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Legal Lessons - ETOH

Mike Weinstock, MD and Matthew DeLaney, MD
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When taking care of intoxicated patients clinicians need to consider several unique sources of medicolegal risk. While intoxicated patients may retain their capacity to make decisions it is important to weigh the patient's potential risk against their autonomy.

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Lisa W. -

Thank you so much for this conversation.

I'm a PA who works at a 40 bed community hosptial emergency department, including 8 beds in a mental health emergency room (MHER) wing.

We are the only hospital in our county that has adult inpatient psychiatric beds. The combination of the MHER and inpatient psych beds means that nearly every mental health patient in the county comes to our hosptial. Several years ago we were one of the first hosptial's in the state to pilot Hack's Impairment Index (HII score) to put an objective number on clinical sobriety. This has entirely changed our practice.

Historically, we used breathalyze or serum EtOH for sobriety assessment on all intoxicated patients and then had the elaborate charts on the wall that would predict metabolism rate. As we all know, many chronic alcoholics are fully functional at 200+ but we would wait hours and hours and hours (and then some would start to detox and get shaky and angry...).

Now, we test this using the HII score. The test is repeated until the score is acceptable for psychiatric evaluation. The form is scanned into the chart and becomes a part of the permanent medical record. This tool is now being widely used in the state of Michigan. We also use the HII score for our non-psychiatric intoxicated patients to determine when the can be safely discharged either into the care of a sober safe driver or to walk home (we would still not allow someone to drive themself home based on this score).

More information here: https://www.mpcip.org/mpcip/mi-smart-psychiatric-medical-clearance/hii-score/

This is the actual tool: https://www.mpcip.org/wp-content/uploads/HII-Score-MPCIP_with-tracing-template.pdf

This has been an absolute game changer for us and I wanted to share it with the UC Rap listeners as well.

Mike W., MD -

Thanks for your comments Lisa - so good to see - I have also had this problem with chronic alcoholic patients. Lisa, thx SO much for these posts!
M

scott w., Md -

Great segment thanks. Their are many psych pts who I think need further care, but I think it is borderline if we can hold them and do it. For example, I had a pt recently come in twice in a week for bugs in his ears. The first time a PA saw him and discharged him. Second time he had lots of abrasions to ear b/c of vigorous q-tip use. I don't think he was intoxicated. History of psychiatric disease. I tried to convince him
the bugs in the ear is a manifestation of his psych disease and to let me have psych see him, but he refused. He was walking, talking, answers other questions appropriately and not homicidal/suicidal. My judgement was even though I thought he needed psych help I couldn't force it on him. This piece makes me feel I certainly had no ground to force a psych eval on him and that it wasn't even close. Would you agree?

Mike W., MD -

Agree. There are many patients who would benefit from taking our advice (of course) but our role is to give advice and the patient's role to accept or reject it. We can't force patients to take medications we prescribe. We can't force psychiatric help on a patient unless they represent a risk to self or others.
M

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Urgent Care Rap January 2021 Written Summary 321 KB - PDF

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