Thursday, March 06, 2008

The Ravages of Alcoholism

The patient was 44 years old. By the time I got to see him he was already on the ventilator. He was also on levophed (commonly referred to as "leave em dead") and dopamine, both to support a faltering blood pressure. I stopped to review the labs. What a mess! His bilirubin was 22 (normal around 1.5) and his other liver function tests were off the wall. He was anemic and his blood chemistries were not compatible with mammalian life. His ammonia level was 144 (normal less than 40). Ammonia is normally detoxified by the liver, and high levels seen in liver failure are thought to contribute to a depressed mental status known as hepatic encephalopathy.

The patient was indeed comatose and so my only history came from reading the chart.The patient had reported drinking about a quart of vodka a day, while smoking 2 packs of cigarettes a day. You would think that this was a combustible combination, but apparently he had not exploded and was simply found down on the kitchen floor.

I entered the room only to feel the shifting air pressure, to catch the flitting shadows in my peripheral vision. The Angel was already on the job.

"Hey!" I said, "Give me a chance to examine the guy."

The laughter was unnerving, as usual, and the voice still scared me a little.

"Don't waste time on this one, I am here to collect him."

"How do you know I can't save him? Some times the liver can heal once you stop the booze."

Again, the rasping laugh. "Yes. You could save him so he could live to drink again."

He had a point. I went about my exam, first checking the drips and the monitors. Pretty grim. Max doses of pressors, vitals marginal. He was a deep yellow bronze, jaundiced from his liver failure. His belly was distended and tense, filled wih the fluid of ascites. His feet were quite swollen, when I squeezed, my fingers left deep imprints. At this point the family, sister and mother, came in.

I introduced myself and then reviewed his condition with them. I closed my remarks by stating that his condition was terminal and that he had no chance at all of survival. I braced myself for a hostile argument, but it didn't come. They were both exhausted, undoubtedly by years of cleaning up the mess left by an alcoholic son or brother. What I saw was mostly relief. They asked a few questions and then agreed to withdraw support. We stopped his IV fluids and pressors, and he died within 5 minutes.

I scanned the room for the Angel, but felt nothing. I went outside to write a note. This man was only 44, younger than me by ten years, but he had drank himself to death. It appeared that he had also tortured his family along the way. Now maybe all involved could move on. I tried to picture myself in their situation, one of my beautiful sons dying in an ICU at only 44 years old, but the images wouldn't come, it just didn't compute. I did resolve to appreciate my good fortune, and cherish every minute I had with my children.

I finished my note and left the ICU, already dialing my wife's cell just to say hello.

3 Comments:

Anonymous Anonymous said...

Ten years ago on March 10 my mother-in-law died from the ravages of alcoholism at age 55. It's a very similar story, I'm sure told over and over again. The family put her on life support, due to her wishes, and waited. The ICU Doc (perhaps you?) gently counseled the family that there was no point after about 24 hours. They removed the support and she died. However, the angel had come and gone many hours before. The family has moved on, but she haunts us in subtle ways. Regret and guilt hangs in the air and we all wonder what we could have done differently.

10:42 AM  
Anonymous Anonymous said...

We get a lot of similar patients in our ICU as we have a large Liver transplant service, it's difficult to balance feelings of both compassion and blame with end stage EtOH patients

11:25 PM  
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