For drunk patients, hospital has something EMS doesn't

Our training doesn't prepare us to make diagnosis of ‘assumption' of alcohol intoxication

The EMS provider workday is filled with the mundane, the boring, and the occasional high-pucker factor call. It’s not a bit ironic that we spend most of our training time preparing for the latter, and very little on the former; in turn it sets us up for the potential of making critical mistakes in clinical judgment.

To be blunt, many of us operate in a blissfully ignorant state of affairs – we believe that a couple hundred hours of training is sufficient to make a snap medical judgment of pronouncing someone 'just drunk' and somehow not worthy of further evaluation. If we’re lucky, we make the right call 99 times out of 100. The sad fact, though, is you just have to be wrong once to throw it all away. News about a paramedic and emergency physician who are under fire after accusations they refused proper treatment to an intoxicated patient is a good example.

The way that society views public intoxication has swung from a law enforcement issue, to a medical concern. Alcohol intoxication suppresses airway patency and masks the signs of more serious underlying problems. Multiple conditions mimic the effects of ethanol ingestion, including brain trauma and hyperglycemia. The “diagnosis” of being drunk is really a diagnosis of exclusion – it’s  what’s left after all other possibilities are explored and discarded. 

Sadly, too often we make 'just drunk'  a diagnosis of assumption. The patient looks drunks, smells drunk, sounds drunk – heck, the patient must be drunk. The assumption clouds our clinical judgment and causes us to pass moral judgment. Neither result is desirable in the practicing clinician. 

To take intoxicated individuals to an emergency department can be frustrating. It ties up human and financial resources that could be better used. But until we have the right tools, training and mindset to make the right call accurately and consistently, transports of these patients are warranted. At least the ED has the best intervention to diagnose the problem. It’s called tincture of time. That’s something we don’t have.

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