The practice of emergency medicine requires a working knowledge of many common injuries and disease processes. However, treating intoxicated patients is one of the most common and most perilous aspects of the job. This is because these patients are often far more than intoxicated.
As Dr. Christopher Colwell points out in his lecture “Management of the Combative Intoxicated Patient,” available now for CME credit through AudioDigest, the issue is especially nuanced because it involves both medical and legal considerations. Who decides what happens — the patient, the family or the clinician? Who is ultimately responsible for the choices made and their outcomes? Patients may or may not understand the issues and dangers at hand and may insist on transfer or discharge when neither is appropriate. Dr. Colwell’s talk offers guidance on how to ensure the safety of patients and staff coupled with practical tips on how to safeguard the civil liberties of patients while also helping physicians avoid the witness stand.
Why Are They Agitated?
Intoxicated, agitated patients can be frustrating, and we can easily assume that their behavior is due to their intoxication. But one of the most important points Dr. Colwell makes is that clinicians must always ask, “Why is this patient agitated?” Patients may suffer from many things that “blur the picture,” including head trauma, hypoglycemia or even hypoxia, all of which make adequate history and physical difficult.
Alcohol Level? Not So Fast!
Dr. Colwell also advises clinicians to avoid measuring alcohol levels on their intoxicated patients until after they decide to keep or discharge them. There is no single alcohol level that ensures a good decision regarding disposition of the intoxicated patient, and ultimately the alcohol level can be used against the physician in court. The clinical gestalt of the physician is most important.
How Should You Restrain?
In treating intoxicated patients, Dr. Colwell reminds physicians not to use restraints for behavior control, but instead for medical evaluation, and to move as quickly as possible from physical to chemical methods. He also discusses the careful use of pharmaceuticals such as benzodiazepines, ketamine and even the much beloved droperidol (if you can find it!) in the various clinical scenarios described. This is particularly important in the management of agitated delirium, which can prove dangerous to patients who are intoxicated with cocaine, methamphetamine or synthetic marijuana.
Since physicians are all too human and subject to their own emotional responses, Dr. Colwell reminds them to be careful in how they document the use of restraints. In addition, they should never chart when angry or emotional.
Dr. Colwell also gives sound advice on the legal issues that could come into play. Physicians always want to respect the autonomy of patients, but sometimes it may be necessary to make decisions for them.
However, he says that physicians won’t go wrong according to legal opinion if they:
- Truly consider the patient unable to make a good decision.
- See that the patient is unable to understand the risks and benefits involved.
- Hold or admit them for their own safety.
Be the Good Guys
In this setting, the law still casts doctors as the “good guys.” Dr. Colwell reminds physicians that they are obliged to act in the way that is safest for their patients, even if the patients object. “Do what you would rather defend” is perhaps one of the best aphorisms to keep in mind when treating intoxicated or combative patients.