Wednesday, May 31, 2006

The Demon Drink

Mrs Bellamy came in a month or two ago. She was feeling a bit below par. Lost appetite, heartburn, bit of upper abdominal pain. We talked about lifestyle, and being a bit of a bonne-viveuse she admitted to at least a half a bottle of wine a day. For years.

Apparently the whole "units" thing had passed her by completely. When we sat down and added them up she came in at around fifty a week. Or around four times the recommended level. That said she had none of the hallmarks of dependence. She felt no need for an "eye opener" first thing, didn't find herself worrying where her next drink was coming from, had never been embarrased or discommoded in any way by her drinking.

Still it sounded likely her symptoms and alcohol had some connection. We agreed she would do some bloods and come back for the results. Meantime she agreed to look at her drinking.

Sure enough her liver function was very distorted. The enzyme most commonly implicated in long term alcohol use was significantly raised. (Normal values are up to around 45, hers chimed in at around 500.) She was also very slightly chemically jaundiced with a bilirubin just outside the normal range though there was no observable yellowing of her skin or eyes.

Knowing all of this she stopped drinking. Just like that. No weaning off. No drugs to cover withdawal. And no withdrawal symptoms at all.

Within a month her bloods were improving. Bilirubin back to normal. Enzyme level around 150. Symptoms all abolished. After another month her blood picture returned to normal. She has been dry now for 4 months and has a clean bill of health. She's very pleased. She now knows all about units, and might even go back to the odd glass of wine on occasions, but overall it looks like she is determied to stay well and not to go back to her past habits. We are often sceptical when patients tell us this, but I an inclined to believe Lillian. She has never presented as though she were dependent and very rapidly took the right steps to look after her health once the problem had been identified.

I can think of at least a dozen other similar cases where I have not been able to persuade them to curtail their drinking, and have sat here powerless to do more than chart and react to their inevitable decline, but once in a while someone like Lillian comes along and shows that there is an alternative.


Z said...

Oh dear. That'll probably be me in another decade or so.
*Memo to self* keep well away from the doctor and his all-too-revealing tests.

MJ said...

At least some patients listen to what you have to say then and take notice of their test results. The ones I come across take no notice of their (usually abnormal) test results and discharge themselves against medical advice.

You've proved there is hope in this world.


Doctor Jest said...

z-- it only starts to matter if it makes you feel poorly or gets out of control. I'm sure you need not worry on either count ;-)

mj-- oh dear. Sounds like a bad day at the coalface. I'm sure you didn't really need me to tell you there is hope. Why not pull up a chair and tell me all about it...

ex-alcoholic said...

After years of serious drinking, I gave up alcohol about 12 years ago - doing without the fuzzy brain every morning was the easy part. What was harder was losing a social life, because of no longer going into pubs, or drinking at friends' houses. ALL English social life revolves around alcohol.

Doctor Jest said...

ex-- very true. especially in the "open all hours" "footy on the big screen" era. And from personal observation we seem intent on exporting this to most of coastal europe too :-(.

Congratulations on 12 years. What have you found to replace the social loss if you don't mind my asking?

Z said...

Thank you, yes I'm fine. I stopped drinking for a month last summer (in run-down to daughter's wedding) and was reassured to discover that I felt no different at all.

In the pub, friends cheerily accept you as a non-drinker - but what do you have if you don't want sweet or fruity drinks? Water? Makes you a cheap date, but hardly convivial.

Doctor Jest said...

z-- It's getting easier to ask for a coffee some places. Occasionally what they give you is almost drinkable. Then again I am a terrible coffee snob.

I s'pose you might also get tea. Personally can't see the point, but perhaps that's just me.

MJ said...

Not really. Just the trials and tribulations of working in a Clinical Decisions Unit (i.e. general dumping gorund for the more complex A&E patients).

Just a little fed up with patients self-presenting saying they feel ill, doctors running the neccessary tests, them coming back abnormal and as soon as the patient is about to be admitted for treatment, patient suddenly decides that they want to go home.

I guess the worst patient I was thinking about when I wrote that was a paracetamol O/D with a high plasma concentration and was indicated to have parvolex treatment. However, she thought she was making too much fuss and decided to go home. Psych team couldn't make her stay and she was convincing them she was fine and it was out of character for her to do something like that (in fairness it was). So, she walked out and I don't know how she is.

I'm just worried and seeing one of your patients take your advice made me feel slightly better.


ex-alcoholic said...

Being on the outside can be quite amusing, and how many of those drinking friendships are real anyway?

Doctor Jest said...

mj-- So you're Doctor House. It's the living with uncertainty that gets you in this job for sure. Patients like that you have to hope re-present if they need to, after a chance to have a think. Also, for all we live in a world of numbers and levels people have a continuing capacity to buck the trend and recover without, or sometimes in spite of our interventions.

The only thing to hang on to in cases like this is the knowledge that you have done your job the best you can, and allow that all patients absolutely deserve to have their autonomy respected if they can be shown to have thought through the consequences of their actions.

Have a better one.

Doctor Jest said...

ex-- I'm sure you're right on both counts. OTOH the same can be said of most friendships founded solely on any shared iterest.

MJ said...

Dr. House?!?!

Hmmm... I hope to think I have a little more of a bedside manner than him and treat my colleagues with a little more respect. Plus I don't get to deal with interesting tertiary referrals, just A&E cases that won't be treated within 4 hours (bloody government with their time limits) which usually involves DSH, the unidentified injuries, head injuries and intoxicated patients.

Not exactly House at all!

I just hope she represented somewhere, or got help. The liver can be miraculous at recovering though.

Doctor Jest said...

mj-- you might have noticed a lot of what I write is a bit tongue in cheek. Your job description just sounded more glam than SHO / Reg in A&E.

And Amen to your sentiments.

MJ said...

Well to put my job description into old fashioned medical terms (before the government went all fancy and starting renaming things) I'm just a plain old SHO in critical care who is hoping to become a SpR in emergency medicine. I don't really know where the whole 'Clinical Decisions Unit' tag came from - probably a 'Hewittism'.