“Fine.” My heart thudded in my ears. I couldn’t think. Mrs. Warwick cursed and hollered gibberish as the nurse wrapped restraints around her wrists and tied them to the bedrails.
Someone was tapping my shoulder. “Shouldn’t we give her some benzos?” Jeff, the medical student, was asking. I took a deep breath and refocused. I explained that in most cases of delirium, benzodiazepines—antianxiety medicines that include diazepam (Valium)—can actually worsen symptoms. Instead, I asked the nurse to give her haloperidol (Haldol), an antipsychotic that can safely calm a delirious patient.
The Haldol wouldn’t take effect for at least 30 minutes. I feared that Mrs. Warwick would go into cardiac arrest or have an arrhythmia or a stroke or be overwhelmed by infection, and I didn’t know what else to do. We were going nowhere with our diagnoses while my patient was plummeting downhill.
Leah, the intern, interrupted my frantic thoughts. “I keep thinking this looks like DT,” she said. “Though I know it can’t be…”
DT is an abbreviation for delirium tremens, a life-threatening state that affects 5 percent of people withdrawing from alcohol. People with DT are disoriented, sweaty, and febrile, and they sometimes hallucinate. Dangerous cardiac arrhythmias and respiratory failure can lead to death. A century ago, 37 percent of people with DT died; nowadays, due to better treatment, it is about 5 percent.
“You can’t have DT with one glass of wine a day,” I said, my mind furiously trying to piece things together.
Mr. Warwick walked back in at that moment. He was shocked to find his wife tied to the bed, wailing. He demanded to know what was going on. I gulped and hoped what I was about to say wouldn’t offend him. “I know you said your wife didn’t drink much, but she looks like she might be withdrawing from alcohol. Is it possible that she drinks more than you told us?”
He stared at me, his face blank, and I started to apologize. But then he lifted a hand. “Truth is, she drinks a lot.” Tears formed in his eyes. “Much more in the last three years, since she retired. She drinks when I’m at work. She thinks it’s a secret. I thought she’d stop on the cruise, since we’d be together all the time. I didn’t know stopping could make her so ill.”
Now things were starting to make sense. “So she was drinking a lot, and then on the cruise she was having only one drink a day, for the last four days.” I was thinking out loud. “She felt poorly because she was starting to go into alcohol withdrawal. And now she’s in delirium tremens.”
I turned to my team and the nurse. “We need to get benzos on board—now.”
The nurse hurried off, and the medical student looked confused. “But you said they were dangerous in delirium.”
I explained that in alcohol withdrawal syndromes, benzodiazepines can be lifesaving. Neurons in the brain strive to maintain a balance (homeostasis) between sedation and excitement. There are two main types of neurotransmitters involved. GABA is inhibitory and causes sedation; glutamate, its opposite, is excitatory. Specific receptors on the neurons detect GABA (the GABA receptor) and glutamate (the NMDA receptor). Alcohol is sensed through the GABA receptor. Like GABA, it enhances sedation. In a chronic drinker, the presence of all that sedating alcohol in the body means that the neurons don’t need so many GABA receptors. They cut down on those and create more excitatory NMDA receptors.
When a chronic drinker abruptly stops drinking, the balance is thrown off. With fewer inhibiting GABA receptors and more excitatory NMDA/glutamate receptors, the neurons become overstimulated. In mild alcohol withdrawal, a person will become jittery, anxious, and irritable; in DT, the person’s system will go haywire. Benzodiazepines, like alcohol, work at the GABA receptor and induce a sedated and safer state. The benzodiazepines can then be tapered off gradually while the brain resets its balance.
When Mrs. Warwick left the hospital five days later, she was back to normal, minus any plans to drink alcohol ever again. “Scared straight,” the medical student remarked after the Warwicks headed back to England. That would be great, I told him, but I knew she would probably drink again if she didn’t seek help.
The key to preventing DT in any hospitalized patient with a drinking problem is giving benzodiazepines as soon as possible. But doing so depends on our ability to recognize a patient at risk. Too often we overlook the diagnosis in people who don’t look like alcoholics—especially older women, up to 8 percent (pdf) of whom have an alcohol problem.
Sometimes a missed drink, whether missed by the drinker or by the doctor, can be a matter of life and death.
Anna Reisman is an internist in West Haven, Connecticut. The cases described in Vital Signs are real, but names and certain details have been changed.