What does it mean to be intoxicated? Some say it’s the blood level, others that it’s the clinical exam.
Matt Delaney MD, Sam Ashoo MD, Greg Henry MD and Anand Swaminathan MD
There is a great deal of variability in management of drunk patients by physicians.
We are not good at determining clinical sobriety or blood alcohol levels.
Document that the patient is eating, drinking, walking and appears to be making appropriate decisions and make sure this corresponds with nursing documentation.
Waiting for the alcohol level to fall to below legal limits can be dangerous in chronic drinkers as it may precipitate withdrawal when they reach sober levels
Drunk patients can sometimes be a source of entertainment or a soul-crushing resource drain that will bring an Emergency Department to a screeching halt. These are risky patients; they do dangerous things and hide dangerous diseases. There is a lot of variability in the practice of how we deal with these patients.How do we figure out who is drunk and who is sober?
There are some providers who designate a patient as clinically sober, while others get a blood alcohol level to determine sobriety. There is very little literature to suggest that a clinical approach to sobriety is any better than getting labs. Both of these practice patterns have significant limitations and carry a certain amount of medical risk.
There is fairly good support in the medical and legal literature for the idea of clinical sobriety. What does this consist of? You look for obvious signs of psychomotor and cognitive impairment and make your best guess. However, it is often unclear who is clinically sober, and we are not good at determining clinical sobriety.
Mahler SA, et al. Clinical sobriety assessment by emergency physicians in blunt trauma patients with acute alcohol exposure. J Emerg Med. 2010 Nov;39(5):685-90. PMID: 19615845 This study looked at blunt trauma patients who had consumed alcohol, and determined their blood alcohol level (BAL). Patients with a BAL < 80mg/dL were considered clinically sober. Patients with a BAL > 80 mg/dL were considered intoxicated. The providers were blinded to the BAL and asked whether or not the patient was clinically sober.
What did they find? We were very good at determining if the patient was intoxicated (about 96% of the time). However, we were bad at determining who was clinically sober. The emergency physicians were able to identify sober patients only 32% of the time. We have a difficult time identifying patients who have had some alcohol but are not intoxicated. However, the physicians were not asked if the patient was intoxicated or sober, but to identify if the blood alcohol level was over or under 80 mg/dL. There is a lot of variability at the lower end of the spectrum. Alcoholics weren’t excluded. Laboratory determination of BAL does not reflect the extreme individual variability of the effects of alcohol on the population.
We are not good at guessing the blood alcohol level of patients.
Olson KN, et al. Relationship between blood alcohol concentration and observable symptoms of intoxication in patients presenting to an emergency department. Alcohol Alcohol. 2013 Jul-Aug;48(3):386-9. [Free open access article] They found that we tend to overestimate the blood alcohol level in patients who appear intoxicated but are not chronic drinkers. We tend to underestimate the BAL in patients who are chronic drinkers. They found poor correlation between the BAL and visible signs of intoxication, across all ranges of blood alcohol level.
There probably isn’t a huge risk in assuming a patient is more intoxicated than they are. If the patient seems intoxicated, check on them frequently and make sure they are sobering appropriately.
Document clinical sobriety such as eating, drinking, walking, and appearing to be making appropriate decisions. Check the nursing notes and make sure that you are on the same page. You don’t want to discharge a patient when the nursing notes say the patient is altered with an ataxic, unsteady gait.
If you are going to get blood alcohol concentrations, don’t ignore a high level. In the United States, all states consider someone to be impaired if their blood alcohol level is greater than 80 mg/dL or 0.08. From a legal perspective, a patient is legally intoxicated above this level, despite their clinical appearance. There is little legal support for the idea that a person could be clinically sober while having an elevated blood alcohol level.
We see patients who are alcoholics and who present with very high blood alcohol levels, but seem totally fine. From a legal standpoint, this is a shady area. The risk comes from ignoring the elevated blood alcohol concentration.
Some will observe non-chronic drinkers who are intoxicated for a few hours. You don’t necessarily need to repeat a level to prove they are sober. You do need to watch them for a reasonable amount of time. It is thought that non-chronic drinkers will metabolize ethanol at a rate of 20mg/dL/hr. A patient with a blood level of 200mg/dL may need 5-6 hours of observation until their blood alcohol level drops below the limit of 80 mg/dL.
This is more difficult in patients who are chronic drinkers. Their metabolism is different than a non-drinker. These patients may not plan to get sober. The patients may go into alcohol withdrawal. If you are strictly following the blood alcohol level, you may make decisions that are not in the patient’s best interest to get them below a legal threshold.
Below the limit might not be good enough. There is a certain subset of patients who are intoxicated although their blood alcohol level is below the legal limit. This can put them at risk of injury after discharge.
Phillips DP, et al. Official blame for drivers with very low blood alcohol content: there is no safe combination of drinking and driving. Inj Prev. 2015 Apr;21(e1):e28-35. PMID: 24397929 Patients with a legal but detectable blood alcohol level had a significant increase in accident severity compared to drivers who had not consumed alcohol.
Is it totally safe to discharge them? The legal literature is scattered on this. Delaney will let patients with elevated blood alcohol levels metabolize until they should be under the legal limit, document that they are clinically sober, and help arrange a ride home. If the patient is in the Emergency Department solely for alcohol intoxication, Delaney will discharge them home if they are improving and have a sober ride. If the patient is in an accident with a potential missed injury, they should be observed until clinically sober and re-assessed for occult injury.
Many patients who are drunk want to sign out against medical advice. The courts are reluctant to say a patient does not have capacity. Delaney will sign the patient out against medical advice. He calls the police and tells them he has an intoxicated patient that he is worried about. He does not restrain them due to intoxication.
There is the correct school of thought and the wrong school of thought. Clinical sobriety is a clinical exam. The number is irrelevant.
Is there is utility in getting a blood alcohol level from a medicolegal perspective? Blood alcohol levels were adopted by the states to determine who was able to operate a motor vehicle. They selected a number that seemed correct, knowing that there is a wide spectrum. Patients may have co-ingestions of other medications that contribute to altered mental status.
We don’t have cases where not obtaining a blood alcohol level made a difference. The examination and evaluation of the patient is what is important. Most legal cases arise due to failure to document the abilities and limitations of the patient.
Kowalski versus St. Francis Hospital. An intoxicated patient eloped from the Emergency Department and was hit by a car. He became a quadriplegic. He sued the physician and hospital, saying that he should not have been allowed to leave as he did not have decision-making capacity. The physicians and nurses had documented that the patient was alert, was awake, was oriented, walked normally, and looked fine. His blood alcohol was elevated. The state Supreme Court ruled that they did not have the right to hold the patient against his will if he met the rules of competency. They would have committed the felony of battery.
The patient is normal when determined by documented examination and nothing else. The number is useless and variable.
However, a patient with an anticipated change in their mental status (such as a patient who received naloxone after opiate withdrawal and is at risk of repeat symptoms when the medication wears off) may be reasonably held against their will, as they present a danger to themselves or others due to a disease entity that may return. This is not the case with alcohol, unless they are consuming more in the Emergency Department.
If the patient has neurologic findings, such as ataxia or altered mental status, you won’t discharge them even if they have a low blood alcohol level.
Swaminathan does not usually get blood alcohol levels unless he is unsure if the patient is altered due to alcohol intoxication.
What if the patient had a blood alcohol level drawn that was elevated but they seem sober? This depends on where you work and how the patient will leave. If you work in an area where the patient has to drive home, you can’t send them out to drive home. Getting them a sober driver is probably the way to go. If you didn’t get a blood alcohol level and sent them out to drive home, you aren’t really in a better situation.
Waiting for the alcohol level to fall to below legal limits can be dangerous in chronic drinkers, as it may precipitate withdrawal when they reach sober levels. Also, when the patient is sober enough to walk around and wants to go home, they will disrupt your department until they leave. Establish that the patient has capacity to leave before they go home. If they can walk, talk, and tell you what is going on, you can establish capacity without them reaching the legal BAL limit.
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