By William Hay
“Why aren’t you working in Boston anymore?” I asked him one night at the end of my trauma rotation in internship. He was one of my finest mentors with incredible clinical skills and a personable way with the staff. He had been stand offish when I first met him, the aloof white coat giving us interns orders and doing rounds. But one weekend had been particularly hairy and we’d pulled through. All of us working around the clock to deal with the onslaught of emergency cases.
Normally the hospital is pretty maxed out but then a big city event comes into town and then it’s overtime and overwork, too few nurses, too few doctors and too few beds. I can’t remember the event, a rock concert or a sporting event. It didn’t matter. Just a place where they served a lot of booze to make a lot of money and didn’t consider that half the trauma seen in hospital emergencies are booze related.
The violence, knifing, battery, gunshots is even higher. It had been one of those weekends that we got to know each other. He’d told me about his wife and home, the things that come up in the middle of the night when we wait for xrays to come so that we can decide whether Mr. Smith’s baseball bat injury is just a contusion or a fracture.
Mr. Smith was the last of a long list which included head injuries, stabbings, heart attacks and way too many drunks brought in by the police from the streets where if the police hadn’t stopped to pick them up they would have frozen in the night. It got to 40 below thereabouts and the cars didn’t start without a plugged in all night electric heater to keep the oil pan warm.
“Alcoholism”, he answered. I certainly didn’t expect to hear that. He didn’t seem like any of the folk we were treating. Here he was this senior medical staff man esteemed and reknowned and as I heard him he was telling me he’d had to leave Harvard for boozing.
“See this cavitation in the upper quadrant of this xray. That’s Klebsiella pneumonia, almost pathognomic for alcoholism. The drunks fall down and lying on their side aspirate vomit into their upper lobes and bugs grow. We don’t see as much as we used to. More and more it’s just general pneumococcus or strep pneumonia but sometimes you’ll see this. And there it is.” I looked at the xray with him thankful to have a classic textbook finding show up and have it pointed out.
However, I was now confused if his answer “alcoholism” was to my question or to the patients xray.
“Make sure this guy gets 100 mg of Thiamine,” he said. I’d already written the order. Wernicke’s, the reversible brain disease caused by Vitamin B deficiency with classic triad of ataxia, confusion and ocular palsy so often was a product of us starting IV glucose in these folk who’d leached out their vitamins and for the body to handle the sugar load it used up the last of the Vit. B leaving none for the brain. Instantaneous delirium and dementia if not reversed. Permanent brain damage if not caught. Too often missed so that now any one who is even suspected of having an alcohol abuse history gets Thiamine. Which of course means that the druggies, junkies and street folk get their thiamine and the business executive doesn’t. The latter goes crazy and ends up in a home while the “stereotypical” drunk gets better and remembers where to buy his booze for another week.
“Alcoholism, sir? I asked.
“Yes, I was working as the head of emergency in the big city ER. Lots of trauma. Lots of gunshot wounds. You’ve seen it on tv. We didn’t have the resources or staff there that they have on television. But we had fun. The nurses have a lot of heart down there and we didn’t take ourselves as seriously as you do up here in Canada. Maybe we just had to be so good we could afford to laugh.”
“Nurse could you see Mr. Brown’s magnesium level is checked. If it’s normal leave it but let me know if it’s low so we can top it up.”
“What happened?” I asked.
“Coffee enema’s. I was giving the drunks coffee enema’s to wake them up. They’d come in obtunded and I just figured the safest thing to do was to give them coffee enema’s. It worked. We didn’t have beds to admit them and we couldn’t send them out of the emergency room till they were more awake. You see all those guys we’ve got waiting out there drinking coffee. The police bring them in. We check them and admit them or sit them down and hold them till they’re better. Well, the guys I was seeing were so gone I couldn’t get a history of what else they were taking. Lots of barb and benzo abuse then. So I got the idea that coffee enemas would work. The nurses weren’t impressed with me but it worked and I kind of figured it would be a deterrent in a way.”
“Nurse, Mr. Jones in three can go now. His blood alcohol is 100. When he came in it was 250 so it’s falling.“ Down south I’d get these guys, take a blood alcohol but we’d not know if it was rising or falling. They’d be in the coma range 400 to 500 and I’d give them the enema and they’d wake up enough to tell me when they had their last drink. "
"But it was the coffee and sugar. "
“The coffee and sugar?” I asked.
“If the guy was awake I asked him if he wanted sugar in his coffee If he said yes, I’d put it in.”
“They fired me, what can I say”.