Name my poison? ‘etoh’ in emergency room requests

September 14, 2010

I enjoy historical novels. Three of my favorites are London, The Forest, and Pillars of the Earth. One of the details I enjoy is the names.

I enjoy historical novels. Three of my favorites are London, The Forest, and Pillars of the Earth. One of the details I enjoy is the names. Tom Builder and John Mason leave little doubt what these men do for a living.

Names like Tipperwink and Justindoodle make you chuckle every time you read them. You have to wonder how those names originated. I assume Tipler says something about my ancestor's social proclivities.

Alcohol is a prominent part of life in much of the world. In the U.S., it plays a large role in healthcare. Like tobacco, it directly causes a number of diseases. Unlike tobacco, it also indirectly affects medical care, especially in the ER.

All night long I see etoh written on imaging requests from emergency rooms. It comes in an amazing array of contexts. Four simple letters are used to convey a wide range of clinical scenarios, imply an etiology for myriad problems, and explain away a textbook full of imaging shortfalls.

I wonder sometimes if such a lack of specificity is a good thing to have in the medical record. Not that we don't understand exactly what the situation is, but are we giving ammo to plaintiffs' attorneys? Given the Charles-Manson-likefervor The Joint Commission and hospital suits have for clear communications, I am surprised this is tolerated.

From across the country I see requests that say “AMS, etoh.” To me this translates as “altered mental status-the patient is drunk- we have no way of discerning if there is anything else going on in addition to his/her being drunk.”

Often I get an exam, usually a head CT, with motion artifact. The request will have some variant of “repeated scan, etoh.” To me this reads as “the patient is drunk and would not hold still for the exam. I tried talking to him and repeated the exam, but he still moved.” I think most radiologists would get the same message, and I think the communication is usually accurate in this setting.

Maybe it is my own personal bias, but sometimes I get the impression that there is an underlying attitude, an implied message, that the patient is not really ill, just drunk.

There is an undercurrent of maddening frustration that comes from having done everything right and someone else then screwing up your work. It is hard to put a finger on, perhaps the way it is phrased, or even the emphatic handwriting used on etoh.

Still, many times a night, I get the feeling I am dealing with frustrated technologists who are trying their best to get good images on an uncooperative drunk who probably just needs to sleep it off. They do their best, working hard to get diagnostic exams, which often still turn out less than optimal. We all understand this. The trouble is, as a resident once told me “Even turkeys get sick.”

What happens when an intoxicated patient has a real illness, the imaging and physical exam are compromised by his actions, and the diagnosis is missed? Who is to blame? My own bias is toward personal responsibility. However, I think our legal system has gone to an extreme in the opposite direction, and that is where these questions are ultimately answered. This is my problem with etoh. Does it in any way imply less than 100% effort by the caregivers?

The abbreviation etoh adds no information. In my mind it implies many things, but includes no facts. If the patient doesn't, or can't, cooperate for a scan, that should be written in the record, not etoh. If you repeat a scan for motion, that is what the record should say, not etoh. The first line of all my reports is the history written on the request, minus any reference to etoh.

I leave the etoh for the days when I am not working. Mine is a hard name to live up to, but I'm trying.