Injured and drunk in the emergency department

We are missing the opportunity to get impaired drivers off the road and into alcohol treatment.

Managing injured, intoxicated drivers is an issue of significant importance to emergency departments. Emergency phy­sicians see more than their share of victims of vehicle crashes in which alcohol played a key role. In 2005, alcohol was a contributing factor in over 28% of all police-reported fatal motor vehicle collisions in British Columbia—127 people were killed and 3400 were injured. 

Injured, intoxicated drivers treated in emergency departments are likely to have a history of heavy alcohol consumption, a high incidence of alcohol abuse, and alcohol dependence. They often have a history of impaired driving and continue to drive drunk even after their visit to emergency. Other jurisdictions have shown that licensing sanctions combined with remedial programs resulted in the greatest reduction in alcohol-related driving incidents.[1]
 
However, in Canada injured, intox­icated drivers are rarely subjected to any licensing sanctions because they are rarely convicted of impaired driving. Two studies have been completed in Canada that evaluated the proportion of injured, alcohol-impaired drivers who are subsequently convicted of an impaired driving Criminal Code offense. 

Results from the first study, undertaken in British Columbia, found that 11% of injured, intoxicated drivers who are treated in hospital are convicted of impaired driving.[2] In the second study, characteristics and conviction rates were entered into the regional trauma registry for injured, alcohol-impaired drivers admitted to hospital in the Calgary Health Region. The conviction rate was 15%.[3] 

These low conviction rates are in stark contrast to the conviction rates of injured, impaired drivers in other comparable democracies—jurisdictions that have different laws, policies, and procedures. In Victoria, Australia, for example, more than 90% of injured, intoxicated drivers are convicted of impaired driving. In Sweden 85% of alcohol-positive hospitalized drivers are convicted of impaired driving. 

There is a reason why the conviction rate of injured intoxicated drivers is so low in this country. The current blood seizure provisions of the Criminal Code are complex and unworkable. As a result, the overwhelming majority of impaired drivers who kill and injure other road users are not charged, let alone convicted, of the serious crimes they commit. 

The current law has made hospitals a safe haven for these offenders. The primary reason for the dramatically higher conviction rates in Sweden and Victoria, Australia, is the broad legal authority given to the police to de­mand breath and blood samples. Even impaired patients not convicted of impaired driving could still be reported to the Office of the Superintendent of Motor Vehicles (OSMV). 

BC’s Motor Vehicle Act requires that health professionals report a patient to the OSMV if that patient has a condition that may affect driving and the practitioner has advised the patient not to drive and the practitioner is aware that the patient continues to drive. 

In over 25 years of practice in a busy emergency department I have never seen a patient who fulfilled this requirement for mandatory reporting to the OSMV. Following the letter of the law, I would have to see patients after a car accident, advise them not to drive, see them again in the emergency department, and be told that they were continuing to drive in spite my advice. 

In 2005, BC introduced a remedial program that all criminally convicted drinking drivers are required to complete. Also, the superintendent can require the program be taken based on driving record (for example, Motor Vehicle Act drinking driving convictions) or when medical evidence exists of alcohol addiction (such as a report from a GP), even if there is no criminal conviction. 

If a driver doesn’t complete the course, his or her driver’s licence will be canceled or remain canceled. As a condition of relicensing, the superintendent may require the driver to install an ignition interlock device in their vehicle. The program will be evaluated in 2009.

Counseling should start as soon as possible. Visits to the emergency department can be a window of opportunity in which alcohol counseling can be very effective. Unfortunately, this counseling is not readily available. Although some hospitals have in-patient chemical dependency resource teams, it is often difficult to arrange for a patient to receive alcohol counseling in the emergency department. 

When an injured, alcohol-impaired driver is treated in the emergency department, the opportunity to apply the strategy of a combined approach of licensing action and counseling is, therefore, almost always missed. 

The Emergency Medical Services Committee has drafted a number of resolutions for consideration by the BCMA that would do a great deal to help solve this serious problem. We urge the Department of Justice of the Government of Canada to amend aspects of the Criminal Code related to the offence of impaired driving in the circumstance in which the alleged intoxicated driver has been injured and is being treated in a hospital. 

Changes to the legislation need to be implemented so that injured drivers with alcohol abuse problems can readily be reported to the OSMV. We recommend that alcohol and drug abuse counseling be promptly available to every patient injured in a motor vehicle crash and who has a blood alcohol level greater than 17.3 mmol/L. 

This alcohol counseling should be made available to pa­tients in the emergency department prior to discharge and be offered to patients in hospital if they are ad­mitted and on an outpatient basis if they are discharged. We all know of the carnage that drinking drivers can cause. Effective strategies are required to deal with this problem, and we should all push hard to have these strategies implemented. 

—Roy Purssell, MD
Chair, Emergency Medical Services Committee

References

1. McKnight AJ, Voas RK. The effect of license suspension upon DWI recidivism. Alcohol, Drugs Driving 1986;7:43-54.
2. Purssell RA, Yarema M, Wilson J, et al. Pro­portion of injured alcohol-impaired drivers subsequently convicted of an impair­ed driving criminal code offence in British Columbia. Can J Emerg Med 2004;6:80-88. 
3. Goecke ME, Kirkpatrick AW, Laupland KB, et al. Characteristics and conviction rates of injured alcohol-impaired drivers admitted to a tertiary care Canadian Trauma Centre. Clin Invest Med 2007;30:26-32.