I am taking a diversion from the usual CDI blog entry to recall a powerful episode from my early years training to be a physician.
Patients with advanced alcoholism are at times frustrating and vexing to deal with, for a variety of reasons. They can become very malnourished, and can have unusual vitamin deficiencies. As the liver gets damaged, it can no longer manufacture the blood components that promote clotting; as a result the patients are prone to bleeding.
That scarred liver can make it hard for the heart to pump blood through. The blood backs up, and eventually shows up as engorged veins surrounding the lower esophagus. One of the crisis points that a patient with advanced alcoholism reaches is when one of the engorged veins (varices) in the esophagus starts to bleed. When one of those varices starts letting loose, it is a life-and-death situation. The alcoholic GI bleeder.
1975. Early in my internship training. I was roused from a sound sleep in the middle of the night to come to the emergency room. There on a stretcher was my first alcoholic GI bleeder. He was intoxicated, stuporous, smelly, disheveled, unshaven, and quite filthy. He had old and new vomit on his shirt, and smelled of urine and much more. He was retching and vomiting up bright red blood.
This situation represents a walking textbook of medicine, as many things are all going wrong at the same time. Proper and meticulous attention to all the details is essential. And proper sequencing is also very important. If you correct one nutritional deficiency without correcting its matching counterpart, you can precipitate a violent and potentially lethal reaction. It is important to do the right things at the right time for the right reasons.
So we went to work. Start an intravenous (IV) line (quite a task with him thrashing, retching, and cursing). Correct a potentially low blood sugar, add critical vitamins, correct the deficient blood clotting factors and get blood transfusions ready to go.
While juggling all of this, we also had to get that bleeding stopped. If someone is bleeding from a surface wound, you apply pressure, put a clamp on an artery, and/or sew things back up. When the source of bleeding is a vein in the lower esophagus, none of these options are available. Instead, you try and pass a tube into the stomach (usually through the nose), and inflate a large balloon on the end of the tube, thereby applying some pressure to the bleeding point and slowing or stopping the bleeding. More advanced procedures are available now, but at that time, this was all we had.
My resident and I worked all night on the patient, and well into the next day. I ended up covered with a considerable amount of stomach contents, blood, and various other substances unidentified but definitely undesirable. The bleeding slowed down, the nutritional problems got corrected. We were pouring in blood, but keeping up with the losses. The patient had developed blood in his stools (“melena”). This has a very characteristic strong odor; you can tell immediately when walking onto a hospital ward if there is a GI bleeder present, as you can smell the melena. We were faced several times during the night with a soiled bed from this problem. I choke and nearly vomit when confronted with this. While cleaning the bed is not typically the doctor’s job, I ended up helping to change the sheets, as much to hurry the disposal of the stench as anything.
One last major problem we had to battle was alcohol withdrawal. The body gets hooked on the alcohol, and when it is suddenly deprived, dire consequences can ensue. Hallucinations, cardiovascular collapse, seizures, delirium tremens. We gave the patient diazepam IV to replace the alcohol, then gradually withdrew the diazepam.
We did it. We saved him. This is the ultimate experience for the medical man (as opposed to the surgeon). We were presented with one of the most difficult conglomeration of problems to manage, and we prevailed. Detective work, analysis, brainstorming sessions, tube passes, melena cleanings, x-ray reviews, it all paid off. We learned a lot about teamwork, too, as this was not the work of just one or two individuals.
We all walked around like we had won the Superbowl. To top it all off, the patient had “found religion”. He had come about as close as one can come to death, and had been pulled back. He was badly shaken by this, and resolved never to drink again. He would devote himself to sobriety and making good of his life. Wow, not only did we save him from death, but we turned his life around. It just doesn’t get any better than this. We all clapped and wished him well as he left the hospital many weeks later. I pushed the wheelchair myself to the front door and, grinning from ear to ear, shook his hand and wished him well in his new-found life.
The rest of the day we all walked around with silly grins on our faces. Damn, we were good. We really did it. Doctor. So this is what it’s like!
I was “on call” that night at the hospital. The Emergency Room called (again in the middle of the night). He was back. He was drunk. He was bleeding. It seems he was so excited by his sobriety, his salvation and by finding his new path, that he went out drinking to celebrate. The rest of the night was spent again with tubes, IVs, transfusions, vomit, feces, urine, and melena. He died that night in the ER, surrounded by his bodily excretions, and large puddles of blood.
My resulting depression and disillusionment cannot be put into words. Made even more acute, more cruel by the fact that it was proceeded by the heights of ecstasy. This was an agonizing defeat.
I took care of many more alcoholics and GI bleeders before my medical training was over. Some we lost, a few we saved. To this day (more than 40 years later) I still bristle at the smell of melena, as all those memories come flooding back.
The thrill of victory. The agony of defeat.
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