Monday 30 May 2016

Repeat customers

Though my official job title is "Trauma Surgeon", during a normal work day I play multiple roles.  At any given moment I could be Surgeon (obviously), Drug and/or Alcohol Counselor, Paediatrician, Intensive Care Doctor, Drill Sergeant, Social Worker, Dog Sitter (don't ask), or Babysitter.  In addition to all that, one rather prominent hat I wear is Teacher.  A rather vital (though possibly overlooked) part of my job is not only to take care of Stupid People after they've done a Very Stupid Thing, but to make sure they don't do that Very Stupid Thing ever again.  Much of the time, however, I have little confidence that my education takes hold because they A) don't listen to me, B) don't care, or C) don't have the brain capacity to learn new things.

Because of one or more of these things, unfortunately I do have some repeat customers.  Like Arthur (not his real name™).

A very drunken Arthur was brought to me one very drunken night several drunken months ago.  He was too intoxicated to walk in a straight line so had tried crossing the road in some kind of zig-zag pattern.  Unfortunately for Arthur, cars have a very difficult time avoiding people walking in a seemingly random pattern, especially at night when the sot is wearing all black on a dark unlit road.  Based on an interview with the driver and the damage to the car, the medics informed me that he had struck his head on the windscreen before bouncing over the car and landing in an inebriated puddle.  When he first arrived to me, Arthur was rather combative and argumentative.  That's a problem in trauma, because this obnoxious behaviour can be due to multiple things:
  1. intoxication
  2. brain injury
  3. the guy is just an asshole
. . . Or some combination of the three.

He reeked of alcohol, so we were clearly dealing with #1 (at least).  Fortunately we were able to calm him relatively easily with some soft, soothing words.  HAHA no, actually we had to use some IV sedatives to prevent him from thrashing around and injuring himself or one of my staff (or me).  Once he was calm (read: moderately sedated), we successfully obtained a CT scan of his brain which showed a subdural haematoma (so add #2 to Arthur's list of problems).  This is a serious, occasionally life-threatening condition.

Fortunately for Arthur a repeat scan several hours later showed that the bleeding had stopped and his brain had not swelled significantly.  Over the next few days he remained belligerent but otherwise neurologically intact.  I tried talking to him several times about his drinking, but every time I brought it up he yelled at me to leave.  The injury to the brain was not in the area that controls personality or impulsiveness, so I had to attribute his constant unpleasantness to #3.  Regardless, he was transferred out of the intensive care unit a day or two later.  

And then he walked out.

Arthur's nurse called me to tell me that he had told her that he was going for a walk six hours ago.  He never came back, and I never got the chance to give him my Drinking and Walking speech.

{Dramatic pause for foreshadowing}

Fast-forward about six months.  Though I was not on call, I got a surprise text from one of the people I work with at the hospital asking if I remembered Arthur.  "Vaguely", I replied, my Inner Pessimist reminding me that she was obviously asking me this for a reason.  And not a good reason.  I seriously doubted Arthur had come back to the hospital to give me a thank you and hearty handshake.

As usual, my Inner Pessimist was right.

This time Arthur had fallen down while drunk, even drunker than when I had seen him previously.  His blood alcohol level was about six times the legal limit, and he had much more bleeding in his brain this time, enough to necessitate an emergency craniotomy.

Arthur died two days later.

Unfortunately Arthur was too addicted, too stupid, or both.  Though I try not to let any preconceived ideas cloud my judgment, based on our interactions I doubt any speech from me would have changed his ultimate outcome.  But perhaps a few stern words could have sunk in.  Perhaps.

Sadly he never gave me the chance, and I'll never know. 


  1. I am willing to bet that Arthur had heard that speech, or one very much like it, many times before. Because, although Trauma Services saw him twice, I can just about guarantee that the Emergency Department saw him about a bajillion times. He likely had the speech, substance abuse/psych evals and offers to help with treatment or 12 step programs. These efforts, based on your description, were likely met with cursing, threats and yelling. It's sad and depressing, but sometimes, no matter how much effort is made, people continue to make terrible decisions.

  2. Poor Arthur. :( this is so sad and what is more sad? How common it is for people to make life changing and sometime life ending decisions. I'm sorry that you didn't have the chance to talk to him, Doc, but I am sure that even stern words from you would not have changed the outcome for Arthur.

  3. I wouldn't doubt that he'd be so ungrateful that he even wrote a bad yelp review for bad service on his first trip.

    1. Since you brought up Yelp I wonder if Doc saw this recent story:

      Don't post this if it's too far off topic but I thought it might provide fodder for a blog or Daily Beast post maybe?

      You can say any negative thing you want about a practitioner but the object of your wrath isn't allowed to defend themselves due to HIPAA.

    2. I think there should be a law that once the patient reveals their own information, the court considers them to have released the hospital from HIPAA restrictions.

    3. I like how you think.

    4. Or if they have posted it on Facebook, complete with pictures!

    5. yes, that would count as releasing their own information.

  4. either your legal limit is lower than mine, or Arthur was a true professional. according to the standard charts, he should have been in a coma, not breathing, at 6 times the limit where I am.

    1. Seriously. .48? Dude should have died from that.

    2. You'd be surprised how high professional drinkers' BAC can be and yet still be moderately functional.

    3. best score I've heard of one of my customers getting was about 3½ times the limit - after he'd divided his car into three pieces and left himself in the middle of the road.

    4. Also different areas have different limits. 0.05 in Western Australia for example.

    5. yep, and while not trying to track the doc down, I had to consider that to be a possibility.
      on which subject, we had another one last night. the people who were in the car that got hit are a testament to seat belts.

    6. Doc B.

      You'd be surprised how high professional drinkers' BAC can be and yet still be moderately functional.

      back an ungodly number of years ago, my father invited my oldest brother for a good beer after learning that said brother bought a 6 pack of beer @ 16 years old (brother is now 42).

      For the occasion, father bought 2 crates of 24 pack of beer + 3 bottle of 40 ounces vodka. Although brother had its fair share (considering it was only the second time in his life to drink alcoholic beverage), it was my father who drank most of it in a single sitting...

      Brother never touched alcohol ever since.


  5. It's amazing how irrational we really all are, and addiction is just an extreme manifestation of that. We've all had times when we have risked our health or friends or family or happiness for that promotion/one true love/next drink/status update that's the subject of our current obsession. For most of us these things are mercifully benign and fleeting but when they are as damaging and habit-forming as excessive drinking, it's not surprising that people get into trouble. Our physiological reward systems, that served us well as tribal hunters, are just not equipped for modern life and everything it makes available.

    I applaud the good work that you do Doc' but one day we may, perhaps, understand addiction well enough that you (or perhaps one of the Little Bastards that follow you) will be able to refer guys like Arthur to someone who can address the cause of their problems and help cut down on your repeat patrons. Then again, some people will always be idiots!


  6. This case illustrates one of the questions I used to ask all the ER and ICU residents early on.
    As a treater, If a patient like Arthur comes in disoriented and confused, or in coma, and you draw a blood ETOH level on him, what value would you rather see 20 minutes later - 0 or 300 mg%?
    About 85% of the residents answer 300 - because then they have the diagnosis.
    Of course that is the wrong answer.
    I explain to them you would much rather see 0. At 300 you do not know whether he has a coexistent condition and you might put him away to sober up for 8 hours. IF he happens to have another coexistent problem, you have a big problem. Happens more than you think. There are about 20 conditions that get confused with alcohol intoxication.
    At 0 you know the workup must proceed apace because you know what it is not.
    It doesn't matter whether you are usually right when that 300 comes back, the cost of error is too high. All it takes is one drunk guy who fell off his barstool or one women who was drinking and stopped taking her insulin.
    Try that quiz with your residents.
    Cory F.

  7. I'm just wondering. Why do they call addiction a brain disease?


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