Types of Patients X: Alcohol Detox

Despite (or maybe because of) its status as a legal drug, alcohol consumption is nearly culturally universal, as is addiction and abuse, and the health complications of alcohol use occur across the lifespan.

Although recent research has shown that certain races and individuals with specific genetic profiles may be predisposed to alcoholism, defined as physical dependency upon ethyl alcohol (ETOH), the social and psychological aspects of alcohol addiction exist in all races and cultures.

As well, whereas legal consumption of alcohol is restricted in most societies to certain age groups, the negative health consequences of alcohol use effect all age groups. From alcohol-related accidents to fetal alcohol sydrome (FAS) to liver disease, etc., alcohol consumption, excessive or not, results in untold costs in terms of lives and health care dollars.

One group of individuals often ignored when we talk about the effects of alcohol addicition and abuse is, ironically, the addict. News stories and statistics usually track the unintended victims of abuse--sober accident victims, infants born with FAS--but addicts themselves are usually blamed for their problem and therefore the negative health effects of alcoholism upon them are usually assumed to be chosen, inexcusable, unnecessary...ultimately, a drain on the health care system.

For this reason, alcoholics seeking treatment for alcoholism present a challenge of compassion to ER nurses. Usually we treat patients whose injuries or illnesses are unintentional. With alcoholism, we treat an illness that is the result of the patient's volition. Other illnesses are similarly the result of individual's choices--smoking and lung disease, obesity and just about everything else!--but addiction to alcohol (or other drugs) seems a less sympathetic and more dangerous consequence of an obnxious habit.

I focus on the physical aspects of alcoholism and the nursing interventions necessary to protect the patient seeking detox from the untoward side effects not of alcohol abuse but of the detox process, itself. Attention to the psychological aspects of alcohol abuse and addiction is a more proper intervention while the patient is inpatient, not in the ER. Therefore, aside from supporting the patient's decision to seek detox, I leave philosophical and psychological discussions out of my nursing care.

A-B-C-Ds. Not hard. Usually patients seeking detox are functional, at least from the standpoint of body functions.

However, in the secondary survey (a nursing assessment that takes place after the primary ABCs are assessed and intervened, if neccessary), the D indicates differential diagnosis and/or disability. Aside from the psychological difficulty of breaking a habit, there are potential physical dangers to the patient attempting detox. The initial intervention for these occurs in the ER.

Alcoholics are often relatively malnourished and the sudden cessation of drinking can induce biochemical changes with serious side effects. The most serious side effect is seizure activity. Relative deficiencies in various B-complex vitamins due to malabsorption, specifically Thiamine and Folic acid, predispose the patient to seizures.

Nursing, therefore, must intervene by administering these essential nutrients, usually via IV, and engaging seizure precautions: intravenous access, oxygen and suction supplies at the bedside, and the administration of a benzodiazepine. Usually lorazepam is used because it has both sedative/anticonvulsant as well as anti-anxiety properties.

The anxiolytic property is necessary to permit the patient to get beyond the physical effects (mostly euphoria) of alcohol intake that are often the source of compulsive drinking. The more anxiety the patient experiences, the more likely their decision to detox wanes. Successful detox, therefore, relies upon the transient use of a substitute drug.

Basic lab work is also necessary before the patient is admitted. Complete blood count (CBC), comprehensive metabolic panel (CMP), blood alcohol content (BAC, or medical ETOH), and a urinary drug assay.

The rest, of course, is up to the patient. I can treat detox patients but I can't ultimately detox them. They have to do that for themselves.

(Don't) Dial-a-Nurse

One of the most frustrating aspects of working in an ER is fielding calls from people who want to discuss their symptoms over the phone and expect a diagnosis, home treatment plan, or advice about whether or not to seek emergency treatment. Sometimes these individuals are calling about themselves, but most often it is a parent calling about a child's symptoms.

Ostensibly, my hospital does not permit ER nurses to give advice over the phone. The reason for this is liability. If I gave advice to someone about symptoms I cannot properly assess in person, I run the risk of misdiagnosis or mistreatment or both.

Similarly, I have a 50/50 chance of recommending correctly whether or not someone needs to seek emergency treatment. If I tell them to come to the ER and they do and, in fact, they have an emergent condition, then I might be their hero. But when they are stuck with a bill for an unnecessary ER visit, I'm the villian.

And, worse, if I suggest that they do not have an emergent condition when in fact they do, perhaps life-threatening, and they don't come in, well...

The belief that it is easy to distinguish emergent or life-threatening conditions over the phone is the subject of this short (and scary, to an ER nurse) article.

www.nytimes.com/2008/02/12/health/12magn.html?_r=1&th&emc=th&oref=slogin


Regardless of my hospital's policy, the administration continues to publish the ER's phone number against our requests and will not allow us to have a phone message to answer as many other businesses, doctors' offices, and health care agencies do (a message that usually begins, "If you have an emergency, hang up and dial 911..."), claiming that such a message is too impersonal.

(Ironically, the only department in our hospital that has such a messaging service is Human Resources!)

How do I negotiate this mine-field?

I try to put myself in the caller's place and tell them what I would do if I were experiencing or witnessing the symptoms they are relating to me. Telling them what I would do if I were them or if it was my child strikes me as offering an informed opinion, not advice, and is a reasonable way to communicate what I think but ultimately leave the decision up to the caller.

They should just be happy I don't give them my mother's stock advice: "It'll be better in the morning."

Nursing Compliments

Recently, I completed a recommendation letter for a fellow nurse who is applying to a graduate program in trauma nursing. She wants to become a Clinical Nurse Specialist, similar to a Nurse Practitioner. I've known her for awhile, like her, and thinks she's a good nurse. It was not hard to think of a few good things to say.

But I didn't just want to say "good things." I wanted to say the best thing!

Thomas Merton, a Trappist Monk, once wrote, "Build a chair as if for an angel." His meaning was clear. If you are going to produce something, do it in the best way and for the highest good you can imagine.

Writing a recommendation letter for someone is tricky business. You don't know who will read it. Who are the members of the selection committee? Is there a selection committee? Will the reader be a sticky organizational bureaucrat, or is there room for creativity, levity? Knowing these things is important if one is trying to say the best thing for the circumstances.

I erred of the side of saying the best thing I could say regardless of the circumstances. Along with all the hagiographic blah blah blah, I simply wrote: "I would have no difficulty entrusting Ms. (Nurse) with my patients, with myself as a patient, or with any of my family members as patients."

Certainly the highest compliment one nurse can bestow upon another.

Hospital O'Hare

I've been a nurse for awhile, and after a few years, like any other job, I've exhausted the opportunity for new and unique experiences. Most of what I do everyday on the job is like what I do every other day on the job. As monotonous as that sounds, at least these ordinary experiences are fun and interesting to me.

That said, I experienced a "first" a few days ago.

When I started working as a nurse, I was on a medical-surgical unit. This is the main nursing floor in most hospitals, a place where patients stay for awhile, either with an illness that is not quickly treated or after surgery, recovering.

What I liked about this sort of nursing was the familiarity of patients from day to day. Often I would have the same four or five patients for days at a time. The length of time I had with them allowed me to build reporte, often finding out more about their ordinary lives, their likes and dislikes, what made them tick. This amount of time also gave me a greater opportunity to influence their thoughts about health habits and how they might change their behaviors to encourage and maintain maximum health.

But this consistency also had some draw backs, the most depressing of which was taking care of really obnoxious patients for days at a time.

In the emergency room, however, I see patients for maybe a couple of hours, half a shift at most (6 hours). This means I see more patients and a greater variety of patients in each twelve hours I work. The trade-off is I also have less opportunity to chat, figure them out, influence their health-related choices.

Not so the other day.

The other day I received report on a patient from the night nurse--the patient had arrived at 0545--and I duly reported off on the very same patient to the very same night nurse twelve hours later. In all, the patient spent fifteen hours in our ER, long enough to develop new symptoms that she hadn't even come in with! That was a first for me.

I attribute this to a scatter-brained, passive-aggressive ER doctor, an internist by training who has no sense of time-management and who has to fix everything about a patient (and sometimes their families!) This doc had patients circling for hours that day--my patient wasn't the only one--like "Discharged from ER" was a busy airport where patients couldn't land. I've seen worse up-in-the-air at O'Hare!

And it was an overtime shift for me...