Patients with altered mental status can challenge medics. Managing such patients is fraught with pitfalls that can be medically and legally significant.
You are called to a residence in an upscale neighborhood to assist police where a teenage party has been going on. No adults are present. Called by neighbors because of excessive noise, police found a young female, minimally responsive and possibly overdosed on ETOH/drugs, lying on a sofa and responding only to loud verbal and painful stimuli. Her responses to your questions consist mainly of curses, "Leave me alone," and pushing you away. Her appearance and vital signs are as follows:
Hot, dry, pink skin;
Pulse: 126 bpm;
Tympanic temperature: 100.5°F;
A patient with an altered level of consciousness should be approached carefully and in a nonconfrontational manner. Patient rapport is essential to obtaining a thorough assessment.
Observation of the patient's surroundings may yield valuable clues. Is there evidence of ETOH or other drug ingestion, such as drug paraphernalia, empty bottles or telltale smells?
Assessment of the patient with altered mental status must include the following key elements:
1. Level of consciousness. Is the patient aware of his surroundings? 2. Attention. Is the patient able to focus or concentrate on one task at a time, or is he easily distracted? 3. Memory. Can the patient record data in the brain and repeat it at will? Thorough assessment of memory includes short-term memory, such as the ability to repeat a sequence of objects several minutes after they are first introduced, and long-term memory, such as the names and birth dates of family members or being able to repeat the alphabet. 4. Cognitive ability. Can the patient process abstract thoughts coherently, such as explaining, "Why can't pigs fly?" Can he perform simple math or word problems, such as "Subtract 7 from 100 as many times as you can," or "Spell the word world backward?" 5. Affect and mood. Affect is an objective assessment of the patient's demeanor and reaction to stimuli, while mood is a more subjective assessment of the patient's emotional state. Are both of them appropriate for the patient's current situation? 6. Probable cause of the present condition. What is the underlying pathophysiology causing the patient's altered mental state? One commonly used mnemonic is AEIOUTIPS:
Alcohol, ingested toxins;
Epilepsy, endocrine, exocrine or electrolytes;
Overdose, opioids or oxygen deprivation;
Infection, inherited defects;
Stroke, shock, space-occupying lesions.1,2
1. What's your name? 2. Do you have any medical problems? Are you seeing a doctor? What medications do you take? Can you show them to me? Have you had any alcohol or recreational drugs today? 3. Will you play a game with me? Will you try to remember three things I'm going to tell you? Book, candle, scissors. Repeat these to me. [Continue until the patient can repeat the three objects. If he cannot, the test is failed.] 4. Where are you right now? 5. What day is it? 6. What's your Social Security number? 7. What's your birthday? 8. Where were you born? 9. Say your ABCs, starting with G and ending with S. 10. Count backward starting with 13 and ending with 4. 11. Spell world backward. 12. What were the three objects I asked you to remember? [book, candle, scissors] 13. Take this sheet of paper in your right hand and read and do what it says. [It says "Close your eyes."] 14. Take the piece of paper I handed you and fold it in half and then in half again, and then place it on the floor (table, etc.).3 What constitutes failure? Failure of one or more of the tests indicates lack of present mental capacity to make an informed decision about treatment.
Not every case requires the full status exam. But one must always document the findings in terms of facts, not conclusions. Rather than documenting conclusions without supporting evidence, such as AAOx4, document your questions and the patient's responses that led to your conclusion.
It's not enough to evaluate a patient's mental status; also take into consideration underlying conditions that may be responsible for the diminished LOC and rule them out.
A patient with diminished mental status must be evaluated carefully to rule out organic or traumatic reasons for the condition, as well as to identify possible causes, such as drug ingestion.
Note: Laws allowing law enforcement officers to arrest for mental impairment vary from state to state. Become familiar with your local laws and practices.
Never assume your patient is malingering or does not have a legitimate medical complaint. Such assumptions will land you in court in a lawsuit you cannot win.
Measure your patient's current mental status with proven techniques--make no assumptions. Document questions and responses.
The medics in this case determined their patient had not ingested ETOH but had taken several ecstasy tablets given to her by other people. She had no idea of the possible consequences of her ingestion, and she refused to answer questions about her mental or physical status.
Based on her responses and history of drug ingestion, the medics determined this young woman did not have the present mental capacity to understand her condition and make rational treatment decisions. They enlisted the help of the police, who placed her in custody, and treated and transported her upon their order.
Steven "Kelly" Grayson, NREMT-P, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He has spent the past 14 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a former president of the Louisiana EMS Instructor Society and board member of the Louisiana Association of Nationally Registered EMTs. He is a frequent EMS conference speaker and the author of the book En Route: A Paramedic's Stories of Life, Death, and Everything In Between, and the popular blog A Day in the Life of An Ambulance Driver.
William E. (Gene) Gandy, JD, LP, has been a paramedic and EMS educator for over 30 years. He has implemented a two-year associate's degree paramedic program for a community college, served as both a volunteer and paid paramedic, and practiced in both rural and urban settings and in the offshore oil industry. He has testified in court as an expert witness in a number of cases involving EMS providers and lectures on medical/legal aspects of EMS. He lives in Tucson, AZ.