Monday, April 16, 2018

The Things That Medical School Won't Teach You (8): "Dealing with Drunk Patients"

After a short stint of dealing with inebriated patients within the casualty department lately, I guess this is as good a time as ever to highlight one of the mainstays (and frustrations) of the healthcare experience; and there can be no better way of showing this than to indulge you in a very sordid experience from my internship.

So there I was working in Casualty, and having an average kind of day. The calm was interrupted by a bit of a ruckus as a group from a county referral hospital that will remain unnamed (including Medical Officer interns) brings a patient into the Casualty area. The patient's dramatic story goes a little something like this:
He had been drinking at a local tavern, and once he had consumed his fill, he decided that he was not going to pay the bill. He was most clear in communicating this to the bar owner, who happened to be a woman, and on this day she was not going to settle for this level of belligerence. She therefore proceeded to take a Fanta bottle and smash it against the left side of the bloke's neck.
So he's literally been hand delivered to us - a referral - because it has been determined that he's ended up with a laceration to his jugular vein. Without even staying to answer any more questions, the whole group disappears, leaving us to mull over the fate of this unfortunate soul. This was certainly a task that might have been better handled by a Vascular Surgeon (heck, even a General Surgeon), so I relayed the message to my Medical Officer (MO) and he told me to take a "peek under the hood", and make my assessment.
So I take him into the minor theater with two assistants in tow to help me cope with any eventualities...and that's when things get interesting: the patient who appeared almost lifeless up until this point suddenly starts drunkenly flailing his limbs all over the place, you'd think he was reliving some vividly joyous moment in the pub. Not only do I face the risk of perhaps dealing with a gusher of a leaking blood vessel, I have the added pressure of dealing with an uncooperative idiot. So I do the only thing I can do: ask for more people to hold this person down, which ended up being 3 more people (his relatives).
So, with the idiot well secured, I have one of my assistants peel off the heavy layer of compression dressing from his neck, with me standing with the needle holder and suture ready to start suturing. Sure enough, there was a laceration; but, luckily, the bleeding was minimal and definitely not from the jugular vein. After placing enough sutures and getting an adequate level of hemostasis, I sent him to the ward for observation and to sober up. Lord knows I wanted to rap his head with my knuckles, but I just held back the urge and walked away.       
No matter your attitude towards alcohol usage, I guarantee that you will without a doubt be irritated about dealing with an inebriated patient. Now, technically, people can drink alcohol at any time of day on any day of the week, you are more likely to be overwhelmed by such patients at night time and the weekend; but as in the experience I quoted above, that patient showed up around 3 pm on a weekday, so if you're from a "drinking nation" you'll have to be prepared whenever.

There really is no way of telling what kind of inebriated patient you'll get; alcohol elicits many different responses from its consumers. Some people might just be happy and might even get more courageous (even awkwardly flirtatious), while others become a chaotic storm of anger and rudeness; then you also have the person who'll drink themself into such a stupor that they become like the living dead, practically comatose. Alcohol also turns some people into scholars of no particular renown. I have also encountered the emotional wreck (more often a woman, but on many occasions also a man) who becomes so overcome by emotion and just breaks down crying. It really is a wheel of fortune scenario.

Anyway, the patient is one thing, their complication is another: Good old trauma is probably number one on the list, with these discombobulated folk tripping over themselves or getting into fights, which results in them getting cuts, bruises, broken bones, head injuries, etc. Others overdo the drinking and come in with hangovers or (for those who neglect to eat) with dangerously low blood sugar levels (hypoglycemia). Again, for some, hysteria is their only real complication.

As soon as a drunk patient shows up in the casualty area, you can just see the staff roll their eyes, looking out of the side of their eyes with palpable discontent. You might not be a judgmental person under ordinary circumstances, but some questions will just pop up in your head, even for the slightest of moments; kind of like these:

  1. It is only 2 pm on a Monday. Surely there must be something more constructive you could be doing with your time?
  2. My friend, how many drinks do you have to take to lose enough of your dignity to show up here smelling like urine and poop?
  3. (for the family member whose drunk relative you've treated before) When are you intending to get him into rehab?
  4. You probably have children. Is this the best thing you could be doing with your time?
  5. What convinced you that it was a wise idea to drive anywhere in this kind of condition

But like all good professionals, we put our best foot forward and get to addressing the issues at hand. Now is not the time to be criticizing and getting disgusted; it's time to be compassionate! And we will definitely try to be compassionate, but the patient determines the extent of compassion that they get.

If your experience is like the one I encountered with the patient with the neck laceration, you've got to ask yourself how much you really value your life, health and relationships, and whether you're willing to sacrifice them over your job. In this day of diseases like HIV, Hepatitis B, C and Lord knows what other bloodborne pathogens are skulking about, you certainly don't want to end up with a needle-stick injury. Medical practice spends all/most of its time being associated with the Hippocratic "Do no Harm", but on the job training will teach you that you have to protect yourself first.

You should never assume that you have to do something "concrete" for a drunk patient. For some of them, all they'll need is to be observed while they sleep off their drunken stupor; if you want to get fancy, you could boost them up with an infusion of normal saline and Vitamin B complex. Some people will show up with nasty cuts and wounds, but the alcohol will make them superhuman - immune to pain - and extra combative; rather than risk sparking off a fight in the casualty, you're better off letting the patient go home and sober up. Trust me, when the alcohol wears off and the pain becomes unbearable, they'll come back for the stitching that they may have turned down a few short hours ago.

The hysterical drunks are pretty much just looking for attention from loved ones. The drunks you really have to look out for are the ones with major injuries that require urgent intervention. In line with taking care of yourself and your fellow staff, be prepared to

  1. Sedate the patient. Diazepam and Chlorpromazine will be your friends. (unless the patient has a head injury, in which case Chlorpromazine will be a better choice)
  2. Strap that patient to the bed with no mercy
After that, attend to the patient with the speed required. I'm not saying things would be trouble free by this point: you could maybe hope to be insulted or just reviled by the drunk patient, but at least you'll have some control over the situation; and control is really important, because you never really realize how small and confined your casualty area is until some pandemonium breaks out.

After all the drama is over, you can have a big laugh about it. These war stories are "comedic gold"...well perhaps only among fellow medical staff. Your other sane friends might be hard pressed to find humour in tales revolving around bondage, blood and guts, and needles. Most importantly, you'll have the kind of on the job experiences that'll make you a better clinician.

God Bless

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