This is for you new people

Since you all follow the Mutual Aid lists and Continuing Education tab on this site, I shouldn’t have to repost this, but watching this fail video from FAILBlog is a great learning tool for young EMSers, or anyone studying to advance in medicine.

First, watch the video, then some questions.  I don’t have answers, and was not there  to talk to this man, but I think since he is on TV he must be an actor, so let’s enjoy, shall we?

Now, without replaying the video, answer the following questions:

1. What happened?

2. What is this man’s GCS score?

3. Is he competent to refuse transport in your jurisdiction? Why or why not?

4. Could this be his normal mentation?

5. If not, what would you suspect a person who presents like this actor acted to be under the influence of?

If you replayed the video, you cheated.

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46 thoughts on “This is for you new people”

  1. I didn’t replay the video, so don’t judge my answers too harshly :)
    1. They dun got robbed, man!
    2. I’d give him a 13…but I’m not exactly proficient at these.
    3. Not sure of the exact protocol in my jurisdiction (I don’t work EMS at the moment) but without knowing any more of what’s going on, I’d have to say yes.
    4. It’s possible. Hard to tell and I wouldn’t assume it, but it is possible.
    5. Drugs, alcohol, extreme stress/fear…

  2. 1. They were victims of an attempted robbery, and he resisted.
    2. GCS is 15. He’s slurred as hell, and obviously impaired, but he’s interacting appropriately and answering questions coherently.He is aware of his surroundings, and interacting with the interviewer. There is no delay between the interviewer’s questions and his answers, and the answers are comprehensible, even if the speech is slurred.
    3. My employer probably would say he is incompetent to refuse care, but part of that is the fact that they abhor refusals because a) they are not profitable, and b) they are fraught with legal liability – and probably in that order. Me, I don’t necessarily agree with company policy
    4. I doubt it’s his normal mentation.
    5. Probably alcohol, but I wouldn’t be surprised if his tox screen came back “Yes.”

    People who are organically impaired or under the influence of drugs do not necessarily lack the present mental capacity to make informed decisions – or refusals. It makes it far more likely that they’re incompetent, but it is by no means a guarantee.

    The wise medic would do a simple test to document present mental capacity before a refusal was obtained, and document accordingly. A Folstein mini-mental exam works well, and takes less time to perform than it does to describe it.

    And it’s a lot more defensible than simply writing, “Patient AAOx4, and refuses care.”

  3. 1. they got robbed by sumdood!
    2. GCS of 15
    3.Completely competent to refuse (and I really hope he does)
    4.I would assume yes, from his mannerisms and appearance
    5. drugs, ETOH, or both. combined with a complete lack of basic grammar and English rules

  4. I didn't replay the video, so don't judge my answers too harshly :)
    1. They dun got robbed, man!
    2. I'd give him a 13…but I'm not exactly proficient at these.
    3. Not sure of the exact protocol in my jurisdiction (I don't work EMS at the moment) but without knowing any more of what's going on, I'd have to say yes.
    4. It's possible. Hard to tell and I wouldn't assume it, but it is possible.
    5. Drugs, alcohol, extreme stress/fear…

  5. 1. They were victims of an attempted robbery, and he resisted.
    2. GCS is 15. He's slurred as hell, and obviously impaired, but he's interacting appropriately and answering questions coherently.He is aware of his surroundings, and interacting with the interviewer. There is no delay between the interviewer's questions and his answers, and the answers are comprehensible, even if the speech is slurred.
    3. My employer probably would say he is incompetent to refuse care, but part of that is the fact that they abhor refusals because a) they are not profitable, and b) they are fraught with legal liability – and probably in that order. Me, I don't necessarily agree with company policy
    4. I doubt it's his normal mentation.
    5. Probably alcohol, but I wouldn't be surprised if his tox screen came back “Yes.”

    People who are organically impaired or under the influence of drugs do not necessarily lack the present mental capacity to make informed decisions – or refusals. It makes it far more likely that they're incompetent, but it is by no means a guarantee.

    The wise medic would do a simple test to document present mental capacity before a refusal was obtained, and document accordingly. A Folstein mini-mental exam works well, and takes less time to perform than it does to describe it.

    And it's a lot more defensible than simply writing, “Patient AAOx4, and refuses care.”

  6. 1. they got robbed by sumdood!
    2. GCS of 15
    3.Completely competent to refuse (and I really hope he does)
    4.I would assume yes, from his mannerisms and appearance
    5. drugs, ETOH, or both. combined with a complete lack of basic grammar and English rules

  7. Hrm, ok, let’s see, the accent didn’t help as I’m from the UK – is this technically a redneck?

    1. It would appear that they’ve been the victims of a burglary-assault, which he tried to resist.
    2. It would be 15 on paper, but handed over as “fourteen and a half”, which is something I’ve picked up from local crews – it’s a GCS of 15, but not fully compos mentis due to external influences, typically drugs or alcohol.
    3. Probably yes, though there are other questions that need answering first, like have you been drinking?
    4. It’s possible, though unlikely.
    5. Probably alcohol, possibly combined with cannabis or other illicit substance.

    1. That would be an insult to rednecks everywhere. Redneck is more of a pejorative for social class than intelligence.

      If I was looking for an American pejorative for this guy I’d use white trash, but as a compassionate EMS professional I wouldn’t even think that. :)

  8. Hrm, ok, let's see, the accent didn't help as I'm from the UK – is this technically a redneck?

    1. It would appear that they've been the victims of a burglary-assault, which he tried to resist.
    2. It would be 15 on paper, but handed over as “fourteen and a half”, which is something I've picked up from local crews – it's a GCS of 15, but not fully compos mentis due to external influences, typically drugs or alcohol.
    3. Probably yes, though there are other questions that need answering first, like have you been drinking?
    4. It's possible, though unlikely.
    5. Probably alcohol, possibly combined with cannabis or other illicit substance.

  9. 1. He got robbed and he tried to chase the robbers.
    2. What’s GCS? I’m only a first responder student, and that wasn’t in the book. ;p
    3. Seeing how I’m not allowed to perfom patient refusals, that’s the EMT’s job, not mine. (In all seriousness, I’ll have to double check my book, but I believe that I cannot get a refusal as a first responder.)
    4. I’ll go with above, possible, but unlikely.
    5. Probably suffering from alcoholism. Possible chance of a downer or hallucinagen.

  10. 1. They were being robbed and he did something.
    2. Glasgow Coma Scale 15. It was confusing to us, but seemed coherent in context with the interviewer. He was mostly just hard to understand.
    3. I don’t have a set of protocals yet as a newbie, but I’d turn it around, Is he incompetent enough to be forced to go with me? Nope.
    4. Maybe, but I doubt it.
    5. Mind altering drugs, or head trauma. Did he get in an altercation when doing something about the robbery?

  11. 1. He got robbed and he tried to chase the robbers.
    2. What's GCS? I'm only a first responder student, and that wasn't in the book. ;p
    3. Seeing how I'm not allowed to perfom patient refusals, that's the EMT's job, not mine. (In all seriousness, I'll have to double check my book, but I believe that I cannot get a refusal as a first responder.)
    4. I'll go with above, possible, but unlikely.
    5. Probably suffering from alcoholism. Possible chance of a downer or hallucinagen.

  12. 1) so clearly, they got robbed and we was in “a killin zone”
    2)GCS is 15, he seems to follow commands appropriately his eyes are open and he’s oriented to whats going on around him
    3) I’m not going to make him go but that being said considering a thorough assesment I’d be on the look out for any sign of a head injury from his altercation with the robbers
    4) While I doubt his normal mental status is exactly like this I wouldnt be shocked to find that a long term drug and etoh problem had caused this sort of slurred speech and mumbling, so while I doubt it it is possible that this is baseline for him…maybe ask a family member or friend if he seems to be acting normally
    5) He seems drunk, does he smell it? his movements seem a bit jerky to me, any illicit drug use? maybe some wet? or just weed? hes obviously amped up but he just got in a fight so I’ll not begrudge him that

  13. 1. What happened? Someone got robbed…

    2. What is this man’s GCS score? 14…at best…. I would almost give verbal the “incomprehensible sounds” haha
    3. Is he competent to refuse transport in your jurisdiction? If he can tell me who he is, where he is, and what day it is yes. Why or why not? A&O x 3 is all we need

    4. Could this be his normal mentation? Could be…

    5. If not, what would you suspect a person who presents like this actor acted to be under the influence of? ETOH or other sedatives…. or way to much NASCAR… I heard if WT gets a NASCAR OD they can be hard to understand….

    1. Dan, I would disagree in one aspect: “AAOx3 is not all you need.

      That is a conclusion based upon facts not in evidence, and unless you document what you asked to make that determination, and what the patient’s responses were, a sharp attorney can rip it apart in court.

      Better to document your factual observations of the patient’s behavior and his responses to questioning, than to simply say AAOx3.

      That’s a term EMTs use very blithely, and one that makes a plaintiff’s attorney salivate.

      Likewise for documenting that you smelled “ETOH” on the patient’s breath.

      1. Good points. I still need to get better at CYA (cover your ass) with my paper work. I ment A&Ox3 is all that is required by our city to let a pt refuse transport. But the ETOH could be a problem for a refusual, so I change my response to “is he able to refuse transport:” to a… Well probably not cause he’s probably to drunk/high.

      2. You don’t smell ETOH unless you take off his shoes, then you can gag and say his feet stink.

        Alcohol calls [a drunk] should be documented something like ‘no odor of alcoholic beverage on breath’ or “noted odor of alcoholic beverage on breath with slurred speech, unsteady gait, nystagmus {horizontal} and empty
        liquor containers near where pt found”.
        Ethnanol doesn’t have an odor, or so I have been taught.

        1. Exactly. What you’re smelling are byproducts of alcohol metabolism, namely ketoaldehydes.

          The same ketoaldehydes produced in diabetic ketoacidosis, actually. The smells are indistinguishable.

  14. 1. They were being robbed and he did something.
    2. Glasgow Coma Scale 15. It was confusing to us, but seemed coherent in context with the interviewer. He was mostly just hard to understand.
    3. I don't have a set of protocals yet as a newbie, but I'd turn it around, Is he incompetent enough to be forced to go with me? Nope.
    4. Maybe, but I doubt it.
    5. Mind altering drugs, or head trauma. Did he get in an altercation when doing something about the robbery?

  15. That would be an insult to rednecks everywhere. Redneck is more of a pejorative for social class than intelligence.

    If I was looking for an American pejorative for this guy I'd use white trash, but as a compassionate EMS professional I wouldn't even think that. :)

  16. 1) so clearly, they got robbed and we was in “a killin zone”
    2)GCS is 15, he seems to follow commands appropriately his eyes are open and he's oriented to whats going on around him
    3) I'm not going to make him go but that being said considering a thorough assesment I'd be on the look out for any sign of a head injury from his altercation with the robbers
    4) While I doubt his normal mental status is exactly like this I wouldnt be shocked to find that a long term drug and etoh problem had caused this sort of slurred speech and mumbling, so while I doubt it it is possible that this is baseline for him…maybe ask a family member or friend if he seems to be acting normally
    5) He seems drunk, does he smell it? his movements seem a bit jerky to me, any illicit drug use? maybe some wet? or just weed? hes obviously amped up but he just got in a fight so I'll not begrudge him that

  17. 1. What happened? Someone got robbed…

    2. What is this man’s GCS score? 14…at best…. I would almost give verbal the “incomprehensible sounds” haha
    3. Is he competent to refuse transport in your jurisdiction? If he can tell me who he is, where he is, and what day it is yes. Why or why not? A&O x 3 is all we need

    4. Could this be his normal mentation? Could be…

    5. If not, what would you suspect a person who presents like this actor acted to be under the influence of? ETOH or other sedatives…. or way to much NASCAR… I heard if WT gets a NASCAR OD they can be hard to understand….

  18. Dan, I would disagree in one aspect: “AAOx3 is not all you need.

    That is a conclusion based upon facts not in evidence, and unless you document what you asked to make that determination, and what the patient's responses were, a sharp attorney can rip it apart in court.

    Better to document your factual observations of the patient's behavior and his responses to questioning, than to simply say AAOx3.

    That's a term EMTs use very blithely, and one that makes a plaintiff's attorney salivate.

    Likewise for documenting that you smelled “ETOH” on the patient's breath.

  19. Good points. I still need to get better at CYA (cover your ass) with my paper work. I ment A&Ox3 is all that is required by our city to let a pt refuse transport. But the ETOH could be a problem for a refusual, so I change my response to “is he able to refuse transport:” to a… Well probably not cause he's probably to drunk/high.

  20. What happened? What? The heck?
    Ferget Glascow, his RGCS is at least 17 [Redneck Gangsta Coma Store]
    Yes.
    Could be mine.
    200 years of Confederate thinkin

  21. I should dive in here. The main reason I posted this is because of the reasons mentioned above, describing this man’s mental state can be a mine field, especially if this case goes to court. Had a new EMT documented A&Ox3, any lawyer worth their paper degree would rip into what “Alert” means to you and “Oriented to what? The number 3?” (Yes I got that one once, hence why I never use it.)
    The GCS bit was a reminder that the GCS is used to pass along to the hospital so they can see if the pt got better or worse compared to their score. I’ve wheeled conscious, alert, aware and awake persons given scores of 9 and 10 in the ER. Dead people get a 3. dude, really?
    This dude is a solid 15, no doubt in my mind.

    Slurred speech is not uncommon. Inappropriate verbage or “Local Color” is also common, all of which can skew an assessment of an uninjured, well person who happens to be above the influence of an unknown substance.

    In my service there are two check boxes I must initial half awake when presented with any refusal:
    Person does not appear to be under the influence of drugs or alcohol
    and
    Person presents competent to make medical decisions.

    Most of my clients and only a few of my patients meet these two criteria as my employer would like, but it all bases it on a gray definition of influence and competent. It’s all down to me, how I write it and how I handle it.

    If no complaint and no injury/illness, dude is PDT-Patient Declines Transport, if he so chooses of course.

  22. What happened? What? The heck?
    Ferget Glascow, his RGCS is at least 17 [Redneck Gangsta Coma Store]
    Yes.
    Could be mine.
    200 years of Confederate thinkin

  23. You don't smell ETOH unless you take off his shoes, then you can gag and say his feet stink.

    Alcohol calls [a drunk] should be documented something like 'no odor of alcoholic beverage on breath' or “noted odor of alcoholic beverage on breath with slurred speech, unsteady gait, nystagmus {horizontal} and empty
    liquor containers near where pt found”.
    Ethnanol doesn't have an odor, or so I have been taught.

  24. Exactly. What you're smelling are byproducts of alcohol metabolism, namely ketoaldehydes.

    The same ketoaldehydes produced in diabetic ketoacidosis, actually. The smells are indistinguishable.

  25. I should dive in here. The main reason I posted this is because of the reasons mentioned above, describing this man's mental state can be a mine field, especially if this case goes to court. Had a new EMT documented A&Ox3, any lawyer worth their paper degree would rip into what “Alert” means to you and “Oriented to what? The number 3?” (Yes I got that one once, hence why I never use it.)
    The GCS bit was a reminder that the GCS is used to pass along to the hospital so they can see if the pt got better or worse compared to their score. I've wheeled conscious, alert, aware and awake persons given scores of 9 and 10 in the ER. Dead people get a 3. dude, really?
    This dude is a solid 15, no doubt in my mind.

    Slurred speech is not uncommon. Inappropriate verbage or “Local Color” is also common, all of which can skew an assessment of an uninjured, well person who happens to be above the influence of an unknown substance.

    In my service there are two check boxes I must initial half awake when presented with any refusal:
    Person does not appear to be under the influence of drugs or alcohol
    and
    Person presents competent to make medical decisions.

    Most of my clients and only a few of my patients meet these two criteria as my employer would like, but it all bases it on a gray definition of influence and competent. It's all down to me, how I write it and how I handle it.

    If no complaint and no injury/illness, dude is PDT-Patient Declines Transport, if he so chooses of course.

  26. here i try
    1: alsmot got rob
    2: Gcs 15
    3: in here the answer would be yes , if he is free of will ,able to understant the meaning and ans also if i previde him of the fact
    4:cant prononce fact missing (mental capacitie , med history, …)
    5:may be RHO or may be under drugs or low blod sugars , or past head trauma

  27. here i try
    1: alsmot got rob
    2: Gcs 15
    3: in here the answer would be yes , if he is free of will ,able to understant the meaning and ans also if i previde him of the fact
    4:cant prononce fact missing (mental capacitie , med history, …)
    5:may be RHO or may be under drugs or low blod sugars , or past head trauma

  28. 1. Attempted robbery

    2. Seems to coherently remember the events, hence 15.

    3. If he’s alert, orientated to person/place/purpose/time, can understand the risks of refusing treatment and is competent (e.g. not under the influence, however 1 beer is not “under the influence,” but competent can include other issues besides substance abuse), then yes. If he’s not, then no. The problem I see is his language. Is this his normal word choice and verbal style or is it significantly influenced by substance use? Just because someone talks strangely doesn’t mean he is or isn’t competent. Location, socioeconomic class, education, and plenty of other intangibles will affect these. Heck, if we want to go by word choice, I’d argue that most people who post on EMS forums are not competent to refuse care, little less render it.

    4. Could this be his normal mentation? Yes. Could this be abnormal? Yes.

    5.Alcohol, THC, glue.

  29. 1. Attempted robbery

    2. Seems to coherently remember the events, hence 15.

    3. If he's alert, orientated to person/place/purpose/time, can understand the risks of refusing treatment and is competent (e.g. not under the influence, however 1 beer is not “under the influence,” but competent can include other issues besides substance abuse), then yes. If he's not, then no. The problem I see is his language. Is this his normal word choice and verbal style or is it significantly influenced by substance use? Just because someone talks strangely doesn't mean he is or isn't competent. Location, socioeconomic class, education, and plenty of other intangibles will affect these. Heck, if we want to go by word choice, I'd argue that most people who post on EMS forums are not competent to refuse care, little less render it.

    4. Could this be his normal mentation? Yes. Could this be abnormal? Yes.

    5.Alcohol, THC, glue.

  30. Well, as all i seem to get is adverts apart from the last 15 seconds I had to watch it twice. They guy seems to have a swollen and black eye which maybe an indicator to some sort of assault and head injury so basically unless he gets aggressive with me he’s going in to hospital in the back of my ambulance or with the police if he resists. There’s no way you can be sure that the slurred speech, unsteadiness and incomprehensible answers arent the result of a blow to the face/head. Of course that may well be an old injury that has no bearing on his state but are you willing to stake your job and maybe his life on it? I wouldnt be unless they are witness’s there who can confirm that its an old injury and thats his normal state. GCS and competency dont have a bearing on it in my book, you treat the individual, not a set of bullet points.

  31. Well, as all i seem to get is adverts apart from the last 15 seconds I had to watch it twice. They guy seems to have a swollen and black eye which maybe an indicator to some sort of assault and head injury so basically unless he gets aggressive with me he's going in to hospital in the back of my ambulance or with the police if he resists. There's no way you can be sure that the slurred speech, unsteadiness and incomprehensible answers arent the result of a blow to the face/head. Of course that may well be an old injury that has no bearing on his state but are you willing to stake your job and maybe his life on it? I wouldnt be unless they are witness's there who can confirm that its an old injury and thats his normal state. GCS and competency dont have a bearing on it in my book, you treat the individual, not a set of bullet points.

  32. 1. He was a victim of an attempted robbery.

    2. GCS of 15

    3. Yes. He is aware of everything going on around him and to him, he *appears* to be an adult of legal age to make that decision for himself.

    4. This could absolutely be his normal mentation. I work in a rural area and there are a number of uneducated people who are hard to comprehend. I would like to ask his buddy if this is normal for him though.

    5. Again, I work in an area where a lot of people talk and have similar mannerisms as this gentleman and based off of this video I could not and would not attempt to put a finger on why he is acting this way unless through my questioning him or his buddy admit to alcohol or drug use. He does seem a little rattled by the events so that is possibly a factor in his behavior.

  33. 1. He was a victim of an attempted robbery.

    2. GCS of 15

    3. Yes. He is aware of everything going on around him and to him, he *appears* to be an adult of legal age to make that decision for himself.

    4. This could absolutely be his normal mentation. I work in a rural area and there are a number of uneducated people who are hard to comprehend. I would like to ask his buddy if this is normal for him though.

    5. Again, I work in an area where a lot of people talk and have similar mannerisms as this gentleman and based off of this video I could not and would not attempt to put a finger on why he is acting this way unless through my questioning him or his buddy admit to alcohol or drug use. He does seem a little rattled by the events so that is possibly a factor in his behavior.

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