Digest

This podcast episode of EMS 2020 reviews a real out-of-hospital call involving a 64-year-old female reported to be hallucinating. The hosts discuss the initial assessment of altered level of consciousness (LOC), the patient's inconsistent history, and her eventual refusal of transport. They delve into the complexities of assessing capacity to refuse care, implied consent, and the challenges EMS faces in persuading patients. The case ultimately reveals the patient suffers from alcohol withdrawal syndrome and potential Wernicke-Korsakoff syndrome, prompting a discussion on these conditions, their neurological impacts, and the importance of thiamine. The episode also touches upon tiered EMS systems, BLS scope of practice, and the critical role of thorough documentation in ambiguous patient encounters.

Outlines

00:00:00

Introduction and EMS System Overview

The hosts introduce the podcast EMS 2020, which reviews real out-of-hospital calls, and encourage listener submissions. They provide an overview of the ABC Ludo EMS system in Queensland, Australia, detailing its tiered structure and BLS scope, and briefly discuss their studio setup.

00:09:22

The Call: Hallucinating Patient and Initial Assessment

The hosts detail a non-emergent call to a residence for a hallucinating 64-year-old female. They emphasize treating the situation as an altered level of consciousness (LOC) call, discussing initial findings, patient history, and inconsistencies noted by EMS crews.

00:29:30

Analyzing Altered LOC and Patient Refusal Challenges

The discussion focuses on analyzing altered LOC through categories like fuel, brokenness, intoxication, and behavior. The hosts highlight the difficulty in capturing mental status, the patient's refusal of transport despite concerns, and the legal considerations of implied consent versus patient autonomy.

00:42:39

EMS Persuasion, Police Intervention, and Sister's Involvement

EMS crews attempt to persuade the patient to accept transport due to her condition. A police officer suggests a hold, and after the patient's sister intervenes, she finally agrees to go to the hospital.

00:57:24

Transport and Hospital Diagnosis: Alcohol Withdrawal and Wernicke-Korsakoff

The patient is transported, exhibiting further confusion and jaundice. Hospital findings reveal acute liver injury, gallstones, and alcohol withdrawal syndrome. The hosts explain alcohol withdrawal, its stages, and the potential for Wernicke-Korsakoff syndrome.

01:08:59

Understanding Alcohol Withdrawal and Wernicke-Korsakoff Syndrome

This section details delirium tremens as the most severe form of alcohol withdrawal and introduces Wernicke-Korsakoff syndrome, a thiamine deficiency linked to alcohol abuse, explaining its two phases: Wernicke's encephalopathy and Korsakoff syndrome.

01:15:10

Crew Performance, EMS Systems, and Pre-Game Mindset

The hosts evaluate the crew's performance, emphasizing that a correct diagnosis isn't always necessary for a good job. They explore EMS system design, praising expanded BLS scope and intermediary care, and discuss the financial challenges of EMS models. A "pre-game" mindset for challenging calls is stressed.

01:23:43

Refusal of Care, Capacity Assessment, and BLS Skills

The complexities of patient refusals and assessing capacity to refuse care are discussed, going beyond "alert and oriented." The treatment of the patient as sepsis is noted, highlighting that fundamental BLS skills like clinical decision-making and communication are crucial.

Keywords

Q&A

• What is the significance of the patient being alert and oriented to person, place, time, and event in the context of her refusal of transport?

  While being alert and oriented generally supports a patient's right to refuse medical treatment, it complicates the situation when there are clear signs of altered mental status or inability to make decisions in their own best interest, creating a legal gray area for EMS providers.

• What are the key differences between minor and major alcohol withdrawal, and what are the risks associated with each?

  Minor withdrawal typically involves tremors, anxiety, and nausea within 6-24 hours of the last drink. Major withdrawal, starting 10-72 hours after cessation, adds hallucinations and can progress to seizures or delirium tremens (DTs), which can be life-threatening.

• How did the police officer's intervention influence the outcome of the call?

  The police officer's proactive decision to explore placing the patient on a hold due to her inability to care for herself provided an alternative pathway when EMS was unable to persuade her to go to the hospital, ultimately leading to the patient agreeing to transport.

• What medical conditions were ultimately diagnosed in the patient after transport to the hospital?

  The patient was diagnosed with acute liver injury, gallstones, possible cholecystitis, mild rhabdomyolysis, alcohol withdrawal syndrome, coagulopathy, and acute respiratory failure with hypoxia.

• What are the key differences between major alcohol withdrawal and delirium tremens?

  While both involve withdrawal symptoms, delirium tremens is the most severe form. Major withdrawal might include hallucinations but the patient remains alert and oriented. Delirium tremens involves global confusion and disorientation in addition to other withdrawal symptoms.

• How does alcohol abuse lead to Wernicke-Korsakoff syndrome?

  Alcohol disrupts the absorption of thiamine (vitamin B1) in the GI tract and hinders the liver's ability to convert stored thiamine into a usable coenzyme, leading to deficiency and neuronal damage.

• What are the two main phases of Wernicke-Korsakoff syndrome?

  The two phases are Wernicke's encephalopathy, which is treatable and reversible with thiamine, characterized by confusion, ataxia, and nystagmus; and Korsakoff syndrome, which involves permanent memory impairment and confabulations.

• What criteria should be assessed to determine a patient's capacity to refuse medical care?

  Assess if the person can clearly communicate a choice, understand relevant information, appreciate how that information pertains to their situation, and employ reason to arrive at their choice.

• Why is thorough documentation crucial when a patient refuses care, especially in ambiguous situations?

  Detailed documentation provides a defense in potential future lawsuits by demonstrating that the patient had the capacity to refuse and that the provider followed appropriate protocols, protecting both the patient and the provider.

• How do BLS units contribute to the efficiency of an EMS system, particularly in rural areas?

  BLS units can handle lower-acuity calls, freeing up ALS units for critical patients. In rural areas, they can improve response times and provide a baseline level of care where paramedic availability is limited.

Show Notes