The case
‘Come quickly, doctor. He’s seeing gremlins crawling over the carpet.’ As visit requests went, it was certainly one that grabbed my attention. So I attended promptly, not least because the patient’s wife, who had made the call, was so distressed and distracted by her husband’s condition that she couldn’t really give a coherent account of what was going on.
I knew the patient well. He was an alcoholic and I’d seen him only a few days previously with abdominal pain, which I’d attributed to alcoholic gastritis. Now, en route, I ran through a mental list of diagnostic possibilities – and, in an alcoholic, there are many. He could have been withdrawing, suffering the effects of a head injury or developing an encephalopathy. Or perhaps I had underestimated his abdominal pain and he was now in the throes of pancreatitis or peritonitis.
The outcome
He was certainly confused, sweaty and extremely agitated. But he was afebrile, not in pain, and there were no other pointers in the history or examination to suggest a specific physical illness. And he really was seeing gremlins crawling over the carpet, among other florid visual hallucinations. ‘Is it because he stopped drinking after he saw you, doctor?’ asked his wife.
Which prompted me to recall our conversation. He had been drinking more than 100 units of cider per week – as he had done for a good year or two. This last consultation had seemed just another in a catalogue of alcohol-related complications, which previously included depression, GORD, peripheral neuropathy and hypertension. And, as I had done on countless occasions in the past, I had explained that the underlying issue was his alcohol intake and that, should he continue, then he was likely to have serious problems.
As ever, he had listened courteously and nodded in agreement, but I knew he would carry on as before. Except this time, he hadn’t. Clearly, he was suffering acute alcohol withdrawal and required admission for detoxification. We were lucky he hadn’t already suffered fits.
What I learned
Just occasionally, and somewhat randomly, previously resistant patients will decide to follow your advice to the letter. The problem is, by the time they do, that advice may be given more in hope than expectation and so may lack the necessary detail and nuance. In retrospect, an exasperated, ‘You really have to stop the booze’ didn’t constitute a carefully thought out management plan.
How this changed my practice
With alcoholic patients, I specifically tell them not to stop drinking suddenly. I explain that doesn’t mean I’m happy for them to carry on as they are, and I reinforce that abstinence is the goal. But I emphasise this needs to be achieved in a planned way – preferably through a proper detox regime, but, failing that, by slow, self-imposed withdrawal. And if they ask why, I mention the gremlins.
Dr Keith Hopcroft is a GP in Laindon, Essex
Submit your own ‘case that changed my practice’ article to adam.legge@pulsetoday.co.uk. There is a £100 honorarium for every article.
