Tuesday, June 29, 2010

Note to self...

When a VA patient tells you he drinks 1-2 glasses of wine a night...
times that by 6.

Seriously though, if there is anything I have learned when it comes to our veteran's....it's that they like their alcohol. Some are more obvious than others and most will never admit it outright, but 95% of the time you can safely guess that if a patient is coming to you from surgery... be prepared for alcohol withdrawal symptoms.

For example... right now I am taking care of a post-op CABG x1 with an AVR. Basically, he had a one vessel graft on a coronary artery and a prosthetic valve placed in his heart. He's a relatively healthy guy considering what we are used to here. No history of drug use, smokes a pipe, told his surgeon he drinks one shot of gin a week. Told the social worker he drinks a shot of gin a week AND 1-2 glasses of wine a night....

"Yup, that explains it." I said to myself.

When I came on shift, I noticed the patient had been having minimal signs of alcohol withdrawal, just some tiny tremors that I thought looked strange. I pulled the intern and resident to the bedside to have them take a look.

"You know when a dog is sleeping and they're dreaming about something and you see them do that funny twitch thing, or you see them start to move their legs like they're running."

I can't believe I'm actually explaining a patient's symptoms like this.

"Uh huh," the resident nods as the intern begins doing a neuro check on my patient. The docs are nice enough to humor me.

"Well, thats what he's been doing. He isn't doing it now but if I mess with him at all, like do a fingerstick or anything, he starts doing it." Luckily, just as I was about to touch him to see if it would happen...he began twitching on his own.

"SEE, like that!" I point at him, SO thankful that this time, when I actually get the doctors about something, it happens when they are at the bedside and not the second they leave instead...
I swear I'm not crazy.

We all came to the conclusion that we weren't quite sure what was going on, and since his pressures didn't drop too much when it happened and he was remaining stable... well we basically all shrugged our shoulders and decided to just hope it'd stop.

It didn't...

Around 2am, this patient who had been on enough fentanyl and versed to knock out an elephant and should have been zonked out of his mind, SAT UP, in bed, wide eyed and reaching for his ET tube. I jumped up, grabbed his hands and began explaining to him calmly that he was in the ICU and his surgery was over and he was fine...but that he had a breathing tube in his throat and IV lines everywhere and cannot grab them and needed to go back to sleep. Yes, the longest run on sentence ever. He looked at me for a while, nodded his head and then began to fight me like mad....at which point I decided I needed back up and yelled for my neighbor to come in and restrain him while I increased his sedation.

This is the classic case of the patient not admitting to the true amount of alcohol they drink on a daily basis. The amount of sedation this patient required was a sure fire sign that he had quite a tolerance built up. Anyone who can wake up on 5mg/hr versed and 500mcg/hr fentanyl has got to knock a few back pretty often.

All in all it ended up being fine. Thank goodness for dexmedetomidine... the wonderful drug that sedates you but doesn't depress your respiratory drive = we can extubate you and keep you calm at the same time. :)

And next time, I'll remember to pay a little more attention when someone says they drink "1-2 drinks" a day.


  1. Oh man! That's true that you really have to use your clinical judgment when it comes to alcohol withdrawal. Vets are tough guys. . .can you imagine waking up with an ETT down your throat s/p open heart surgery? OMG.

  2. I'm so sorry you're having a terrible day! Hope the weekend goes better.