My patient is right on the brink.
Of what, I try not to think.
Money goes up in smoke
With whiskey and Coke.
The problem’s made worse with the drink.
The patient had a pain in the wrist.
Me: How did it happen?
Patient: I’m not sure. I was drinking pretty hard, and when I woke up, there was blood on the floor and my wrist started hurting a day or two later. I guess I blacked out.
Me: What do you like to drink?
Patient: Whiskey and Coke.
Me: When was the last time you had a whiskey and Coke?
Me: How many did you have?
Patient: Well, I drink most nights. I have five or six whiskey and Cokes, and three straight shots.
Patient: That’s five nights a week, probably double on my two nights off.
Me: Do you think that this amount of alcohol is a problem?
Me: Then we will agree that we disagree about that. I think you have a problem and you don’t think you do. We’re not going to agree. Here’s what can’t you can’t disagree with: this amount of alcohol presents a risk of death and disability, it is the reason that you’re here today. And I recommend you quit drinking completely.
Patient: Ain’t gonna happen.
Me: If you ever think you have a problem with alcohol, the door’s open. We can help you. But for right now, let’s get an x-ray. I’ll be back in a couple of minutes.
Years ago I would have tried to be right about the alcohol. I attempted to make the patients see the errors of their ways. Such an approach doesn’t work, it alienates patients, and it frustrates me. These days I can perform my moral obligation without incurring the wrath of the patient. Then it struck me there was an additional moral obligation.
Me: Your x-ray is fine. Do you drink in or drink out?
Me: Who drives home?”
Patient: I walk.
Me: Good move.
The patient reveals the circumstances that started his heavy drinking: the sudden, unexpected violent demise of a friend. The patient watched it happen and was helpless to stop the tragedy.
We sit in a pool of silence and the patient looks at the floor. I wait for the patient to talk. I listen to the same information rehashed till the need to talk finishes.
I diagnose post traumatic stress disorder, and I talk the diagnosis over with him. I prescribe propranolol, to damp the effects of adrenaline overload. We discuss the problem of main effect versus side effect and how he’ll need to come in frequently to titrate the dose.
Then I bring out the calculator.
Me: How much is a whiskey and Coke?
Patient: $2.50. I know.
Me: You did the math?
Me: How much a year?
Patient: I don’t know.
Me: So you didn’t do the math. And how much for the straight shots?
Patient: I know, I know.
Me: How much?
Patient: Three dollars.
Me: OK, six times that and three times that, times five nights per week times fifty-two weeks per year.
Patient: I know.
Me: (I show the patient the calculator).
Patient: Wow. That’s a lot of money.
Me: And we didn’t figure in your nights off.
I didn’t forget about the wrist, nor about the three other complicated problems the patient had.
I hope he’ll be back.