncssmdc]

Sometimes anthonyt...you can say it so well...

We have had insane issues with this over the 3yrs I have worked for my service. Go figure I live in one of the top binge drinking states in the union. Usually, it involves a cop that does not want the person puking the the back of their squad, so hey, call the ambulance.

How it works here now is this (after a sit down with the PD). The PD makes the decision that the pt is going to the hospital IF the pt chooses to refuse. They involve our medical opinion, but in reality they have made up their minds before we get there. The deal is that the cop is placing them under some type of temporary detainment. There are no citiations issued (to the best of my knowlege). The pt is then required to go with us to the hosptial. Once in the ambulance and after the cops leave, EMS can no longer detain them if they want to leave, nor can the ER when we get them there.

My solution to this has always been documentation, and when I am done with that, more documentation. I don't know if what I descibed above even makes any sense, but it allows everyone (PD and EMS) a certain amount of CYA for the cases like MedicQT descibed.

[vudumedic]

We have zero policy on this except "it depends." What are your SOG's regarding pt refusals with obvious intoxication?

Base contact and as long the Pt is A&O 4/4 can understand risks and consequences. Then if the Base says yes

[strwblue]

OK..I will answer like a professional.

Alert to Place = "Ask your patient a place oriented question that can not be answered by just looking around." example: What state are we in? Just asking them do you know were you are, is not checking for place orientation.

Oriented to Time = "Ask your patient who is the President. (Reguardless if you like the one in office or not.) If they answer Nixon or Johnson you might have a problem. If they Bush or Clinton well they are at least close.

Remeber ever patient has their own baseline. Your patient maybe conpletely at par for their baseline. Rushing an Alzhimiers (sp) patient off to the ER becuase they tripped and bumped thier knee but can't tell you who the current president is maybe over kill. We need to rely on an number of variables not just one or two.

[scribble]

Base contact and as long the Pt is A&O 4/4 can understand risks and consequences. Then if the Base says yes
There we go...those have got to be the magic words!

[PSYCtest040]

OK..I will answer like a professional.

Alert to Place = "Ask your patient a place oriented question that can not be answered by just looking around." example: What state are we in? Just asking them do you know were you are, is not checking for place orientation.

Oriented to Time = "Ask your patient who is the President. (Reguardless if you like the one in office or not.) If they answer Nixon or Johnson you might have a problem. If they Bush or Clinton well they are at least close.

Remeber ever patient has their own baseline. Your patient maybe conpletely at par for their baseline. Rushing an Alzhimiers (sp) patient off to the ER becuase they tripped and bumped thier knee but can't tell you who the current president is maybe over kill. We need to rely on an number of variables not just one or two.

Not an intox but still AMS. 86 YO involved in a head on MVA. First question, "Sir, what is your name?" He answered it correctly (I know because the police had his licence out.) Second question, "Sir, can you tell me what town you are in right now?" All I got was a blank stare. "OK sir can you tell me what state you are in right now?" still get a blank stare. "OK, sir can you tell me what planet you live on?" Again blanke stare. Allllllll righty then you get a full work up.

[shamrock]

our protocol says GCS of 14. No further injuries or C/O. Grady does not like to have thier beds filled with drunks with no complaints. Our Jail will take anybody as they have PA's and RN's who don't care. Heck they kept a guy with honest to God leprosy a couple of weeks ago then decided he needed to be seen at the ER so he didn't pass it on to any other prisoners. We have a very liberal treat and release/refusal program. 95% of drunk people don't meet transport criteria.

[medicmade]

Dido, I had a drunk the other day and his wife called twice because she didnt want to leave him alone. This guy comes out of his room and tells us to get the Fu#$ out of his house, guess what...bye bye. Refusing intoxicated pt's are not in our portocal's because that road has been crossed and lost. The only thing that you can do here is tell the person who called 911 is to go to the court house and file commitment papers on them, and then leo takes them to the hospital.





People who are AO*3, have a right to choose their own destiny. I don't care if they're drunk or not. I have been drunk a time or two, and if someone had pulled my cantankerous ass into the hospital, there would've been trouble. Not the, "I need security on the dock, he's a live one." sort of trouble, but the "I don't understand why I am losing my license, and being forced to answer false imprisonment, battery, and kidnapping charges," kind of trouble.

Who the Hell, do you folks think you are, that you can make a decision for someone else, when that person satisfies legal competency tests? Just as the police are not qualified to decide when a person needs to sleep it off, we are not either. In fact, the only one qualified to decide that is the person who is drunk.

What we are, however, qualified to do is, decide whether someone is alert and oriented to person, place, and time, oh, and sometimes situation. If you are oriented properly, then the only person qualified to determine whether you should go to the ER, is you. Period. If not, then you take a ride.

This is still a free country, and so long as what you are doing does not endanger another, nor infringe upon the rights of others, then you are free to continue doing it. Being drunk, is not a medical emergency. Being drunk is not a reason to strip me of my rights, and freedoms.

Oh, and your protocols, be damned. If you kidnap someone, and do so willingly, you are breaking the law. It doesn't matter that a doctor says you can, or not. Doctors are not judges, and barring medical emergencies in which you are incapacitated, have not the right to deny you freedom.

[Ditch Doc]

Sorry, I have not read all of the posts on this thread due to eyes bleeding from trying to catch up on a few months of posts.

Around here, drunk or otherwise, CAOx4 can refuse transport. I have never known a medic to note on an PCR "Pt was sloppy-ass drunk". Normally we note +ETOH, how much 'shine was drank, and CAOx_____.

Just having it on your breath does not necessarily mean you are impared, and last I checked, we could not have them blow or walk the line.

But, If I believe the Pt truly needs to go to the ED, I will call Control and put it in the doc's hands. Once he makes his decision, EMS is covered.

[Firespec35]

Once again (I know I say this with most posts) I am in a different situation than most. When I work events I usually see 3-4 drunks a night, hell I usually pick them out of the crowd. If they are A&OX3 they are good. A&OX2 but relatively with it and with friends they get to leave with the friends taking care of the drunk. A&OX2 and relatively with it no friends usually we call family if they have a phone (90% of people don't know phone numbers today). If they are A&Ox1 or just plain look like crap then they get transported. Anyone A&Ox2 and leaving with friends gets an accucheck before they leave just to make sure. One trick I use to assess competency is a relatively simple math problem like 27-14 or something like that. It's not so much the answer as watching them come up with the answer. I can usually tell if they are just bad at math or if it is the alcohol.

[kjrff23]

They sign and so does at least 1 cop.