Breaking rules: what about ETOH for DTs?

sunnybrook83 · Jun 7, 2002

Can't help you out on why not on developing DT's, but I've had orders for shots of whiskey or beer for pts who are alcoholics to prevent DT's. ( They were admitted for other reasons). I've even had an alcohol drip on one guy to keep him from going into DT's. he was too sick to drink, and too sick to go through dt's, so we dripped him!!

CATHYW · Jun 7, 2002

Simple-if they know coming to the ER would get them a shot of something besides a diazepine, you'd NEVER get'em out of the ER! Plus, as soon as one of them got a drink, he'd be up and OTD, not wanting further tx. Then he'd spread the word to his buddies, and all 7734 would break loose! These folks are revolving door patients anyway-every time they run out of $ for booze they drop by the ER to detox, painlessly. They know the drill better than we do!

micro, RN · Jun 8, 2002

in my opinion with a well thought out and professionally and scientifically sought out severity assessment scale to follow protocol.........giving ETOH would not stabilize or do anything for this patient just starting or going through DT's

but this is only my professional opinion.....

of course to do this, you have to have the adequately trained staff and and very proficient and dedicated MD's behind the program.............

and without judgement.............

ratchit · Jun 8, 2002

I have never understood why we DT people who don't want to be DT'd. We put them at risk for seizures, aspiration pneumonias, risk of injury from being restrained.... Not to mention the risk to the health of the staff who get hit, bitten, and spit at by these people for days on end. Wonder why your acute MI patient is sitting in the ER for 24+ hours? Have to wonder how many ICU beds and nurses are tied up with people who don't want our help and who are going to hit the bar on the way home?

I don't mean to sound harsh here; I'm all for helping people who WANT the help. But I've DT'd the same people too many times not to wonder why we put them and us through it.

Can ya tell I had the same guy twice 8 days apart, admit diagnosis both times "altered mental status" both times with an ETOH level >.400. duh. Yes, I'm grumpy.

OBNURSEHEATHER · Jun 8, 2002

The fact is, at some point, the individual is going to have to go through withdrawal. Yes, a bit of ETOH would stabilize them, but what about when that ETOH wears off? Then what? A little more ETOH? You'd be contributing to the already viscious cycle that is alcoholism.

Alcohol withdrawal is a very dangerous medical situation, and should be dealt with as such. Most rehab facilities don't have the capabilities to handle the medical emergency that alcohol w/d can become.

In fact, when I worked at an inpatient rehab, it was the alcohol pt's we watched most. Their symptoms of withdrawal are the most dangerous and life threatening.

Heather

MollyJ · Jun 8, 2002

Alcohol is a poison that most of us use in amounts that the body can detoxify. We detox patients with a history of high daily use when they are starting treatment OR when they are going to be a in a situation where alcohol won't be available. Once source said we detox patients to normalize the patient's neurochemistry so that their functioning may normalize. Acute withdrawal is the first phase; the regaining of equilibrium, the second phase, can take some time longer.

I looked at this question more than once before answering since, unlike Heather, i never worked a detox unit in my life. What she said is true. Particularly alcohol withdrawal can be life-threatening.

I realize that this question is posted for the sake of discussion or argument. It is akin to asking, "Why don't we let smokers who say that smoking helps them breathe easier smoke?" The answer is, simply, we have better tools than that.

Continued use of alcohol by an alcoholic could lock them into a pattern of binge use, is associated with problems like alcohol poisoning, and is a known GI irritant, is known to be associated with harms to multilple body systems (Cardiomyopathies, carcinogen, neuropathies, Wernicke's syndrome, brain damage and degeneration to name a few). Most of us don't like playing "control the drug use" with our drug addicted clients; I can't imagine playing control the EToH use with the alcohol addict. Many of us have seen alcohol used therpeutically (some poisonings, used to be a tocolytic) but these were all designed for very short term use.

The reason we detox patients is to avoid the symptoms of withdrawal, some of which, in the EToH addicted patient are life threatening. They include: Increased autonomic hyperactivity included tachycardia and hypertension; hand tremor; insomnia; n/v; transient visual, tactile or auditory hallucinations or illusions; psychomotor agitation; anxiety; and grand mal seizures. We all have experienced how these problems can complicate treating virtually any dx.

A good detox regimen protects the patient from the most serious side effects of withdrawal without gearing up their cravings like alcohol would. It IS a measured, scientifically studied regimen designed for patient safety.

Drug addiction is so destructive. I remember my absolute disdain for drunks. They were volatile, time consuming and pathetic. Ratchit, a good detox regimen decreases the risks you mention. You've listed risks of withdrawal. That's the whole point of detox; it reduces the patients risk.

Huganurse · Jun 8, 2002

This reminds me of the time my Dad needed surgery. He picked the hospital that would provide him with a beer on his lunch and dinner tray. LOL.

ratchit · Jun 8, 2002

Molly, I do hear what you're saying and I agree that a good detox program helps the symptoms a great deal. But no matter how good the program is, there are risks. And it's a frustrating, potentially dangerous, drain on resources and risk to patient safety to put someone who doesn't want it though it.

Someone wants help? Even though we know it will take several tries with relapses in between? I'll do anything to help. Some risk, some benefits.

Someone admitted for another reason that has no interest in stopping drinking or drugs? Why do it to them? It's not a deciding factor, but why do it to us? Some risk, no benefits.

We do have better tools than making people DT. But we have great CABG technology, too. We have great neurosurgery and oncology skills. If the patient doesnt' want the treatment, we don't force them. And those DT protocols don't work for everyone, either. (Like the patient I had last week- I've NEVER given that much librium, ativan, valium, serax, and haldol- NOTHING worked. He didn't seize this time, but he was miserable as was everyone around him. And it was his second time in 2 weeks. Knew he was an alcoholic, didn't want help.)

There are some big and some small differences between a pure medical diagnosis like CAD and a mixed medical/psych diagnosis like alcoholism. But I don't think we should be able to force people who don't want any procedure to go through it.

MollyJ · Jun 9, 2002

Ratchit and all

I don't know the answers to the scenario you propose. The said patient wants some kind of help since he keeps showing up at the hospital.

And his alcoholism is part of his care plan, an immutable part as you say.

Detox isn't pleasant and you are right--they take those present with them through the detox. There is no way to make this man's care "less risky" since his alcohol addiction is an inherent part of who he is. The detox regimen is just less risky than a hallucinating, seizing patient with accelerating hypertension. We're not going to get to "no risk" in this scenario.

Your point that these patients are expensive repeaters in the system that take up lots of resources and are care intensive is well taken. That is the part of the care of drunks I remember in the hospital. This doesn't seem to be getting any better and it seems to be getting worse. Until our system is ready to make some rational decisions about who gets CURATIVE care and who doesn't, this madness will probably continue. I think that the line between curative care and CARE needs to be defined with great care (at the risk of being accused of overusing the word "care").

Ratchit, don't forget to tell your repeater drunk how frightening and worrisome it is for you to see him in this same "spot" over and over and again, especially when you see how hard it is for him.

RNforLongTime · Jun 11, 2002

We Have a pt who is admitted at LEAST 6 times a year for pancreatitis. He's an alcoholic. Dr ordered Librium IM but our Pharm. doesn't carry that! So he got ativan. Last night he wigged out bad. Had to call Security. Finally knocked him out with Haldol 5mg and Ativan 1mg. He was chewing on his tele wires and his IV tubing. Pulled his own NG out the other night and then put it back in himself! He has no mucsle mass for IM inj.

He's skin and bones!

Have had Docs order shots of whiskey, BV whatever for Alcoholics who are admitted with other probs. Pharmacy had to get the stuff from liquor store and we had to sign it out just like a Narc!

OrthoNutter · Jun 11, 2002

Originally posted by ratchit
I have never understood why we DT people who don't want to be DT'd. We put them at risk for seizures, aspiration pneumonias, risk of injury from being restrained.... Not to mention the risk to the health of the staff who get hit, bitten, and spit at by these people for days on end. Wonder why your acute MI patient is sitting in the ER for 24+ hours? Have to wonder how many ICU beds and nurses are tied up with people who don't want our help and who are going to hit the bar on the way home?

I don't mean to sound harsh here; I'm all for helping people who WANT the help. But I've DT'd the same people too many times not to wonder why we put them and us through it.

Can ya tell I had the same guy twice 8 days apart, admit diagnosis both times "altered mental status" both times with an ETOH level >.400. duh. Yes, I'm grumpy.

I am totally with you on that. It's a complete waste of time. It's good to hear that some facilities have Detox units. What a dream that would be. Where I work, they go to acute medical, and if that's full then they go to the place with the spare beds. We got five of them in on the weekend (long weekend plus it's getting on to winter here) and all of them spent their time outside smoking. They were never there except to get their valium, food and to catch a few zzz's now and then. That ordinarily wouldn't bother me, only they stuck some # NOFs down in MATERNITY because we had no beds left to take them.

Can I just say....what on earth were they thinking???? :eek: