Saving Sylvia Cleary

Sylvia Cleary rolled up the sleeves of her starched white blouse to show me a few pale, blotchy bruises on her forearms. A soft-spoken forty-six-year-old secretary who wore a red A-line skirt and decorated her dark brown bob with rhinestone barrettes, she had come to my clinic at Bellevue Hospital with a sense, as she put it, that something was metabolically wrong. I reassured her that plenty of people bruise themselves without realizing it. The results of her routine blood tests were puzzling. There was marked inflammation of the liver, possibly cirrhosis. To me, an inexperienced intern, it seemed unlikely that alcohol--one of the most common causes of cirrhosis--had anything to do with the bruises. A week later, Ms. Cleary was back for her blood test results. A few questions revealed that she'd been drinking at least a pint of scotch a day for more than ten years. It was hard to believe. She seemed so reasonable, so together. Perhaps, with my guidance, she could give up drinking. I reminded myself what I'd learned in medical school lectures: alcoholism is a disease. I chose my words carefully. I didn't want to scare her away. "The scotch," I said, "is damaging your liver. The bruises are a sign of this. You really need to think about resisting the urge to drink." She nodded, rubbed her hands together. "I'll have to do it, then." Going cold turkey could be dangerous; even a small change could trigger a withdrawal seizure. I asked her to consider the hospital's inpatient detox program. "I'd rather do it myself," she said. "I can handle it." I worried about her over the next few days and decided to give her a call. I'd find out if she was okay, and a few words of encouragement might help her stay on track. The first time I called, she reassured me that things were fine. She was cutting down without any problem. The second time, she told me not to worry and said she'd see me in a month. I picked up the phone several times during the next three weeks, but at the last minute I'd hang up before dialing. I told my attending physician about my concern over Ms. Cleary. Let the baby bird out of the nest, he said. The phrase seemed a little abrupt. It may have made sense for some patients, like the down-and-out alcoholics--the disheveled, smelly, ornery men who'd show up in the ER trembling and feverish after spending the last of their disability checks on booze days earlier. With them, I'd go through the motions mechanically: the statement of the obvious ("You're an alcoholic, and you're destroying your liver."); the taper of Librium, a medication that mimicked the effects of alcohol in a safe, controllable way; the Alcoholics Anonymous recommendation; the clinic appointment for follow-up that was never kept. Other than easing their withdrawal symptoms, I couldn't help them. But for high-functioning addicts like Ms. Cleary, didn't I need to do more? A month later, we were both beaming. Ms. Cleary had completely stopped drinking scotch. Her secret, she confided, the flush in her cheeks matching the color of her cranberry jumper, was wine--she believed that it was less damaging to her liver. My smile froze. I pulled my chair closer to hers. To the liver, I explained, struggling to keep my tone even, alcohol is alcohol. Her healthy pink glow, I noticed, was actually a filigree of burst capillaries, another sign of liver disease. I asked her again to consider inpatient detox. She was as reluctant as before, but when I pointed out that the timing was good--she'd just left one job and had a few weeks before she planned to start temping--she agreed to give it a try. I went up to the detox unit a few days later. She was a bit groggy from the Librium but appeared upbeat about the experience. The only woman there, she was enjoying the attention. "The guys are so polite," she whispered, smiling at a heavyset, grizzled man shuffling by. …