Day Tripper

A friendly reminder to all my clients:  There is no point in lying to me, I already know what happened.  Your event is nothing new, no matter what it is.  You act like a 14 year old trying to hide porn under your mattress or cigarettes in your sock drawer thinking you're the first to ever think of it.  So when I ask you a question, and you lie, and I ask the question again, take the hint.



A fall victim is bleeding.



OK, I'll leave the reasoning for a code 3 response to a "possible broken nose" aside for this once because what happened when we got there was too much fun.

Arriving in the parking lot of the local market early in our shift we find a man seated awkwardly on the ground, keys and a small shopping bag nearby.  Also nearby is a half circle of a half dozen private security people from a nearby landmark who are all waving us over.  Thanks, fellas, never would have found you.

As I approach none of them breaks formation to come give me a candid run down of events, they just stand as if waiting for the show.

That was my first indication this would be interesting.

HM: Hi there, I'm Justin, are you OK down there? What happened?

DT (Day Tripper): I just want to go home, but they won't let me.

HM: Who won't let you? These folks? (As I motion to the security guards)

DT: Yeah, they called the cops.

HM:(as I'm completing my primary and beginning my secondary) Well, I'm not the cops, how did you end up on the ground and where are your glasses?

The 1cm laceration on his nose and cheek give away we was wearing glasses when his face hit the pavement, he has no other injuries.

DT: They took them.  Can I go now?

I helped him to his feet and we brushed him off, which is when his lack of balance gave away that the odor I smell is not crappy cologne that smells like vodka.  He stumbles into me as I'm holding his hand and the ambulance has pulled up about 12 feet away and opened their doors.

We walk (Oh. My. God.) to the rig and he's looking over his shoulder at something behind us with a new fear in his eyes.

The police are now on the scene and one of MC's buddies is off his bike and notices our new friend's keys on the ground.  For now he keeps his distance.

DT: I don't want to go to the hospital, I don't need a hospital.

HM: That may be so, but lets just get a few things sorted out first here in the ambulance where there's less of a crowd. How much have you had to drink today?

DT: I'm not drunk.

HM: That's not what I asked.  Let's start all over again, shall we? My name is Justin and I'm here to help you.  How much have you had to drink today?

DT: Nothing.  Who do you think you are asking me that?  I want your badge number.

HM: I just told you, my name is Justin and I'm here to help you.  Now, we'll start over again keeping in mind I do this all day long.  This is how I feed my family, so when I think something is going on, chances are it is. Alright?  Hi, I'm Justin.  How much have you had to drink today?

DT: (Looking over my shoulder at the motor officer) a few shots.

HM: Thank you.  See, that was so much easier than lying to another man in the face.  Don't you feel better?

DT: yeah. (almost proud of himself)

HM: Great! now, how many is a few? To me a few is 4.

DT: Yeah 4. (Now he begins to smile)

After establishing the time frame of the ingestion and the type of beverage and checking our other metrics for assessment the decision is made that the patient does not meet criteria for refusal of transport.  Myself and the transport medic agree it may not be necessary, but he fails 3 of the 10 requirements to refuse.

DT is not thrilled and begins to tell us all about how to do our jobs.  He was about to climb out of the ambulance when our friendly neighborhood motor officer stepped to the tailboard and peeked in.

MC: (Not the real MC, but the boots were nice.) If you step out of this ambulance and reach for your keys we'll be speaking to one another.

DT sat back silent.

DT: OK, I'll go.

Almost in a whisper he agreed to be transported because the other option suddenly seemed more complicated.


Suz said…
That cop was almost as cool as the real MC.
Ryan Fouts said…
I enjoyed the story, as we deal with DT's a lot in my jurisdiction.

Just a question, (not questioning) but asking the question...spinal motion restriction on the patient that is not able to refuse due to his potential level of intoxication putting him in the position to no longer be competent? It is interesting to note how a DT will fall un-aided (no out-stretched arms, etc.) when stumbling about due to their choice of beverage consumption prior to the event. Even with the smallest sign of injury (1" lac to nose and face from glasses) can't take away from the possibility of other injury internal or otherwise. Alcohol being a depressant can mask the sensation of pain, especially when attempting to perform a physical exam and spinal assessment. Often times, even the ED physician will have to wait to "clear the spine" until after the patient has sobered and will often send the patient to CT to rule out the possibility of closed head injury.

Just a thought...thanks for sharing!

Thehappymedic said…
Thanks for reading.
The metrics to refuse transport are remarkably different than the metrics for "spinal motion restriction."  The trauma to the nose was caused by a piece of metal breaking his fall.  There was no indication for precuations of any kind, regardless of what the lawyers want us all to believe.
He was ambulatory, with help, which was a result of the admitted intoxicants, not a brain bleed from a fall from height.
ER MD's wait to "clear the spine" while letting folks like this walk to the bathroom, completing the task usually to avoid having to explain why they didn't perform the task.
Alcohol can indeed mask pain, but since the cut on his nose did hurt it was safe to trust the rest of our assessment.

It can be a tricky place to get refusals from people who have no reliable way of vacating an area under their own power.  As was the case in this event the three metrics that were failed were:
"Does not appear to be under the influence of alcohol or drugs"
"Recognizes need for further assessment"
"Appears competent to make medical decisions"

Cut. Dry. Done.
Ryan Fouts said…
With alcohol or any other drug or substance you will have an impaired ability to assess the patient's pain/level of discomfort with any sort of accuracy.  He would meet the definition of intoxicated as you stated in your refusal metric. He also meets the definition of lacking "present mental capacity" as in your third refusal metric. These 2 items would call into question his ability to accurately respond to your physical assessment of his injuries.

Granted the prehospital metrics are conservative on the side of SMR (I have attached a copy of my system's SMR guideline for reference), we have to remember the limitations we have in the field. One, we don't have the time to wait until the patient "sobers up" in order to be able to perform a proper physical assessment and, two, we don't have the diagnostic tools (X-Ray or CT) to assist in making the determination that his spine or otherwise (head, etc) have not been injured while the patient is intoxicated. 

It is along the same lines of a mental health police officer, psychiatrist/psychologist, physician or whoever else is authorized to perform a mental health exam on someone who is suicidal while the patient is under the influence of alcohol or any other substance. The substance invalidates the exam. Granted there is more of a legal component to this exam because your are taking away someone's rights for a minimum of 72hrs, depending on your state's laws.

I definitely hear what your saying, but I think a pretty fine line is being tread when this is said, "Alcohol can indeed mask pain, but since the cut on his nose did hurt it was safe to trust the rest of our assessment...". I don't see how this can validate the "impaired decision making capacity" of the patient.

I don't make these assertions with the "lawyers" in mind, but the patient.

The bottom line is it's not so "Cut. Dry. Done."

the Happy Medic said…
Ryan, thanks for reading and a great response.  It is difficult to completely describe these situations with so many facts changes to comply with HIPAA, but the fact remains that the refusal matrix and the assessment matrix have different parameters.  Your attached SMR page is wonderful but is missing one key point, perhaps on another page, "Patient experienced an event that may lead to spinal cord injury."  Using your guide I would be using SMR on 50-75% of the patients I encounter, most of whom have no illness or injury.

Taking one page of policy out of context of the system isn't an accurate picture of that system, we all know that.

This person had not experienced a fall consistent with a skinned knee let alone spinal precautions.  The cut on his nose was from his glasses.  I currently have a larger cut on my foot.

Indeed my "cut. dry. done." was perhaps oversimplifying what on line is a 3 minute scenario when it was really closer to 30 minutes, but i shared it as a reminder that we are SMRing the elderly, children, the intoxicated, cancer patients and the like with zero scientific justification.  Unfortunately the only research I can use in my assessments is my protocols and policies and they are in black ink on white paper.

Alcohol does not immediately eliminate a person's ability to make their own decisions or feel pain but I will argue that the ability to make decisions becomes impaired far sooner than the inability to feel pain and reliably respond to an assessment.

Thanks for the comment and the upload! Didn't know you guys could do that.  Cool.
Ryan Fouts said…
Great discussion...I enjoy a little thinkin' every now and then. Take care.