Alcohol ‘Poisoning’… Or Is It?

Hi, 
Today I'm bringing up the topic of alcohol and whether Protocol 23: Overdose/ Poisoning (Ingestion) is the appropriate protocol. I've read numerous posts, and I've had debates within my center. Points I've come across are: “Alcohol poisoning” is a diagnosis and Altered Status is expected in a person who is intoxicated.

Should every drunk be considered a poisoning/overdose? We should evaluate based on symptoms only. If the complaint is vomiting, go Protocol 26: Sick Person (Specific Diagnosis). If there's blood in the vomit, go Protocol 21: Hemorrhage (Bleeding)/Lacerations. If the patient is unconscious, go Protocol 31: Unconscious/ Fainting (Near).

My responses to these points are: While the term “alcohol poisoning” is considered a diagnosis, that is not what we mean here in the EMD environment. First, if someone calls and reports, “I think my friend has alcohol poisoning,” how is this any different from someone calling and saying, “I think my friend took too much Tylenol^™” or “I think my friend is overdosing on heroin”?

Second, the term “poisoning” in the EMD environment only means that the “overdose” was unintentional. When someone states that someone has alcohol poisoning, I'm not choosing my protocol selection based on the word poisoning; I'm choosing it based on it indicating too much alcohol, just as I would in the Tylenol™ or heroin example. The Key Questions would determine whether this is a poisoning or an overdose, based on intent.

Yes, altered status is expected in an intoxicated person. However, it's important to keep in mind that people don't typically call 911 for someone who's exhibiting normal drunk behaviors (at least for Fire/ EMS; I'm not talking about the police department). If I get a call saying someone has consumed too much alcohol, while I still think it's important to get details on Case Entry 3, my assumption would be that the symptoms are not normal for the patient. No, not every drunk is a poisoning/ overdose. As I alluded to in my previous points, it becomes an overdose/poisoning when "too much" has been consumed and it's prompting someone to call 911.

Ryan Cummins Communication Training Officer
EMD Mansfield Police Department, Texas (USA)

Hi Ryan,

Thank you for your thoughtful question and detailed rationale.
The MPDS^® has never had a line of questioning or a specific code for alcohol intoxication or “poisoning,” and the IAED™ has not been made aware of any untoward outcomes related to this fact since the Academy’s inception about 40 years ago. Our concern is, and always has been, potential misdiagnosis by the layperson making the complaint, and the implied stigma that this assumption has historically carried throughout the chain of patient care in public safety and beyond—at times with medical and legal consequences.

There are countless cases, many of them resulting in litigation, that were attributed to a clinician's assumption that an ill or injured patient “was just drunk.” The primary and real consequence of alcohol inebriation is an unprotected airway in an unconscious or semiconscious patient, and this condition is adequately controlled in the protocol, in an unbiased way, without a specific ETOH code being inappropriately needed. (The term “ETOH” is commonly used by medical personnel and is the chemical abbreviation for Ethanol—the specific type of alcohol in beer, wine, and liquors).

While we appreciate your comparison of alcohol “poisoning” to an overdose of acetaminophen or narcotics, or even the ingestion of a caustic substance such as bleach, the reality is that these are very different mechanisms that have specific concerns and remedies that justify their specific inclusion in the MPDS. Acetaminophen, and many other pharmaceuticals, can be extremely toxic at even relatively low doses, respiratory depression caused by narcotic overdose can be immediately counteracted with Narcan, and caustic substances can be specifically addressed by responders or the local poison control center (not to mention mental health care providers) when this cause is known.

Important to this discussion is that all three of these mentioned occurrences carry significant concern even in asymptomatic patients, thus the need for specific protocol Determinant Coding. Alcohol intoxication, however, is appropriately managed in the MPDS, regardless of the presenting sign or symptom, and with far less potential for misdiagnosis and the stigma that too often comes with it. Whether the complaint is aggressive or belligerent behavior (hypoxia, internal hemorrhaging?), unconsciousness (circulatory collapse, sepsis?), or loss of balance or persistent vomiting (stroke?), it’s prudent to remember that it’s possible to be both sick and drunk.

The MPDS is a clinical, symptom-based protocol, while Police Priority Dispatch System^™ (PPDS^®) Chief Complaint selection is based on the citizen usually having an actual “complaint.” Calls to police concerning inebriation are generally behavioral-based and involve public irritation or concern, while MPDS calls are generally symptom-based where the medical well-being of the patient is the foremost reason for the call. They certainly may “bleed over” at times, but that generally works well in a center using both protocols.

We hope this explanation has addressed your concerns, and thanks again for the submission.

Brett A. Patterson Academics, Research, & Standards Associate Chair
Medical Council of Standards International Academies of Emergency Dispatch

Greg adds: 
Ryan, you make a good point about getting very specific information right from the start of the case, beginning with the answer to “Tell me exactly what happened,” and continuing with completing all Key Questions.

While it’s certainly true that too much alcohol too fast from drinking can, on its own, be potentially dangerous as a central nervous system depressant, the question we struggle with is: Can the EMD get detailed enough information from the caller to isolate a true alcohol overdose in a patient— i.e., too much alcohol depressing their central nervous system—or must we continue to suspect a hidden underlying cause such as a head injury, stroke, insulin shock, or septic shock?

Right now, the answer is we don’t exactly know; hence our reluctance to call all these cases an overdose and use Protocol 23 as a matter of course.

As Bryon Schultz, IAED Subject Matter Expert—Medical, says: In the EMD arena, being non-visual and not hands-on with the patient, it is nearly impossible to be confident in addressing these situations on Protocol 23. Nearly every time this situation is brought to us, the information is anecdotal, lacking facts, and usually starts with “We had this one call.” We at the IAED are always welcoming and encourage dialogue and client experiences (including real audio calls). However, we must have facts and data before making a change of this substance and significance.

Perhaps you can help us. We encourage you to provide us with your case evidence by submitting a Proposal for Change (PFC) that includes documented cases with a detailed explanation of the protocol used, the problem, any patient outcome information available, and your proposed solution. We’re always looking for useful data and research-based PFCs to help us evaluate and improve the MPDS.

www.emergencydispatch.org/whatwe-do/proposal-for-change
Regards, Greg Scott Associate Director of Protocol Evolution IAED

Doc adds:
Reported “alcohol poisoning” is really a layperson’s “diagnosis,” not a real prehospital medical determination, especially when coming in at the level of 911 reporting. Many an emergency responder or arresting police officer has later discovered that “the drunk” they disregarded or threw in the “tank” was suffering from diabetic insulin shock or some other sinister, but not so obvious, medical, or even traumatic, condition.

We were taught at The Charity Hospital of New Orleans (Louisiana, USA), that the “drunk” should be considered to always have three “conditions” to rule out. Here they are with one set of actual examples. The first “condition” is the obvious one: the apparent intoxication. The second “condition” is the superficial reason for the call: a forehead laceration in a bar fight. The third “condition” is the hidden thing, like a subdural hematoma (bleed around the brain). If you don’t routinely look for all three, you might not be a happy camper at the end of your late-night shift!

The presentation of actual described behavior (including a patiently asked, “Tell me exactly what happened”) and priority symptoms is most always sufficient to categorize and safely code these patients. As we taught our paramedics, albeit as they initially laughed, “Drunks die, too!” Nuff said …
Doc