It is standard wisdom that when patients say they drink two beers a day, you should double that amount. Possibly triple it. I’ve had patients tell me they “don’t drink anymore,” meaning any more then they did before.
Though we tend to believe our patients when they recite their litany of pains and woes, when it comes to alcohol (and several other topics such as chronic pain, disability exams, and worker’s compensation) our credulity is often tested.
Mr. Q had been my patient for several years. He was a chain-smoking, hard-drinking Korean War veteran. He was a diminutive, cachectic, dyspneic, but extremely pleasant man. He was always accompanied to my clinic (in my prehospitalist days) with his ever-suffering, massive, and markedly less affable wife in tow.
His COPD was progressively worsening, and one day he told me he was going to quit smoking. His wife laughed unpleasantly, and commented that he’d quit just like he’d quit drinking. He prided himself on the keg of beer he kept in his garage. It was this keg that drove his wife most crazy, and perhaps that was the source of his pride. He went from two packs a day to five cigarettes. He said he planned to wake up every morning and load five in an empty pack, and these would be his five for the day. He would smoke the hell out of them, but if he ran out he would wait till the next morning to reload. His wife, as usual, sat and scowled and undermined his efforts.
On a subsequent visit, when he said he was down to five cigarettes, she laughed and said he was lying; he was smoking in the closet, in the car, wherever he could when she wasn’t looking—especially in the garage. Yet, some how I believed him. Maybe.
Before he came under my care Mr. Q also had been diagnosed with cirrhosis. I warned him many times about his need to stop drinking. I gave him lurid descriptions of esophageal varices and exsanguination, and other hepatic complications too fierce to mention. He always asserted that he didn’t drink anymore, with a large wink; his wife squirming in her chair. She snorted and said he should tell that to the keg in the garage. She said he would sit there all night long, drinking and watching the old black and white. I could see him wanting to escape her beady-eyed gaze. Yet I found this harder to believe than the possibility that he’d cut back his smoking.
Over the next year or so I pleaded with him to stop drinking as he developed diabetes. I knew a dozen beers a day couldn’t be helping his condition. I talked about diet and exercise, and he just laughed at me. He said he wasn’t going to exercise much with his lungs and remarked that if I’d tasted his wife’s cooking, diet wouldn’t be an issue. I marveled at what strange, attractive force held these two people together. Mutual hatred seemed the answer.
Two months later I admitted him to the hospital with a cardiac arrhythmia. He’d popped into atrial fibrillation. His wife grumbled that her husband hadn’t been out of the garage in a week. A diagnosis immediately came to mind: holiday heart. He’d drunk himself into an arrhythmia.
I got his heart rate under control but was frustrated with my seemingly fruitless efforts to control his drinking. His wife stormed out of his hospital room. The first time I was alone with him, I asked him why he’d never stopped drinking. He looked at me and laughed bitterly. He said he knew I wouldn’t believe him but that he had not had a drink in three years. The keg had been dry all that time, he just liked to sit in the garage and pretend he was having a few to keep away from his wife. He enjoyed his garage, the tools he was too sick to use, and his old black-and-white television.
How could this be? The history and exam did not jibe with this at all. He looked and acted like an alcoholic. Yet if his story were true, how could I explain his current condition? I wanted to believe him, but his persistent liver dysfunction, diabetes, and new arrhythmia argued against it. I looked at him. He was a gnarled, emphysematous shell of a man. At least he had a nice tan. I commented on this, mentioning that he must spend some time out of the garage to keep his melanocytes so primed. He looked at me quizzically. He said he never went outside, unless it was to get the newspaper; he hated sitting in the sun.
A light bulb lit in my head, then exploded into a million pieces. What if he really hadn’t been drinking? What else could explain this clinical picture? I was sure I knew the answer now, and a lab test quickly confirmed it. To my chagrin, his ferritin was more than 2,000. Bronze diabetes: his liver abnormalities, diabetes, pseudo-tan, and cardiac arrhythmia were due to iron deposition. He had hemochromatosis!
Several years later, Mr. Q died of complications of COPD. His son found him sitting in a lounge chair in his garage, with the old black and white tuned to his favorite station. He did not die from the diagnosis I had missed. Would his clinical outcome have been any different if the diagnosis had been made earlier? Probably not. Further, if his wife had known he wasn’t drinking, he might have lost his place of refuge. I promised myself that the next time a patient told me how much they drank that I would try to be less cynical in my response.
The day he died I went home and opened a fine merlot and poured myself a glass—then didn’t drink it. TH
Dr. Newman is the physician editor of The Hospitalist. He’s also consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.