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bk84nation

Restraining overdose patients in ER?

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Hey all, I have worked in 2 different ERs in the last 5 years and have noticed varying practices on what to do with opiate or ETOH patients that want to leave. We get (as I assume most ERs do) frequent arrival of patients either given narcan in the field or being just found drunk in the streets and brought in for evaluation. The majority of the drunks are frequent flyers and we see them ~ 3x week. Its just protocol for the police/EMS to scoop these guys from the park bench they passed out on and bring them in.  My first job trained me assume the worst with these patient (subdural bleed, rebound opiate OD after narcan wears off, etc.. and to jump through the hoops and restrain these patients if need be to prove pt is safe, can make own decisions and can be discharged after labs, observation, repeat BAC, etc..). Im seeing some providers let a lot of patients walk out after they get narcan after an 1 hour observation, or not doing any work up on the drunks -- just feeding them, watching them until they are "walky/talky" and nurses agree patient "has steady gait, etc...).  Seems risky to practice this way. Thoughts?

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I'm only a year out but the culture of my residency program is very much one of taking these patients seriously.  One of the older respected doctors always says "God put alcoholics on this earth to keep doctors humble"... there are just so many things that can and do go wrong with these people.  We always take their complaints seriously and have low thresholds for head CTs etc.  Several of my cases that have "gone wrong" or bounced back have been things we missed on alcoholics who just can't provide an appropriate history, so they require excellent exams and repeat hx after sobering.  When it comes to letting them leave AMA while still being very drunk, I think this is also putting the liability on you.  We had a case of a drunk patient who left our hospital after we watched them become more or less sober... they then left and got drunk again, stumbled in front of oncoming traffic, and our hospital was sued.  Their take home point was that you have to document really well that they have obtained clinical sobriety and are safe to go home.  Of course, it puts us in a tough position of trying to restrain the drunk patient... lots of pitfalls when it comes to chemical restraint here.  

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Opiate overdoses: 4 hour watch since last dose of Narcan (usually based on EMS report).  I'll usually put them on a psyche hold if I can't persuade them to stay.  Their mental status is usually pretty good.  If not, they definitely are put on a psyche hold.  Usually no workup.

 

EtOH intox: much lower thresh hold for workup.  Kept until clinically sober.

 

I seldom have a patient physically restrained.  Sedation: ativan, geodon, ketamine much preferred.

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Narcotics ODs don't leave until I know what is in them, the time they last took anything, how much narcan they have been given, how much more will they need, etc.  Alcohol ODs get significant W/Us, even if we know them, because we do know them and we know their bleed histories, cirrhosis hx, etc.  Psychs, Addicts and Alcoholics get sicker per capita than the general population.  To overlook this is dangerous.  If they don't cooperate, its sedation city for a while (Ketamine, Zyprexa, Haldol) and if they utter a word even remotely suggesting they want to see psych services, they can't leave.  Should they try, they are met at the door by PD and brought right back in and treated chemically. 

 

Be careful with these patients - these are the ones that absolutely burn you.

 

G

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yup, easy to get burned by the frequent flyer druggie. one of my attendings (not a PA fortunately) recently had one of our regulars code on him when they thought he was just crying wolf again and put him in an unmonitored hallway bed.

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I work in an ER where alcohol intoxication is our #1 yearly diagnosis. In my 3 years there, I've seen too many of our homeless alcoholic frequent flyers die. Head bleeds, sepsis, freeze/overheat, hit by cars, etc. Last week I had a patient with the highest ETOH level I've seen yet -- 0.649! Workup was otherwise unremarkable and he was walking within 4 hours.

 

Generally, in my ER we don't do much with our drunks. Of course, everyone has a very low threshold for a workup if they are new to us, frequent flyer but looking worse than usual, have any signs of trauma, or have significant past medical history. Otherwise, we let them nap and observe closely. Once they're "clinically sober" I'll discharge, but some elope before I'm comfortable with a discharge. Our security won't restrain them unless I force it, and I frequently don't even know they're walking out the door until it is too late (we don't have security in our department at all times). I HATE hallway beds because of stories like above, and always keep patients on the monitor. We don't give IV fluids or even check alcohol levels on some. 99% of the time all is good and we see them again in a day or 2. Everyone is always worried about that 1% though, because any day could be the day they fall/walk into traffic/take a nap in the wrong place. We will sometimes give cab vouchers to shelters, however this was a significant drain on the department (over $20k per month) so we try to be judicious about this. Luckily we have a detox facility we can send some patients to if level is between 0.2-0.4 and they are ambulatory, but our most frequent patients are banned for various reasons. They are crippling to our department and definitely a contributing factor as to why our hospital is closing in a couple months.

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What's the ratio of badness with these guys?  1:1000?  1:100??  1:50???

 

It's high, and you can't clear them with a H&P if they aren't talking to you clearly.  If they can't clearly communicate to me that they are perfectly fine then they get worked up.

 

It costs the hospital probably $50 for the head CT.  

 

It can cost you 20,000 TIMES that much if you miss something.

 

They get the CT.

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As others stated, I have a low threshold for workup in an ETOH pt.  Any signs of trauma and they get worked up...they describe trauma...they get worked up. If they are just drunk, I watch them as long as they allow it.  If they really want to go and are A&OX3 I insist that they call someone who can pick them up. If no ride, I personally road test them; the nurses tend to just want these pts gone and will just say they walk fine without actually walking them...I've seen it time and time again, so I do it myself.  I have trust issues.  I have seen frequent flyers come in and die and everybody gets caught with their pants down; feels like the first time...every time. 

 

At minimum: basic labs, UA, IV NS bolus, Vitamins, food tray if able to tolerate PO, recheck blood sugar before d/c, and road test. 

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What's your reasoning for IV fluid bolus being included in every drunk patient? Obviously, if they appear ill, have abnormal vitals, any signs of trauma, or significant medical history etc then IV placement +/- fluids depending on situation. But why do it in the stable, uncomplicated intoxicated patient? It doesn't sober pts up faster or decrease average visit length. Instead, I find that it makes uncomplicated drunk patients urinate more and increase fall risk because they try to get up to find the bathroom. Also makes nurses angry to place the IV and then clean up more urine if they're the bedwetting type. 

 

I agree with directly observing the patient ambulating before discharge. Our nurses too are always eager for a quick d/c but they've learned that I'm one of the providers that won't let that slide. Also exam and charting on these patients has to be EXTREMELY thorough every single time.

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A trick I learned about drunks is they'll wake up more readily if their bladders are full - so it helps with getting them up and around...which is a step (excuse the pun) towards discharge.

 

SK

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Drunks are dry, most chronic alcoholics live in a state of dehydration. A single fluid bolus isn't going to hurt them nor is it going to turn them into a fountain of urine. It's easier to get them up and moving if you have corrected a small measure of their dehydration.  

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Yes I agree -- fluids for any patient with signs of dehydration. In those without evidence of dehydration, sure, a liter bolus won't hurt them. But, it also isn't necessary. It does make them more likely to become fountains of urine. And the cost of nursing time is significant if needing to hold them down, they're a difficult stick, or end up needing to be bathed. The literature shows no difference in length of visit (even though there are few relevant studies). Obviously practice styles and patient populations may differ... but my point is that giving IV fluids doesn't have to be an automatic part of the treatment plan in every intoxicated patient. Waiting until they wake up and can tolerate PO fluids AND make it to the bathroom would have similar benefit of hydration without added cost of time/supplies at the end of the day. Just something to consider in the future!

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PS - The urine issue is probably exaggerated in my department because our hospital refuses to restock our disposable urinals, and we have only 2 bathrooms for our patients to share. Add these issues to a patient who can't ambulate without assistance to the restroom, and we've got a nursing disaster. It honestly feels like practicing in a 3rd world country at times :(

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