What next? (alcohol edition)

hand drowningAn emergency physician publicly and honestly wrestles with an all too common problem in emergency departments.

I’m an emergency physician at an urban hospital, and I see alcoholics every single shift, brought in by the ambulance “found down” — that is, found passed out in public places or belligerent on the streets.

When these patients get to the ER, it’s a remarkably underwhelming workup. We remove their urine-soaked clothes, put them on our monitors, and, for the most part, let them “MTF” — metabolize to freedom, which is to say they can leave when they can walk.

We’ll survey for signs of trauma or injury and possibly do very basic labs to check for gross metabolic abnormalities, but more often we just give them some IV fluids and vitamins. When they’re sober enough to make the bleary-eyed walk to the bathroom down the hall, I deem them stable for discharge and release them from whence they came.

It is undoubtedly one of the worst cases of “patchwork” healthcare that exist. Because while emergency medicine is by definition short-term care, we get to know our “frequent fliers” quite well — our noncompliant heart failure patients, gang members who just can’t stop getting shot, our end-stage COPD patients who still smoke a pack a day, our sickle cell patients, and yes, our addicts.

Just how powerless do they feel?

So the question begs, why do I as an emergency physician not do more to stop their disease, the same way I do for organic chronic disease? I do ask every alcoholic if they are ready to quit, as one of the central tenets of recovery is that the alcoholic has to want to quit. But nine times out of ten, they tell me, “Naw, doc, I’m cool,” as they eye their water bottle at bedside that smells suspiciously like Everclear.

So what is an emergency physician to do, who still has the rest of the room full of patients to take care of? You do what you can and tell them they will die if they continue on, give them the stock print-out of support resources that they inevitably leave behind with the dirty sheets, and hope you don’t see them again. If you want to go above and beyond, you can send the bright-eyed bushy-tailed medical student or the bleeding-heart social worker in to give it their best shot also.

A strange thing happens, however, after I receive some variation of the “Naw, doc, I’m cool” response: I ask them when they plan to have their next drink. I ask which liquor store they’re going to go to, how long it’s going to take for them to get there, and if they have money in their pocket for it. Because alcohol withdrawal is just as, if not more so, dangerous than alcohol overdose itself. There are few withdrawals from substances that can kill, but alcohol is the foremost of them. So they tell me they have their daily fifth of vodka still at home, they show me the bus pass they will use to get there, and I let them go and continue my complicity with their disease.

There are apparent issues with this form of addiction medicine, but most of all a resource one: with the emergency room so often just the purgatory between drinks for alcoholics, few emergency departments are actually equipped to offer these addicts the help they need beyond their acute intoxication.

I detect a bit of patient blaming here. That bothers me. But, the writer gets at the real problem here. It’s a systems failure. It’s clear from the article that they’ve got nothing meaningful to offer the patient. In that context, the helpers have no help to offer and, therefore, no hope to offer.

If these patients were offered real help with sincere hope, how many of them might give it a shot? And, once their engaged with helpers who have something to offer, how many of them could we get out of this cycle of emergency department admissions.

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