'At 25, alcohol had destroyed his liver. We couldn't save him'

The damage caused by drinking is more complex and serious than a few broken heads on a Saturday night. A&E doctor Simon Reilly reports from the front line
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Indy Lifestyle Online

In order to monitor the effects of alcohol on the nation's health, many emergency departments now have a little tick-box on the computer that politely asks "Alcohol-related?" when you discharge a patient from the system. Other than publishing them annually and tutting loudly, no-one really knows what to do with these figures, but at least we can now collect the data more efficiently. I want the default setting of the tick-box changed, so you have to un-tick the box of patients whose problem was not related to alcohol. I think it would save time.

It's easy to imagine how you think alcohol would impact on an emergency department – binge drink-fuelled violence is the typical image. But while the effects are indeed huge, they are often a lot more complex than that getting your face broken on a Saturday night. Take the following real cases, from my own personal experience, over a recent two-day period.

There was the guy who had fallen off a chair and was so uncooperative that we could not get decent x-rays of his neck, which we suspected he had injured. "Combative" drunks are difficult to deal with for all sorts of reasons, not least that sometimes their behaviour is not down to drink, but down to a head injury. Miss that and you can end up on the sharp end of a coroner's inquest. We eventually managed to get a CT scan of this man's neck, which he had indeed broken. Thankfully it was a stable, self-healing type of break, as long as he takes care of himself for a few weeks. Getting drunk and falling over would be the obvious sort of thing to avoid here. So fingers crossed.

Then there was the 19-year-old East European immigrant admitted overnight after being found insensibly drunk. He was being "disruptive" on the ward. By "disruptive", I mean grabbing all the tubs of alcohol-based hand-gel found everywhere in hospitals these days and necking the contents. We managed to find a place for him at a homeless persons' hostel. Last I heard he had absconded and checked himself into a neighbouring emergency department, no doubt with the intention of drinking it dry.

Next was the 40-year-old almost crippled by peripheral neuropathy. This condition can be brought on by excess alcohol, which slowly pickles your nervous system, starting with the longest, most vulnerable nerves. So you end up with feet that feel like they're done up in bubble wrap and look like they're in the charge of a pissed puppeteer.

After coming round from an alcohol-induced seizure, he was well enough to go home. The problem was that he lived in a first-floor flat and couldn't negotiate the stairs unless we arranged a two-person ambulance. We'd already established that he was on a minimum of a litre of vodka a day at present, so I wondered just how that worked out for someone house-bound by a flight of steps. Thank goodness for the internet. His first job of every day was to log on and order his vodka, which arrived by lunch-time. Delivered, free of extra charge, right to the door.

Alcohol does strange things to you. As illustrated in a recent government TV campaign, it fuels confidence whilst simultaneously sapping ability and judgment. It makes people do stupid things. Like trying to light a barbecue with petrol; petrol that you've decided to keep handy in a slightly leaky plastic drinks bottle in your jacket. In this case, the effects of alcohol extended into the emergency room, where the victim decided that he could manage the full-thickness burns on his chest himself, thanks all the same, and took his own discharge against medical advice (and perhaps more tellingly, girlfriend's advice). With calamine lotion being such a poor substitute for skin grafting, he was back 48 hours later: sober, apologetic, and with burns so badly infected he nearly succumbed to full-blown septicaemia.

Booze does strange things to your body, as well as your psyche. These effects become more apparent when you move on from the binge drinkers to the more serious, stay-at-home, dedicated consumers. The liver has the job of breaking down alcohol. It has plenty of other things to do as well, such as producing blood clotting agents and draining almost the entire blood supply from the digestive system to metabolise your food. Once your consumption of alcohol goes above a certain level, the liver diverts nearly all its resources into dealing with the onslaught. Push it even further and the liver cells themselves start to get damaged, eventually leading to that famous companion of chronic excess drinking, cirrhosis.

A cirrhotic liver is difficult to pump blood through. Pressure in blood vessels within the liver rises, eventually leading to widening of veins inside the gullet. These "oesophageal varices" are pretty much as they sound – varicose veins in your oesophagus. When they burst, they bleed. A lot. And by the time varices have developed, the degree of liver damage established means the blood is not clotting as it should.

Bleeding oesophageal varices used to be something I only saw in middle-aged heavy drinkers. Last week I saw it in a 25-year-old. We managed to replace some of the lost blood, but his clotting was so deranged that the bleeding was eventually unstoppable. He died later that day, bleeding profusely from both ends of his digestive system.

Talking of blood, the ambulance service have just fetched in a very, very drunk man, who has a head wound, has already punched a paramedic and is thrashing around the trolley spraying blood in all directions. It's 10am on a weekday morning. Someone thinks the man may be "Hep C positive", hepatitis C being one of the nastier and more easily transmitted blood-borne viral infections. You don't want a splash of fresh blood in your eyes or mouth if you can help it, especially as there is no vaccine and little effective treatment against Hep C. Somewhere there is a pair of goggles and a splash-proof face mask. While someone finds them, the rest of us draw lots. The lucky winner gets to stitch the patient's head up.

Less dramatic – but just as much of a therapeutic challenge – was the woman in her mid-thirties desperate to stop drinking. Emergency departments tend to be the last stop of many who are trying to get help. So when this woman's GP refused to prescribe medication to help her reduce her drinking, when she had been told there was a six-week wait to see an alcohol counsellor – and when she discovered how much it costs to book yourself in to a private clinic – she ended up with us. What she needed and needed desperately was an in-patient detox bed. The acute physical withdrawal (not only unpleasant, but with alcohol, sometimes fatal) can be managed at the same as starting psychological treatments and putting in place strategies to address long-term abstinence. In-patient detox beds simply don't exist in my area, nor in many parts of the NHS. So we fudged things. She pretended to have a fit and I got her admitted to an acute medical bed. A tiny victory over the system and the beginning of the start of her recovery. Hopefully.

It's cases like these – young people with horrible but preventable disease, that I can't help bringing to mind when adverts for alcohol pop up on the telly. Obviously it's against the rules to suggest that drinking will make you sexy, but you can be pretty sure you'll be surrounded by some fantastic-looking young people if you buy the right brands of booze. None of these people appear to be jaundiced, or to have fallen over in the street and smashed some teeth out, or to have drowned in their own vomit, but that's because they follow the advice in the corner of the screen, and enjoy their alcohol "sensibly".

What you never see advertised are the increasing number of cheap products sold by the plastic-bottled litre or two, rather than in chic 75cl glassware. Supermarket own-brand vodka, that nobody ever drank with anything other than the determination of getting quickly and comprehensively smashed; the garishly-labelled white cider, or the weird mixtures of fruit juices and ethanol and the tonic wines like the notorious "commotion lotion" Buckfast Wine, popular north of the border, where the world's strongest beer (32 per cent abv) has also been launched.

There's an already well-rehearsed argument when it comes to alcohol pricing – minimum pricing being the latest policy being considered by the current government – and it's easy to predict who will say what. "Health" campaigners say cheap alcohol encourages drinking by youngsters and that supermarkets even use cheap booze as a loss leader to promote other sales. But it's hard to dodge the apparent subliminal message here, which is that it's only poor people who drink dangerously; something which is patently untrue.

The "alcohol lobby" maintains that it is unfair to penalise the less well-off by introducing minimum prices, especially given that it is only small percentage of those who drink that have problems.

Trying to control the use of alcohol through its price does feel a little like "prohibition lite" and doomed to failure. I have yet to meet a smoker who decides to quit because of the cost.

Having said that, put me in charge for a day and I would increase the tax on alcohol slightly. Not to deter the drinker, but to raise money specifically for the treatment of alcohol dependency. Detox clinics and liver transplants are prohibitively expensive.

I can see that the big names in the drinks industry would rather sponsor prestigious sporting events than have their name associated with treatment facilities, but when your liver starts to fail, or you reach that rock bottom that many addicts need before they seek recovery, you don't need to go to a rugby match, or watch some horse racing.

You need quality help; help which someone has to pay for.



Simon Reilly is a pseudonym. The author works as a senior emergency department physician in an acute NHS Trust

Alcohol: how much is too much?

* Government guidelines recommend that men limit their consumption of alcohol to 21 units a week and women to 14 units. Estimates suggest that one in three men and one in seven women in the UK exceed these safe guidelines.



* Research indicates that 80 per cent of people are misinformed about these guidelines. Further problems emerge with the measurement of a unit – a glass of wine can contain between one and three units, depending on the wine and the size of the glass.



* Prolonged drinking puts huge strain on the liver, often leading to cirrhosis, caused by build-up of scar tissue on the organ. A number of cancers are more common among drinkers.



* In the shorter term, alcohol also prompts the production of excess acid in the stomach, causing irritation to the digestive system which results in pain, vomiting and diarrhoea. In heavy drinkers the effects may be amplified, causing inflammation of the stomach's lining and bleeding may result.



* Heavy drinking has been linked with anxiety, depression, memory loss and dementia.

Avantika Chilkoti

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