Complacency can be an EMS provider’s worst nightmare, according to Emery (Paul) Roberts, a firefighter paramedic with Fines Creek (N.C.) Fire Department. It might be too easy to dismiss the patient with slurred speech, an odor on his breath and an altered mental status as an intoxicated person.
But is he really just drunk? Or could it be something else entirely, such as a patient in shock, or a diabetic emergency, or psychosis, or infection, or oxygen deprivation, or any one of a number of conditions that could present with those same symptoms?
“It’s not always clear cut,” said Roberts, the presenter of a Firehouse Expo class called Just Another Drunk, Or Is It?” “You have to look beyond the obvious.”
Patients with altered mental status should not be considered drunk just because it seems to be the obvious logical solution to the emergency. That’s a pitfall that could end a provider’s career because of inadequate or inappropriate care, Roberts said.
Using a mnemonic, Roberts said providers who encounter people who are apparently intoxicated need to keep in mind a fictitious place called CRAMPS, NH which includes a number of kinds of shock including Cardiogenic, Respiratory, Anaphylactic, Metabolic (including diabetes), Psychogenic, Septic, Neurogenic and Hypoglycemic. All those varieties of shock can manifest into symptoms of intoxication, Roberts said.
Traumatic shock and infections can do the same things and cloud the providers’ judgment on the type of care an individual needs, Roberts said.
Using case studies, Roberts offered two patient scenarios. One was a 48-year-old male who was laying on a couch with slurred speech, lethargy and an odor to his breath; the other was an 8-year-old with virtually the same symptoms.
There’s an automatic assumption the older man is drunk and the young male is in a diabetic emergency, Roberts said, noting that it’s exactly that kind of predetermination and complacency that can cause providers to overlook the fact that the man is a CVA patient and the 8-year-old boy was drinking his grandmother’s tea laced with “sipping whiskey.”
Roberts had a new twist on the mnemonic CYA which typically means "cover your a**." In his world, it means Can You Authenticate.
“You have to authenticate your work,” Roberts said, noting that many lawsuits have been dismissed once paramedics and EMTs provide the verification and paperwork that show they provided quality care and didn’t overlook things. He’s even encountered providers who put WNL on reports which means “We Never Looked.”
“That’s unacceptable,” Roberts said. “…You need to dig deep inside and look at why you became an EMT.”
Roberts talked about other intoxicants that can produce symptoms of a drunk or worse, including synthetic and designer drugs like bath salts which are not new. He said the government did a study on the effects of synthetic drugs, like those found in what are now called bath salts in 1964.
“They have been around for a long time and they are not going anywhere,” Roberts said, noting that every time a ban is place on a synthetic drug, drug designers modify the potions slightly which means they are no longer banned under law because they are technically not the same thing.
A couple of new illicit drugs on the market are something called Monkey Juice, which is heroin and Benadryl that’s mixed in water and consumed. It’s popular among young teens and pre-teens.
“Drug dealers have to market their products somehow and that’s how they are doing it,” Roberts said. “Give it to them early and they’ll be potentially hooked for life.” There’s even a type of meth that’s combined with Kool-Aid brand drink mix and consumed orally called Strawberry Quick, he said.
“You can’t have little kids walking around with track marks on their arms,” Roberts said.
There was a man who recently figured out a way to get high from smoking finely ground peanut shells, a process that yields results that are close to that experience from smoking marijuana, Roberts said.
Over the counter drugs can also be used to get high including cough syrup, which can produce euphoric like dreams and other hallucinations. In quantities too concentrated, they can produce an of out-of-body experience and the inability to reason and follow simple instructions and commands.
Markers for use on stationary, glue, aerosol propellants and a variety of cleaning agents can be “huffed” to get high, which all present similar symptoms, Roberts said.
And there are even new ways to get intoxicated on the old standby – alcohol, Roberts said.
Some have found that nebulizing alcohol is a very fast way of becoming intoxicated, Roberts said, noting that it’s dangerous because it is absorbed immediately into the blood stream.
“So, there are no stop-gaps like there are when a person drinks alcohol,” Roberts said, noting that people start throwing up when they’ve had too much to drink. That won’t happen, however, when the nebulizer is used.
Plants can be intoxicants too, particularly common ones like Morning Glories, Angel Trumpets and Datura which create a kind of atropine that can last up to three days, Roberts said, adding that some plants can produce substances like LSD and LSA.
So, when it comes down to dealing with people who appear to be intoxicated, whether it’s a person slumped over the wheel of a car, or passed out on a sidewalk, or face down on a desk in the office, it’s the provider’s duty to look well beyond the obvious and look for the root cause of the person’s condition, Roberts said. Even “frequent fliers” deserve a second look and verification, even if it is the umpteenth time providers have responded.
“It only takes one bad person to make us all look bad,” Roberts warned.