Glug glug thunk
Scattered reflections on alcoholism
The liver is a fascinatingly complex organ; I don’t know all of the hundreds1 of things it does, but a lot of it can be boiled down to “keeping your food from killing you.” A lot of our foods have things in them that could hurt us, because plants don’t like it when things eat them, so the liver gets first crack at everything you eat. Everything you digest enters the bloodstream at the portal vein, which goes directly to the liver for initial processing. It’s your body’s TSA checkpoint!
Unfortunately, many people have an unhealthy relationship with alcohol, which is famously not good for your liver2. Alcoholic cirrhosis turns your liver into a hard lump of blubber. In addition to making it hard for the liver to, y’know, do its job, a hard liver creates portal vein hypertension—the blood gets backed up in an erythrocyte traffic jam, creating swollen spots in and around your esophagus. Those spots—known as esophageal varices3—are basically big balloons of blood, and they leak or pop easily. This is why certain end-stage alcoholics vomit and defecate blood all the time.
Before you ask, yes, this is primarily a respiratory therapy blog, and alcoholism doesn’t really hurt the lungs directly. But I deal with alcoholics a lot, and they’re really quite horrifying, so I thought I would give everybody a (rather rambling) peek behind the curtain so you understand in a more visceral way why moderation is good. A little alcohol is fine. I like port and scotch, myself. If you do too, that’s great. If you drink occasionally, or even small amounts regularly, it’s fine. It might even be good for you, like a centenarian Italian grandma who had a glass of vino rosso every day for seventy-five years. If, on the other hand, you drink a quart of vodka per day4, you’re going to wind up becoming my problem before too long.
I lead with the varices because they get dealt with via—hold on, lemme look up the correct spelling—esophagogastroduodenoscopy, better known as an EGD. The doc sends a probe down your esophagus to “band” the varices so they’re less prone to popping. But it’s possible for the EGD to go very wrong and nick the varices itself, such that the patient starts hemorrhaging. This, in my experience, ends poorly for the patient. I’ve seen it happen a couple of times, and it’s quite dramatic. Like, borderline Kill Bill levels of dramatic. It sticks in a fellow’s memory.
Not all alcoholics seem to develop varices; I’m not sure why, this is something of an outsider’s account. Some of them just get jaundice when their livers die. Jaundice, as you probably know, turns your skin and the whites of your eyes a yellowish color5. What you may not know is that the pigment in there, bilirubin, is made from broken-down hemoglobin. Your body deliberately makes red blood cells to be cheap, crummy, and disposable, since they get banged around squeezing through capillaries. You’re constantly making more of them and recycling the old used-up ones, millions at a time. Your body keeps the heme iron and throws out the associated proteins, which are brownish. This is why poop is generally brown6. If your liver’s shot, though, the pigment hangs around in the body. So you might say that alcoholics have crappy skin.
You cannot live without a liver7, so if yours is wrecked, you need a transplant. Unfortunately, the supply of donated organs is finite, and people can need new livers for a variety of reasons, so the people rationing the organs tend to put alcoholics at the bottom of the transplant list. They don’t want to see you again in a few years when you total another one. You can improve your chances with six months’ clean living, assuming you can pull it off and also stay alive that long, but there’s another catch: as noted, alcoholics tend to ruin their kidneys too. It’s quite hard to arrange even one organ transplant, and at any given time there will be many people around the country with that same liver/kidney combo, so once both organs are end-stage, it’s pretty well a death sentence. We might, someday, develop a way to lab-grow replacement organs at a practical cost, but we’re not there yet. You’re going to have to live (or not) with the consequences of your actions.
Now, you might not be in much of a shape to reflect on your mistakes, because alcohol also wrecks your brain after prolonged heavy use. Alcoholic dementia, they call it. My late aunt had it. It can be hard to distinguish from ordinary dementia unless it hits you quite young, but when it hits hard, you can wind up as basically a permanent unperson, babbling and moaning incoherently until you die. I had a patient recently whom we thought was in withdrawal, being treated on CIWA8, but after a while the nurse speculated that the behavior we were seeing was probably the patient’s baseline.
This somewhat disjointed post is dedicated to that patient, and to the three or four others I dealt with on that one floor, in one hospital, on one day. We tend to have a surprisingly mild cultural image of alcoholics9, probably because alcohol is legal and doesn’t make disgusting smoke like cigarettes. Drunks don’t overdose abruptly like meth-heads, or commit crimes so they can afford their vice. Low-quality but safe booze, being legal, is cheap, and the empty bottles look much nicer in the gutter than a used syringe. Plus there really are tons of people who drink in moderation, so the average guy you see having a glass of wine is probably not going to kill himself with it. Even if he’s not drinking an exactly healthy level, he can be a heavier sort of drinker without being a full-on out-of-control alcoholic. This serves as cultural camouflage for the problem cases.
If you have a strong negative image associated with alcohol abuse, you probably think of wife-beaters, drunk drivers, or brawlers—the kinds of ethanol-based dysfunctions that hurt people other than the alcoholic himself. I don’t see that many drunk drivers, as it happens, probably because a lot of them get pulled over, die on the scene, or die in or en route to the ER. I do see a lot, and I mean a LOT, of alcoholics. They’re more common than druggies, even if you assign those who abuse both to the “druggie” column. Big bellies, skin like turmeric, babbling and thrashing around10. They’re everywhere.
I don’t have a neat proposed solution for this, or even a clean conclusion to come to. Just … be aware that this is a thing. These people exist. They’re suffering. They’re not struggling tormented geniuses, any more than the druggies are. They’re just people who made a bad choice and can’t stop so now their bodies are falling apart. Presently, they will die, and we will send them down to the morgue in a box. We have to free up beds for the next set of problem drinkers.
Per David Macaulay’s The Way We Work, which I just consulted to see if there was a short list.
It ain’t that great for your kidneys either. The kidneys are also magnificent organs and more directly related to respiratory care, but let’s give the liver its moment to shine.
The singular of varices is varix—just looked that up too—but in practices we refer to varices, because you tend to get a bunch at once. They’re gregarious little death buttons.
I have read this exact quantity of this form of liquor in multiple doctors’ notes. It’s some sort of strange attractor for dysfunctional behavior.
Assuming you have a pale complexion to begin with; black guys who drink too much just get the yellow sclerae.
GI bleeding, the kind caused by varices, may turn it black. An alcoholic with jaundice but no varices may have unusually pale feces instead.
It’s got “live” right there in the name. This is a handy mnemonic to help you remember whether or not you should ruin yours.
Clinical Institute Withdrawal Assessment, a standard protocol for dealing with drunks inpatient. You hit them with drugs to manage their symptoms until they’re through the withdrawal phase, basically. For details, ask a hospital nurse, but you might get an earful.
Going back a long way; the traditional red clown nose came about because clowns originated as stock drunks with flushed red noses. Ha ha! He’s slowly killing himself.
I saw Leaving Las Vegas as a teenager or young adult; it ends with Nicolas Cage, looking about the same as he does in all his movies IIRC, having sex with Elisabeth Shue shortly before he dies. In retrospect, I have to roll my eyes at the suggestion that a dying alcoholic is going to be that coherent, or that he could sustain an erection for that matter (c’mon, guys, massive intoxication is famous for that, it’s in MacBeth and everything). Compared to that, “Las Vegas streetwalkers look like Elisabeth Shue” is a trifling embellishment. Probably because the movie was based on a semi-autobiographical novel by an alcoholic who was not yet too ravaged to sit down and write something somebody would want to read.