There was no hiding his ailment and why he had been admitted to the physical rehabilitation hospital. I could tell by looking at him from down the hallway: his yellow jaundiced skin, the muscle wasting in his limbs, the protuberant abdomen. As he moved closer to me, being slowly pushed in his wheelchair by a physical therapist, the sallow yellow where the whites of his eyes should have been startled me and when I held his gaze for a few seconds, I saw the colorless despair. He wasn’t my patient, but he was very similar to other patients suffering from end stage alcoholic liver disease that I have taken care of in the last several years, and I felt empathy for his suffering.
Many patients with alcoholic liver disease end up needing inpatient rehabilitation because they required acute hospitalizations for life-threatening bleeding from somewhere in their digestive tracts. When the liver gets hardened and cirrhotic from years or decades of heavy drinking, it morphs into a dried out and cemented sponge, causing a back-up of pressure into blood vessels, increasing the likelihood that veins in the esophagus, stomach, or intestines will bleed. Patients with end stage liver disease also have low platelets, little blood fragments whose job is to plug up holes in the blood vessels while waiting for the rest of the coagulation or clotting army to arrive. Often patients who drink excessively have vitamin deficiencies that lead to anemia, or low red blood cell counts, as hemoglobin requires vitamin B-12 and folate for its production in the bone marrow. This unlucky triple whammy: increased pressure, impaired clotting ability, and low blood counts, often leads to massive bleeding.
One particular patient I once cared for had the lowest hemoglobin measurement that I had ever seen measured in a patient. When he presented to the emergency room throwing up bright red blood, his hemoglobin was only 4.3 g/dl, while normal for a male is at least 13.5 g/dl. He initially survived, miraculously, due to a massive blood transfusion protocol, in which he received multiple units of red blood cells, plasma, and platelets. He also underwent a surgical scoping procedure whereby the gastroenterologist found the bleeding vessels in his esophagus and clipped them so that they stopped bleeding. After he was stabilized, he came to rehabilitation, to start the slow therapeutic process to regain enough strength to hopefully return home to his family. He was only there for five days until he started throwing up blood again and returned to the acute hospital. He died the following week, as all his organs started shutting down, one by one. He was only 32 years old and had started drinking alcohol heavily as a teenager.
All organs in the body are affected by heavy alcohol use, even the brain. I recently had a female patient who was admitted to rehab, not from bleeding but from something called hepatic encephalopathy, or loss of brain function when the liver is unable to filter toxins from the blood. She did not know where she was or why she was in the hospital. She knew the city she lived in, but not the month or the year. She had difficulty making rational decisions, like wanting to get up in the middle of the night to make scrambled eggs. The worse part of her encephalopathy was her personality changes. Once a kind and thoughtful woman, she now was erratic, irritable, angry, often picking fights and hitting her husband.
He understood her behavior was due to her diseased brain but knowing this did not make it any easier to handle her outbursts. When she got to the rehabilitation hospital, she had difficulty committing to doing any of the therapies, would try to get up out of bed constantly, despite the alarms. She fell several times due to severely impaired balance as alcohol also affects the sensory nerves in your feet. She refused to take her medications and increasingly became aggressive with the staff. I called her husband and told him that she wasn’t participating in the rehabilitation program, that it wasn’t the right place for her. He was scared to take her home, as he also couldn’t control her. I explained the options: he could come pick her up and take her home, or I could transfer her to the acute hospital to be evaluated for an acute inpatient psychiatric admission. It broke my heart that I could not help her. I did not want to hold her down and give her injections of psychiatric medications. He came to pick her up the next day and I ordered home health nursing and therapies to come to their home, as well as social work to offer more support to her husband. One week later she was readmitted to the acute hospital with an infection and died shortly thereafter in the ICU. I wonder if her husband felt some relief along with the pain of losing his spouse.
I can only imagine the array of emotions families and patients experience when it comes to managing the illnesses associated with alcoholic liver disease. Although many patients stop drinking months or years before their eventual deaths, it is often too late, with no way to repair the damage to their bodies. I remember the waves of fear, sadness, and anger from another woman who asked me to be honest with her on the day she picked up her alcoholic husband from the rehabilitation hospital. I told her the grim statistics of the likelihood of him dying in the next 6 months based upon where he fell on the spectrum of alcoholic liver disease. The pain emanated off her in waves, as she explained to me how he had lost his job due to his alcoholism, which quickly led to losing their home, and then their car. She was heading back to the motel room they rented from week to week, taking the bus, worried about how they were going to pay for the medications that would hopefully keep him from being hospitalized once again. I ordered home health services including social work, and gave her the phone number for Al-Anon, knowing the high likelihood he would soon be back to the hospital. It was only a matter of time.