Annals of Medicine: Remembering Walter

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Over the years I came to know Ken* a little. He would come into the ER about every three to six months, slightly drunk, morally exhausted, physically tremulous, and emotionally overwhelmed. Most of his self-respect was gone or hanging on by a thread of remembered value. He wanted something from me, something that was for me to give or withhold. He was always polite and always prepared for the possibility that I would say no. He wanted voluntary in-hospital alcohol detoxification.

Voluntary alcohol detoxification is different from treatment for acute alcohol withdrawal. Alcohol withdrawal can be fatal. Acute alcohol withdrawal typically occurs 12 to 24 hours after an alcoholic stops drinking abruptly. Alcohol withdrawal is a true medical emergency with a high mortality rate and we admit all those patients. Mortality ranges from two to 25 percent, depending on how severe the withdrawal is.

In contrast, voluntary alcohol detox is just that, voluntary, usually long before there is any risk of acute alcohol withdrawal or associated medical needs. To safely and comfortably get an alcoholic through the stages of detoxifying from alcohol takes anywhere from 3 to 5 days in the hospital for monitoring and treatment with the appropriate sedatives. A day in the hospital typically costs between two and four thousand dollars. The most ancient and low-tech option for preventing abrupt alcohol withdrawal in hospitalized alcoholics is whisky or beer served as needed. Our pharmacy still stocks several brands that can be ordered on admitted patients. How Mad Men! Mostly, however, we now use tapering doses of sedative type drugs such as Librium in place of the alcohol. It does take some of the raffish nostalgia out of writing the admitting orders, though.

While all hospitals can easily provide alcohol detox, for various reasons very few actually do it. Insurance coverage is iffy, the patients can be frustrating to deal with, the disease itself isn’t imminently fatal and, most importantly, alcohol detox is rarely successful once the patient leaves the hospital. To be accurate, the success rate is not known. It is hard to track the success of a treatment that is confidential or even anonymous and when relapse of the disease is often denied or not reported. But the best estimates and my own experience suggest that the success rate is pretty close to, but not quite, never.

In the ER I get requests for voluntary medical detox all the time, but they are typically from spouses, parents, children or other family members of the patient. The patient usually sits passively through these encounters, intoxicated, bored and often faintly amused. When asked, the patient will deny the desire to stop drinking. When I tell the families that it really has to be the patient’s choice and that detox is not really an option today, the patient will smile triumphantly and say, “See? No one wants to help me!” Did I mention the patients can be frustrating?

To make it even more challenging, the families will then transfer their anger at the patient onto me, as if I could magically fix him, but won’t. When we do discharge these patients, we never recommend that the patients go home and stop drinking abruptly due to the risk of alcohol withdrawal, but rather suggest a more gradual tapering of alcohol intake. This leads to some absurd discharge instructions, usually something like “Please stop drinking slowly.” Punctuation counts, people!

So, faced with Ken’s request for admission one more time for voluntary detox, I had to make a medical decision based on no science and only my beliefs and values. I had to try to judge the sincerity of his desire this time and his true motivations. This is ethically dangerous territory, and I really would like a little help, but no one has the answer. Like all ER doctors, I have been manipulated many times in the past. The last lady I had admitted to the hospital under similar circumstances revealed to the inpatient team that she was trying to avoid a court date for shoplifting.

I had admitted Ken for voluntary detox multiple times, shreds of my med school idealism and optimism still smoldering somewhere in my weary ER doc heart, and every time he would later return, drunk and penitent. Today would be no different. But each time I saw him I remembered the wise words of a wizened old alcoholic named Walter. Walter worked in the ER at Yale with me many years ago. He was a volunteer, a drunk of 30 years, now sober for 25 years. Walter’s self-appointed task was to approach each alcoholic in the department and offer detox. He never stopped asking and he would convince us to admit patients over and over again despite the apparent futility. I asked Walter how many attempts were too many, when to stop trying? His answer was simple: never. His reason was equally simple. “Because that’s what eventually worked for me.”

“And,” he added, “every day since has been a gift.”

So I admitted Ken yet again, Walter’s patient, persistent voice in my head.

Finally, one day Ken showed up in the ER for an unrelated complaint. He was sober and had been for eight months. He apologized for his many lapses and thanked me for giving him multiple chances to get sober. Searching for some insight, I asked what had finally worked for him. He had no clear answer. For him, like Walter, he simply had to go through it too many times to count until one day he just tired of it and stopped drinking.

I don’t know if he will stay sober. The cost of his current sobriety: over $100,000 in medical bills. The cost to restore his self-respect: priceless.

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