Patients with advanced alcoholism are at times frustrating and vexing to deal with, for a variety of reasons. It's been more than 40 years, but I can never forget the experience I had with one patient who suffered from this addiction.
In 1975, early in my internship training, I was roused from a sound sleep in the middle of the night to come to the emergency room. There on a stretcher was my first alcoholic GI bleeder. He was intoxicated, stuporous, smelly, disheveled, unshaven and quite filthy. He had old and new vomit on his shirt, and smelled of urine and much more. He was retching and vomiting up bright red blood.
This situation represents a walking textbook of medicine, as many things are all going wrong at the same time. Proper and meticulous attention to all the details is essential. And proper sequencing is also very important. If you correct one nutritional deficiency without correcting its matching counterpart, you can precipitate a violent and potentially lethal reaction. It is important to do the right things at the right time for the right reasons.
So the team went to work: Start an intravenous (IV) line (quite a task with him thrashing, retching and cursing). Correct a potentially low blood sugar, add critical vitamins, correct the deficient blood clotting factors and get blood transfusions ready to go.
While juggling all of this, we also had to get that bleeding stopped. But because the source of the bleeding was a vein in the lower esophagus, we had to pass a tube into the stomach through the nose and inflate a large balloon on the end of the tube, thereby applying some pressure to the bleeding point and slowing or stopping the bleeding. More advanced procedures are available now, but at that time, this was all we had.
My resident and I worked all night on the patient, and well into the next day. I ended up covered with a considerable amount of stomach contents, blood and various other substances unidentified but definitely undesirable. The bleeding slowed down, the nutritional problems got corrected. We were pouring in blood, but keeping up with the losses.
The patient had developed blood in his stools ("melena"). This has a very characteristic and unforgettable strong odor. We were faced several times during the night with a soiled bed from this problem. While cleaning the bed is not typically the doctor's job, I ended up helping to change the sheets, as much to hurry the disposal of the stench as anything.
One last major problem we had to battle was alcohol withdrawal. The body gets hooked on the alcohol and when it is suddenly deprived, dire consequences can ensue. Hallucinations, cardiovascular collapse, seizures, delirium tremens. We gave the patient diazepam IV to replace the alcohol, then gradually withdrew the diazepam.
We did it. We saved him. This is the ultimate experience for the medical man (as opposed to the surgeon). We were presented with one of the most difficult conglomeration of problems to manage and we prevailed. Detective work, analysis, brainstorming sessions, tube passes, melena cleanings, X-ray reviews, it all paid off. We learned a lot about teamwork, too, as this was not the work of just one or two individuals.
We all walked around like we had won the Super Bowl. To top it all off, the patient had "found religion." He had come about as close as one can come to death and had been pulled back. He was badly shaken by this and resolved never to drink again. He planned to devote himself to sobriety and do good with his life.
It was amazing. Not only did we save him from death, but we turned his life around. It just doesn't get any better than that. We all clapped and wished him well as he left the hospital many weeks later. I pushed the wheelchair myself to the front door and, grinning from ear to ear, shook his hand and wished him well in his newfound life.
The rest of the day we all walked around with silly grins on our faces. Damn, we were good. We really did it. Doctor. So this is what it's like!
I was “on call” that night at the hospital. The emergency room called (again in the middle of the night). He was back. He was drunk. He was bleeding. It seems he was so excited by his sobriety, his salvation and by finding his new path that he went out drinking to celebrate. The rest of the night was spent again with tubes, IVs, transfusions, vomit, feces, urine and melena. He died that night in the ER, surrounded by his bodily excretions and large puddles of blood.
My resulting depression and disillusionment cannot be put into words. Made even more acute, more cruel by the fact that it was preceded by the heights of ecstasy. This was an agonizing defeat.
I took care of many more alcoholics and GI bleeders before my medical training was over. Some we lost, a few we saved. To this day (more than 40 years later) I still bristle at the smell of melena, as all those memories come flooding back.
The thrill of victory. The agony of defeat.
Jonathan Elion, M.D., FACC, is a practicing board-certified cardiologist in Providence, Rhode Island, and an associate professor of medicine at Brown University.