Drinking Herself to Death

     It's a special-event weekend at the local university, and the Attack One crew has been responding to one call after another in the campus area. There have been some particularly large parties at the social clubs, and some larger-than-usual intake of alcohol at the parties and sporting events. Ambulances have been making frequent visits, and the ED's been busy each time the Attack One crew has been there. Just after the magic hour of 2 a.m., the dispatcher calls once more for a "possible alcohol poisoning."

     The crew arrives at a still-active event in one of the party houses and is guided to a young woman lying on a couch on the main floor. No one quite has a history of what happened. Bystanders can only report that she'd been there with friends, and has been sleeping on the couch "for a while." Her friends left, and now other party guests can't wake her up. No one even knows her name.

     Poor lighting and loud music make it difficult to assess the patient, so the crew decides to move her to the ambulance. They find a student ID card in her pocket, but she has no purse or other belongings. They load her onto the flexible patient sleeve and start to make their way to the front door. The patient arouses a little, makes some retching noises as though she's going to vomit, then becomes quiet again. As they get close to the door, another young lady appears. "Is this the girl who passed out from the barstool," she asks, "or the one who fell down the stairs?"

     No one knows, but the girl who asked the question thinks this girl's blonde hair matches that of the girl who fell unconscious off a barstool about two hours ago. She also thinks she knows some of the girls who came to the party with the patient. There is no one else still present who has any idea what happened.

     The patient is placed in the ambulance, and for the first time the paramedic can assess her. An EMT is dedicated to finishing work in the house, following up with the young lady who might have information about friends and sweeping the house to make sure there isn't another patient (the stair-faller) lying unconscious somewhere. A female campus security guard helps the crew look for additional identification on the patient. Nothing is found beyond the student ID, which gives her age as 21. The campus police have no access to parent contacts.

     The paramedic conducts the first full patient assessment in the ambulance. The original examination found no signs of trauma. The patient responds reliably by withdrawing from painful stimuli, and at times responds to loud verbal stimuli. Her pupils are equal, midsize and reactive. Her breath smells of alcohol. She is not incontinent of urine, and has no bite marks on her tongue. There are no signs of intravenous drug use. Fingerstick blood sugar is 112. On close secondary examination, a small contusion is noted on the left side of her skull.

     En route to the hospital, the girl opens her eyes briefly and again begins retching. The crew rolls her onto her left side in case she vomits. The patient's oxygen saturation improves on supplemental oxygen by nasal cannula. The only other change is a bump up in her blood pressure, to 154/90, just before arrival at the ED.

Initial Assessment

     A 21-year-old female, minimally responsive at a college party site.

     Airway: Marginal. Patient occasionally arouses and retches as though she's going to vomit.

     Breathing: Breathing regularly.

     Circulation: Normal capillary refill, pink skin.

     Disability: Arouses to painful stimuli, and occasionally to loud verbal stimuli. Pupils equal, midsize.

     Exposure of Other Major Problems: Bystanders unable to give a clear history, but someone believes she fell off a barstool.

Vital Signs

AMPLE Assessment

     Allergies: None known to bystanders; no alert bracelet.

     Medications: Unknown.

     Past Medical History: Unknown.

     Last Intake: Food intake through the evening, and reportedly a large quantity of alcohol.

     Event: Patient with a decreased level of consciousness due to unknown reasons.

Hospital Management

     The ED is busy, especially for 0230 in the morning. Few nurses are available—they're occupied with other patients. The emergency physician is intubating someone in a trauma room. The crew transfers their patient onto the ED cart, leaving her on her side to avoid a situation where she might vomit and potentially aspirate. The ED nurse and tech staff take a quick report, and offer to pass the information on to the emergency doc when she becomes available. They confirm vital signs consistent with the last set of EMS vitals, and that the patient has a gag reflex and will lie on her side. They place a Foley catheter, find no resistance from the patient and drain about 1,400 cc of urine.

     As much as the crew wants to go back in service, they feel they should stay near their patient, get any additional information from the EMT trying to contact friends or family, and pass that information on to the physician. They complete the patient care report and restock and clean the ambulance, placing the equipment back in service with dispatch.

     The patient becomes more somnolent, and her breathing becomes a bit more noisy. Then she suddenly retches again, and vomits violently through the side of the ED stretcher. It contains food, no blood, and a heavy smell of alcohol products. The Attack One crew supports her on her side so she doesn't aspirate. Done vomiting, she returns immediately to sleep.

     Then the EMT calls on the cell phone. She has located the patient's friends, who had returned to their dorm room. They confirmed that around midnight, she'd fallen from a barstool after drinking quite a bit. As she fell, she'd hit the left side of her head on a nearby chair. They were aware of no medical problems or other trauma. Her friends had picked the patient up off the floor, carried her to the couch to "sleep it off" and thought she would return to the dormitory with someone else. The EMT has also worked with the college staff to contact her parents, and suggested they go to the hospital.

     With that information, an Attack One crew member tracks down the nurse and physician and asks them to come back into the patient's room. Together, they evaluate her skull again, and note the contusion in her left temporal area, which seems a little bigger than before. They review the friends' story and the vomiting episode. The physician examines the patient and asks that she go immediately for a CT scan of her head.

     The patient is expedited to CT scan, where she vomits again as they prepare her. The scan begins, and the CT technician immediately notes a problem and calls the physician. The patient has an acute bleed on the left side, underneath the area where the small contusion was noted. This "epidural bleed" is a particularly dangerous form of intracranial bleeding, and occurs frequently without an overlying bone fracture or scalp laceration. The physician asks that the patient be brought back to the ED immediately, and calls the operating room and neurosurgeon.

     The patient goes to the operating room, has the blood removed and wakes up two days later. She has a quick rehabilitation, and ultimately returns to school.

Customer Service Tip:

     College students usually have concerned parents who may still be legally responsible for them. They will usually be contacted by the hospital, often for insurance reasons. Parents of college students may live far away, but it's common for their phone numbers to be in the memories of students' cell phones. At an appropriate time, the parents will need to be notified; they may have critical medical information about the patient that is necessary for good emergency care.

     This case demonstrates one of the potential dangers of situations where young people are under the influence of alcohol or drugs. This group of patients may resolve altered levels of consciousness by just "sleeping it off," but there are a small number of situations where there is another dangerous and hidden threat to life or long-term functioning. There can be hidden trauma; there may be hidden "street drugs" or "club drugs" with completely unpredictable effects; there may be a hidden sexual assault; or the altered patient can suddenly vomit and aspirate, with terrible implications.

     Prehospital priorities for patients with altered LOCs are a good event history, a complete evaluation looking for predictable problems, protection of the airway, and great turnover of the patient and event history at the ED. The event history should include what was ingested, if any "street drugs" were included, if any injury occurred (especially to the head), whether the patient said they were trying to do anything to harm themselves, if the patient had a seizure or has a history of them, and if the patient has any underlying medical problems that may have played into the event. If anything in the event history raises a concern that the patient was assaulted or inappropriately undressed, it is important to involve law enforcement and ED staff. These patients should have airway protection at all times, and many can be easily rolled onto their sides to prevent aspiration, especially when immobilized on a spine board.

     Epidural bleeding is a critical injury. It is typically associated with a blow to the side of the head, and that blow may not cause a significant scalp injury or skull fracture. Many of these patients have brief losses of consciousness, then awaken for a period. They may be completely alert, oriented and functional for some time before the bleeding inside the skull begins to have clinical effects. Typical symptoms then become pain, nausea and decreased level of consciousness. Epidural bleeding is from an arterial source, and as the bleeding expands it then causes profuse vomiting (often referred to as projectile vomiting), a dilated pupil on the side of the bleed, seizures and coma. Death or severe permanent brain damage are ultimate outcomes.

     This patient had several potential threats the EMS crew averted. They made an extraordinary effort to chase down her history. Their good event history allowed the critical injury to be identified before permanent damage occurred. They noticed the spike in blood pressure and the vomiting episode, and didn't allow the patient to aspirate. They engaged the university staff in assisting with patient identification, searching for assault activity and locating the parents. Finally, they were diligent in obtaining and passing on the history to the ED staff, allowing appropriate decisions to be made for the patient.

     Learning Point: In the college-aged young adult, a variety of recreational and sporting activities can cause significant impairments in consciousness. Their histories may be difficult to obtain. A good event history is critical to patient care in all episodes of trauma and when patients present with altered LOCs. In some cases, EMS may need to go to great lengths in pursuit of necessary history. Passing on any history to ED staff will allow appropriate decisions to be made for the patient.

     James J. Augustine, MD, FACEP, is deputy chief-assistant medical director for Washington, DC, Fire and EMS. Contact him at jaugustine@emp.com.