Pickled Potential

Many people will have the view that Emergency Departments are inundated with patients suffering the effects - directly or indirectly - of alcohol, and that this must be particularly true at the weekends.  

The truth is that somewhere between 1 in 4 and 1 in 5 of attendances to EDs are related to alcohol.  This is quite a number:  80 or so patients a day, close to 600 patients a week, up to 30,000 patients a year in the ED at the Royal Infirmary of Edinburgh alone.

The spectrum of presentations is similarly vast, and this weekend just gone highlighted this in stark fashion.  Again, the common perception is that these numbers represent minor or moderate injuries caused by intoxication and misadventure, the consequences of alcohol-fuelled disagreements, or more serious road traffic accidents or falls.

However, there are other serious effects of alcohol misuse that cross the divides of age, social class and underlying health, and have profound and damaging effects on patients and their families.

Greg has come to the ED for the fourth time this year.  He is in his early 20's, has a trade which he has been unable to employ for 18months, and has presented requesting a "detox".  He is one of 5 patients I reviewed this weekend who were suffering the effects of acute alcohol withdrawal, and he looks awful.

He is pale, sweaty, restless, vomiting profusely and has the rapid tremor and anxiety that is typical of alcohol withdrawal.  His pulse is rapid, his senses are heightened and "jangling", and he wants help.

"I just need a couple of days in hospital, Doc.  I need to stop."

He has been without a drink for about 36hours or so, and has been given a sizeable but appropriate does of medication to ease the withdrawal after arriving through our triage process. 

"I feel like I'm going to fit." 

The poignancy of a 22yr old knowing the likely course of alcohol withdrawal is not lost.

Nonetheless, he may be right - he is still at risk of suffering a seizure at this point of withdrawal unless the medication starts to dampen his body's response shortly.   This is our first priority - to ensure that the physical effects of rapid changes in substance use are managed safely and without complications such as seizures, abnormalities in the salt balance, or bleeding in the gut or elsewhere.

3 cubicles along, I have just come from a conversation with a 42 yr old man, whose Father is also requesting an admission for his son. 

"His mother can't deal with him..."

He tells me his son's impressive achievements in many fields, including bronze sculpting, before the demon drink took hold of his life.  It is heartbreaking to hear him plead on behalf of his boy, and I momentarily drift into thinking "what would I do if this was one of my sons on the trolley?". 

The impact on families as a whole is enormous, the lost years and potential to society so crushing, and I am sure that we only see a small proportion of the cases in the ED.

So what can we offer in an acute hospital setting?  We are well set-up to offer help and treatment during the acute withdrawal phase, and can point patients and families to community services that offer support, advice, and a framework for changing the habit of alcoholism. 

What we can't do is exorcise the demons that nudge folk to make the choices that damage themselves and others.

After an hour or so, I go back to speak to Greg.  He is much more settled and many of the effects of the withdrawal are now resolved.  I ask him:

"What makes you drink when you are at home?"

He describes his routine, the influence of "friends" who come round to his place with litres of spirits and cider, and how hard it is to resist.

"How is that going to be changed by a couple of days in hospital?"

There is no answer.  These are incredibly difficult social situations to disentangle, but for every admission to hospital, we have to ask "what value does it give to the patient"?  It does, after all, have its associated risks, as does any intervention.

Does this represent a lack of compassion, reasoning, or understanding for a life course I couldn't possibly understand? I dearly hope not, and in the end, Greg leaves the ED feeling better, with some advice about how to use some medication to help his progress, and with all the contacts for his community services.  In the end, it will be up to him to decide his own path.

On the other side of the ED, I am called to a lady who feels like she is drowning whenever she lies flat.  There is fluid tracking up from her belly, filling one whole side of her chest, and constricting her neck.  It has accumulated because her excessive alcohol intake has destroyed her liver to the extent that it has become a withered knotted remnant, forcing fluid out into her abdomen.  Her path is far more certain unfortunately.

Everything in moderation.