It started out as a fun and exciting night – dinner and drinks, and then tickets to see Tom Petty perform in an outdoor venue. Three hours after dinner, inside the stadium crammed with fellow fans, a 54-year-old female felt lightheaded and faint. A security guard summoned the onsite event medical team, while a fellow concertgoer, who witnessed her sit down abruptly and lean on her daughter, instinctively dialed 911.
The event medical team brought her to the medical treatment area, assessed her and treated her with a cooling towel and a bottle of water to drink. Due to a lapse in event security, the 911-responding BLS unit arrived at the medical tent, despite the venue ALS event medical team assuring the responding unit that they could cancel the call. The BLS unit insisted they had made patient contact and would need to do an RMA on the patient. The 911-responding ALS unit, ironically, took the cancellation from the venue medical team and went on to their next call.
The BLS unit contacted their online medical control physician who, upon hearing the patient had consumed two alcoholic beverages four hours earlier, ordered the BLS unit to take the patient to the emergency department.
The patient, alert and oriented, with no neurological or motor deficiencies and whose symptoms had resolved through hydration and cooling by the event medical staff, refused to be transported to a hospital emergency department. Upon hearing her refusal, the BLS unit involved the police department to take the patient into custody for transport to the hospital, which the police department hesitated to do.
With the patient still refusing to be transported, the BLS unit called for one of their patrol supervisors to respond. Five hours after drinks had been consumed by the patient, and 45 minutes after the main act had concluded their performance, the BLS unit with the patient and law enforcement waited for the EMS patrol supervisor on the sidewalk outside, as the venue closed its gates and locked up.
In all likelihood, the EMS patrol supervisor most likely would have arrived and authorized the BLS unit to accept the RMA due to the acute lack of impairment exhibited by the patient. Scenarios such as this can turn out very differently if law enforcement is willing to simply go along with what the online medical control physician tells the EMS crew, or if the patient is not educated in their rights, as this patient clearly was.
The consumption of alcohol resulting in an altered status from intoxication is a common call for many modern 911 systems. Most tenured EMS providers will have at least one or two anecdotes regarding patients who have recently consumed alcohol, had a non-alcohol-related episodic medical issue, were alert and oriented with the ability to self-ambulate, yet were still forced to go to the hospital against their wishes due to either standing protocol, law enforcement rules or online medical control direction.
Traditionally, EMS providers are not equipped with either the techniques or the tools to objectively determine the intoxication level of an individual. Consequently, we are unable to properly assess an individual’s ability to make his own decisions. Yet, these non-invasive tools have existed for decades and are often used by law enforcement.
Determining decision-making capacity
While the consumption of alcohol may have mind-altering effects, it hasn’t been illegal to imbibe since the repeal of prohibition in 1933. Similarly, the act of consuming alcohol alone does not render an individual unable to make decisions for herself, and does not constitute the loss of her rights – including the right to make her own decisions about medical treatment.
In determining decision-making capability, most EMS providers depend on an evaluation of a patient’s level of alertness regarding orientation to time, place, person and circumstances. Some systems additionally provide guidance based on motor skills, such as the ability to walk with a steady gait and the ability to stand without swaying.
The effects of alcohol vary by individual, based on a number of factors including height, weight, gender and both the type and amount of alcohol consumed. Environmental conditions and caloric intake – or a lack thereof – can also be contributing factors.
Due to the number of variables involved, there needs to be an objective way to measure what effects alcohol consumption has on an individual. The Standardized Field Sobriety Test is the law enforcement method of determining intoxication without the use of devices, however its administration requires additional training and it remains a subjective assessment.
For a scientifically proven objective assessment, law enforcement relies on the breathalyzer. This method also requires additional training and physical tools, but has the benefit of being widely-accepted by scientists, the courts and the public as an unbiased evaluation.
Field sobriety tests: The overlooked training
SFST is generally the first step in determining whether someone is intoxicated after an admission or in the presence of reasonable suspicion. The National Highway Traffic Safety Administration publishes a course often used by law enforcement officers to understand, administer, detect and document a field sobriety test. Elements of an SFST include checking for Horizontal Gaze Nystagmus, Walk-And-Turn, and One-Leg Stand.
- The Horizontal Gaze Nystagmus: The HGN is assessed by holding a pen or other similar object and instructing the subject to follow the object with their eyes while moving it from center to left and right. Nystagmus is the involuntary jerking of the eye and becomes exacerbated when under the influence of alcohol. The lack of smooth pursuit by the eye and distinct nystagmus are indicators the subject is likely under the influence. Because the reaction is involuntary, it is difficult for the subject to conceal or control the movement.
- The Walk-and-Turn: The WAT is assessed by instructing the subject to walk nine steps on a line heel-to-toe and is commonly depicted on television and in the movies. Subjects that have difficulty balancing, start the test before the instructions are completed, and fail to follow the instructions are more likely to be under the influence of alcohol.
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The One-Leg Stand: The OLS is another divided attention method. Subjects are instructed to stand with one leg raised six inches above the ground with a pointed toe, arms at their side, and asked to count aloud by the thousands for thirty seconds. Subjects who show difficulty balancing, begin the test before the instructions are complete, use their arms for balance, or fail the instructions are possibly under the influence of alcohol.
Critics of this particular test note the test can be difficult for a sober person to pass under ideal conditions, let alone an impaired individual, however the OLS is still used when administering a field sobriety test.
Field sobriety tests have been scientifically proven to be the most effective non-invasive assessment at determining intoxication. There are a number of non-standardized tests, such as reciting the alphabet backwards, counting backwards, or instructing the individual to close their eyes and touch their nose with a finger, but these have not proven to be as effective as the standardized testing.
Breathalyzers: The omitted tool
Alcohol breathalyzers have been around since the turn of the 20th Century. In the 1960s, the devices became portable, and law enforcement agencies significantly increased their deployment when determining a motor vehicle operator’s level of intoxication.
Breathalyzers do not measure actual blood alcohol content, but estimate it by measuring the percentage of alcohol present in one’s breath during the gas exchange between the lungs and blood. Portable devices most often use an electrochemical fuel cell that oxidizes any ethanol present, creating electric current that is then measured and displays the approximate blood alcohol content. The more ethanol present, the greater the electrical current created, the higher the estimated blood alcohol present.
The breath sampling can be done either automatically or manually. On the auto setting, the device will sample after a certain volume of breath has passed through the machine in order to sample deep lung breath, sometimes referred to as “alveolar breath,” that is closer to the exchange of gases and would be more representative of the blood content.
Department of Transportation procedure for breath alcohol testing includes both an initial screening and, if the results are a .02 BAC or higher, a second confirmation screening. For EMS purposes, the second screening may not be necessary, since our goal is to determine decision-making capacity at the time of refusal, and not gathering evidence for criminal charges or capacity for work in a safety-sensitive position.
The NHTSA maintains a list of devices known as the Conforming Products List of Alcohol Screening Devices for use in DOT alcohol screenings, as well as for law enforcement. Selecting a device from this list will help ensure the integrity of any screening performed by EMS personnel.
Challenges to implementing breathalyzers in EMS systems:
The omission of using SFST procedures and breathalyzers in EMS can be attributed to a number of factors, namely provider safety and the cost-effectiveness of additional training. Because breathalyzers are most often associated with law enforcement and the public associates them with the possibility of criminal prosecution, their use by EMS personnel could unintentionally escalate a patient-provider interaction.
Adopting breathalyzers as a widespread tool within EMS would also require additional training, maintenance, and upkeep, with no apparent avenue for reimbursement following its deployment.
As a result, instead of EMS crews utilizing proven measures of alcohol consumption to determine a patient’s competence to make their own decisions, providers often take the path of least resistance by assuming consumption equates with impairment, which in many cases, forces providers use intimidation in order to guarantee patient compliance.
It is important to note that both SFST and breathalyzers are not included in the current EMS scope of practice. The fact is that assessment by SFST and breathalyzers are not medical in nature. There are no medical qualifications required to administer these tests.
Despite this, by successfully completing DOT approved training programs, there are many EMTs and paramedics who are currently credentialed through their medical director to perform these assessments in providing occupational health services at industrial complexes and construction sites. EMS agencies can implement these practices through a similar medical director credentialing process, until such a time as they are officially added to the EMS scope of practice.
Operate as a patient advocate
The benefits of using breathalyzers in EMS can far outweigh the cost, especially when the responding unit is in a situation with a patient, who appears unimpaired but refuses to go to the hospital, and a medical control physician who insists the patient must be transported based on their admittance to consuming any amount of alcohol.
Were EMS to instead employ proven techniques and devices, the EMS provider would have a far greater opportunity to operate as a true patient advocate invested in the best interests of their patients as well as of others on the road.
As we continue to move towards scientific, evidence-based medicine in prehospital care, as EMS providers, we should be in the vanguard when it comes to the implementation of methodical, evidence-based assessments in our patient interactions. The use of an objective tool with irrefutable, scientifically-based results may provide proof of a patient’s intoxication, justifying their removal to a medical facility when it is against their wishes, but in their best interest.
Such solid evidentiary results also have the benefit of insulating EMS crews from the potential liability of violating a person’s rights and accusations of kidnapping. Conversely, the use of a breathalyzer by an EMS crew may very well determine a patient’s sobriety, empowering that crew to fulfill a patient’s wishes, be it treatment or an informed refusal, and, in the latter case, to put themselves back in service quickly, an undeniable benefit for the communities they serve.
