Side Effects of Sleep: The Perils of Treating Chronic Intoxicants in the ED

The glass doors to the emergency department (ED) part, and in rolls Mr. W, who was discharged only hours before. “Guess who’s back?” remarks EMS (Emergency Medical Services). It’s Mr. W’s third visit in the last twenty four hours, his sixth visit in two days, all for the same chief complaint: ‘alcohol intoxication.’  In the first half or 2014 alone, his list of ED visits fills three computer screens. He’s homeless and chronically intoxicated, and yet, his drunkenness works as an acute medical problem worthy of EMS transport.

Bars and nightclubs buzz with drunk people and they’re not pulled away and thrown into ambulances. However, during this particular eight hour shift, EMS chauffeur ten homeless, intoxicated people. Like Mr. W, they don’t seek help for substance abuse or assistance with housing. The medical care we provide–food and a stretcher–might glow with a patina of compassion, but on closer examination, it smolders the edges of prevailing medical and ethical standards. Mr W is a patient of ours not because he is drunk, but because of where he is drunk.

This distortion of mission begins, paradoxically, with a perversion of the Emergency Medical Treatment and Active Labor Act (EMTALA). Passed by the US Congress into law in 1986, the statute is broad and complex, but it’s core principles rest on non-discrimination and equal access to emergency care regardless of a person’s citizenship and ability to pay. It mandates EDs to perform a medical screening exam on every patient to determine whether a medical emergency exists. Emergency medicine has embraced this social justice mission. Over time, however, EMTALA has transformed the ED’s open door into a one way valve.

We talk with Mr. W and conduct a physical exam. This process is critical, even if ‘alcohol’ intoxication’ is the chief complaint. The homeless suffer high rates of substance abuse, medical co-morbidities, mental illness, and HIV. They’re constantly knocking against a cruel and violent environment. But once it’s determined that an acute medical emergency doesn’t exist, we’re still faced with an intoxicated Mr. W. He’s now a medical-legal risk, susceptible to injury and making harmful decisions; even though intoxication is his baseline state, and he navigates these risks everyday.

Years ago, he would have been committing a crime–public intoxication–which would have landed him in a jail cell. After a couple of high profile deaths in jail ‘drunk tanks,’ state laws were changed. Public intoxication was decriminalized, shifting the burden of responsibility from the police department to EMS and ultimately, to city hospitals.  Here, he becomes a patient, only nobody pretends we’ll make him better or change his behavior.

This is the part when what counts as care becomes tricky. We hope he’ll drift off to sleep, a state of rest and alcohol deprivation. Sobriety becomes a goal and side-effect of sleep. If Mr. W dozes too long and sobers too much, his body rebels from alcohol withdrawal. For minor shakes, we give sedatives and discharge him quickly, expecting that he’ll treat himself with more alcohol. Severe withdrawal requires admission to the hospital. If he was on the street with access to alcohol, this might not have happened. In my mind, alcohol withdrawal from overstaying in the ED counts as an iatrogenic harm.

Those of us who orchestrate this absurd balancing act don’t have the time to reflect on the inevitable outcome. We discharge Mr W in a state of minor alcohol withdrawal that needs to be cured at the local liquor store.  Alcohol is his panacea and his penance. Since various local shelters have rules against acute intoxication, Mr W will return in a few hours when he is found sleeping on the street, or in a doorway.

Some chronic inebriates found drinking and sleeping in public view never ask to come to the ED. In fact, the ED becomes the source of their chief complaint: “I want to leave.” But the one-way valve is a trap for both of us, and we soon fulfill the roles imposed upon us.

They express dismay through insults and physical threats. When calming attempts fail, restraints are sometimes necessary to protect the safety of the patient and staff. The decision to remove a patient’s liberty is as critical as any we make in our practice. Though restraint policies specify using the least restrictive methods possible, the process of physical restraint is not without risks of injury to the patient, security officers and the health care team. Chemical sedation, meanwhile, is rife with potential complications, including compromising the patient’s airway and ability to breathe. Even if all goes well, the patient risks sleeping too long and tipping into withdrawal. Sometimes, the prudent ethical, medical and medical-legal strategy points to letting the intoxicant leave.

Is the ED the best place for the chronic inebriates? The benefits of our care are nebulous, while the risks have a habit of steam-rolling. Caring for patients like Mr. W is the occasion when we fear that we’re tramping on one of medicine’s central moral precepts: At first, do no harm. What are our goals of care? Watch him for hours and hours until it’s determined he has functional capacity, a medical-legal sweet spot between intoxication and sobriety, then discharge him to booze up again and return by EMS?

When outcomes are studied in the name of  improving healthcare quality and reducing mistakes, how can the ED’s role in Mr. W’s self destructive cycle be considered acceptable practice?

But can we, as a society, leave Mr. W and others on the streets? We fear that EMTALA’s mandate and the ED’s open door policy has spared fiscally challenged communities from developing meaningful alternative solutions for this vulnerable population. Because EMS can bring Mr. W to the ED doesn’t mean they should.  Has EMTALA’s mandate forced us to try to beat a societal problem with a medical stick?

The ED staff is already grappling with a greater number of high complex, high acuity patients. Some cities have started to provide coordinated services aimed at the core issues–homelessness, substance abuse, and mental illness. What counts as appropriate ‘care’ for patients like Mr. W isn’t a turkey sandwich and a place to sleep, but a coordinated, interdisciplinary community response.

By Jay Baruch and Otis Warren

Jay Baruch (@JBaruchMD) is Associate Professor, Department of Emergency Medicine at Alpert Medical School of Brown University, as well as fiction writer, essayist, speaker, baffled participant in healthcare, and unabashed advocate for more creativity in medicine.

Otis Warren is Assistant Professor (Clinical) of Emergency Medicine at The Alpert Medical School of Brown University. His areas of academic focus include traumatic brain injury and alcohol intoxication.

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