Sunday, March 14, 2010

Intoxicating Twinkies

You may not have heard this yet, but on occasion college students use alcoholic beverages. However, at the inner city hospital in Missouri where I did my ER training, intoxicated college students were nowhere to be seen. We had plenty of folks come in with “the odor commonly associated with alcoholic beverages” on their person.…I especially remember a regular client who would produce a glittering fountain effect when he was laying supine on an exam bed and didn’t want to get up to empty his bladder…but these were often your stereotypical alcoholics, the ones who often frequent street corners and dwell under bridges. These are the folks who are well trained, the ones for whom an alcohol level of 300(which is enough to put a novice drinker into a coma and onto a ventilator) actually results in symptoms of alcohol withdrawal. It’s this group of patients that taught me that clinical intoxication, where someone is incapable of functioning on their own in a safe manner, is far different than legal intoxication, where the alcohol level is above a certain number specified by statute. Most of these folks do just fine in a chronic state of inebriation, and often take offense at the suggestion that they might want to consider detox or rehab. After all, they don’t have a drinking problem; they can hold their alcohol quite well, thank you very much. And amazingly, until their liver fails at some point in the future, most of them actually do.

(A brief aside on alcohol levels for a tale of creative parenting. One day when I was unable to get a babysitter I brought my son to the ED with me. He spent most of the day in the nearby locked and secured doctor’s lounge, and I would check on him every twenty minutes or so to make sure he was doing okay. We ordered pizza, and when it arrived he came out to the main desk in the ED and we sat together and had “Father and Son Working Lunch.” We were discussing the event s of the day…namely, what armor he was about to try out in MechQuest…when a nurse asked me if an intoxicated patient could go home. The usual answer is that they can go home when they are fully oriented and either 1) have a ride home or 2) have a predicted alcohol level below the legal limit for public intoxication. But I saw this as a teaching moment, a wonderful opportunity for The Child to gain some practical math skills.

“Got a question for you. If each drink raises your alcohol level about 25 points, and the legal limit of being drink is 80 points, how many drinks does it take to make you drunk?

He rolled his eyes at me, the usual response of the American Pre-Teen to any attempt to impart parental wisdom, and turned away to devote his entire focus on insuring the pizza in his hand was cheese only and not contaminated by any sliver of mushroom from my half of the pie. Still, I persisted.

“This is stuff you’ll need to know in college, so may as well learn it now.”

He put his elbow on the desk, rested his head in his hand, and stared straight down at the desk, his usual gesture of frustration (and mine as well…the apple hit pretty close). He thought for a moment, periodically stealing glances at the pizza to make sure this was not a feint so I could insert a mushroom into his lunch. He sighed. “About three, I guess,” came back the correct, if exasperated reply.

“That’s right. So it means that when get old enough to have a beer, you can’t have any more than three.” That’s the wisdom part. “But let’s do another problem. Let’s say that a person’s alcohol level is 350. If you burn up 25 points of alcohol each hour, how long will it take him to get back to normal?” (Please note that “normal” is defined as an alcohol level of zero. We’re not teaching psychology or personality disorders here. Besides, he’ll start working on that problem as soon as he starts dating.)

“14 Hours. Wow. That’s a long time. And a lot of beer.”

I believe this could be the next revolution in teaching middle school arithmetic. A generation ago there was “New Math.” Now we can move on to “Beer Math.”)

Anyway, I never really provided medical care for drunk college students until I started working at the University of Florida. It turns out that there was a code name for intoxicated college girls; they were “muffins.” Their male counterparts were “stud muffins.” Indeed, one of my most pleasant memories of those days was the early morning when there was knock on my door and I opened it to find the bright, shining face of the ex-cheerleader I had dinner with the night before. She was standing there, resplendent in her blondeness and youth, holding a basket of freshly baked goods. “See!” she beamed, far too happy for the hour of the day. “I’m your muffin muffin!”

Most of the students we cared for were pretty routine. They passed out at a party and came to the ED. We gave them IV fluids and waited a few hours. They sobered up, had a headache, felt guilty, and promised never to do it again. We reminded them (when appropriate to do so) that the drinking age in Florida was 21, and that while weren’t turning anyone in to the cops, they really should stay on the good side of the law. Appropriately chagrined, they left with a gaggle of their friends. For the guys, it was usually a rowdy group more than happy to recount all the AWESOME stuff he had done while wasted; for the girls, a few close friends providing emotional support by telling her whom she had gone off with and why he was such a pig.

Every now and then one would stand out. I recall one in particular, a frat boy brought in by the campus police. He was not only intoxicated, but violent, taking swings at everyone including the police (NEVER a good strategy), and the best thing to do for everyone was restrain him to keep him safe. As might be expected, he protested quite loudly, and as explicit in letting us know that his FATHER was a LAWYER in BOCA RATON and we CAN’T DO ANYTHING WITHOUT TALKING TO HIM.

We are well aware of our rights in the ED, even if patients aren’t. If a patient is unable to make an informed decision for themselves, we need to substitute our reasonable medical judgment for theirs and provide an appropriate level of care until they are in a position to exercise their own autonomy. So I had no qualms about our course of action. Still, something about his whole attitude had gotten under my skin. So I decided to take him at his word. I called his father.

This was long before I become a father myself, so I had no idea what might happen when I picked up the phone. My intent was simply to teach the patient a lesson by bothering his father in the middle of the night with his problematic behavior. Now that I am the progenitor of my very own Tween, I recognize that the phone call from the ED in the middle of the night fits into the category of a parent’s worst nightmare.

“Hello, is this the father of Bobby Smith?”

A moan, then a clearing of the throat. A whispered response, not wanting to wake someone else nearby.

“Mmmm-hmmm.”

“Mr. Smith, this is Dr. Rodenberg in the ER at Shands Hospital in Gainesville. Your son was brought in, and I’d like to talk with you about what’s happened.”

There was a moment of silence…brief to me, likely a lifetime for him. The voice snapped to attention, the volume grew, an urgency and sharpness now in his speech.

“What? What is it? Is he okay?”

I suddenly realized what I had done. Here I had called his father to satisfy my own irritation, and the father thought I was going to tell him his son was dead. No way out, no way to recover from this one in any kind of graceful fashion.

“Sir, I am so sorry I startled you. I want you to know that your son is all right.” I heard a held breath being released on the other end of the line. There was nothing to do other than follow through with the original plan. “He was brought in by the campus police because he had too much to drink. He was being violent and was at risk of hurting himself or someone else, so we’ve had to restrain him. He wanted to be sure to let you know what was going on.”

Another moment of silence. “Thank you, doctor. You do whatever you need to do.” The voice had slipped into “operational” mode. “Give me some time to get dressed, and I’ll be there as soon as I can.”

Five hours and 300 miles later, his father showed up in the waiting room and asked to speak with me. He could not have been any nicer. He said he understood what had happened, he was sorry for any problems his son had caused, and he thanked me profusely for caring for his son and for letting him know what was going on. He said he would insure that this kind of thing never happened again.

I went to see the patient, sobered up, restraints off, looking sheepish.

“I was kind of a jerk last night. (I’m substituting “jerk” for the actual word because this is a family blog.) I’m really sorry.”

“No problem. And it was pleasure to speak to your father last night. Good man.”

His eyes grew wide. “You talked to my Dad?”

“Yeah, of course. You told us we had to before we did anything to you. In fact, he’s waiting outside for you right now.”

I think at that point Bobby truly understood just how bad a hangover could be.
****************************************************
At my current hospital in Daytona Beach, we see drunk college students as well. Fortunately, they are not too pervasive year-round, but tend to concentrate their presence within the weeks of March and April known as Spring Break. Daytona used to be the place for Spring Break, but now other destinations are popular as well. I know this not only from the Convention and Visitors Bureau and MTV, but also because “Girls Gone Wild” is now filmed all over the country, and the Spankwire.com bus that was parked at the intersection of US 92 and A1A this morning on my way home listed a complete itinerary on the rear panel of the vehicle. Folks in Panama City had better start marking their calendars.

(Before you get the wrong “cookies” on your computer, know that Spankwire.com is a website featuring visual representations of consenting adults engaged in varied forms of relationships. I think it’s designed to be educational. Lord knows I learned a few things by watching. )

As I write this we’re right in the middle of Spring Break, and last night I saw a poor little twinkie…that’s the local word for an intoxicated young lady…that managed to make even this hard, flea-bitten ol’ ED rat feel genuinely paternal. But before I tell you the story, I should note that I’m not too certain I like the word “Twinkie” being used in this context. I happen to think that the Hostess Twinkie is simply the greatest snack food of all time and, as Ron Burgundy says, “If you disagree, I will fight you.” Not only does the Twinkie hold the secret of creamy goodness for today, but the total lack of natural ingredients and apparently infinite shelf life means that that we should be stockpiling them in bunkers for the upcoming nuclear holocaust/divine apocalypse/global economic meltdown / your disaster d’jour. (Attention Twinkie fans: Run, do not walk, to see “Zombieland.”)

But back to our story. Young Kelly was brought in by ambulance. Laying curled up in a fetal position on the bed, her hair was disheveled, one of her waaaay-too-large fake eyelashes was half peeled away, and there were dark circles around her eyes where her makeup had been smeared by tears, sweat, or a cosmetologically-inclined raccoon. She couldn’t tell me much. She knew her name, and that she was from Georgia. (No, Florida fans, I’m not going there.) Other than that, the answer to everything was “3.5.” I guess when you think you have a good answer you should stick with it, because Kelly’s answer to everything, from what city she was in to the date, from what she remembered about the night to her number of fingers on both hands, was unmistakably, unshakably, and emphatically “3.5.”

There’s a routine that goes along with managing patients who are intoxicated by alcohol. The first step is to actually examine the patient to make sure that nothing’s being missed. Of the wide range of ED nightmares, one of them is the patient who is blown off as being drunk when, in fact, they also have a significant head or neck injury. In a similar fashion, baseline laboratory tests and drug screens are obtained to make sure there’s no biochemical abnormality or another drug “on board” which can be masked by the presence of hooch. While some doctors tend to do routine CT scans on these patients to rule out head injury, I think most of us who see a lot of these patients only get them when there are specific signs or symptoms suggestive of head injury, or when a patient without any of these indicators doesn’t “wake up” appropriately while being observed in the ED. Besides, there’s only so much radiation in this world, and you don’t want to use it up all at once.

(A few interesting sidebars while I’m thinking about it. There is one condition in which alcohol is actually a specific antidote to another poison. When people are desperate to drink they may imbibe in antifreeze, which contains a chemical called ethylene glycol. Once the chemical is in the body, what results is a buildup of acids that lead to vomiting, kidney failure, cardiovascular collapse, and death. This conversion is mediated by an enzyme called alcohol dehydrogenase, and this gives rise to the use of alcohol as an antidote. The enzyme has more than a 100-fold greater affinity for alcohol than for ethylene glycol. So if you give a patient a large volume of alcohol, it will bind up all the enzymes so the ethylene glycol is converted to acids at a much slower rate that the body can handle. So the traditional treatment for antifreeze poisoning has been to get the patient wasted. There is now a more specific antidote on the market known as fomepizole, which is better for the patient but nowhere n as much fun. And here’s one more bit of trivia. Most manufacturers of antifreeze put some kind of fluorescent dye in the product so mechanics can spot leaks in a car’s cooling system using an ultraviolet light. So one way you can quickly get a sense of if a patient has ingested antifreeze is to shine a “black light” on them and see if their mouth or their urine glows.

Speaking of interesting places to get a drink, last month I saw a woman from a local detox center who had drank a whole bottle of liquid hand sanitizer. It turns out that hand sanitizer is 60% alcohol, or 120 proof; and a ten-ounce bottle will drive your alcohol level up over 350. But at least you’ll be squeaky clean inside and out.)

Once you’ve made sure you haven’t missed anything, treatment is pretty easy. Having established that the patient’s level of consciousness isn’t so depressed that it puts their airway at risk, there’s not a lot to do. Alcohol is a diuretic, and most everyone who gets drunk gets dehydrated (that’s one component of the “morning after”), so IV fluids are given. Chronic alcoholics often have specific nutritional deficiencies which can result in acute brain issues (encephalopathy), so they usually get some multivitamins and thiamine along with their fluids. The multivitamin solution is yellow, so the IV is often called a “banana bag;” the entire set of fluids, vitamins, and thiamine is known as a “rally pack.” If a concurrent drug ingestion is suspected, the patient is usually given something to help absorb any other circulating agent. But after this, there’s really not too much more to do. So Kelly got an IV, and Kelly got to drink some activated charcoal (known scientifically as the “icky black stuff”) to remove any drugs that might be in her system. And when the alcohol level came back, it was 337, over 4 times the legal limit of 80 within the borders of The Sunshine State. (“Good job, son. That is just about 14 beers.”)

(Years ago, we used to amuse ourselves in the depths of the night by betting on blood alcohol levels. Each person playing would have a chance to assess the patient, and then go place a quarter on the chalk rack underneath a large white marker board. You would write down your guess and your name, and when the level came back the person who came closest to the result without going over won the pot. We don’t do that anymore, because it’s disrespectful to the patients, because hospital policy forbids wagering on patient, and because the family practice residents used to steal the quarters when no one was looking.)

A few hours passed, and some friends came to join her. Talking with them, they said they had all gone to a local club; they saw Kelly with a group of young men abut 11, and then, as the Hee Haw song says, “Pfft! She was gone!” And you really can’t blame her friends for not being out on the streets looking for her. Where do you look? In a city you don’t know, with dozens of bars, miles of beachfront, and thousands of hotel rooms, finding Kelly would have been an impossible task. So they did the right thing under the circumstances. They went back to their hotel room and waited. Our nurse found her hotel keycard in her pocket; we called the hotel, got connected with her room, and the right connections were made.

Six hours later, Kelly looked a lot better. She was up and about, walking gingerly as if testing the floor for the first time, but nonetheless well on her feet. She knew where she was and the day and date. Unfortunately, she still had no idea what had happened to her, nor any idea how the traces of amphetamine had gotten into her system. But at least she didn’t have on a “Girls Gone Wild” tee-shirt (the kind you get when you sign the model release), so maybe things were looking up. I counseled her and her friends about alcohol use; I reinforced that the drinking age in Florida was actually 21; we discussed the fact that she would have an interesting morning when she woke up again, and that Motrin and Gatorade were going to be her best friends for a while. In the end, I felt bad for her, because she could be any one of our sons and daughters. Except mine, of course, who will be chained to his desk doing beer math until he’s 30.

2 comments:

  1. Funny, funny stuff, especially the bit about the Gator Dad.

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  2. I remember this incident!

    ReplyDelete