Alcohol Intoxication, Injuries, and Dangerous Behaviors–And the Revolving Emergency Department Door

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Abstract
Suicides, homicides, motor vehicle crashes, and other violent deaths and injuries are linked inextricably to alcoholism. The association of injury and alcoholism should be particularly obvious to Emergency Department (ED) physicians. We sought to determine the extent to which intoxicated patients in an ED were properly diagnosed, counselled, and referred for substance abuse care. We reviewed the charts of 153 consecutive patients seen in a teaching hospital ED who had blood alcohol levels above 100 mg. Most were male (70), white (62), young (mean age, 34 years) and severely intoxicated (mean BAL, 245; range, 109–558 mg). Forty-six per cent of visits were for trauma; half of the patients were victims of violent assaults. The intoxicated patients received extensive medical and surgical management: an average of five tests or X-rays were performed per patient; 75 received at least one medication; at discharge 48 were referred for followup to medical or surgical clinics. In contrast, few patients were evaluated for dangerous behaviors or referred for treatment of alcoholism: only 19 patients (12.5) were asked about depression, suicide, or homicide; 15 were advised to stop drinking; 13 received a referral to a psychiatrist, mental health worker, or alcohol rehabilitation facility. Forty-seven per cent of patients received “stat” intravenous thiamine (although the Wernicke-Korsakoff syndrome is rare). In contrast, only 16 received a stat on-site psychiatric consultation (although dangerous behaviors are common in alcoholics). There was a strong, statistically significant negative association between the occurrence of an injury and the decision to initiate treatment and referrals for alcoholism. The odds of receiving psychiatric care or an alcohol treatment referral by injured patients, compared to noninjured patients, was 0.28 (CI95 = 0.12, 0.66). ED physicians may know that alcoholism is a principal risk factor for trauma, but they are silent about it in their practices. Physician education and a coordinated approach to psychiatric evaluation and referrals are needed. Acutely intoxicated patients in the ED present an opportunity for therapeutic intervention which is usually missed.