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Saving Sylvia Cleary.

Sylvia Cleary rolled up the sleeves of her starched white blouse to show me a few pale, blotchy bruises on her forearms. A soft-spoken forty-six-year-old secretary who wore a red A-line skirt and decorated her dark brown bob with rhinestone barrettes, she had come to my clinic at Bellevue Hospital with a sense, as she put it, that something was metabolically wrong. I reassured her that plenty of people bruise themselves without realizing it.

The results of her routine blood tests were puzzling. There was marked inflammation of the liver, possibly cirrhosis. To me, an inexperienced intern, it seemed unlikely that alcohol--one of the most common causes of cirrhosis--had anything to do with the bruises.

A week later, Ms. Cleary was back for her blood test results. A few questions revealed that she'd been drinking at least a pint of scotch a day for more than ten years. It was hard to believe. She seemed so reasonable, so together. Perhaps, with my guidance, she could give up drinking.

I reminded myself what I'd learned in medical school lectures: alcoholism is a disease. I chose my words carefully. I didn't want to scare her away.

"The scotch," I said, "is damaging your liver. The bruises are a sign of this. You really need to think about resisting the urge to drink."

She nodded, rubbed her hands together. "I'll have to do it, then."

Going cold turkey could be dangerous; even a small change could trigger a withdrawal seizure. I asked her to consider the hospital's inpatient detox program.

"I'd rather do it myself," she said. "I can handle it."

I worried about her over the next few days and decided to give her a call. I'd find out if she was okay, and a few words of encouragement might help her stay on track. The first time I called, she reassured me that things were fine. She was cutting down without any problem. The second time, she told me not to worry and said she'd see me in a month. I picked up the phone several times during the next three weeks, but at the last minute I'd hang up before dialing.

I told my attending physician about my concern over Ms. Cleary. Let the baby bird out of the nest, he said. The phrase seemed a little abrupt. It may have made sense for some patients, like the down-and-out alcoholics--the disheveled, smelly, ornery men who'd show up in the ER trembling and feverish after spending the last of their disability checks on booze days earlier. With them, I'd go through the motions mechanically: the statement of the obvious ("You're an alcoholic, and you're destroying your liver."); the taper of Librium, a medication that mimicked the effects of alcohol in a safe, controllable way; the Alcoholics Anonymous recommendation; the clinic appointment for follow-up that was never kept. Other than easing their withdrawal symptoms, I couldn't help them. But for high-functioning addicts like Ms. Cleary, didn't I need to do more?

A month later, we were both beaming. Ms. Cleary had completely stopped drinking scotch.

Her secret, she confided, the flush in her cheeks matching the color of her cranberry jumper, was wine--she believed that it was less damaging to her liver.

My smile froze. I pulled my chair closer to hers. To the liver, I explained, struggling to keep my tone even, alcohol is alcohol. Her healthy pink glow, I noticed, was actually a filigree of burst capillaries, another sign of liver disease. I asked her again to consider inpatient detox. She was as reluctant as before, but when I pointed out that the timing was good--she'd just left one job and had a few weeks before she planned to start temping--she agreed to give it a try.

I went up to the detox unit a few days later. She was a bit groggy from the Librium but appeared upbeat about the experience. The only woman there, she was enjoying the attention. "The guys are so polite," she whispered, smiling at a heavyset, grizzled man shuffling by. "They insist on carrying my meal tray."

She leaned down to pull up a ruffled sock, her face partially hidden, and told me that she was checking out early. She had lined up a job interview and couldn't miss it. I asked her to consider staying. She said she'd be fine.

She called a few weeks later to report that she was still sober. It wasn't easy, she said. For awhile, she couldn't find an AA group that she liked. One day, in a foul mood, she picked up a pile of Chinese restaurant menus that littered the floor of her lobby, marched down the street to the restaurant, and threw them inside. That same evening she found herself walking toward the liquor store but on the way decided to give AA one more try. I hadn't been aware of the variation: there were groups that catered to the elderly, teenagers, singles, agnostics. She giggled: the one she found that night was a gay men's group. She loved it.

Three months passed before Ms. Cleary's January appointment. When I saw her in the waiting room, I was horrified. She looked as if she were in the late stages of pregnancy. Her ankles and feet bulged with so much fluid that, despite the frigid weather, she was wearing bedroom slippers. Her frilly blouse clung to the sides of her distended belly. In between moments of nodding off, Ms. Cleary told me how she'd gone to a few more AA meetings, but when she'd lost the job a month earlier, she'd started drinking again. It's ruining me, she said, motioning to her belly and legs. She had already cut back to a couple glasses every few days and was planning on quitting for good. Could I give her something for the swelling?

I wanted to shake her. Didn't she know she was killing herself? Trying to maintain my composure, I told her that she needed to get it together and quit or she would die. She swore that this time she would really stop, for good, no matter what it took. I wanted to believe her. I arranged an appointment with the liver clinic and prescribed some diuretics. She took my hand to thank me, clinging to it for a second too long.

Two weeks later, she had lost five pounds. I could almost make out the shape of her ankles.

After that, Ms. Cleary stopped coming to clinic. I called her several times to remind her of her appointments. She never called back. Maybe she had started drinking again. Maybe she had succumbed to her cirrhosis. Or perhaps she'd simply moved away, found a job that offered medical insurance, switched to a private physician. One night, I dreamed that a college friend had become a heroin addict. I called him to tell him he should quit. Fuck you, he said. Was that what Ms. Cleary was trying to tell me? After she'd missed three more appointments, I decided that for one reason or another, she didn't want to see me anymore.

More than a year later, in the beginning of my third year of residency, Ms. Cleary paged me. This was resourceful; it wasn't easy for a patient to get access to the paging system. She had wanted to call months earlier but worried that she had let me down. But in the last week she'd felt bloated and exhausted. I was glad to have another chance to help. Since I wouldn't be back in clinic for a few weeks, I recommended that she see one of my fellow residents the next afternoon.

Three days after, I heard that Ms. Cleary was in the intensive care unit. My heart sank when I saw her. Her skin was deep saffron, the unmistakable color of end-stage liver disease. She was holding up a hand mirror and reapplying her lipstick. When she noticed me, she flashed a wide smile. She filled me in on the past year's events: steady work had made it impossible for her to get to the Bellevue clinic; a pharmacist friend had been refilling her diuretics. A couple of months earlier, after a relationship failed, she had started drinking again. After we spoke on the phone a few days earlier, she had decided to wait until she could see me. Two days later she'd vomited blood, passed out, and ended up in the ICU. I felt a lump in my throat. How could I have ignored what was staring at me in the face? The bruises, the broken blood vessels: even back when I first met her, she was an end-stage alcoholic with advanced cirrhosis.

With a giddy laugh, Ms. Cleary admitted that she really had gotten the message this time. She felt truly ready to stop drinking forever.

I blinked back tears when I saw her the next day. Her dark yellow wrists flapped as she reached for my hand. She had disappeared for so long and now she was dying in front of me. She still recognized me but chatted with unseen creatures as well.

There was nothing left to do. She lay on her back, eyes closed, mouth open, her musty odor filling the room. A basin of her bloody vomit was balanced on the sink.

The next morning her bed was empty.

What is the physician's role with a high-functioning alcoholic? The truth is that whether the patient is a skid row bum or a neatly dressed secretary, we can't do much. But here's what we can do: we can start an unbiased conversation about alcohol--forge a connection. We can ask about the disease when no one else will. Our potential with alcoholic patients may be limited, but there is also opportunity.

Recently, I met a new patient, John Conroy, a sixty-year old homeless man with the familiar ruddy face of a drinker. Mr. Conroy knew he drank too much and wasn't surprised to find out his liver was already showing the effects. I asked him to talk about his relationship with alcohol: what he drank (gallon jugs of red wine; Glenlivet, when he could get his hands on it); why he loved drinking (it helped him forget the pain of missing his wife, who had died of cancer ten years earlier); when he didn't love it (when he'd wake up shaking and smelling like piss). At the next visit, I explained that his drinking, like diabetes or high blood pressure, was a disease, and that to quit, he'd need help, whether it was from AA or a rehab program. Treatment, I told him, would initially be intensive and time-consuming, but the effort would pay off in the long term. He wasn't interested. When you're ready, I said, you'll know. I told him I'd see him in a month and closed his chart.
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Title Annotation:in practice
Author:Reisman, Anna B.
Publication:The Hastings Center Report
Date:Jul 1, 2007
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