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Drugs of Abuse

To pick up where my last post left off, I thought I would write about a more common case than LSD. That would be alcohol intoxication. SFGH's director of Emergency Medicine, Alan Gelb, noticed a decade by decade decline in LSD presentation to the ED but a consistent stream of alcohol related illness. Now that I look back at the past month at SFGH, I can hardly estimate the multitude of medical cases related to alcohol.

As a disclaimer, I don't want to get self righteous or moralize about the subject. I certainly have embarrassed myself on numerous occasions with too much alcohol--and on a suprisingly large number without alcohol for that matter. We all know about the dangers of drinking and driving--40% of motor vehicle fatalities. Having never had any close friends or family members in AA, it never hit me how destructive it can be on a regular basis until this month.

And this was the month to treat alcohol intoxication. It may be that there were a few holidays including July 4th or that it was particularly warm and festive in San Francisco this summer. Or it could be that 3/4 of Americans drink at any point in the year (coffee, milk and soft drinks are still more popular). On my way home from work over the past 2 years, I have stopped to help during one cardiac arrest and two motor vehicle collisions. This month, on one night, I stopped twice on the Stanford campus to see the flashing lights of an ambulance retrieve a drunken student.

Those students went to the Stanford ED with little intervention on my part beyond what the paramedics had already done. In a situation of acute intoxication morbidity is usually related to traumatic injury. Those students were able to talk so their airways were clear, and they were breathing without any signs of aspirating their vomit, and they had strong pulses, with no visible external trauma to their heads or bodies. Whoever was working in the ED probably put them on a gurney and waited for them to sober up until they could accurately deny any pain or injury and return home safely without hurting themselves or others. It is possible that they also received some IV fluid as well. Though it doesn't help with excretion or conversion to acetaldehyde, it does counter act the tachycardia and low blood pressure that some people get as a result of dehydration or decreased blood vessel tone.

Heavy chronic ethanol ingestion is usually more destructive because of its social impact and associated health problems. As high as 7% of our population can fall into the category of alcohol abuse. The health care costs have been estimated at 185 billion which seems to out weight the cardioprotective benefits of a daily red wine. Much like acute ingestion, a major concern is trauma and I have seen countless alcohol related injuries on any given day. More insidious in the chronic alcoholic is the complete dependence and withdrawal risks. Almost every other day I will see someone who has had a seizure after trying to quit drinking. These can be scary and life threatening and only treated with more alcohol or a benzodiazipine. Though I have not seen it yet, chronic alcoholics can become confused because of a thiamine deficiency and resultant neuronal dysfunction (sometimes this can be irreversible). Finally, I have also diagnosed a few head bleeds or subdural hematomas in chronic alcoholics. They tend to have more accidents, more brain atrophy so there is more room for the brain to move in the skull and veins to tear, and they often need to be admitted for these bleeds. Very often we will put these patients through the CT scanner.

Though I can remember great times drinking, it has been a sobering experience taking care of all the times that it didn't turn out so well.
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About the Author

The Stanford Emergency Room is the center of emergency care at Stanford University.