Today’s Burning Question: I am a firefighter paramedic and we were told that noting in a patient care report that we suspect that a patient is under the influence of alcohol can get us into trouble. In fact one paramedic reportedly got ripped apart in court by even using the word alcohol in his report. What are we supposed to do? If I write in my report that the patient smelled of alcohol am I really sticking my neck out?
Answer: Like most questions that are asked of an attorney, my answer has to start with the obligatory: “it depends”. In this case it really does depend.
It is “possible” that a paramedic who puts in a PCR that a patient is “under the influence” or perhaps simply notes “ETOH”, will incur the wrath of a skilled trial attorney. Any time an attorney wants to discredit a medic he will scour the report searching for “low hanging fruit.” One such “low hanging fruit” that attorneys may seek to use on cross-examination are conclusions such as “ETOH”.
That is why it is so important for paramedics and firefighters alike to write their reports stating FACTS not CONCLUSIONS. The report needs to state the facts upon which the conclusion is based so that the reader is led to the conclusion WITHOUT the report writer even having to state it.
In the case of a patient who appears to be intoxicated – recognize that intoxication is a conclusion. Like any conclusion that we reach, the conclusion must be based upon facts. Simply state the facts upon which the conclusion is based: The patient was unsteady on her feet, spoke with slurred speech, had bloodshot eyes and had a beer-like odor on her breath.
Even better would be another statement of fact: “Patient stated she consumed four beers prior to feeling ill.” Facts are things that you observe with your own five senses: sight, smell, touch, hearing and taste (try to avoid the last one on runs when ever possible…).
Get in the habit of writing down facts and avoiding conclusions when writing reports. Besides making any cross examination go better, the facts will be there for your recollection. Two or three years later when you are called upon in a deposition or at trial to recollect an incident from a report, the facts you include will be there to assist your recollection. A simple conclusion of “ETOH” will likely be of little to no help.