Hey, it’s Carlos again!

We have all had familiar faces, high volume utilizers, frequent flyers whatever you want to refer to them as, people that for whatever reason we see often. You start to build a relationship, get to know them, build trust, and know what is normal for them, and what is not. And while they can be a lot at times, you can still often learn something from them.

One of my favorites, we’ll call him Carlos, was a regular customer in the Emergency Department I worked at in South Jersey. It was a smaller community hospital in a resort town with lots of bars and not much else to do when it got cold. In the summer, it got crazy busy with a huge influx of people heading to the beaches, and those bars I mentioned earlier. 

Carlos was in his 60s. Suffered from alcohol dependency, diabetes, kidney disease and hypertension. We got to know each other very well, I knew his medical history, birth day, his home address, his wife/girlfriend’s (they were married, got divorced but then stayed together) name and even most of her medical history because she was often a patient, too. Carlos was typically intoxicated, but not really a problem, just liked to run his mouth and BS, harmless and actually pretty entertaining.

Over time Carlos taught me, and others, some important lessons in not being complacent, how to talk to people and being deliberate in exactly what you’re saying. 

Carlos would typically come in intoxicated, his blood sugar would either be too high because he didn’t take his meds, or too low because he took too much insulin, or took the right amount and didn’t eat. Carlos was a lot of things, but he was almost never unconscious, he was too stubborn for that and wouldn’t have wanted to miss the opportunity to talk shit. One night, however, he was unconscious. The medics that brought him in were two really experienced guys. They were usually on it, however this night they rolled their eyes, blew him off and said “It’s Carlos”, with a dismissive shrug of the shoulder and wave of the hand. Those of us that knew Carlos knew that this didn’t seem right and asked if they had checked a sugar. Assuming he was just drunk, they hadn’t. It was somewhere in the 20s when we checked it, a new record low for Carlos. The medics got pale, Carlos got D50 and we all learned a lesson. Always check a blood sugar with altered mental status, don’t assume the patient is “just drunk”.  

Comorbid conditions are common in the alcohol dependent population, either primarily because of their chronic alcohol use or because of lack of access or use of healthcare. Just because someone is drunk, or has been drinking, doesn’t mean that they don’t have a concurrent medical issue. Assumptions, bias and complacency get you pulled into the medical directors office, or worse, leads to poor patient outcomes. Familiar faces with typically benign complaints get sick, too, and should still get a thorough, appropriate assessment based on their complaint.

Naturally, Carlos was fine. He slept it off, got some food, kept his sugar up and off he went. 

A few weeks later he was back, this time with altered mental status and suspected overdose on his medication. Myself and the doctor were imploring him to tell us what he took, repeatedly saying “Carlos, we know you took too many of your meds, tell us which of your meds you took.” Different variations of that, but always referring to which of “his” medications he took. 

Just as we gave up and were going to leave the room, Carlos vomits. Of course, there are pills floating in the emesis basin. Without missing a beat, Carlos looks at us, smiles and says “You asked what pills of mine I took, these ain’t my pills, they’re hers”, pointing to his wife. Can’t fault the guy, he was right, we did ask about HIS medications. 

Being deliberate with your questions and thinking about how and what you are asking is important. You don’t want to be misinterpreted, unclear, or in Carlos’s case, not ask the right question. 

That’s not the first time Carlos tried to get one over on us, like I said, he loved to talk shit. One night he came in, hammered drunk, I think he had fallen. I asked him how many beers he had, of course he laughed with a big smile and gave the predictable answer. “Two”, he said. I laughed with him and asked “What were they, 40’s?”. He laughed harder, “Yeah, and it was three of ‘em”. 

Carlos was a good guy, suffered from addiction and made some poor life choices, but was entertaining nonetheless. The last time I saw him was when I was working as a medic, it was the first time I had been to his home and the first time I saw him outside of the ER. His ex-wife, who was then his girlfriend and now fiancé was there, as well. Carlos was hypoglycemic and intoxicated, and actually unconscious again. Once we got his sugar up and he came back around, he opened his eyes, looked and me, gave me his usual big smile and said “John, what the hell are you doing here?” 

This was over a decade ago. Unfortunately , Carlos has since passed away. Carlos was not perfect, but none of us are, and we rarely know a persons entire story.

Bias and complacency kills. Treat everyone the same, and don’t make assumptions.

Links:

Comorbities of alcoholism: Link

Alcoholism and Psychiatric Disorders: Link

EMCrit: Alcoholic Hepatits: Link