Emergi-Press: Case from The Field – January / February Issue

Which of the following should be your next diagnostic action in this patient with altered mental status in the field?

1. Ask questions about desire to hurt himself or others
2. Check a blood glucose
3. Perform a 12-lead ECG to evaluate his tachycardia
4. Request law enforcement assistance

Correct Answer: B

Explanation: A rapid glucose check should be performed early in any patient with ALOC. Hypoglycemia is a common cause of ALOC that can mimic both intoxication and stroke symptoms. Identifying and correcting low blood sugar can quickly resolve symptoms. The other actions may be appropriate later, but do not replace the need for an immediate glucose check during the initial assessment.

Blood glucose check is performed per TP 1229, Altered Level Of Consciousness (ALOC) and returns at 76. You continue with a focused secondary assessment, noting signs consistent with intoxication or withdrawal, including tremors, sweating, and restlessness. He is persistently tachycardic and is unable to answer basic questions about where he is, how long he has been there, or how he plans to care for himself.

Given the patient’s tremors, sweating, and restlessness, what is the most likely underlying cause of his ALOC?

1. Alcohol intoxication
2. Alcohol withdrawal
3. Hypoglycemia
4. Opioid overdose

Correct Answer: B

Explanation: The patient’s ALOC, tremors, sweating, and restlessness are classic signs of alcohol withdrawal. Hypoglycemia has been ruled out with a normal rapid glucose check. Alcohol intoxication often causes slurred speech, incoordination, and impaired judgment, but does not typically produce the tachycardia, tremors, and sweating seen in withdrawal.

Recognizing that the patient’s impairments go beyond simple intoxication, you inform him that you would like to transport him to the hospital for evaluation. He becomes adamant and clearly states that he has no desire to leave his current seating location. When asked why he is refusing transport he states, “I’m waiting for someone.” He again refuses food and water, as well as your offers to help him stand or move to a safer area away from the trashcan and broken glass.

Which of the following are criteria used in determining grave disability under SB‑43? (Select all that apply)

1. Unable to provide food, clothing, or shelter
2. Unable to ensure personal safety
3. Unable to engage meaningfully in conversation
4. Unable to access necessary medical care
5. Unable to follow directions

Correct Answer: A, B, D

Explanation: Under SB‑43, grave disability is defined as the inability of a person to meet their basic needs for food, clothing, shelter, ensure personal safety, or access necessary medical care due to a mental health disorder, severe substance use disorder, or both. His inability to engage in meaningful conversation does not in itself indicate grave disability. Focus is on functional impairment affecting survival, safety, and care, not simply confusion, communication issues, or noncompliance.

The patient’s open sores, refusal of food, and prolonged exposure to environmental hazards indicate that he is not meeting basic needs. The broken glass, scattered trash, urine-filled bottles, and proximity to foot traffic outside the store further increase the risk of injury.

These findings prompt you to expand your evaluation beyond medical stabilization and consider whether the patient may meet grave disability criteria under SB-43.

The patient is refusing transport and may meet criteria for grave disability under SB-43. It is important that you perform and document an assessment of functional safety by asking the patient simple, concrete questions and documenting his answers to these questions. Examples of such questions asked to this patient, and the documentation resulting from them, may include:

• I asked the patient “Do you have a place to stay tonight?”. Patient responded, ‘I got everything I need.
• I asked the patient “Have you eaten today? Patient shrugged but refused to answer this question or provide information on last food intake
• I asked the patient, “Do you understand that you’re lying near broken glass?”. Patient responded “There ain’t no glasses here. I broke my glasses. I’m seeing the world without them.” with inappropriate laughter.
• I noted to patient that wounds on his arms looked possibly infected and asked if  a doctor had looked at them. Patient responded, “F—you and your doctors. F—you.”

As noted in the questions above, the patient cannot describe any plan to obtain food, shelter, or medical care for his wounds. He continues to refuse your offers of transport to the Emergency Department.

Q: What should you do next?

1. Contact law enforcement to evaluate for a 5150 hold
2. Document patient’s refusal of transport and leave the scene
3. Forcibly restrain and sedate patient for transport, if safe to do so
4. Provide resources for sobering centers in the area

Correct Answer: A

Explanation: Under SB‑43, patients who cannot meet basic needs, maintain personal safety, or access necessary medical care may meet grave disability criteria for a 5150 hold. EMS should involve law enforcement rather than leaving the patient at risk or attempting to forcibly transport him without law enforcement assistance. Offering drug treatment or sobering resources may be appropriate for patients who are intoxicated or report active drug use but do not meet criteria for grave disability.

Law enforcement arrives and after you present your concerns the patient is evaluated and placed on a 5150 hold. He is escorted to the ambulance but becomes agitated and receives midazolam 10mg IM for severe agitation, is placed on monitors with nasal capnography, and receives also 1L normal saline for his persistent tachcyardia. You maintain continuous monitoring of vital signs and mental status throughout the transfer remaining alert for any worsening tremors, agitation, or signs of decreased ventilation/tidal volume. Your handoff at the Emergency Department includes your observations of his initial disorientation, refusal of care, environmental hazards that you witnessed, and the circumstances that prompted the 5150 evaluation.

Your actions ensure the patient’s immediate safety, facilitate appropriate medical evaluation, and demonstrate how EMS can recognize grave disability under SB‑43.

Which of the following best describes the primary focus of EMS when evaluating a patient under SB‑43?

1. Assessing functional impairment affecting basic needs, safety, and access to care
2. Diagnosing a specific mental health or substance use disorder
3. Determining long-term treatment plans for psychiatric conditions
4. Conducting a full cognitive assessment in the field

Correct Answer: A

 Explanation: Under SB‑43, EMS focuses on identifying functional impairments that threaten a patient’s ability to meet basic needs, maintain personal safety, or access necessary medical care. EMS does not make formal psychiatric diagnoses, determine long-term treatment plans, or conduct full cognitive assessments. Their role is to recognize immediate risks and connect the patient to appropriate resources to ensure safety.

Q: Which of the following questions might you ask as part of your assessment for potential grave disability per SB-43?  (Select all that apply)

1. Do you have access to food and water right now?
2. Have you used alcohol or drugs recently?
3. Are you feeling sad or anxious?
4. Where are you planning to sleep tonight?
5. Are you getting any medical care for your wounds?

Correct Answer: A, B, D, E

Explanation: Questions about immediate survival, shelter, support networks, recent substance use, and ability to care for medical conditions are relevant when assessing functional capacity and potential risks. Emotional state questions, while clinically useful, do not determine grave disability under SB 43 and are therefore not necessary for assessment for grave disability under SB-43. However, if you are concerned about major depression or suicidal thoughts/attempts, this question may be relevant.

On specific questioning the patient reports he has been living on the streets for almost 12 months after losing his apartment. He used to find work as a handyman and day laborer but now earns money by panhandling since he doesn’t qualify for any benefits such as EBT. He reports that his wounds started as cuts and scrapes from sleeping outdoors, and further states “this is part of the deal when you have no one and nothing to help you. You’re stuck out here, and you’ve got to make do to survive.”

He explains that he has been sleeping in an encampment nearby alternating with a shelter on particularly cold nights and has enough money from panhandling to buy food “if I miss the mealtime at the shelter or the line is too long”. He states that he has high blood pressure and is currently on antibiotics for an infected wound in his leg. He endorses occasional meth use (last used earlier today) and daily alcohol use. He has no family nearby but reports that he is connected with a caseworker at the nearby mission who “is trying to get me a place”. He declines transport to the hospital and prefers to continue to a nearby encampment where he slept last night.

Based on the patient’s presentation, does the patient meet grave disability criteria under SB-43?

1. Yes, because he is homeless and has minor injuries
2. Yes, because he used meth earlier today
3. No, because he is alert and oriented and can communicate his plan
4. No, because he is able to obtain food, shelter, and medical care independently

Correct Answer: D

Explanation: Although the patient is homeless, disheveled, and used meth and alcohol earlier today, he demonstrates that he can meet his basic needs, maintain personal safety, and access resources when necessary. This shows he does not meet SB 43 criteria for grave disability. Homelessness, minor injuries, or recent substance use alone do not constitute grave disability if the patient retains functional independence.

You confirm that he understands the risks of refusing medical treatment and that he can call 9-1-1 again in the future if he should desire medical care. You also verify that he understands the instructions for care of his wounds and reinforce that he should seek medical attention if his injuries worsen or if he experiences any new symptoms. The patient acknowledges your instructions and continues safely toward the encampment. Although you ask for him to sign AMA disclosure the patient refuses to do so.

• SB‑43 expands the definition of grave disability to include severe substance use disorder as well as mental health conditions as factors that impair basic needs, safety, or access to care.
• EMS does not need to screen or diagnose every patient but should remain alert to any concerns regarding threats to safety, basic needs, or access to care.
• Field consideration of a 5150 hold per SB-43 criteria is most likely to apply when evaluating a patient with a medical concern who is refusing transport.
• When concerned, EMS can involve law enforcement for a 5150 hold, contact mental health crisis teams if available, or transport the patient if medically unstable.
• In cases where the patient agrees to transport from a situation where you would otherwise consider 5150 hold, inform ED staff of the situation and your concerns.
• Early recognition and intervention can improve both patient and community safety.