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Clinical Sobriety

Matt DeLaney MD, Sam Ashoo, MD, and Greg Henry, MD
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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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05:33

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EM:RAP 2015 August Summary 1 MB - PDF

What does it mean to be intoxicated? Some say it’s the blood level, others that it’s the clinical exam.

Clinical Sobriety

Matt Delaney MD, Sam Ashoo MD, Greg Henry MD and Anand Swaminathan MD


PEARLS:

    1. There is a great deal of variability in management of drunk patients by physicians.
    2. We are not good at determining clinical sobriety or blood alcohol levels.
    3. Document that the patient is eating, drinking, walking and appears to be making appropriate decisions and make sure this corresponds with nursing documentation.
    4. 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

Delaney

  • 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.

Ashoo

  • There is the correct school of thought and the wrong school of thought. Clinical sobriety is a clinical exam. The number is irrelevant.

Henry

  • 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

  • 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.

Sean G., M.D. -

I find the ETOH level has a role. Lets face it there are occassional times when we are surprised someone's ETOH level is neg...we were sure they were "just drunk" yet the ETOH was neg. Of course if we never send the level we wont see that. When I know a pt to be a habitual drunkard that lives behind the Walmart say and shows up every night once the wether gets cold drunk....yeah I get not sending levels on guys like that. However, when you have no experience with a pt and he is brought in "intox" by EMS it is often hard to be sure they are "just drunk" if they are really out of it they will take all shift at times to sober up, the entire time u have to hope u made the right call and this isnt just a little alcohol with something else like GHB, Robitussin, head bleed, encephalopathy, toxic alcohol, Bzs, barbs, and on and on... On these folks I like to send the level and if it comes back at 300+ I feel a little bit better about watchful waiting. I also think a potential juror may understand why you attributed AMS to such an alcohol level, when if u have none on the chart, and God forbid it turns out to be something else u will come off as arrogant and careless. Also it seems people are acting like this is a binary decision.... either get a level or clear clinically...whats wrong with getting a level to document in writing a seriously high ETOH THEN clear clinically? I just think u are taking a bit of a risk assuming its "just alcohol" unless the individual has a very steady pattern of such presentations. On the rare occasions the "drunk" had a 0 ETOH level I was glad I knew that at 1 am as opposed to my partner figuring that out at 1 pm.

Sam Ashoo, MD -

I agree with you Sean. You give some excellent examples of when an alcohol level may be helpful. As you said, the decision is not binary. However, let's not confuse what we are saying: an initial alcohol level may be helpful in the correct clinical scenario. A repeat alcohol level is not necessary for judgement of sobriety. Many psychiatric facilities require alcohol levels below an arbitrary number. That is not an appropriate or safe practice. The clinical exam is what we are after. Is the patient awake, alert, appropriate, and does he/she have a sober ride? If yes, why draw a level.?Also, keep in mind that legal alcohol limits are for driving. This not generalizable to daily function. The question is should it be routine to draw alcohol levels and the answer is no. Pick the correct scenario and it helps. Pick the wrong one, and it becomes wasteful, time consuming, or even distracting like the chronic alcoholic with a subdural thought to be just intoxicated. It can be difficult, but that's why we get paid to think.

Sean G., M.D. -

I agree I see no point in a repeat ETOH ever, similarly I dont think I have ever found a UTox to have been a helpful test though its pretty much required for psych evals. Getting paid to think is great IMO...unfortunately as u have probably noticed many forces in healthcare seem to be working towards removing that important aspect of our field....all the CMS mandates and core measures seemingly pushing towards an ever more cook book style of practice....very frustrating. I mean just my Utox example...seems a slap in the face of we clinicians that these protocols assign more importance to useless data then to a clinician's professional opinion.

Sam Ashoo, MD -

I hear you brother. It can be frustrating. There is a movement toward protocols and standardization to reduce variability. I recently heard Kevin Klauer describe it as something like this : standardization is just removing the outliers beyond a standard deviation and off loading our brains to focus on the nuances of medicine instead of having us use brain power for the simple stuff (like making sure a urine pregnancy test gets ordered for abdominal pain). I liked that description. I have focused my efforts on guiding those protocols instead of fighting them. In doing so, I have found that there is great need for intelligent , informed opinions from physicians when developing those protocols. Going back to the psychiatric example: my experience has been that many items we find unnecessary are often included due to those rare cases and personal anecdotes from the psychiatrists. However, every now and then I am pleasantly surprised by their reasoning. I encourage you to stay the course and use the frustration you feel to guide improvement. There is much need for a physician who sees a problem and seeks a solution instead of becoming discouraged.

Tor K. -

I don't understand this hand-wringing about alcohol levels. They are not expensive, and they are easy to obtain on the unconscious patient, which is the patient in which they are usually most relevant. If drunk people magically had their alcohol levels displayed on their foreheads, I think most of us would find that helpful, in conjunction with all other clinical factors, in making a variety of clinical decisions.

Sean G., M.D. -

I dont think anyone is wringing their hands...just making the point that to use a level as a method of "clearing" a patient for safe d/c is not a good idea. I was making the point that an initial level has some utility when a pt is severely altered, as if it is not sig high it really demands you search for another reason for the AMS. Just had a few occasions in 19 years where a person who was quite altered and had AOB turned out to have very little or no ETOH on board and I was glad I knew that early and not later.

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