Cutting back on the drink...

A fairly put-together 30 year-old lady came in with some moderate epigastric pain and nausea for a few days. She said she over did it over the weekend before at a bachelorette party but no real other medical history besides some poorly controlled hypertension and a rapid tremor that she claimed had been there since birth. Oh...and by the way she drank about a bottle and a half of wine most nights. Labs showed elevated amylase and lipase, so we went with acute pancreatitis (alcoholic vs. gall stone). The enzymes came down after a few days of NPO and hydration and the GB U/S was clean, so we decided to send her home after she tolerated PO without pain or nausea and we were able to send her home with her tremor and hypertension. Well, the whole HTN and tremor history sounded pretty funny to me...but my attending brushed it off, so I did too...who am I to question the attending? I rotated onto the CCU team the following Monday thinking that she was doing well.

About a day after discharge, the poor girl has a seizure and spends 2 days in the ICU where she was suddenly hypotensive and dyspneic, placed on BIPAP. She got an ECHO that showed an EF around 20% due to alcoholic cardiomyopathy. Suddenly that hypertension and tremor looked a bit more noteworthy than before...I saw my attending rounding and all I could ask is "WHAT'D YOU DO???".

She ended up doing pretty well, fortunately. But missing a girl in alcohol withdrawl is kind of a big deal in my book and I hope the attending knew it. I felt aweful that I hadn't spoken up about my tingling spidey sense...not that my attending would have paid attention to me anyway.


Dragonfly said...

That sort of thing often leads into an interesting discussion about the "role" of the medical student. Are we hospital wallpaper, or are we a member of the team? Since we aren't employed (but are indemnified), where are our responsibilities? Should the patients be protected from the indignity of medical students or does our learning directly or indirectly help them?
I (and I'm sure I'm not the first one by any stretch) have been alternately told I am "an extremely useful and valued member of the team", "a pest", "in the way", "annoying the patients", "too enthusiastic", "have an admirable work ethic", "the patient wanted to thank you". I've had patients not want me watching their flu vaccine, to patients who insist on calling me doctor (please don't). Ok, didn't mean to make this an essay, but try not to feel bad about it. All we can do in that sort of situation is try to apply what we have learned as best we can when we are in the position to do something about it.

Albinoblackbear said...

ETOH withdrawal is something that is often missed in the ED--and also downplayed as a major risk when patients are admitted.

It is frustrating because when I worked in acute psyche EVERYONE had to have an alcohol withdrawal screen and was put on standing orders as necessary. In the ED I find getting that aspect of the patients care often gets overlooked (or ignored), this has led to some majorly poor outcomes.