Every Now and Then, You Win

“Hey Wanderer, there’s a guy in 32 that wants to talk to you.”

Great, I think to myself. It’s a complaint, or a problem, or something unpleasant. Prejudicial? Probably, but the way things have been lately it’s the reality. Head up, smile plastered on I head over to 32.

As I walk in I see a familiar face. He had been with us for about 2 weeks, dealing with the effects of alcoholic cardiomyopathy and most of us only gave him even odds to stay sober and in good shape. I had spent a lot of time educating, reinforcing and generally trying to help him beat the odds so it was good to see him because he looked like it all had worked.

“Hey,” he said, ” I’ve been sober now for 73 days thanks to you guys.”

We talked for awhile as he related everything that had gone on since discharge and how he had really turned his life around. It was nice to hear for a change.

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Banana Bags? I Got Them.

Crass-Pollination: An ER blog: Enough with the Banana Bags already.

Uh, yeah.  I’ll second that.

Unfortunately, our docs believe they can save every drunk and therefore, admit them all.  Of course all of them need telemetry monitoring because they are “tachycardic” forgetting that in tachycardia, you treat the underlying issue.  Y’know, like dehydration?  But no, these wonderful specimens of human existence get dumped on our floor for days, if not weeks while we dry them out.

A couple of weeks ago we had a nurse nearly knocked out by one of these assholes.  He got 4-point leathers and a ton of drugs.  The nurse got a concussion and no recourse but lost time and an injury.

Then there was the drunk who the doc didn’t want to send to the ICU and ended up needing more than 30mg of IV Ativan in a 12-hour shift, just to keep things to a dull roar.  Doc refused to send him even as he became more and more agitated and aggressive despite the Ativan, until the morning docs came to see him, where he promptly was sent to ICU for an Ativan drip in restraints.

My favorite of all times happened when I was an nurse extern.  We spent nearly 2 weeks drying this guy out.  Loads of Ativan, days upon days of sitters, thousands upon thousands of dollars worth of care.  The day he was discharged I saw him walking out of the convenience store 2 blocks from the hospital with a case of beer under his arm.  That was so worth it.

Our ED docs seem to have a major aversion to letting these guys (yes, they are 99% male) sober up a tad in the ED then kick them loose in time to get to detox to be admitted there – where they need to be.  We’re not going to save them.  If you have had 10 admits and 18 ED visits for ETOH in the last year, one more probably isn’t going to make a difference.

I am just so tired of it.

a caveat (there always is…)

I understand and know that delirium tremens can kill, that withdrawal seizures are just as dangerous and understand the pathophysiology behind chronic alcohol withdrawal, even the esoteric things like Wernicke’s  Encephalopathy, Wernicke-Korsakoff Syndrome and alcoholic cardiomyopthy and realize that admissions are justified in many cases, just not of the majority that I have encountered.  To me, ETOH is as good of an admitting diagnosis as “Incontinence”(not a neuro thing mind you) – in other words, full of crap.

In the Trenches NYE

Once again I found myself ringing in the New Year with co-workers.  Not that they’re not fun to be around, but it’s not like I can dance and kiss them at midnight.

It’s funny though to watch the admissions though the night.  Until midnight, there was nothing.  The ED was dead.  Just a couple of the usual detritus of abdominal pain, nausea/vomiting and the requisite psych hold.  But after midnight it was all ETOH-related.  ETOH/Fall, knee injury, ETOH, fall with back pain and since I was in charge of the observation unit as well that night, I was getting the calls.

“Yeah, we need an obs bed for a “syncope” patient.”  said the house supervisor

“Syncope huh?  You mean falling down drunk, right?”

And the night continued like that.  Syncope chick tested positive for coke, ETOH, a UTI and Trich.  But denied that she drank, takes drugs or smokes (we didn’t go into the sleeping around part…)  I learned that you could test positive for coke just by  being around people smoking meth!  I never knew!

All in all it was much the same as every other night.  But for a New Year, with a full moon it could have been much worse.

A True Professional

Nation & World | Driver registered blood-alcohol level of 0.708 | Seattle Times Newspaper.

RAPID CITY, S.D. — South Dakota authorities say a woman found passed out in a stolen delivery van last month registered a blood-alcohol content of 0.708 percent, nearly nine times the legal limit and a possible record for the state.

Some people are professional sportsmen, others professional poker players, some though are professional drinkers.  To end up with a BAC of .708 you kind of have to be a professional drunk.  While it may be outrageous, you kind of have to respect the dedication this would take.  Not to mention the cost involved.

Strong work!

Amateur

David Hasselhoff Alcohol Poisoning; Rushed To Hospital | RadarOnline.com

.390?  And passing out?  What a pussy.  How many times have we seen >.400 and lucidly carrying on converstaion?  OK, not that many, but have seen many higher than that and still semi-coherent, or enough to at least tell you to “Fuck off and leave me alone!”

Sure, many of these folks have more experience than “Mitch”, but hey, you can’t blame a guy for trying.

Or as KITT would say, “Michael” (in that smarmy sounding English accent) “I do belive that driving while in this condition is unadvisable.”

Dedication

A couple of nights ago we admitted one of our fine upstanding citizens after a fall on the ice.  He admitted to drinking 2 24oz.  beers to fortify himself for the trek to the local corner store to replenish his supplies while there was a lull between the snow and ice.  On admit to the ED he was lethargic, but woke on command and talked, albeit with slurred speech.  Not apparently that drunk and considering the large lump and laceration on his forehead, maybe he was still a little dazed.

They did the standard work-up as the sutured (poorly..) his laceration, including labs and a head CT.  The CT was negative for any acute process, but did show some atrophy.  Labs with one exception were relatively normal, kind of.

Any guesses what his ETOH level was?

A.  >10
B. 223
C.  499
D.  156

Not to mention issues with his ETOH level, he also had end-stage liver disease, status-post TIPS with esophageal varices and a history of seizure disorder.  Not exactly the most well-kempt of individuals mind you.  You could smell him in the hallway and he was far too lethargic to have him shower.  But back to his level.

If you guessed C., you would be correct.  Yep, 499.  Based on an online calculator, he would have had to drink 15 12oz. malt liquors in 1 hour to get a level that high.  2 big beers my ass.  He was dedicated.  Dedicated to destroying his young life.  And that was the kicker, he was only 38.  It’s sad and sick all at the same time.  The worst was that he had been doing this for many years to achieve the level of liver damage he was experiencing.  Unfortunately it seemed like the wasn’t going to stop and that the social safety nets in-place were either burned away or had completely failed.  And no matter what we as health care professionals did, he had continued to do this for years and probably wouldn’t stop until he ended up dead.  Which maybe was his ulterior motive in it all.  Now, when I crack open a beer I think about this case and realize how lucky I am.

Seeker vs. Wanderer: The Rematch

I knew this day would happen: he would come back to the floor. I recounted our last encounter here. And tonight he was on the census. A cold chill swept over me as I looked over that innocent piece of paper. I knew. He was part of MY assignment.

For those not into reading the back story it is thus: admitted for a CABG due to severe diffuse 3-vessel disease; history of multiple psychological issues not limited to polysubstance abuse and ETOH. Not exactly what I would call a good surgical candidate. Our first match ended in a split decision. He got some of what he wanted, I got a little of what I wanted.

Now after a lengthy stay in the Unit, punctuated by a bout of pneumonia, a PE, septic shock along with the expression of underlying psychosis and delirium as evidenced by agitation, belligerence and violence towards staff. He had spent a long time intubated, more to support him through the wonderful detox process than anything else. He had become very good friends with a variety of restraints. But no longer was he critical enough to keep in the Unit, intubated and sedated. So up to the floor he came.

I knew that right away I was going to have to set boundaries.  It was the first thing I needed to do.  So in I walked.  “Oh yeah, I remember you.” he said.  “Can I get some pain medication?”

“Not right not, I’m going to have to look and see when you’re due next.”  I responded.

“Yeah, but it’s time.  Right?” he countered with.

So I looked him in the eye and said, “Let me tell you what.  I will make sure you get what is prescribed, when it is due.  Not before.  I will do this.  Your part is this:  no comin’ out in the hall, harassing us, creating a scene any of that.  You up for this?”

“OK, but I know it’s time.” he said.

“Let me go look.”  Out in the hall I looked.  It was a long time until it was due.  And out into the hall he wandered.

“I wanted to tell you.  I was wrong.  It’s not due for another hour.  I was looking at the clock wrong” he admitted.

“Alright.  I’ll be back at  10…on the dot.”

So I kept going, working my tail off trying like mad to make sure that I was in that room when it was time. I knew that I was walking a fine line, putting my credibility on the line.  If I didn’t show, my credibility was shot, null and void.  If I came through, I could establish a level of trust that would keep him calm and make my experience a little easier.  I looked at the clock, I had fifteen minutes to give meds to another patient and be back in time to give away pain meds.  Yeah, right.

You see, if the IV was OK and not kinked, it would have worked out perfectly.  But like most things in nursing, perfect is pretty damn far away.  I spent a couple of minutes wrangling the IV, re-taping it, flushing it and ensuing it was still patent before giving out some steroids.  All of sudden my charge nurse pokes her head into the room.  “Do you have meds for Mr. S.?  He’s causing a scene in the hallway.”  Shit, I mutter to myself looking belatedly at the clock on the wall: 10:01.  He’s nothing if not punctual.

“Yep, got ’em right here,” I said hading them over to her.  I knew I was screwed, that I had lost the credibility and trust I worked to create.  A wave of anger swept over me.  Why was I so enthralled…no controlled by this?  Was it more than just self-preservation, or was it something deeper?  No matter what he thought, I was in control of the situation, I had to be.  I had set the boundaries and what I expected.  So I headed over to the room.  “Didja’ get your meds?”  I asked.

“Yeah, but they were late.” he said.

“But you got them.  I was involved, but you got taken care of.  Next dose it at 2.  I’ll be in then. Anything else you need?”  I came back with.  Nothing but sullen silence.  He refused the other evening meds, but did let me check a CBG.  Small battles add up to a larger war.

Fast forward to 2am.  In I go, give the meds and let him get back to bed.  “I’ll be back at 6.  I need to do vitals and draw labs, let me know if you need anything.”

At 6, I walk in.  Silence greets me.  “I bought your meds like I said.”   Nothing.  He just rolled over.  “You don’t want them right now?”

“No” he blubbered, “they don’t do anything anyways.  I just want to sleep.” he finished with a whimper.

“No problem.  I’m going to draw labs out of your PICC and leave you be to sleep.  Let me know if you need the pain meds.”  I said.

I realized what he was playing at.  Sympathy.  He wanted me to feel sorry and say, “Oh let me call the doc and see if I can get something that will work.” No, I was not going to play that game.  The docs knew and were aware of the situation.  They wouldn’t have given me anything even if I had called.  Back at the nursing station one of my colleagues said to me, “Did you hear what he said when he came out to get a drink?

“No, do tell.”

“Yeah, he pretty much said this:  I can’t wait to get out of this place. First thing I’m goin’ to do is get a 12-pack of beers, sit down and drink the whole thing.”  she said.

Great, I thought, we fix him and he goes back and does everything he could do to ruin all the hard work we did.  It made me mad.  I knew that it wasn’t an insurance company that was going to eat this.  No, it was working folks like you and me that were going to bear the burden.  Yes, your tax dollars hard at work.  Here we were, paying (indirectly if course) to save someone who really did even want to be saved and who vowed to undo all of it the moment he left the hospital.  Now I don’t have a problem taking care of folks who aren’t as lucky as I am.  In fact I would like to do more things to help out those who can’t help themselves.  But in this case it was all I could do not to tell him exactly how I felt, and it wouldn’t have been in the most socially-acceptable terms.  Many people see this as a chance to start fresh, like getting a new lease on life and try to do anything they can to make sure it sticks. They take the lessons to heart and become personally invested in the process.  Some don’t. They pass on the opportunity.  They’re the ones that will keep getting admitted.  The ones that we will again and again until they drop.  We’ll keep tuning them up and sending them back out, until they eventually stay for months at a time and maybe get a celestial discharge.  If we’re lucky.

But I digress.  He got discharged.  And hasn’t come back.  Yet.

Chalk this one up as a split decision too – ’cause I don’t think you can ever win in this situation.