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Booze in the Nose.

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of “alcohol on her breath”. I’ve started a lot of charts like this. Seen PD run reports that said the same. I’ve seen it testified to in court….  And it is pretty interesting, in part because you can’t smell alcohol. Sure, you can smell booze–the other crap in the alcoholic beverage. But nope, you can’t smell “alcohol” on someones breath.

 

Smell of alcohol on the breath. There is a very poor correlation between the strength of the smell of alcohol on the breath and the BAC. Pure alcohol has very little smell. It is the metabolism of other substances in alcoholic beverages that produces most of the smell. This explains why a person who drinks large amounts of high-proof vodka (a more pure form of alcohol) may have only a faint smell of alcohol on the breath. On the other hand, a person who drinks a modest amount of beer may have a strong smell of alcohol on the breath.

 

This is hammered on by DUI lawyers, with mixed results:

“I Smelled a Strong Odor of Alcohol on the Suspect’s Breath”

Posted by Lawrence Taylor on June 23rd, 2006

You will never see a DUI case where the officer does not report an odor of alcohol on the suspect’s breath. Never. The officer expects to smell it and it is a psychological fact that we see, hear and smell what we expect to see, hear and smell. In fact, most police DUI reports are formatted for the usual symptoms: there will be a box for “odor of alcohol”, which the officer checks off. There are often three boxes, labelled “strong”, “moderate” and “weak”; there is no box for “none”, so that is not an option for the officer.  The ”strong” box is almost always checked.  Presumably, the stronger the odor of alcohol, the more intoxicated the person arrested.

There is only one problem with this:  alcohol in a beverage has no odor.

Assuming the officer actually does smell an odor on the breath, what he is smelling is not ethyl alcohol but the flavoring in the beverage. And the flavoring can be deceptive as to the strength or amount consumed. Beer and wine, for example, are the least intoxicating drinks but will cause the strongest odor. A much stronger drink, such as scotch, will have a weaker odor. And vodka leaves virtually no odor at all.

Consider a simple experiment. Have a friend drink a can of “near beer” — the stuff that looks, smells and tastes like beer but has no alcohol in it. Then smell his breath. You will smell an “odor of alcohol” — and maybe a strong one.

And, of course, there can be any number of causes of an “odor of alcohol” on a person’s breath: mouth wash, throat spray, cough syrup. Illness, indigestion or simple bad breath has been the cause of more than one officer’s trigger-quick conclusion that the suspect has an “odor of alcohol on his breath”.

The point of all this is that the odor of alcohol has very little relevence in a drunk driving case. It may or may not indicate that the person has consumed alcohol. It has absolutely no evidentiary value on the much more important question of how much the person has consumed — orwhat he had to drink, or when. Depending upon circumstances, a person with a single drink can have a “strong odor of alcohol on his breath”, and an extremely inebriated person can have a “weak” odor. And an experienced and honest DUI officer will readily admit this….if he is ever asked.

Unfortunately, evidence of the odor of alcohol on a person�s breath can have a significant impact on a DUI case. This is because most officers who pull a driver over for some driving irregularity at night are looking for further signs of drunk driving. When the officer approaches the driver’s window and smells alcohol, that confirms his suspicions. Since few can pass the “field sobriety tests”, particularly under the conditons in which they are given, an arrest is likely.

Are there any scientific studies to back up my claim that breath alcohol odor is largely irrelevant yet disproportionately weighted as “evidence” of intoxication?

In 1999, the same scientists whose federally-contracted studies became the basis of the so-called “standardized” battery of field sobriety tests conducted another study on the effectiveness of alcohol odor in detecting intoxication. These researchers used 20 experienced officers working with 14 subjects who were tested at blood-alcohol concentrations (BACs) ranging from zero to .13 percent. Over a four-hour period, the officers smelled the subject’s breath odor under optimal conditions, with the subjects hidden from view.

The conclusions of the study: Odor strength estimates were unrelated to BAC levels. In fact, estimates of BAC levels failed to rise above random guesses. Further, officers were unable to recognize whether the alcohol beverage was beer, wine, bourbon or vodka. According to the scientists, these results demonstrate that even under the best of conditions, breath odor detection is unreliable. Moscowittz, Burns & Furgeson, “Police Officers’ Detection of Breath Odors from Alcohol Ingestion”, 31(3) Accident Analysis and Prevention 175 (May 1999).

 

So the moral of the story is that we need to examine how we chart suspected intoxicated patients. Being highly suspicious of all medical conditions that could cause these symptoms is important too:

http://www.monkeydoit.com/medical-act-drunk.php

DIABETES
Symptoms of diabetes may make a person appear drunk or intoxicated.
A person with diabetes may exhibit abnormal behavior as a result of the many different signs or symptoms associated with the disease. The signs and symptoms listed here only relate to symptoms that mimic drunk or intoxicated behavior. Generally, these are warning signs that a person needs immediate medical attention and should be treated as a medical emergency. Police dealing with suspects often times mistake diabetes for drug or alcohol use during field sobriety exercises. 

Signs & Symptoms of Diabetes
-- The smell of acetone on the person's breath
-- A distinctive fruity odor on the breath (Police Officers often mistake the smell as alcohol during a field sobriety tests)
-- Dizzy, has trouble keeping balance
-- Altered states of consciousness
-- Arousal such as hostility or mania
-- Apprehensive with no obvious reason
-- Unusual nervousness
-- Disoriented in place or time
-- Confused when asked simple questions or confused in general about circumstances
-- Sweaty with clammy perspiration
-- Inability to concentrate on what you are telling them or on the tasks at hand
-- Sudden mood changes
EPILEPSY
Epileptic seizures generally happen without warning for most people. A seizure is a brain disorder of abnormal electrical activity in the brain. Seizures may be either partial or generalized and will present signs and symptoms that very among individuals. 
Signs & Symptoms of Epilepsy
-- May appear detached from reality
-- The person might be in a dreamy state 
-- Dizzy, unable to maintain balance
-- Falls down
-- Staring spells
-- Unresponsive
-- Walks away during a conversation
-- The person may have pupillary dilation
-- Sweating
-- Problems speaking
-- They may display an inability to answer questions
-- Contorted posture / limbs appear twisted
-- Flushing
-- Memory and time distortion (they may not remember what just happened)
-- May appear unrealistically fearful
-- May exhibit emotional signs of heightened pleasure
-- May exhibit emotional signs of displeasure
-- May appear aggressive or angry
-- Complete loss of consciousness
BRAIN INJURY
Brain injures will generally have signs and symptoms that relate directly to what part of the brain was injured. Here are just a few symptoms that someone could easily mistake as the person being drunk or intoxicated. These will vary among individuals and to what extent the brain was injured.

Signs & Symptoms of Brain Injury
-- The person may exhibit tremors
-- Dizzy, unable to maintain balance
-- Unable to make simple movements of various body parts
-- Inability to perform a sequence of complex movements
-- Unable to focus on tasks
-- Sudden mood changes
-- Inability to focus attention visually
-- Difficulties with hand and eye coordination
-- The person may suffer from hallucinations or visual illusions
-- They may have difficulty in understanding spoken words
-- They may show signs of aggressive behavior
-- The person may slur their speech 
Brain Picture -EpilepsyALZHEIMER'S
Alzheimer's or dementia is unique for every individual. Alzheimer’s is a progressive and fatal brain disease and the most common form of dementia. The signs and symptoms like the other medical conditions listed here may mimic impairment or drunkenness.

Signs & Symptoms of Alzheimer's
-- The person may show signs of paranoia
-- There may be drastic changes in mood
-- Confusion is quite common with people suffering from Alzheimers or dementia
-- They may have problems speaking
-- The person may exhibit aggressive behavior
-- It's common that there will be problems with remembering things

The Small Things: The dispatch story

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Sucks.

Seriously.  It goes like this:

‘”Code 1, unit 320, 2904 W Todd Ave unit 404 for an unknown problem”

We answer up, respond and arrive on scene. This is a local senior appartment center with 3 buildings, not connected, but the apartment numbers seem as though they are. For instance, 2900 has 100-140, 2904 has 141-200, etc.

We arrive, not paying a lot of of attention the apartment number when pulling up. Go up to the 4th floor, and start the look… noticing the apartments start at 440, not 404…

“Metro, 320″

-”Go ahead 320″

“Metro, there is no Unit 404 in this building. Can you please verify the Street Address and Unit Number”

-”stand by”

After a very long pause…

-”320, the RP called back a few minutes ago and said that she had the address wrong. They are in 2900 W Todd, unit 405″

WAIT. WHAT? They called back a FEW MINUTES AGO and you didn’t feel the need to let me know that I was going to the WRONG damn building and the WRONG damn unit?

Sure, in a geezer village there is little to worry about sending me to the wrong place, short of wasting my and the patient’s time. But what about in other neighborhoods, where I could have started pounding on the door of some find upstanding young hoodlum who thought the popo was coming to get him?

You can give me a bazillion updates including the color of their underwear and what they had for Thanksgiving dinner in 1934, but you can’t even tell me where to to find the lady with the pink zebra thong who had jellied cranberries in 1934?

F U Dispatch.

Overheard on the Squawk Box…

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An exchange between another unit and dispatch…

Unit 303c: Metro, 303c.

metro: go ahead 303c

303c: Metro, we’re going to be 10-8…. This one was just pretend. No ambulance needed.

After an unusually long delay…

metro: 10-4, 303c. Sorry about that. We’re just trying to keep it real. Real Good. (with faint laughter in the background)

Had to chuckle a little.

Why it Hurts

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Like a page from a book, dispatch sends us code 3 for a finger amputation. Grumbling as I roll out of bed while dispatch updates us–a 27 year old female at one of the local state-run group homes who intentionally put her hand in a garbage disposal. The grumbling increases. The staff at these facilities leave something to be desired and the patients usually are fine. This has to be an overreaction, doesn’t it?

As we round the corner inside the door, the scene is as expected–practically empty.  One staff member sits with our wheelchair bound patient, everyone else seems to be missing, despite it being meal time. A quick once over leads me to believe there is no amputation, the annoyance sets in.

So I ask my patient “whats going on tonight? How come you did this?” I am completely unprepared for the answers that follow. My patient–a 27 year old paraplegic female who suffers from Bipolar disorder, severe depression, and a gamut of other psychological issues–literally just came from our Behavioral Hospital. The very behavioral hospital she has requested to be transported to several times over the last few weeks due to depression and serious thoughts of suicide.

The story goes like this… as a child she was sexually abused by her father, her brothers, and her uncles. Her father pushed her down a set of stairs leading to a mild Traumatic Brain Injury and complete paralysis from the belly button down.

The state put her back in this home where these ingrates continued to sexually assault, mentally abuse, and psychologically destroy her for the next 9 years.  Finally the father is arrested for assaulting a neighbor’s daughter–when the story comes out again and the state takes her into their custody–only to be bounced from group home to group home, from one mental facility to another and back to the group homes. She has literally begged to be given inpatient treatment and the physicians say she just needs long term counseling. She is unable to do anything for herself–she cannot function without someone pushing her along. Not because she is physically weak, but because she is mentally broken.

She hurts because she has to actually hurt herself to get anyone to listen. I tell her we’ll get her help but she knows what that means. I will take her to yet another hospital where yet another doctor will push her back into the care of undereducated and overworked group home staff. All she wants is to feel safe. She wants to know that she can’t get out and THEY can’t get in–but no one will give this to her.

By the time we arrive at the hospital I know her story. I know enough to know that she needs this help. She knows what she needs, but doesn’t have the resources to do it herself.  As I transfer care I take the doc aside and give him the story. I tell him how I think she is a genuine threat to herself and that her mental anguish is real–not like so many of the calls we go on–the ones that made me grumble as I rolled out of bed. This is the real deal.

– — –

Two months later the tones startle me awake. Code 4, Any unit in position, Cardiac Arrest to an address I am all too familiar with. Dispatch updates with a 28 year old female, unconscious, not breathing, her throat is cut.

My foot reaches the floor. My knuckles are white on the wheel. My partner looks at me and asks me if I’m O.K.  I just drive faster. I walk in, the same deserted scene. The same deafening silence. I look down and know we’re too late. I let out a sigh, turn around and make the call.

I hurt because we failed.


Please tell me you didn’t…

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Call 911 because you couldn’t sleep. Please tell me dispatch didn’t dispatch me code 3 for this “emergency”. Please.

Please tell me you didn’t expect me to be able to fix this… And please, please don’t get mad at me when I suggest you get a job as a means of tiring yourself so that you might be able to fall asleep at night.

Please.

Sometimes it is great when dispatch is wrong…

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Yesterday afternoon I was awoken from my daily nap by the pager tones. Yup. I’m old and take daily naps… or that might be from the boredom. Anyways… The tones went off… then again, then the dispatcher comes on with “Medic 3, Medic 2: Cardiac Arrest, CPR in progress, 8yo female. yada yada location, 8 miles away”

Being woken up by the pager is never pleasant. It is worse than any alarm clock. The feeling of abrupt end to a peaceful nap with what is usually a nonsense call is less than ideal. It leaves you half awake trying to collect your thoughts for what could lie ahead…

Back to the call. I fumble to get my boots back on–I’d like to meet the man who invented zippered boots–and rush out the door. I am in my car and my partner calls asking where I am–apparently my radio is on the fritz and they didn’t hear me copy the call. By the time I’ve hung up I am in the parking lot(I live about 300 yds away from the station) and rushing towards the truck. The lights are already on and one of our volunteers is in the passenger seat. I hop in back and buckle in to buckle down.

We don’t have anyone on scene yet and dispatch cannot get through to the Colony. They only have one phone and left it almost immediately after placing the call. The tension in the truck is more than just uneasy. It feels like we’re walking out of an arrest–not walking in.

We continue Code 3 to what every person in healthcare hates: A Pediatric Code. Death is a fact of LIFE. Cardiac arrests are part of our job. People die–more often than not. Peds Codes still suck. Instead of looking at a spouse or their Adult children, you’re faced with Parents and siblings. You never know what you’re going into and while sometimes that is what makes this so addicting–it can be what makes this line of work so stressful and heartbreaking too.

We are just pulling onto the gravel road that is the last 1 mile of our journey as the local PD comes on the line and gives us direction as to where to park. No status update yet. We are going to a larger colony and he hasn’t made contact yet–in fact he doesn’t until we are walking in the door behind him.

As we pull in I stand up and begin pulling out the airway bag, the first in bag with our ACLS meds, and the monitor. I have them set out, gloves on, and my glasses on–I’ve learned a thing or two–I wear safety glasses(or as I call them “oh SHIT glasses”) to anything that can get messy. Anyone who has worked an arrest knows things can get messy quick. The stomach does NOT like CPR.

We come to a stop after what seems like 40 minutes(but I see later on my time sheet was only 7) and I slide the side door open, making sure to turn the lights in the box on before I step out. I walk briskly into what appears to be a large industrial type kitchen. As I walk up the first step I notice a crowd has gathered. 20-30 women all standing there. They all have an uncertain look on their faces, but there is no histeria. There is no panic. There is a calm uncertainty in the air. I walk around the corner and see a young girl, just laying there. No one is touching her. She has a blanket on her. No CPR in progress, no anything. No comfort from family, nothing. I have to double take. My first instinct was that it was going to be DOA. Then I look back and she is smiling.

My “dead” patient is smiling. She is far from dead–and always has been. In fact she seems fine. And then the story begins.

Because of the quantity that this kitchen cooks for they have a service elevator to bring supplies up from the supply room in the basement. This elevator has a standard wooden door into it and has a gate that comes up to my thighs. This is an older elevator and will work with the doors open.

Apparently my patient was hanging over the railing when someone downstairs called for the elevator. Despite the grinding noise it makes she does not move and the elevator comes down on her, trapping her in place–right across the top of her chest/collar bone. They are unsure of how long she was there before being noticed, or how long it took to get her out. They say a minute–which in some emergencies could mean 5 seconds or the opposite–5 minutes. My guess is not very long based on the appearance of my patient. The bystanders state that she was blue and unresponsive when they pulled her out.
>

I immediately get to assessing my smiley patient. She states it kinda hurts on her chest, but has no other complaints. She is breathing normal, adequately, and without pain. Her lung sounds are present, equal, and clear. Her O2 sats are 99% on room air and all other vitals are within normal limits. She is literally in great condition.

I decide that because of the nature of the incident(and a little CYA medicine) that spinal immobilization is necessary. We quickly package the patient and get on the road. She never once complains, never once cries. She actually smiles a lot. I got her laughing and promised her a day off from school–though I’m not sure her community will follow through.

By the time we get to the ED she is chatty and still happy. She has no complaints other than a little bit of tenderness. Breathe Sounds are still normal and her vitals still stable. After explaining everything to the receiving RN/Doc/Trauma team that they called despite my insistence that it was not necessary, I wish my young patient well and lead her mother to the registration desk.


I walked out of the hospital, my free soda and cookies in hand, in a bit of a blur. I’m convinced that my ride TO the scene was more stressful and exhausting than the call itself. I wish all of my patients handled stress this well!

Pissing off nurses is a baaaad idea…

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My partner really pissed off the nurses today. Because this partner is, well, special… I had to make it clear to the Nurses on staff that it was NOT my fault. 

They wouldn’t even talk to him. Pissing off nurses is baaaaaaaad. Pissing off nurses in a tiny Hospital where you will see them constantly is moronic.

Oh, and dispatch sent us on a wild goose chase today. We were within 2 blocks of the destination and drove in circles for 5 minutes trying to find the damn place. 

A common theme…

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Among EMS blogs and mediblogs in general is the “you don’t need an ambulance/doctor/Rx” philosophy. And truth be told–most of the people who call 911, go the ER, the Doctor, or the pharmacy don’t need the services provided by said facilities.

But, thinking a patient doesn’t need your service and saying it are two different things. In EMS we rarely get the luxury of telling our patients off. Some Docs will do it, but rarely.

This week, I had a Doc actually stand up to a pt. We picked up a frequent flyer who knows the hospitals in this county better than we do–hell, better than docs/administrators/nurses/dispatchers know them.

He has “chronic pain” which of course, can only be cured by morphine. But morphine only works when he gets atian too.

The Doc flat out, no qualms just walks in the room. “I’m out of morphine… Wait. I have a shit-ton of morphine. I’m just not going to give you any. You should feel lucky I wrote you a prescription for tylenol. Come back here again looking for drugs you don’t need and I’ll make sure you wait in triage till the last patient in this hospital dies.”

Well. He walks out while we all stand outside the door gawking –and says… “Next time make sure to remind him what I just said. And tell the secretary that if she ever gives him a room prior to being triaged again I’ll make sure she’s the last patient to die here.”

Ok… so funny went creepy. This doc might be a bit of a dick. This is one of the much smaller facilities around. But still, Docs rarely actually tell their patients they are drug seekers. They beat around the bush. You should see some of the creative dictation they give just to make sure they don’t call their pt a drug seeker.

Fuck it. I think we should brand them.

But all those posts about not needing our services were right. You don’t need an ambulance. You need a glass of water, a bandaid, 3 tylenol, a pepto, some neosporin, a hot meal and some god damn sleep. There are other places you can get those marvelous things other than the damn hospital. But if you think you MUST go to the hospital. Call YELLOW CAB.

PS… it’s f’ing cold outside.

Catching Up…

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Sorry I didn’t post over the weekend… Tried to enjoy the 24 hrs I was home with my wife and monsters. Today was a long day, running on about 2 hrs of sleep. We didn’t have any real “exciting” calls… but we did have one giant P.I.T.A.

Apparently this was her 3rd(THIRD) ambulance ride in less than 8 hrs. She called because she slept with her contacts in and her eyes were burning… but wouldn’t take her contacts out.

Step One: Remove contacts.
Step two: Rinse with Saline.
Step Three: Rinse more.
Step Four: Use some friggin Visine.

Or at least that’s how they do it where I’m from…

Her version:
Step One: Call 911
Step two: Scream, bitch, complain.
Step Three: Arrive at Level 1 Trauma Center–TRIAGE.
Step Four: Get Kicked out of Level 1 Trauma Center for being a PITA.
Step Five: Call 911.
Step Six: Repeat, accept this time walk out, because she had to wait too long.
Step seven: Call 911.
Step Eight: Demand to be taken to the Other Level 1–County.
Step Nine: Flip out when taken to Triage and DEMAND a “Trauma Room”.
Step Ten: Piss off triage nurse and get ignored for 5 hours.

Apparently she didn’t like that we nor the hospitals didn’t give her anything for the “pain”. She then called 911 again, but thankfully from the proper side of the street, so as to allow County to pick her up this time.

Don’t worry though. She won’t be out of her pocket for any of those Code 3 Responses… WTF was dispatch thinking? Code three–the same dispatcher toned out all 3 of them…. Hadn’t he figured it out by then. I get that CAD helps dispatchers a ton… but does that mean they can’t think on their own anymore?