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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

Reality Check

1,638 comments

As usual, the EMS blogosphere has found itself in yet another little tiff. This time Timothy Clemans and Medic22 are in a bit of disagreement about proper use of ALS, among other things.

Timothy seems to believe that ALS skills are wasted on patients that are not in risk of losing life or limb. While Medic22′s way of responding to him might be over the top, I can TOTALLY understand how and why that would happen. See here and here. We all take this pretty damn seriously, so I understand the frustration.

Because I agree with Medic22′s thought process on this, I thought I would chime in a little bit.

If it was up to me I would eliminate prehospital ALS except in cases where ALS care prevents the need for hospital/clinic care and in cases where evidence demonstrates that ALS saves lives. That said, Medic 22 did bring up an excellent point about prehospital pain management.

Is it really that simple? Simply put, I’m out of a job. All of us are. In a systemsign-realitycheck with 11,000 calls a year, we’d be able to pay one medic. Thats it. After the sob story of me being unemployed is over, we’ll address the real issue: why is it that you have to be dying to get compassionate, adequate, respectful care?

If you are sick or injured, but not dying, Timothy is saying that you should only get a taxi ride to the hospital(where you will wait in triage for an hour(or more) and then wait for a nurse to complete an assessment, then a doctor, then maybe get your treatment started).

Are there ALS skills that need to be reviewed? Absolutely, but until you have had to sit in a truck with patients puking their brains out(on your new, shiny boots) you will not understand the validity of our skills that are in between taxi driver and super hero. Pushing Zofran for that nausea not only helped to relieve the discomfort for that patient, it also helped prevent them from further dehydrating themselves (or like a patient a week ago… going into vfib every time she puked… Seriously).

Managing pain in patients is one of the best skill sets we offer(and either the most avoided due to paperwork or most abused by patients).  Allowing grandma some comfort for the 15 mile ride through my Wintry Mid-Western city riddled with potholes and ice chunks is the least I can do after she allowed my whiny ass to stay alive all this time.

I can’t agree more with you! I have been battling this topic for 7 years to no avail. At one point we had our agency MD on board yet the other program MDs in the county voted against it! Again, “nobody ever died of pain” was just one reason. Another was/is the potential abuse issue, especially with fentanyl compounded by the fear ketamine could be stolen off the trucks by youngsters for their Rave parties. Subsequently, our patients receive a proper induction via etomidate but very infrequently the administration of diazepam and morphine post intubation (only a few of us religiously use the agents). What you end up with is a patient who doesn’t remember undergoing paralysis and intubation but wakes up being paralyzed and intubated on a bumpy ride to the hospital.

All this says is that local MDs have zero faith in their medics. If you can’t secure your narcotics, you have no business being in this business. There are dozens of ways to secure them. This is simply an excuse for someone who is afraid to allow their medics the ability to treat.

Medic 22 a dehydrated girl with a low BP and tachycardia needs a line and a fluid blous. That’s ALS. Not an emergency… but something that a paramedic can, and SHOULD do.
Me: what’s the benefit of the prehospital als in that case? if it doesn’t save a life or shorten hospital stay what’s the point
Medic 22: It’s GOOD PATIENT CARE. Its what competent, caring prehospital care providers do.

If the care by paramedics could prevent the need for hospital then I’m all for it. Unfortunately in the case wouldn’t you just be delaying hospital care and doing something just to do it?

First of all, you are assuming we are delaying care. Like I said before:

My scene time consists of a brief primary assessment, possibly a 12 lead and loading the patient where I begin the rest of my treatment–unless the patient absolutely needs other interventions prior to departure. That being said, when I am 15 minutes away from the hospital with someone puking(and further dehydrating themselves) or someone who has moderate wheezes, why shouldn’t I begin treating them?

Again…. It seems that you assume there is some abundance of Life or Limb calls in EMS. Honestly, those exciting calls just don’t come all that much. What we get a lot of is sick baby boomers, indigents, drunks, and people who don’t know any better. Does that mean we shouldn’t treat them while we can?

It is our job to treat patients, and as long as I have time in the back of my truck, I am going to do everything I can to make them more comfortable, happier, and healthier–if at all possible.

"It Can't Hurt" Medicine

4 comments
EMS is essentially an art form. Unlike clinic or hospital based medicine—even medicine practiced in the Emergency room—EMS is a balancing act. We go into a call with a few tools:

  • Protocols–Whether you see this as an advantage or a hinderance, they are here to stay. Protocols allow EMS providers to fall back on guidelines to help them during difficult and challenging patients. They also allow providers to hide behind a shield when they do something for no other reason than “my protocol said so”.
  • Assessment skills–Some medics have them… Some don’t. All of us go to a medic school of some sort. All of us had to pass National Registry. Does this make all medic’s assessment skills equal? Nope. I solve problems. I have a classmate that does less “problem solving” and more pulling the answer from his ass like he is a walking Taber’s Medical Dictionary. Because of the varied assement skills of providers, many protocols are written in a manor that eliminate the need to even assess a patient beyond the ABC’s.
  • Diagnostic tools–From a stethescope to pulse oximetry, capnography, and cardiac monitors–these diagnostic tools can help you to obtain a more clear image of the present problem–they will not diagnose a problem though.
These things together are the basis of our profession. They allow us to do what we do, day in and day out.  Without any one of them, we would, in all reality, be out of business. Sure, we need to be able to make due without pulse ox or capnography, but without a defirilator I am unable to convert V-fib, without my drug box there are a great deal of things I just can’t do. Without my protocols I won’t have the authorization to do what I do. Without my assessment skills I won’t know when and where to use any of the above.

That is all true–unless we practice lowest common denominator(to quote RM), “It can’t hurt” medicine. “It can’t hurt” medicine refers to oxygen for no specific symptom, drugs down to tube in an arrest, etc. Just because we don’t have “proof” that something causes harm, doesn’t mean it helps.

Our job is simple. We are called to help in our patient’s emergency–whether we percieve it as one or not. We are to treat each patient as though their emergency is the most important thing going on–at that time. We are to spend the time needed to determine what THAT patient needs, and give it to them.

Now, some might say we can’t afford this time–but lets be honest. How much time does it take to decide if someone NEEDS oxygen. It is usually rather apparent.

How about if someone NEEDS nitro or ASA? Not all chest pain is created equal. If we are afraid to train our medics to differentiate between cardiac and muscular-skeletal pain we might as well throw new Basics on the truck and skip the training for medics. It would save EMS systems around the country loads of money(though depressingly not enough!)

When did we decide that paramedics where no longer qualified to assess and THEN treat patients. When did we decide that just because we haven’t been told that something could HURT our patient, it is ok to do every time (oxygen, drugs, spinal immobilization, prophylactic IV therapy, etc)?

When will we bring assessment back into EMS? What would YOU do? What freedoms and
limitations does your system place on the providers it employs?

Dr Bryan Bledsoe has a great article out right now about “The Oxygen Myth“. It dicusses the issue
with using oxygen on EVERY patient, rather than patients that actually need it.

Check it out and let me know how you feel.