Just A Drunk

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I was having a nice chat with one of the system medicals with whom I work. She mentioned that one of the most dangerous phrases in Emergency Medicine is that the patient is “Just a drunk.” The reason is that if the patient is perceived as just a drunk, then at every stage along his treatment path, he is likely to be under assessed and the severity of an illness or injury will not be properly assessed. This can lead to disastrous consequences for the patient and all of the practitioners who see him.

As a former co worker used to say when EMS providers were tempted to write off a patient as “just a drunk”,  “Do you really want to spend the rest of your life flipping burgers because of THIS guy?” Which was pretty much the same thing as my doctor friend said last night.

If you doubt me, read the story of David Rosenbaum in this New York Times story.

Here is a quote that sums up the problems, but you really should read the entire story.

The assumption that Mr. Rosenbaum was drunk led ambulance technicians, police officers and the staff at Howard University Hospital to handle him with far less urgency than was necessary for a person with a serious head injury, it said.

The report said vomiting and other symptoms displayed by Mr. Rosenbaum were consistent with brain trauma as well as intoxication, and should have been recognized as such.

“Apathy, indifference and complacency — apparent even during some of our interviews with care givers — undermined the effective, efficient and high-quality delivery of emergency services,” wrote the inspector general, Charles J. Willoughby.

If you follow the news about EMS in our nation’s capitol, you’ll know that nothing much has changed over the 10 years since this happened. Maybe President Trump will do something to make DC EMS Great Again. But that’s a story for a different day. And, if you’re asking, NO I don’t want that job.

I brought that up as an extreme example of what can happen if EMS and other medical providers are lazy in their approach to examining a patient.

I was reminded of this when I was reviewing a call from one of our client agencies. This is a private company that provides both emergency and inter facility transfers. We only see the 9-1-1 calls, of which this is one.

Here is the narrative portion of the Patient Care Report (PCR)

O/S FOUND 57 Y/O FEMALE LAYING ON THE SIDE OF THE ROAD IN THE RECOVERY POSITION. PT AOX4 W/+ABC. PT REPORTED THAT SHE
FELL TRYING TO CROSS THE ROAD AND STRUCK THE BACK OF HER HEAD. REPORTED 7/10 PAIN. PT REPORTED NO OTHER INJURIES.
PT REPORTED NOT EATING TODAY. . PT ASSESSMENT SHOWED NO VISIBLE INJURIES. PT VITALS ASSESSED AND WNL. PT STATED
SHE THINKS SHE IS DRUNK” AND REPORTED HAVING A FEW SCORPION BOWLS AND A FEW SHOTS. PT ASSISTED ONTO STRETCHER BY
2X EMT AND 2X PO. SECURED W/ 5X STRAPS AND 2X RAILS. STRETCHER LOADED INTO AXX FOR TXP TO XXXXXXX HOSPITAL. PT BEGAN TO
VOMIT AND WAS PROVIDED AN EMESIS BAG. ENROUTE VITALS MONITORED. PT REPORTED NO CP OR SOB. PT VOMITED THROUGHOUT
TRANSPORT. U/A ARRIVAL PT UNLOADED FROM AXX. TRIAGE REPORT GIVEN TO RN. PR TRANSFERRED TO BED #1 BY 2X EMT AND 2X
NURSE VIA SHEET DRAW. PT SECURED W/ BRAKES AND RAILS. PT CARE TRANSFERRED TO STAFF W/O INCIDENT.

I’ll add a couple of other notes from the PCR to help with context.

Time:    BP           Pulse   Resp. Rate   O2Sat       Glucose    GCS

20:26   120/70    65         18                  96%            72             15
20:50   120/70    65         18                  98%                             15

Note that there is a 24 minute gap between the two sets of vital signs. Which are almost identical. Duplicate vital signs are an almost sure sign that the second set was done with cut and paste.

In case you’re wondering, the only medical history this patient had was anxiety and her only medication was Lorazepam.

This was a BLS crew, so there are some things that they couldn’t do. However, they could have done a hands on assessment, but other than the check list boilerplate that this PCR system provides for, they didn’t indicate that they did one. They also didn’t utilize a cervical collar to stabilize a potential injury. Nor did they do a Stroke Exam.

They didn’t seem to think that the continuous vomiting during transport was all that important. They did provide an emesis bag, which was good.

They never called to request an ALS intercept, even though we don’t encourage staying on scene to wait for one. If there happened to be an ALS unit in the area, they might have done a better assessment.

I very rarely get any sort of follow up on these calls, because we rarely hear back from the service or their medical director when we do a review and sent a call in. Chances are that the patient was just very drunk and had no significant injury. Since we cant’ see inside her head, the problem is that field providers have no way of knowing if the patient is drunk, on drug, has a serious head injury, or something else is going on.

Which is why “Just a Drunk” calls should put providers on alert if the patient is doing anything other than standing, walking, or sitting normally. Any drunk with an injury should be treated carefully.

Remember that the next time you are tempted to look at a patient as “Just a drunk.”

4 COMMENTS

    • I’m doing new client orientation classes for a system that just came on board. I tell the medics and EMTs that I can always tell when someone works or worked for a long period of time for a private provider.
      Their reports include such important information that they put the rails up, used FIVE straps, brought the oxygen and stretcher into the nursing home, and put on BSI before answering the radio. Or something.
      I tell them that we really don’t care about any of that, or the billing information. We DO care that they write a good narrative, including a physical exam. It’s amazing how often there is absolutely no physical exam documented.

  1. I do peer review myself.

    Within the period of a month we had a medic bring four patients to the hospital with roughly the same set of complaints and symptoms. There was minimal (or absent) care provided. All were inappropriately triaged in the ED initially due to the EMS report.

    Two of the four had intracranial bleeds. Luckily, observant and experienced hospital staff got them scanned and diagnosed early and both did well.

    • It took me several years to understand that triage nurses often took us at our word and that what we said could set the course of patient care. Not all the time, but if it was a nurse who knew me and trusted my word, often he or she would just accept what I said at face value. No, they shouldn’t do that, but I guess it’s human nature. I also found out that not every EMT or paramedic I worked with got the same treatment.

      Which I guess I should take as an endorsement of my diagnostic skills.

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