Learn, Learn, Learn

You’ve probably heard people say that the more they learn, the less they know. If you haven’t heard it, you should. I know it’s true. Every day I live adds to my cornucopia of ignorance, whether it’s having no idea who anyone is anymore in People Magazine, or having no clue of how to use the basic features of my new cell phone. Of course, a life in the ED is a great place for this lesson to be reinforced on a daily basis.

Take drive-through windows at fast-food restaraunts. I always thought the way to use these modern conveniences was to drive up to the menu board, shout your order in the general direction of the speaker, and come around to the window holding out some vain hope that your order will have actually been understood and you will not once again have to explain that you really were serious when you said no mayonnaise.

(Note: It is a well known fact that Jews do not eat mayonnaise. My father once told me that “Any time a person goes into a delicatessen and orders a pastrami sandwich on white bread with mayo, somewhere a Jew dies.” I’m not sure where this taboo came from; it may be because the construction of this creamy concoction usually involves a copious amount of lard. Whatever the reason, it’s clearly a WASP condiment, an ethnic delicacy that I think can be best thought of as…well, actually, its best not thought of at all. My friend Sean, an African-American, tells me that his folks don’t eat mayonnaise, either. Once again the oppressed masses unite. Represent.)

I turns out, though, that there’s another way to get to the drive-in window. What you can do, as demonstrated last week by Mr. Alvin Johnston, is to get drunk and get a craving for Popeye’s Fried Chicken. You then crawl across the hood of the car currently in front of the portal and place your order. When you are encouraged to place your order in a more acceptable manner, preferably away from the property, you retreat to the drugstore across the street and sit quietly awaiting your order on the sidewalk outside. You are then surprised when you are greeted not by a uniformed Popeye’s employee, but by three uniformed police officers who handcuff you to the stretcher despite your protestations of innocence. (When asked why he thinks he got in trouble, he says, “I think they were out of extra crispy.”)

Here’s another thing I’ve recently learned about the fine line between sobriety and otherwise. Mr. O’Malley was brought in by the local gendarmes for public intoxication. Calling our local officers gendarmes makes law enforcement seem more elegant, like calling the big box store Le Target. (I’ve always found it somewhat interesting that while most accidents happen in the home, it’s perfectly okay to be intoxicated within your own residence, but not in the public square where your chances of accidental injury are actually less. From a purely epidemiologic standpoint, the best thing we can do is take every alcoholic, round them up in a grassy supervised pen, and let them sleep it off.)

You’ve probably heard of field sobriety tests. These are those brief exams done by police officers to detect findings that roughly correlate with a blood alcohol level over the generally accepted legal limits. They’re not exact, of course, but failure to pass these tests certainly suggests the possibility of alcohol intoxication. The most common ones are to follow a flashlight or pen with the eyes (high alcohol level produce a particular back-and-forth motion of the eyes called nystagmus), walking a straight in a heel-to-toe fashion (alcohol results in instability of balance), and tests of short-term memory and concentration (both of which are impaired by alcohol use).

The results of these tests, while providing law enforcement with a certain degree of certainty about Mr. O’Malley’s intoxicated status, were considered as inconclusive by the patient himself. It turns out that he had his own field sobriety tests which he was happy to share with me as a way of demonstrating that despite what I might think (and what his blood level would later show), he really wasn’t drunk after all.

The first thing he showed me was that he could bend down the tip of his ring finger on his left hand without bending the middle joint of his finger. For the record, that’s anatomically difficult to do. There are two tendons within each finger that control flexion (bending inwards) of the digit. One runs up from the forearm and wrist to connect to the base of the middle bone in the finger. When this tendon contracts, it bends the first of the two joints of the finger (the proximal interphalangeal joint, or PIP). There is a second tendon that runs up the hand and connects at the base of the last finger bone and bends the second joint (the distal interphalangeal joint, or DIP). The tendons aren’t connected, but are arranged as such so that when you try to bend the tip of your finger, the PIP will automatically flex as well. So this was a real trick, and he emphasized the point by flipping the tip of his finger back and forth like a speed bag at a boxing gym. “You can’t do that if you’re drunk!” he proudly proclaimed. And I did have to admit that it was something I couldn’t do, and it was a pretty impressive feat of digital dexterity. But while clever, it did not really speak to the issue of impaired coordination that is a feature of the intake of two carbon fragments. (We say stuff like that because the alcohol…technically called ethanol…molecule has two carbon atoms. We also say that kind of stuff because it makes us feel smart, and most days in the ED we need all the ego boosting we can get.)

His second feat was to hold his hands parallel to each other, extend his index fingers so they pointed at each other, and rotate his right index finger in a clockwise fashion while moving his left in the opposite direction. Now here was a truly worthy test. This is a clear demonstration of coordination, and he kept going at it with smooth, uninterrupted motion, keeping up a lively conversation while he did so. I, of course, failed miserably to do the same. Which can only mean I must have been intoxicated with something….the love of patient care, perhaps…but clearly I was going to lose this battle.

(I hope that as you read this, you’re trying to do these same things at home, and I fervently hope you’re failing as dramatically as I did. And if you’re like the nurses I work with, the idea of moving one appendage in a clockwise direction and another in a counterclockwise direction stimulated a lively discussion of where else in the body this trick might apply and if tassels help the effect or just get in the way. But for the record I can do one trick, which is to dislocate my thumbs. I’m still trying to find some use for this, but I trust that someday it will either help me to win a bet or defuse a nuclear device.)

So in the end, I gave in to the fact that, as a well trained drinker, he was probably as sober as he was going to get. But the lawyers would still have something to say if he left the hospital and fell in front of a train. So we compromised. Even though we agreed he was just fine, since he looked tired would he be willing to nap here in the ED for, say, twelve hours or so until he got plenty of sleep and a good meal? And coincidentally by that time his alcohol level would be below the legal limit, and he could be released on his own recognizance to seek out more life experiences. We shook hands, and he flicked his finger at me once more to seal the deal. My education continues.