Phillip A. Brewer, MD, FACEP, Assistant Professor of Surgery,
Yale University School of Medicine;
David A. Fiellin, MD, Assistant Professor of Medicine,
Yale University School of Medicine
The following cases illustrate the need for screening, appropriate intervention, and referral. The first case demonstrates how physicians can intervene with positive results. The second case illustrates all too tragically what happens when there is no intervention.
Note: The following account is an actual case history based on a review of the patientís medical and legal records. Individualsí initials or first name, rather than their actual full names, were used to protect the confidentiality of the patient.
D.J., a 53-year old janitor, was involved in a three-car motor vehicle crash in April of 1998. According to the ambulance report, when he was interviewed at the scene his speech was so slurred as to be incomprehensible. He was taken to the emergency department (ED) of a local hospital and examined for injuries. Aside from minor abrasions, there were none.
His exam was consistent with acute alcohol intoxication. His speech was slurred and his eyes were bloodshot with typical jerking movements. His hand movements and attempts to walk were very uncoordinated. His blood alcohol level was 213 mg/100ml. Following a period of observation and sobering, he was further interviewed and he described a pattern of driving while impaired. He was released from the ED and the ED physician sent an impaired driver report to the Department of Motor Vehicles (DMV). The patient was not charged with DUI.
Two days later D.J. received a letter from the DMV informing him that he had been reported as an impaired driver. He was instructed to submit to a medical evaluation with respect to alcohol impairment and to have the physician send the completed form to the DMV. His evaluation indicated a daily drinking level of 3 beers with fairly consistent weekend episodes of 6 or more beers on one occasion. He also experienced alcohol withdrawal jitters and would drink an "eye-opener" to steady his nerves on the morning after a binge. On the basis of these findings, the physicianís report concluded that D.J. was alcohol-dependent and unfit to drive. Dr. D. also referred him to an alcohol treatment program.
At the DMV, a review of D.J.ís driving record revealed two arrests for drunken driving as well as three other moving violations. Because of his driving record and the doctorís report, his operatorís permit was suspended.
Two months after his suspension, D.J. applied for reinstatement. He was referred back to the physician for a re-evaluation. When asked about his current drinking pattern and about follow-up with the treatment program, he was evasive and finally admitted that he continued to drink, "but not as much," and hadnít gone back to the treatment program after an initial visit. Dr. Dís report to the DMV recommended against reinstating his operatorís permit and he was denied.
In early 1999, D.J. again applied for reinstatement and again was sent to see Dr. D. His evaluation was markedly different from the prior visits. D.J. reported that he had completed the treatment program and was going to Alcoholics Anonymous meetings on a regular basis. His physical exam was improved, with no signs of acute or chronic alcohol abuse. Blood tests for ongoing liver damage as might be seen in chronic alcohol abuse were negative. Dr. D concluded that D.J. was in recovery and sent a recommendation to the DMV in favor of reinstatement. This was done and D.J. has been driving for the past 15 months with no further crashes, DUI arrests, or moving violations.
In reviewing this case, it is worth noting that if the ED physician had not reported D.J. to the DMV, he would have continued to drive while impaired, perhaps until he was killed or killed someone else. Although visibly drunk at the scene of the initial crash, D.J. was not charged with DUI. This is typical of injured drunk drivers who are taken to the hospital for evaluation. In fact, as few as 7% of drivers in this situation are charged with DUI. If the ED physician takes advantage of the impaired driver reporting system in his or her state, positive action to prevent further impaired driving is possible. Unfortunately, many physicians are either unaware of the reporting system in their state or do not take advantage of it. Worse, the majority of states do not have a process which allows medical personnel to report impaired drivers.
In conclusion, medical personnel who deal with injured, impaired drivers can take positive steps to prevent further impaired driving, but in order to do so, they need a law in their state which establishes a reporting system and, when there is such a law, they need to be aware of it and use it.
When Jane was 47 years old, she appeared to have a perfect life. She was a nurse manager in a busy urban emergency department where she enjoyed the respect of physicians and nurses alike. Her husband was a very successful housing contractor in an affluent suburb where they had just moved into a newly-built dream home. Her three sons, ages fifteen, thirteen, and ten were all excellent students and athletes.
However, all was not as it seemed. Beneath this appearance of a successful middle-class life lurked a serious problem known only to Jane and a handful of her closest friends. Jane had a drinking problem and her life was about to change forever.
The day her life changed started out routinely enough. After working the overnight shift in the emergency department, she made the 35-mile drive home, showered, and took a nap until shortly after noon. She got up and prepared a breakfast of toast, scrambled eggs, and a Bloody Mary. By the time the bus dropped her boys off from school, she had consumed 3 oz. of alcohol. After eating their snack, her boys did their homework until about 5:00 PM. They then had a light dinner and got into the car with the older boys to go to hockey practice while the ten year old stayed home with his father. If the boys noticed that the Bloody Marys and the two glasses of wine she had with dinner affected Janeís driving, they didnít say anything.
During the one-hour hockey practice, she went to the sports lounge and continued to drink wine. By now she shouldnít have been anywhere near the wheel of a car, but there she was driving her Volvo down damp country roads made even more slippery by the falling leaves. Going 60 miles per hour in a 25 mph zone, she came up over a hill, which was followed by a curve. Under drier conditions and without her state of impairment, she might have been able to negotiate the turn. But as it was, hitting the brakes only caused the car to slide sideways into the large maple tree.
The impact caused the car to wrap around the tree at the pillar between the front and back passenger doors. The boys, who were wearing their seat belts, were still conscious and remember the entire crash. The older one, sitting on the right side of the car shielded his head with his arm and thick winter coat. He was lucky to escape with only a fracture to his right femur. The younger boy, sitting behind his mother, had no broken bones, but did have a pulmonary contusion and a contained splenic laceration.
Jane, who was not restrained, had by far the worst injuries. She had obvious trauma to the face and head with a Glasgow Coma Score of 6. Her airway was threatened by swelling and bleeding from her facial injuries and by her neurological status. A medivac helicopter responded to the scene and, following initial stabilization including intubation, transported her to a trauma center. Her trauma evaluation confirmed a severe cerebral contusion with significant edema. She had multiple fractures of her facial bones, including a severe left orbital blowout. She also had multiple rib fractures and bilateral pulmonary contusions.
Her chances of survival were slim but, miraculously, her cerebral edema did not progress to herniation and after several days, she began to emerge from her coma. She was extubated after two weeks and eventually transferred to a rehabilitation hospital where she continued to improve. She was finally discharged three weeks later with the following sequellae:
In the months following her crash, Janeís life continued to unravel. She continued to drink. Her husband divorced her. Her older sons, who were fortunate to have escaped with their lives, blamed her for the familyís misfortune and refused most contact with her. The oldest son has had significant problems at school and has begun drinking. Jane has been unable to find employment as an R.N. and is living alone in a small apartment. She has no independent means of transportation in a town with very little public transportation. She suffers from severe depression, which exacerbates her alcoholism.
Looking back on the years before it came to this, one must wonder if there were opportunities to intervene and thereby avoid this tragedy. Conversations with Jane and her records confirm that there was no intervention. The issue of drinking was never addressed by her internist or her gynecologist. Her friends were uneasy about Janeís drinking but said nothing. When she showed up on more than one occasion in her local emergency department for minor injuries, she was never screened for alcohol or drug use. She remained undiagnosed for years either because no one suspected her condition or, worse, because they chose to ignore it. Even during her acute hospital stay, this problem was not addressed. It was not until she arrived at the convalescent hospital that an alcohol use/abuse assessment was done.
Would screening and intervention have made any difference? There is ample evidence that it would have. But without it, there was no chance at all to prevent this tragedy, and Janeís medical providers, both long-term and incidental, share in the responsibility for that.
As these two cases demonstrate, alcohol abuse is not the unique domain of a small minority of "deviants." It is a very common and prevalent phenomenon that occurs along a spectrum of intensity and frequency. Because it is so widespread and because even one episode is associated with an increased risk of injury, every emergency patient should be screened for hazardous drinking behavior, just as every emergency patient is screened for allergies and tetanus status.
The fact that universal screening for alcohol abuse is not currently standard emergency practice is the result of a combination of factors including lack of formal training, lack of practical training and mentorship, and attitudinal barriers to considering alcohol issues. We must change this if we hope to achieve the goal of further reducing alcohol-related fatalities on our streets and highways.