Soundings: Paradigm shift
Authors: Kevin Barraclough
Journal: BMJ (2003)

The call from the emergency department came in the wee hours of the morning: the young woman was in. Again. Lynn. She was a frequent flyer, so often in the hospital that many staff members knew her and, unfortunately, sometimes despised her. Incurable. Never a triumph. At best, one heroic stabilisation before the next downfall.

My patient was an alcoholic. Her cart slithered deeper into the morass, finally sinking, leaving just tears behind. What medicine can do for alcoholics seems peripheral—a few drugs, some procedures to prevent or to stop bleeding, and, ultimately, forced sobriety in an institution.

Lynn was in her late 20s, looking like 50-something and wheelchair bound after falling down a flight of stairs years beforehand. On this dreaded morning she had thrown up. Puked blood. Again. Friends had dropped her off like a foundling, with her wheelchair as her cradle. A heap of misery, guilt stricken and avoiding eye contact, quivering and crouching in her dilapidated chariot that looked more like a theatrical prop than a useful medical appliance. Her lips stained red by blood, like exaggerated, careless make up. Her belly protruded as if she were with child. I thought of an old Austrian term, armes Hascherl, a poor creature for whom one cannot help but feel tender pity. Her hobnailed liver barely sustained her life.


Admitting illiteracy seemed too high a price to pay for sobriety


I wondered why she was still at least somewhat alert, what with the ravages of alcohol on her brain. Unkempt, dirty, and neglected by herself and those around her. Did anyone care? She thought dad might come by. Mom? Lynn shrugged her shoulders. So we tucked her in bed, repaired the laboratory values as best we could and tried to make her feel better, dried her out, transfused her, and were again frustrated at not having an artificial liver, at least as a bridge. But bridge to what?


Alcoholism is ill suited for a fundraiser


I called our consultants and sensed incredulity. No, I was not joking, merely attempting to leave my desperate patient with a tiny flicker of hope. Well, OK, last spot on an unmanageably long list. Now I could tell her she was on the desired roster. One condition: abstinence for at least half a year. Was I deceiving her and myself? We talked about the self help organisation Alcoholics Anonymous. Yes, she had repeatedly tried AA. Always dropped out. Why? There came a shy whisper: those darn reading assignments, not only for studying but also to be read aloud in group sessions. She never had learned to read. Admitting illiteracy seemed too high a price to pay for sobriety. She simply stayed away. We called AA: “Yes, we expect them to read. But they don't have to.” Well, would you want to appear obstinate? Or illiterate?

She bled again. No more varices to snare. Her jaundiced skin now shimmered with a light green hue from biliverdin. The flood in her belly came back like a tidal wave. Even our young students sensed that Lynn was slipping away. We called her father and he came. Salt of the earth, I thought. A father who had borne his cross so long. Who could ever fathom this tragedy? He had no questions, no suggestions in his quiet resignation, was as helpless as we. He handed me a business card. Funeral director. Sensing my surprise, he said that he had prepaid Lynn's funeral. Once it was over, just call the number on the card. He hinted that he might not come, now or later. He might not see her ever again. No tears. He was burnt out, used up, had all but lost his paternal love to an empty numbness and perhaps long ago had joined the ranks of shoulder shruggers.

Lynn died, of course. No postmortem examination. The pathologist's findings seemed predictable: a shrunken hard lump in the right upper quadrant of her abdomen, once a liver. Still, no matter how meticulously we all would have searched, we would not have found the cause behind the curse. We cannot dissect a soul.

Alcoholism, a disease devoid of all glamour, is ill suited for a fundraiser in furtherance of care and research. No poster child, the drunkard is shunned, is frequently considered a weakling fringes of society. Does anything destroy self esteem and pride faster than drunkenness? Yet happy people smile from billboards, drink in hand, luring us firstly to play volleyball and then to have a highball. Alcohol, libation to the deity and old social lubricant, also greases the slide to skid row.

Where was the catastrophic failure? In Lynn's genes? Did family, friends, and her teachers desert her early? Did our social fabric become so frayed that she slipped through? Maybe we all failed her...