The Damaged Eyes of Alcoholism

I walked into the dimly lit treatment room, Room 31, to find my next patient quietly and calmly lying in her cot. She had curly graying hair which, when added with the deeply creased wrinkles of her face, made her look much older than her stated age. Despite her attempts to welcome me with a warm smile, her greeting seemed forced. Her smile was but a thready, thin blanket failing to cover the the cold of her pain.

The pain of an alcoholic.

Standing in the corner, huddled together as a unified front, stood two teenagers. A boy and girl. Unlike their mother, they made no attempt to cover their worry. Their appearances were youthful--Converse Chuck Taylor sneakers, straight-legged jeans, graphic t-shirts, and hip stylish haircuts. But their eyes, those pained and aching eyes, bore an unfortunate truth to the years of sadness they had endured. Of their lost innocence.

I introduced myself to the patient before focusing my attention a little more closely on her children. Despite their worry, they were gracious in returning my hellos, introducing themselves.
I turned back to the patient. "Ms. Smith," I asked, "what happened that brought you to our ER this evening?"

Ms. Smith looked at me blankly, a confused haze slowly overtaking her face. I spoke again. "Do you know why you are here this evening?" She continued to stare at me, worrying me with her silence, before eventually nodding her head "no." She spoke. "I have no idea what happened."

I turned to her children. "Can either of you tell me what happened with your mother?"

The son stared down at his feet in response to my question. The daughter, however, connected with my eye contact and spoke up as she nervously tucked her wispy, blondish curls behind her ears. "I think she had a seizure." She got quiet then, her eyes getting more glassy as we continued to hold one another's gaze.

"Please, go on," I encouraged her and she bravely continued her story. She and her brother had been out and, upon returning home, had found their mother lying on the kitchen floor, unresponsive. An abrasion on their mother's forehead and a bleeding tongue greeted them upon closer inspection. After finding a pulse but failing to arouse their mother with yelling and shaking her flaccid body, they called 911. They all rode in the ambulance to the ER. They later put together, with the help of the paramedics, that their mother had probably had an alcohol withdrawal seizure. "She tried to quit cold turkey a few days ago," the daughter continued, shaking her head, "and I told her she needed to go somewhere to get some help."

The mother, intently witnessing her children struggling, started crying as she spoke. "I haven't had a drink for two weeks, honey."

With her words, the son looked up from his feet. "No, Mom, that's not true. You were drunk just over the weekend." The mother offered no excuses to his words.

Just then, the room's curtain pulled open and in walked a middle-aged man, his face strongly resembling the children's faces in both looks and worry.

"Daddy," the girl exclaimed, jumping away from her brother and into her father's arms. "Hi Dad," the son added shyly, giving his father a brief smile before turning his eyes downward again. His pain was palpable.

"Hello, sir," I said, introducing myself, "you must be Mr. Smith."

"I am," he replied, thanking me for taking care of his ex-wife. He turned from me back to his children. "Are you both okay?" he asked, pulling them into his chest for a hug. I caught my breath at his genuine display of love and concern for his kids. It was just what they needed at just the right time.

The kids smiled and looked up into their father's eyes, nodding their heads "yes." Their worried eyes relaxed and I was able to see some small sparkles mirror off their reflection as they continued gazing at their father.

Before turning to a physical exam, I asked a few more questions. It turns out that this patient had an extensive alcohol abuse history. Eight years prior, she had successfully completed an alcohol rehabilitation program and had remained sober for six years, before succumbing to alcohol's temptations again just two years earlier. According to her children and ex-husband, the past few years had been "hell" and had affected all of their lives in a very gloomy, detrimental way. They were just nearing the point of giving up on her, I'm afraid, when two weeks back, the patient announced to her family that she was done with alcohol "for good."

"That didn't last long, though," the son added, "because she got drunk that very night and passed out."

On exam, this woman appeared very fatigued, both mentally and physically. She did have the forehead abrasion that the kids had noticed on their kitchen floor, her eyes nervously flittered horizontally (known medically as nystagmus) within their reddened borders, and her tongue, on the left side, was bitten. Her vital signs were stable and the rest of her exam was unremarkable. It was evident that she had had some type of seizure, most likely an alcohol withdrawal seizure.

We did a full work-up. Her head CT was negative, her labs reflected dangerously low levels of both magnesium and potassium (which we began immediately replacing via her IV), and her alcohol level was zero. Besides addressing her electrolyte imbalances, we also gave her IV multivitamins, hydration, and thiamine to protect her damaged body.

We admitted this patient, much to her family's appreciation. She needed specific medical attention for her alcohol abuse and withdrawal seizure. After arranging all of this, I went back into her room to find this patient and her family much as I had left them, with much love being shared between the children and their father and their mother quietly sitting in the cot observing her children. There was much sadness, for me, from the many facets of this scenario.

"Maam," I said, after reviewing her work-up and disposition, "do you want to stop drinking? Will you accept some help for your problem with alcohol?"

Her answer was music to my ears, and it came without hesitation. "I have to stop drinking," she said. "If not for me, I need to do this for my kids." She paused and looked at her kids, who were now watching her intently. "I love you both too much to continue on this path anymore." With those words, both kids gingerly walked over and wrapped their arms around their mother, the daughter now openly weeping.

How do I know this patient was sincere about wanting help? As I spoke to them about their options for several available in-patient rehabilitation programs, she seemed to be intimately familiar with most of the options. This mother had done her research and had begun taking her own steps toward sobering up and becoming the mother she could be to her children again. She appeared very sincere in wanting nothing more.

I looked at both children hunched over the railings on either side of the treatment cot as they hugged their mother. Despite the daughter's weeping and the son's hesitancy, I could see that their eyes, despite their sparkling and youthfulness just minutes earlier as their father had hugged them, had become edgy, wistful, and nervous again. Old and young and, unfortunately, back to old again, reflecting their aged, hurt souls.

I am not naive. I know it is going to take a lot regained trust and renewed love to keep these children's eyes permanently young. To erase the damage caused by their mother's alcoholism.

Then again, maybe I am naive, because a large part of me thinks that this mother can succeed. For her children's sakes, I can hope for nothing more.

As always, big thanks for reading. I hope your holiday weekend is a good one. Next posting will be Monday, July 5. See you then...

Who Am I Treating?

Occasionally, as difficult as some patients may be to treat in the ER, for whatever reasons, that difficulty may be nothing compared to the stress and negativity brought to the encounter by their accompanying family members or friends. People who "know the patient more than they know themselves" and don't hesitate to try to dictate the course of therapy for the patient.

Don't get me wrong, I appreciate a family's or friend's input greatly. In fact, I welcome it. Sometimes, even, they can be a greater source of the patient's history than the patient himself.

But...sometimes the support person can be totally and completely obnoxious and abrupt in how they choose to communicate with our staff. "Demanding" is a word I hear often. They just know that the patient needs two pillows. Three warm blankets. A new pair of footies. A turkey sandwich. Some ginger ale, not orange juice. The patient likes to lay on their left side, not their right. They need this and this and this test, but not that one. Oh, and by the way, where do they go to get their parking ticket reimbursed for free parking?

I recognize that sometimes this is simply a vain attempt by the visitor to have some sort of control over an uncontrollable situation, sure. A spouse trying to make her sick husband comfortable. A parent trying to ease their child's pain. A best friend trying to step-up to ensure proper treatment. I fully understand all the reasoning behind these situations. More importantly, though, I respect and applaud their advocacy.

Unfortunately, though, sometimes a visitor's intentions can be detrimental to the patient, if the patient is an adult, is coherent, and can easily verbalize their problems and symptoms by themselves.

I was sitting in my hallway seat, several months ago, when I observed the triage nurse escort two women to Room 27. One woman appeared to be in her sixties, the other in her thirties. The older woman appeared irritated, grumpy almost, while the younger woman was smiling and walking alongside the older woman. Neither appeared in any distress.

Within minutes, the patient's name appeared on our computerized list of waiting patients, so I clicked on it. Surprisingly, it was the younger woman who had checked in as the patient.

I walked into the room to find the younger woman sitting comfortably in the treatment cot, a gown draping her thin frame, a smile still on her face. The older woman, who by now I assumed was the patient's mother, sat in a chair under the corner TV. She was still scowling.

I approached the patient first, my hand extended. "Hello, Ms. Brown, I'm Dr. Jim. Nice to meet you, maam." She extended her hand and we shook. "Hello," she returned, meekly. From the corner of the room I heard the other woman speak. "And I'm her mother." I left the patient's side and walked up to the mother, my hand still extended. The mother eyed my hand for several long uncomfortable seconds before finally extending her own. "Nice to meet you, maam," I added after our handshake.

I went back to the patient's bedside. "Ms. Brown," I started, "what can we do to help you today in the emergency room?"

And before Ms. Brown could even begin to answer, her mother started in. "Kathy has a seizure problem and we are due for our yearly neurology appointment and thought we would come here to get everything done."

"In the ER?" I asked. "Yes," said the mother, continuing. "She needs an EEG, an MRI, and you may as well just call the neurologist down to see Kathy as long as we are here. That way, we won't have to waste a day going to their office."

I turned back to Kathy. "Kathy," I said, "how long have you had a seizure disorder?" From the corner of the room, I heard her mother answer. "Since she was seven." I continued focusing my full attention on Kathy. "And Kathy," I said, "have you been having an increase in seizure activity?" Kathy nodded her her head "no" while, again, from the corner of the room, her mother piped-in. "No, it's just time for her annual check-up." Again, I kept my focus on the patient. "Kathy, has there been any changes recently to your anti-seizure medications?" Again, as Kathy nodded "no," I heard the familiar, interrupting voice. "Eight months ago, the doctors increased her dilantin, but otherwise she has been on the same medicines as always."

I had finally had enough. "Kathy," I asked, holding my index finger up to the mother, requesting her to wait, "are you okay to answer my questions? Or is there a reason your mother keeps answering for you?" Kathy looked at her mother to me. "No," she said, "I guess my mother just always likes to be in charge." From the corner of the room, the mother yelled out, "I do not, Kathy."

I looked at the mother and cocked my eyebrow. "What?" she asked, "I haven't been answering all of your questions." "Yes, maam," I assured her, "you have." Her scowl deepened. "I appreciate you trying to help, maam," I said, continuing, "but this is what we are going to do. I am going to ask Kathy all of my questions and then, when I finish, I will give you a chance to add whatever you want, okay?" She dismissed me with a roll of her eyes and a shrug of her shoulders.

So, I had two problems on my hand. A mother who wanted to interrupt my history-taking with every question addressed to her daughter. And, a mother who wanted an extensive work-up and consult that, unfortunately, wasn't going to happen the way she had hoped for her daughter.

Well, I guess it was just one problem, really. A vocal, demanding mother.

After I finished my interview with Kathy, who did a fine job of telling me about her history, I looked toward her mother. "Do you have anything you'd like to add, maam?" She just "humphed" at me and remained quiet. I proceeded with a physical exam that was completely unremarkable.

The triage team had ordered some baseline blood work and some medication levels on Kathy and, after those results were posted, I went in to speak to the women.

"Well," I said, "I have good news. All of your blood work has returned satisfactory. Including your anti-seizure medication levels."

Kathy gave me a grateful smile as her mother spoke up. "But what about her EEG and MRI and neurology consult? Aren't you going to get those done now?" I explained to the mother that those tests, as well as Kathy's neurology appointment, had already been scheduled and that I wouldn't be able to provide those tests through the ER. Not without an emergency concern. And, trust me, there was no emergency concern.

"But," the mother said again, speaking up, "Kathy hasn't been feeling well recently. I want all of those tests done now. We'll wait for the appointment, if that helps."

I assured the mother, again, that Kathy had a great exam, great blood work results, and would need to move forward as planned by her neurology team. In all honesty, I told her, I wouldn't even be able to get this requested workup for one of my family members, unless it was a new-onset seizure or the patient was in status (a seizure that won't stop).

"Kathy," I asked the patient, "are you okay with everything?" "Of course," she answered, sincerely, "I didn't want to come today. Mom thought we could get everything done early so we wouldn't have to waste a couple days next week."

Out of courtesy, I did call the resident on the neurology team to make them aware of this patient's treatment in the ER. They whole-heartedly agreed with our ER approach, reiterating that this patient would need to keep her outpatient appointments.

I discharged this patient to home, knowing that there was no way I was going to make this mother happy. As they walked out of Kathy's treatment room and down the hallway, I noticed that Kathy still was smiling, while her mother maintained the scowl that prevailed during her time with us.

I had to wonder to myself how Kathy maintained such a happy state. I hope her smile was genuine.

The best I could hope for, I guess, was that Kathy, and not her mother, would get the hospital questionnaire. And that she would get some good results from her non-emergent, outpatient-testing, too.

If only we could just make everyone happy...

As always, big thanks for reading. I hope you all had a great weekend. Although I'm traveling for work the next few days, the next post should be on Wednesday, June 16. See you then...anyone with similar stories to share?