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Emergentology: Losing Donald

Walker, Graham, MD

doi: 10.1097/01.EEM.0000535020.86191.a9
Emergentology

Dr. Walker is an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (http://apps.mdcalc.com/), and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter @grahamwalker, and read his past columns at http://bit.ly/EMN-Emergentology.

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The last time I took care of Donald, he tried to punch a nurse in the face. They knew each other: She had cared for him more than 100 times. I accused him of ingesting something besides his usual alcohol because his behavior was so different. Instead of his quintessential loud-and-helpless demeanor, he was aggressive, threatening, and physically violent.

I had seen Donald (not his real name) dozens of times for alcohol intoxication (which of us hadn't?), but he had never been violent. I ordered some labs and a head CT, and signed him out to my oncoming colleague. I followed up the next day, but nothing seemed to have come of it. He must have sobered up from whatever was in his system by morning. His labs were normal, his scan was unchanged, his vitals were fine, and apparently, he later moseyed out of the ED.

I wouldn't have recalled this encounter (Two years ago, and I still remember his last visit, yet another “intoxication NOS” from a regular), except it was the last time I would ever take care of him: I received a message that Donald died a few weeks later.

His death hit me like a ton of bricks. I sat at a conference in stunned, sad silence. Never in a million years did I think Donald would die. He was not just an alcoholic; he had a number of comorbidities that should have ended his life much sooner. He really seemed to have nine lives. More than anything, I felt a weird sense of remorse for yelling at him (even though he took a swing at a nurse) and sadness about not being able to say goodbye.

Donald was not a friend, not even an acquaintance, yet I felt loss and grief. Sober Donald was a quiet, modest, and compliant patient. We would occasionally see him in the ED during his sober phase for a back strain, sore throat, or some mild illness, and he would accept our Tylenol prescription and be on his way.

Bender Donald was a complete Mr. Hyde transformation: needy, demanding, and pitiful, in the literal sense of each word. We would often see him two, three, or occasionally even four times a day at his worst. We tried absolutely everything: inpatient detox, outpatient detox, home caregiver support, inpatient psychiatry, outpatient psychiatry, daily social worker check-ins, addiction counseling, medical addiction treatments. We begged for someone to pursue conservatorship. We talked with our city EMS leaders. The department of public health knew him. Alas, nothing stuck.

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‘We Failed Him’

We all have a Donald in our EDs, and in some weird, messed-up way, he is part of the fabric that we weave, superglue, and duct-tape together to make our emergency medicine family. Our Donalds are typically known only to us and maybe our addiction and psychiatry colleagues. They rarely touch the rest of the hospital or clinic because of their addictions and compliance. The rare times that we needed to admit Donald, the hospitalists were usually gobsmacked by the sheer number of his ED visits. We usually shrugged, and said, “Yeah, that's Donald for you.”

I wish I could have helped him. Truly. He was a troubled man on a troubled path, and I sincerely hope he is finally at rest, in peace, and no longer suffering. But I'm hard-pressed to say, “We failed him.” (I occasionally hear this sentiment from those outside emergency medicine.) We are, of course, often the only people who ever care for the Donalds because they have burned their bridges with everyone else. We highly value individual freedom in the United States, and so we say, “Free to be you and me,” assuming that anything else would be paternalism. I don't have the answer: Wet houses? Antabuse? Conservatorship? But it's always difficult as an emergency physician to see so much suffering over and over and over again and not be able to relieve it, let alone fix it.

I normally try to conclude my articles with a solution, summary, or advice, but I don't think I can this month. Donald was a challenging patient, often to the point of making me want to tear my hair out in frustration and exhaustion. But he was often the topic of conversation in the ED: “Has anyone seen Donald recently? It's been a few months.”

A number of us would say hi to him when he came in sober for an unrelated visit, pay him a compliment about his sobriety, and say how much better he looked. Then the news would slowly trickle throughout the department that he was alive, sober, and well. It's hard to think that such a staple of our ED will never return. I can't honestly say that I'll miss seeing him intoxicated and yelling helplessly in the hallway and having to constantly remind him to stay in bed so he won't fall. Still, I'll miss him.

Goodbye, Donald. Rest in peace.

Personal details about this patient have been changed to protect privacy.

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