Alcohol withdrawal, explained. It’s TribeTeach, son, come get your learn on.
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Full Transcript of “Blame It On The A-A-A-A-A-Alcohol Withdrawal”: Incident Report 082/Tribe Teach 01.
ZDoggMD: (singing) Blame it on the goose gotcha feelin’ loose. Blame it on the henny gotcha feelin’ smelly. (laughter) Blame it on the a-a-a-a-a-alcohol. Blame it on the a-a-a-aaa-aaa-er-er-uhh-er-er (not singing) What’s up Zpac? It’s yer boy (laughter) ZDoggMD and we are comin’ live and direct out of ZStudios. Today we’re gonna do a new thing called Tribe Teach. We are gonna teach about a topic. In this case, it’s gonna be alcohol withdrawal. Why? Because y’all eff it up e’ry day. I’ve seen residents and full fledged attendings screw up the management of alcohol withdrawal and it is a legit problem in our hospitalized patients. And our UN-hospitalized patients. And soon in Tom Hinueber, but he switched to weed because-
Tom H.: That’s why you gotta smoke that ganj, people. You know what I’m sayin’?
Logan: Hey, yo, teach!
Tom H.: Mmmhmm.
ZDoggMD: That’s why they call ‘im Tom “High”nueber. You know what I’m sayin’?
Tom H.: Oh, snap. Yo!
(At same time) ZDoggMD: You see what I did? Tom H.: Yo, teach!
Tom H.: Teach me up, dog.
ZDoggMD: Yo (singing) I was gonna teach but then I got high.
Tom H.: Why, dog?
ZDoggMD: (singing) And then I was gonna teach and then I- (not singing) Okay-
ZDoggMD: -anyway, check it out. I wanted a little bit of housekeeping first. So on Patreon, if you go to patreon.com/zdoggmd, you can actually support this podcast and show and live enterprise… at any level. One dollar an episo- one dollar a week. Five dollars a week. Uh- a thous- TWO thousand dollars a week. And one of the people who supported us at a good level gets a reward. And that is a shout-out of her choice on the show. And do you know who that person is? It is a lovely emergency nurse in Texas which is deluged currently and all our thoughts and prayers are- I’m in- I’m an agnostic- All our prayers uh- and meditations are going out to Texas and everybody out there because they are- It’s amazing. Didn’t- more people saved uh- fellow Texans on jet skis than the Texas government did.
Tom H.: That well what I’ve- that’s what I’ve heard is. I don’t know if that’s apocryphal but it-
(At same time) ZDoggMD: Sounds Tom H: -sounds
Tom H: -awesome!
ZDoggMD: Sounds amazing.
Tom H.: Like, yeah.
ZDoggMD: And if-
Tom H.: They said people are just goin’ out on jet skis, boats, whatever they got-
Tom H.: And just, like, makin’ it happen. Inviting people into their homes. It’s just, like, you know Texas, y’all. Whas’up.
(At same time) ZDoggMD: Tell- Tom H.: Shootin’
Tom H.: -shotguns at the hurricane. Tryin’ ta make it go back to its home cuntry ‘cause we don’t want yer kind here, Haviear. Ya know what aam sayin’?
Logan: ‘Murrica. (laughter)
ZDoggMD: Sweet baby Alah, don’t mess with Texas. (laughter) ‘Cause it- it- even a hurricane can not uh- harm the spirit of Texas. But we do- we are thinking about everybody and all the hospitals there that are effected. And Sunny Bogden, emergency nurse uh- in Texas- is- had her birthday yesterday.
(Everyone singing) Happy birthday to Sunny! Thanks for giving us money!
ZDoggMD: (not singing) So, Sunny. We love you. You’re hella health 3.0. We got to meet when we were- when Tom and I were in Houston speaking at the National Athletic Trainer’s Association. So we love Sunny. If YOU want a shoutout on the show or someone you love, you want them to get a shoutout, help us out on Patreon because it helps support our show. It buys uh- Logan more guns. It buys Tom silly weed hats… that we also get for free from people who send them to us. Aaand speaking of the National Athletic Trainer’s Association, we did that uh- conference in Houston a couple months back. Right, Tommy?
Tom H.: Yup.
ZDoggMD: And let’s go to the inset cam.
(At same time) ZDoggMD: I just got- Tom H.: Back when Houston was not full of water.
ZDoggMD: -a adorable little card from somebody who was at the conference. And I want to read it to you. It says, “Dr. Z, heard you at NATA. We love what you’re doing. It was so nice to hear someone appreciated our athletic trainers. My daughter is in her third year as an athletic trainer in high school in northern Texas.” Texas, represent again! “I was her guest and you just made so much sense. I’m actually going to get my certification as a health coach after hearing you and having a heart for helping people. Please, accept this gift and spreading this awesomeness. -Jennifer Regen.” Check this out! She made- we’re gonna have to go to the Tad cam for this-
ZDoggMD: She made a “Healthcare 3.0” shirt. Look at that. Amazing! And look at the back. Luckily I’m red/green colorblind so I can’t read it at all. It says, “The next generation of healthcare”. So that is the kind of dopeness that the Zpac represents and it’s- It’s good that we get to travel around and talk about health 3.0 and do these live performances, because I think they do actually effect change because she’s gonna become a health coach now. And I have a dope shirt. Thanks Sunny Bogden and let’s start teaching. What do you think Tom Hinueber?
Tom H.: Hit me up, teach! I need to know what to do next time I get the shakes, dog.
ZDoggMD: Son, if anybody’s got the DT’s it’s Tommy T. You know what I’m sayin’? Alright, here’s the deal, guys. Let’s be serious for a second. And I wish we could have offered CME or CEU for this, but it’s a pain in the ass and I don’t want to do it. So screw you guys who are asking for it.
Tom H.: Yeah, plus, now we can say bad words like “fuck” and “butts”.
(At same time) ZDoggMD: Hell, yeah. Tom H.: All kinds of cool stuff.
Logan: And communism.
ZDoggMD: The only thing you can’t do- What did you say, Logan?
Logan: Communism. That’s a dirty word.
Tom H.: That’s the dirtiest word of all, ZDogg.
Logan: That’s the dirtiest word of all, ZDogg.
ZDoggMD: The other thing (laughter) you can’t do in a CME broadcast- I bet y’all didn’t know this- is drink La Croix, wave an American flag because America is a branded entity.
Tom H.: Hell, yeah.
ZDoggMD: That’s America TM.
Logan: Don’t you bring that French shit on this show, Z.
Tom H.: America’s the biggest corporation in the world, y’all. Killin’ it.
(At same time) ZDoggMD: Americorp. Tom H.: Big time business.
Tom H.: Boomin’. (laughter)
ZDoggMD: TM. Alright so, I want to talk about alcohol withdrawal and there’s a reason. I am a hospitalist and I see a shite ton of alcohol withdrawal. And throughout my history in medicine, I have seen it mismanaged. And the thing about alcohol withdrawal that you have to understand is first of all, it’s a massive problem. People underestimate this. So we’ve done episodes of the show about alcohol use disorder and Tom being a drunk and all kinds of things like that, right?
Tom H.: Alcohol use disorder is just alcoholism. They renamed it ‘cause they wanna be fancy.
ZDoggMD: And you know what? We ARE so fancy in the healthcare uh- (laughter) in the healthcare game. (singing) We’re so fancy we called it alcohol use disorder. (not singing) And the thing about alcohol use disorder is it’s pretty prevalent in the general population, but listen to this. 40%, according to some estimates, of the hospitalized population actually suffers from an alcohol use disorder. So some variant of alcoholism, to use the lay term. Now this is a big problem. Why? Because, while opioid withdrawal- you stop opioids- FEELS like you want to die, you rarely do. Alcohol withdrawal can kill you. Like, dead as a doornail. And in a horribly unpleasant way. So when you take a patient into the hospital and they don’t drink alcohol, and they drink alcohol a lot and regularly normally, they can go into a kind of withdrawal and you will see some very interesting patterns… INCLUDING DEATH if you don’t manage it aggressively, quickly. It’s almost like sepsis. If you get too behind, you can drop the ball and the patient can die. And so what we want to do today is talk about how you guys are actually going to save lives and I’m looking at YOU, docs and nurses and respiratory therapists and people in the front lines, touching patients. Because YOU are responsible for saving these lives. 40% (laugh) of people in the- in the hospital may have some variant of alcohol use disorder, although I find that a little bit high, uh- you can do a lot of good here. Alright. WHY, first of all, do you withdraw from alcohol? Why- why is it um- a problem to stop drinking if you drink a lot? Well, Tom do you even know how alcohol works? Does anyone know how it works?
Tom H: It does somethin’ to your liver-
(At same time) Tom H: And then- Logan: Makes you feel good.
Tom H: And then you can’t process stuff in your liver like normal so you feel awesome.
Logan: And ladies look prettier.
ZDoggMD: *sigh* You know umm… people strangely accuse me of being a bro scientist. (laughter) Uh- and I’m, like, “Why? I’m a UCSF trained, Stanford trained, hospitalist in academic circles and I’ve done this and that.” And I think it’s because of you, Tom Hinueber.
Tom H.: Yes.
ZDoggMD: I think because you are my bro. And I’m gonna wear that like a badge of honor.
Tom H.: I love you, bro.
ZDoggMD: I love you, too, bro.
ZDoggMD: If you’ve ever withdraw on me, I will just, I will literally euthanize you.
Tom H.: Don’t you withdraw on me.
ZDoggMD: Don’t you withdraw on me, Tom Hinueber. (laughter) So here’s the deal. The way that it’s felt alcohol exerts some effect is on the GABA receptor system in the brain. So GABA is Gamma-amino butyric acid. Who cares, right? It’s Yo Gabba Gabba. It is a- It’s an inhibitory neurotransmitter. What that means is, it’s brain cells telling other brain cells to shut the fuck up. So stop makin’ excitations. Stop doing stuff. Calm the hell down. That’s what alcohol does. Which explains a lot of things because if it- if it’s inhibiting inhibitory centers of the brain, you get disinhibited. And you get hella beer goggles and you wake up having to gnaw your arm off, right?
Tom H.: That’s when you do cool stuff and have fun times.
ZDoggMD: Like break your uh- finger playing a uh- video golf game at the bar.
Tom H.: (displaying his splinted finger) This is the whitest injury you can have, people. I got this playin’ virtual golf, okay. I’m not- I’m not- I’m not proud.
ZDoggMD: You know what? People talk about white privilege? This is the flip side of that. It’s white stupidity. (laughter) So in any event, you see why we don’t want CME? ‘Cause it comes with a lot of im- let’s just say imperial entanglements. So in the GA- in the GABA system you’re inhibiting neurons and alcohol does that, too. So it effects these systems. When you pull the alcohol away, it turns out GABA receptors that have been used to high levels of alcohol start to kind of go “Eee- we don’t need that many of us and let’s kind of down regulate us and let’s do different things to how we process ion channels and things like that and other mumbo jumbo.” That- it becomes a new normal. That you’re used to certain amounts of alcohol through the dependency on the alcohol, the sedative effect. When you take it away, suddenly you don’t have all this inhibition and the excitatory elements start to fire up. ‘Cause the other thing alcohol does is it um- uh- it actually inhibits some excitatory neuronal pathways as well. So by stopping excitement and increasing inhibition when you take it away the opposite happens. People get RRRUUAAAHH. So that’s why you can see things like agitation, insomnia, vomiting, tremulousness.
Tom H.: Oh, dude. You see all kinds of things on alcohol, dude. It’s crazy on alcohol withdrawal.
Logan: Those are your GABA receptors.
ZDoggMD: You went full Gabba Gabba. (laughter) You know what I love about you guys? You really are the perfect bro scientists. Like I’ll say something like “Yo, it’s GABA.” And the next thing you know it’s Yo Gabba Gabba. (laughter) It’s incredible.
(At same time) (laughter) Logan: What was that? ZDoggMD: Look at that. Oh, my gosh.
ZDoggMD: By the way, that show? Wooooooo. Hello? (laughter) Umm- so (laughter) So here’s the deal, though. The kind of symptoms that you- that you can have- and it’s interesting- so in the 50s, Tom, they did a study. They took a bunch of alcohol naive patients, so people who didn’t drink. So basically Logan.
Tom H.: Mm.
ZDoggMD: And they gave them a shit ton of alcohol for a long period of time. Then they gave another group, like, just intermittent alcohol like- like you. And what they found is that it was the group that had the regular alcohol that were more likely to have withdrawal.
Tom H.: Right.
ZDoggMD: You could do those kind of trials in the 50s. It’s like, “Let’s uh- induce alcohol withdrawal in a bunch of young kids who’ve never drank!” It’s amazing. It’s like- like a little scientific hazing.
Tom H.: Well, ‘cause when you’re doing it intermete- intermediately you’re having withdrawal. It’s just very minor, right? Isn’t a hangover just very minor withdrawal?
ZDoggMD: It- it’s partially a hangover. It’s a partial kind of mini-withdrawal. But see your- your receptors in your brain never have a chance to really adapt to high levels of alcohol so they don’t reach that new set point that then- but that- that’s not to say that you can’t withdraw doing binge drinking.
Tom H.: Yeah.
ZDoggMD: So some people will have that. But really it’s a long term drinker. It’s that guy- the homeless guy that you see that’s just, like, drinking every single day or the high level executive who no one knows, but he’s having three martini lunches and two martini breakfasts and ten martini dinners.
Tom H.: I could never do the- could you ever do the “wake up and have a Bloody Mary” or, you know, whatever? I can’t do that. It sucks.
ZDoggMD: It makes me wanna puke.
Tom H.: Yeah!
ZDoggMD: Yeah. Uh- (laugh) it’s not for me.
Tom H.: I need to just take my hangover like, “I had my fun. Now I take my hangover, right now.”
ZDoggMD: It’s time to take your pill.
Tom H.: Yeah, exactly.
ZDoggMD: Yeah, yeah, yeah. Well, so- so speaking of all that, so when you uh- take the alcohol away. And this is the trick, a chronic drinker often doesn’t choose just to stop drinking. A lot of times it can be something like uh- uh- an illness or a problem or some other issue that triggers them to stop drinking. So maybe they have pancreatitis. Maybe they have an infection. Maybe they have a- um- a heart problem. Maybe they have a kidney problem. Maybe they have liver disease that’s ig- that’s flaring up and they’re losing their appetite, their ability to drink. And then they’re coming into the hospital being weird and you’re like, “Well, it’s alcohol withdrawal.” Well, it could be that. It could also be the underlying disease. You have to be really careful. So, Logan. Pull up the slide that I have from UpToDate. Which is my favorite thing-
Logan: That one, Z?
ZDoggMD: Yeah, that one. That one. (laughter) Yeah, can you give me citations on that?
Tom H.: (laughter) Yeah, that was from uh- Mr. Gabba.
ZDoggMD: Mr. Gabba et al. That was a Yo Y dot Gabba dot et al.
Tom H.: Yo comma dot Gabba.
ZDoggMD: So this is- this is a um- this is a good simple table of the kind of symptoms and signs that you will get in different flavors of withdrawal from alcohol. And remember they all kind of make sense because they- they have to do with taking away the sedative component, right? So in the top there sort of this mild withdrawal stuff. You’ll get trem- shakiness, that’s tremulousness, mild anxiety, headache, sweating- that’s diaphoresis, right- palpitations is the heart racing, anorexia- meaning you don’t want to eat- GI upset- we all know what THAT is- And um- generally your mental state is normal. So if you ask somebody where they are, when they were born, who the president is, they will tell you all the horrible truths, right?
ZDoggMD: Ah- yeah. (snickering) And so that’s- and- and that kind of withdrawal can happen as early as six hours after your last drink if you’re a heavy drinker or up to thirty-six hours. Now that’s mild alcohol withdrawal. We should learn to recognize it because in hospitalized patients you can miss it. You can- you can think it well somebody’s anxious or there- there’s another medical problem going on or where- some other reason that this is happening. Or we just blow it off as somebody who’s fidgety and kind of goofy. And here’s the thing, nurses are the ones who are gonna catch this because they’re with the patient all the time. You know, the residents and the docs, they’re coming in and they’re doing the u-turn at the foot of the bed and they’re walkin’ out. And they’re missing these subtle signs of alcohol withdrawal. That’s why this is so important for nurses. In these situations nurses can ac- nurses can a hundred percent save lives and effect outcomes. Alright. So go back to the- go back to the slide, Logan. Now a little bit further down the line is seizures. Now seizures can happen six to forty-eight hours afterwards. Now remember, seizures can happen because you’re pulling away all this inhibition. Now you have all this unopposed excitement in the brain. And that excitement can lead to electrical storms that cause seizures. These are usually kind of single seizures. They- and people think, “Oh, it’s benign. It’s not a big deal.” The problem is, the more you let those go, the more you can kindle future seizures from withdrawal and go into- have other problems. Status epilepticus, which is continuous uncontrolled seizure, is fairly rare in alcohol withdrawal. And remember, in between the seizures often times the patient might seem completely normal. So this is- you’ve- have you ever had any friends who’ve had seizures when they’ve stopped drinking?
Tom H.: I have had friends who joke about getting the DTs and also will do things like putting Alka-Seltzer in a vodka and keep drinking in the morning. (laughter) And then you’d be like, “Remember when you had the DTs?” And they’ll be like, “I didn’t have that, dude. I’m not an alcoholic, bro. What’re you talkin’- get- pshh- not you, man. Don’t do this to me, Tom.”
ZDoggMD: “I learned it from watching you, Tom!”
(At same time) ZDoggMD: Yeah, but- Tom H.: What a-
ZDoggMD: he- All joking aside, that’s a problem. That is a problem. So we have minor withdrawal, we have seizures. Now this is where it gets interesting because alcoholic hallucinosis. Many people misunderstand and misdiagnose this. This is a visual or a hearing uh- hallucination or a tactile- tactile means you feel stuff. And the classic example is something called formication. Don’t laugh at me. It’s not fornication.
Tom H.: Formication. Oh, yeah!
ZDoggMD: Formication. Forma for the Latin root for ant. And it’s the feeling that ants are crawling on you.
Tom H.: Oh, gross.
ZDoggMD: Yeah, and this is a- this is a not uncommon thing. And, but the- but the interesting thing is, people are a hundred percent aware and alert. And able to tell you, “Oh, my god. I’m hallucinating. I’m seeing a rat running over there.” or “I see insects buzzing. I hear some weird stuff.” or “I feel like ants are on me.” And they’ll look at you like, “What’s going on, doc?” Like, Trump is still the president, it’s still 2017, and I- my name is this. So they’re alert and oriented. They can spell world backwards. They can do all this other stuff. But they’re seeing shit.
Tom H.: Yeah.
ZDoggMD: And that’s alcoholic hallucinosis.
Tom H.: What’s interesting is that says that’s alcohol hallucinosis, but I- I always thought that was delirium tremens.
Tom H.: I thought that was the delirium and then. You know, like the beer, “Delirium Tremens,” has a pink elephant on the bottle.
Tom H.: Right? It’s like a really high quality beer. (laughter) But it’s actually good.
(At same time) ZDoggMD: I’ve had it. It’s really quite- quite good. Tom H.: It’s amazing. Yeah. It’s amazing.
Tom H.: But so I always thought that was the auditory, like visual hallucination part.
ZDoggMD: So let’s get to that. So thi- you know, and again, these different- these have different time courses of when the last drink was to when you see this. Now alcohol hallucinosis, seizures, minor withdrawal… the key thing here, Tom, is that you have a pretty good mental state. You can hold a conversation. You’re in your right mind. You’re not showing elements of delirium. Now withdrawal delirium, also called delirium tremens, is the extreme, sort of worst stage of alcohol withdrawal. And this is a stage that can often uh- in the old days was up to 40% of patients DIED.
Tom H.: Yeah.
ZDoggMD: If they got this. ‘Cause we didn’t know how to treat it. We didn’t have the supportive care. Which- which, by the way, I want to say one thing to the mother fuckers who are constantly like, “You know what? Medicine doesn’t do anything. We should go back to natural shit. My chiropractor can help me.” Yeah? Try alcohol withdrawal.
Tom H.: (laughter) Right.
ZDoggMD: This is one of those cases where-
Tom H.: Yeah.
ZDoggMD: -you can save people’s life with Western medicine and science and ventilatory support and anti-aryth- I mean the whole thing that we do.
Tom H.: What’d you have to do before the treatments we have nowadays. You just had to taper them?
ZDoggMD: Well, I’ll tell you what we used to do at the VA. And we even knew better. We would give them beer.
Tom H.: Yeah.
ZDoggMD: So if someone came in in alcohol withdrawal, we would give them beer. Now that’s frowned upon. (laughter) Because- for several reasons. Alcohol (laughter) in- actual ethanol in sick patients, we don’t know the kinetics of it. It’s unpredictable.
Tom H.: Right.
ZDoggMD: It causes other harm. And so the thought is there are better ways to treat it. But we used to give ‘em- and in VA government issued beer. You could order it from the pharmacy. (laughter) It was a white can. Logan would love this. A white can- this is what happens when communism wins, Logan. You get a- your beer is a white can that says beer on it in black letters. (laughter) That’s literally what it was. Tell me, Zpac, has anybody- anybody ever ordered beer at the VA? ‘Cause that’s- that’s government issued beer. Um- tap the Rockies indeed. So delirium tremens or withdrawal delirium. This is- let’s pull up that slide again, Logan.
ZDoggMD: That’s the bottom one. So delirium. Let me describe what that is. Delirium is- the simplest way to describe it is you have a uh- inability to pay attention to anything and your level of attention goes up and down. Exactly. Gabba, gabba, gabba. That’s delirium. Logan is chronically delirious.
Tom H.: Mm.
ZDoggMD: You don’t-
ZDoggMD: You don’t quite know where you are. You can’t sometimes know who you are. You don’t know the year. And this can fluctuate. In the setting of that, your level of consciousness changes. You’re awake. You’re asleep. You’re drowsy. You’re agitated. All over the place, right? And this is delirium. Now agitation is, again, this activation. You’re bouncing off the walls. Tachycardia is a fast heart rate. And this can get really fast. Like above 120 and higher. And it can lead to other arrhythmia. Like ventricular tachycardia, Torsades- these kind of deadly- potentially deadly um- heart rhythm problems. Hypertension. So high blood pressure. Uh- fever. And diaphoreses is sweating. Now, why? Well it turns out that alcohol has these central sort of calming effects, but it also has some peripheral calming effects as well. When you take the alcohol away, everything goes to shit. And the people who go into delirium tremens tend to be the heaviest drinkers. They tend to be older. They tend to have had previous episodes of withdrawal with uh- symptoms. And so- they- they can often have coexisting liver disease and other problems that may make them higher risk at many levels and that may explain the higher mortality. Nowadays the rate of death from delirium tremens is down to about 5%. Which is still REALLY high.
Tom H.: That’s pretty good, though.
ZDoggMD: It’s better. And the reason is, we learned how to- how to treat this stuff and we’re better at it. But we still suck. And I still see people screw up all the time. First of all by not recognizing what stage of delirium you’re in. Second of all by undertreating it. Third of all by missing an underlying cause. Right? And tho- those are the main things. And, you know, I’ll tell you, I have stories. And when we talk about treatment here in a second, I’ll tell you some of these stories of, like, literally VA patients up all night and me giving them Valium and Valium and Valium and Valium and Valium-
Tom H.: Yeah.
ZDoggMD: And them literally coming out swinging. And me with the nurse just going, “What the hell are we gonna do?” (laughter) And- and- and- and here’s the thing. If you get behind on treating it, it becomes this desperate catch up and they get to the delirium tremens stage and you’re screwed. Now, here’s the thing. The thing about delirium tremens is that it’s almost unheard of to not have previous signs of the other versions of alcohol withdrawal. So you might have the shakes and the hallucinosis. You might have a seizure. You might have a little bit of fast heart rate. You might have sweatiness. Insomnia is a common early sign of- of uh- alcohol withdrawal. So you should be warned that the DTs, as Tom calls them, could be coming. Now the exception is, imagine this situation. Tom is an alcoholic. He is a homeless guy. He’s found down in his own stool.
Tom H.: Hell yeah.
Logan: It could happen.
ZDoggMD: They don’t know what’s going on. Turns out he has a burst appendix.
Tom H.: Mm.
ZDoggMD: He drinks e’ry day on the- on the regular.
Tom H.: On the reg.
(At same time) ZDoggMD: ‘Cause, you know. Why not? Tom H.: Yeah. W’sup. That’s my life. Logan: He’s woke.
ZDoggMD: He’s WOKE! He’s woke AF, people. So Tom ends up getting rushed to the OR where he has a perforated appendix. They fix this stuff. They sew him back up. They put him in the ICU. He’s on a ventilator. Wakes up. He has not had a chance to objectively show signs of alcohol withdrawal. Three days go by. He’s, like, sittin’ there chillin’ and he’s ape shit crazy. (laughter) He’s absolutely delirious. He’s pulling out all the lines. His blood pressure’s 180. His pulse is 150. And his magnesium is dropping. His potassium is dropping. ‘Cause this is one of the things you see in florid delirium tremens is all your electrolytes go wacky. Partially renal problems, partially liver problems, partially fluid balance problems because they’re not eating, they’re not drinking, etcetera. There are vitamin deficiencies in chronic alcoholics. Thiamine, etcetera, etcetera, etcetera. So all this can happen and you have no warning.
Tom H.: Also, I’m hella unpleasant. And I say shit like, “Go get me a sandwich, bitch, or I’ma shit on the floor!”
(At same time) Logan: True story. Tom H.: And it’s not a-
Tom H.: And it’s not a vacant- it’s not a vacant threat. I will do it.
(At same time) Logan: True story. Tom H.: I will shit on the floor.
Tom H.: Lookin’ you right in the eyes.
Logan: His name’s Mr. Bulldog.
ZDoggMD: (laughter) You know it’s rare that uh- (laughter) It’s rare that you make me laugh like that and the reason I laugh is that I’ve had patients exactly like that.
Tom H.: Yup. No, I-
(At same time) ZDoggMD: They will literally take a shit on the floor. Tom H.: That’s a real stor- that’s-
Tom H.: That’s a real story that my wife told me. Uh- by a (tongue click) lovely homeless gentleman here in town. (laughter)
Logan: Oh, I know who you’re talkin’ about.
ZDoggMD: Oh, Ashy Larry.
Logan: Ashy Larry.
ZDoggMD: Ashy Larry. So when Ashy Larry goes into withdrawal- first of all let me make sure that- I’m gonna pull up- ‘cause I took a couple of quick notes. I want to make sure I told you stuff. One of the things you have to know is that the symptoms of alcohol withdrawal can emerge, especially in chronic alcoholics, while you still have alcohol in your blood. So you can have a blood alcohol level of, like, .5 and still start having withdrawal because relative to what your needs for alcohol are (laughter) they’re not quite there. So remember that. Just because you have alcohol in your blood, doesn’t mean you can’t have withdrawal.
Tom H.: Right.
ZDoggMD: Alright so that’s one piece and then (laughter) uh- the other- So- let’s get into- I think we should get into how to treat this, right? Because we can see now, how do we recognize it. You see the symptoms. You see the signs. You know that it could be fatal. And the way people die, by the way- How do you think people might die from delirium tremens? ‘Cause it seems like it’s just a bunch of weird symptoms and- Are you Gabba Gabba-ing me? (laughter) God damn you, Logan Stewart. (laughter)
Tom H.: They probably die ‘cause they get too woke.
(At same time) Tom H: You know what I mean? Logan: Too woke. (laughter)
Logan: They stay woke. (laughter) And the wokeness builds up, Z.
ZDoggMD: No, we’re not bro scientists. We’re legit scientists. (laughter) “Yeah, you get hella woke and then-”
Tom H.: Uh- Let me see. If I had to imagine- uhhhhhhh- I don’t know.
ZDoggMD: Think about it-
Tom H.: Heart attack?
ZDoggMD: That’s a great point. So cardiovascular uh- death is one cause because you’re putting a system under a lot of strain. So, you can either have a heart attack, you can have an arrhythmia, meaning the beats funny and you die. So anything from atrial flutter, atrial fib, tachycardia- ve- ventricular tachycardia, v-fib, etcetera. And that can be made worse by electrolytes. So if you’re not monitoring their blood electrolytes, if you’re not giving them fluid with glucose and thiamine, a lot of times. Because they’re often deficient in that if you don’t give glucose with thiamine, you could precipitate something called a Wernicke crisis which is no good. So… you can die from that stuff. You can also die from aspiration. Which is a fancy way of saying-
(At same time) ZDoggMD: -choking on your own vomit. Tom H.: Yeah, choking on your own vomit. Right.
ZDoggMD: Choking on your own vomit. Because you’re not in your right state of mind which means you’re not protecting your airway. You’re not controlling your-
(At same time) ZDoggMD: -secretions. Tom H.: Yeah.
Tom H.: Tons of rock stars have gone out that way. You know, Jimi Hendrix uh-
ZDoggMD: Hendrix went out-
Tom H.: Bon Scott uh-
Tom H.: The list goes on and on.
ZDoggMD: Billy Dee Williams.
Tom H.: Yeah.
Tom H.: Nah, he’s still alive.
ZDoggMD: Damn it.
Tom H.: Actually… Hey, Jaylene says, (laughter) “I learned about the DTs from watching Leaving Las Vegas. I guess that’s the only thing Nick Cage ever taught me.” Have you seen Leaving Las Vegas? It’s actually a really great movie about an alcoholic.
ZDoggMD: I haven’t seen Leaving Las Vegas, but I’ve seen Nick Cage at my kids’ school. (laughter)
Logan: I’ve seen him drunk. (laughter)
ZDoggMD: I- I- let’s just say-
Logan: Really drunk.
ZDoggMD: If anybody’s gonna need some a CIWA protocol, which we’re gonna talk about in a second, it’s gonna be my boy Nicky.
Tom H.: Oh, yeah. Your kid and his kid are in the same grade, right?
ZDoggMD: Yup. His kid um- (laughter) I won’t say his name, but he named him after a Superman character.
Tom H.: Oh, yeah. That’s right.
ZDoggMD: Yeah. That really uh- uh- umm… Again, I’m gonna not violate HIPAA. He’s not my patient, but he’s a celebrity. So all that being said, um- you can die from delirium tremens. So you want to look at electrolytes. You wanna give fluids. You wanna um- nutrition is important. If people can take orals right away, you do that. Now how do you actually treat alcohol withdrawal? We don’t give beer anymore in the hospital, right? If say- and here’s something I also see, someone has an alcohol withdrawal seizure and they give Dilantin, phenytoin. That’s a typical anti-seizure drug you would give for seizures. Is it the right thing to do? Oh, HELL NO, Zpac. So there’s ne- there has been data that- that is wro- it doesn’t help with alcohol withdrawal seizures. The way you treat alcohol withdrawal- the seizures, the tremulousness, the DTs, etcetera- is with benzodiazepines. That’s the frontline agent. Benzodiazepines are things like Valium, Librium, Ativan, Versed, those kind of agents that act in a similar way. They’re- they’re GABA uh- receptor or GABA- see there it is. There’s my boy, Gabba. GABA stimulants. So they’re gonna- they’re gonna suppress the activation of the brain.
Tom H.: Right.
ZDoggMD: And so, what you’re doing is you’re taking a pharmacologic uh- uh- sort of version of methadone basically for opioid abusers. And the advantage is it’s predict- it’s more predictable. So most of them are cleared in the liver. A couple are cleared in the kidney like Ativan. So you can kind of dose them appropriately. You can give them IV uh- in terms of Ativan and Valium. Or you can give them orally in terms of Librium which is much longer acting. And you can titrate them either in a standing way where you say, “I’m just gonna give ‘em- I’m worried about this guy. I wanna not let him go into withdrawal or he’s got some withdrawal. I’m just gonna give him Librium three times a day.” That’s how they used to do it. And then they did this couple of studies in the 90s and they found that, no, it’s actually much better to titrate how you give these medicines to the patients symptoms. And that’s where it became a nursing nightmare. Because this is what happened, they came up with this thing called a CIWA assessment. It’s the “Clinical Institute Withdrawal Assessment Scale for Alcohol” or C-I-W-A hyphen A-R. And this is a hellishly (laughter) complex series of questions uh- that basically you- that- that- that the nurse basically has to assess or the doctor has to. Usually the nurse. And it’s things like, “Are you feeling any headache? Do you have any anxiety? Are you feeling nauseous? Do you feel like you want a drink?” Whatever- whatever they are. There’s, like, a bunch of questions. And I had the slide and I don’t want to inflict it on you. You can look it up. So based on the- the number score on the CIWA protocol, you can actually decide “Do I treat or not?” based on mild, moderate, or severe withdrawal symptoms. And that requires constant assessment. So almost every 1 hour when you’re starting. Which is very hard for nurses because they’re understaffed already and now they gotta ask this crazy alcoholic a shit ton of questions. And that’s assuming he’s in his right mind to answer.
Tom H.: That’s right.
ZDoggMD: And if he’s not, you can use something called the RASS which is a- a different assessment tool. It’s more based on objective measures that you can use in ICU patients or patients that are unable to cooperate with uh- with the CIWA. Of course, if they’re unable to cooperate with CIWA often they’re in serious withdrawal.
Tom H.: Yeah.
ZDoggMD: So once you’ve docu- you kind of document, “Okay, this guys actually got withdrawal.” then you gotta start giving the benzos. And this is how that’s gonna look. So let me make sure that we go very carefully here ‘cause I don’t wanna-
Logan: I found a picture of the CIWA.
ZDoggMD: Oh, my gosh.
ZDoggMD: Black fish.
Tom H.: I was like, “Why are you googling Seaworld right now and he was like, (laughter) “CIWA. Seaworld. Seaworld.”
Logan: Same thing.
Tom H.: “That’s a funny joke.”
ZDoggMD: Panda. Panda.
(At same time) ZDoggMD: Panda. Tom H.: That doesn’t make any sense.
(At same time) ZDoggMD: I got dolphins in- Logan: I’m funny.
ZDoggMD: Uh- So typically you can start with longer acting benzodiazepines. uh- but you have to be careful. So things like Valium that are oral? You know, 10 milligrams orally and just repeat, repeat, repeat. You know, every hour until the patient is calm and the CIWA score drops. And you have to be careful because in people with liver disease the metabolites can build up and you can actually really oversedate someone and it will all suddenly catch up with you and the patient’s claunghh not breathing.
Tom H.: Hey, yo, teach. Hey, yo, teach. Bro science moment. (laughter) Aren’t you just using drugs to, like, fight drugs, bro?
ZDoggMD: Yes. That’s exactly what we’re doing. (laughter) Because we want people not to die.
Tom H.: But- but- bro, bro. Bro, real quick, bro. Ativan’s, like, totally addictive, bro. So, you’re just gonna get ‘em all strung out on Ativan? Stop putting the Seaworld thing.
ZDoggMD: So actually, you know, it’s funny, Tom, that you bring this up. So there are non-benzodiazepine pharmacologic approaches to treating alcohol withdrawal. They don’t work. They might work in very mild withdrawal- and some mild withdrawal just resolves on its own. But you don’t want to take that risk in the hospital and these patients are already addicted to alcohol. Umm- it probably isn’t a good idea to send them out on benzodiazepines. You detox them, get them through the withdrawal, make sure they’re stable, and then get them into treatment. Of course, that never happens. They go back to the street and they continue to drink.
Tom H.: Right.
ZDoggMD: So that is a dispo plan. That is a discharge plan. It’s always worked for me. It doesn’t solve any problems, but that’s health 1.0 and 2.0 for you, guys. When we get to 3 it’s a different game. So the basic protocol is if look- if they can take oral medications, you want to- you can hit them with Librium, which is chlordiazepoxide, you know. And they’re callin’ it 25 to 100 milligrams um… repeat every hour until the CIWA score is less than 8. And if you can do that in three doses, then that’s great. Then you can give a little bit of Versed or Ativan IV just to get them calm because that’s much shorter acting, it’s cleared through the kidneys, it doesn’t stack as much, it doesn’t have active metabolites. That’s why sometimes you’ll see docs give Valium initially until they’re a little bit calm. This is what I used to do. And then just bump ‘em with Ativan PRN, as needed, for a little bit of uh- for whatever symptoms they’re having. And you treat it to symptoms. And slowly their need for uh- um… that inhibition drops and then they’re clear and you’re good. Then you can talk about- you know, obviously you’re treating the underlying condition and you’re taking care of what’s their long term, sort of, get them off alcohol plan. Right? And that’s uh- true it’s an issue. Now, if you can’t do that, if they’re not taking orals then you gotta hit ‘em with IV. And you can do IV Ativan which is again a short acting. I prefer Valium if their liver is okay. And even if it’s not, sometimes I’ll give a little Valium and that’ll hang around and it’ll knock ‘em down a bit. And their symptoms will calm down. They’ll stop seeing things. They won’t seize- There it is. (laughter) Or they- and, you know, they’ll have less tremor. They’ll feel better. They’ll be more alert. When that happens, if they get a little shaky or they’re a little tachycardic or their blood pressure’s up, you can bump ‘em with a milligram here and there of Ativan. And as their need comes down, you just bump, bump, bump, bump, bump. You can consider, like, they have a need for alcohol that’s decreasing. If you don’t meet it, they’re having seizures and withdrawal and delirium. If you meet it, you’re perfect. And if you over do it, they’re sedated. So you’re trying to just bump around this decreasing line. That’s how you manage that. And the whole time you’re giving fluids, you’re giving magnesium, you’re giving potassium, you’re replacing the electrolytes, you’re checking the uh- the labs. And you’re watching for underlying disease to make sure you’re not missing something like a pancreatitis or a GI bleed or a sepsis or an infection. So, if you do that and they do well, you won the game. If they don’t do well, if you get behind, if you can’t calm them down with this IV stuff, then you start escalating. If they go into florid delirium tremens, they’re agitated, they’re not protecting their airway- That’s when you intubate the shit out of them. You put in a breathing tube and you sedate them with propofol. Propofol- Milk of Amnesia as Doc Vader calls it- is- will- will knock you out and keep you generally quite good while you’re intubated. Now that’s a serious thing and now you have all of the potential complications that come with being on a ventilator, being in the ICU. Infection, aspiration, clots, you know. And then whatever the underlying condition is. So that’s a serious thing. Along the way you can give phenobarbital, too. That’s another thing that under supervision, you often need to be in the ICU, you can give phenobarb in addition to the- the benzodiazepines uh- to try to see if you can knock the alcohol withdrawal down.
Tom H.: When you’re saying you’re titrating down according to symptoms, wha- uh- if you choose the wrong drug, could you end up stacking?
ZDoggMD: Exactly. So this is what happens- and you see- Okay, here are the mistakes that I see. Intern comes on service. Patient’s in alcohol withdrawal. Nurse calls him in the middle of the night. “This patient’s jumping off the wall. Saying he’s seeing ants. His blood pressure’s 160. Help, doctor.” So the intern shows up and says, “Okay. Uh- I read that I should give Valium.” Doesn’t really think that the patient has cirrhosis, end-stage liver disease from chronic alcohol abuse. His liver doesn’t work that good. Valium is cleared through the liver. So what happens is he gives 10 and he gives it IV because the patient’s not swallowing real well. They can’t trust him. He’s throwing his meds all over the place. So he’s like, “I’ll give it IV.” Which means there’s no autoregulation. In other words, you can give it IV even if the patient is a little bit sedated or something’s going on. So he tells the nurse, “Give 10.” Okay, she gives ten. Patient’s still jumping off the wall. “Give another 10.” You know uh- ten minutes later. I have given Valium every ten minutes IV, 10 milligrams, ‘til a patient is calm. And you just sit and watch. You have to be there. Which means not you- not only do you trust and rely on your nurse, but you have to actually show up as a doc, right, and you have to sit there with the nurse. It’s stressful. Like the scariest shit I’ve ever done was alcohol withdrawal at the VA when I was a resident. You’re sitting there with this patient who’s bouncing off the walls and their blood pressure’s crazy and the is looking at you like, “You’re the doctor. Do some shit right now.” Because- and- and- and here’s- here’s the thing, the nurse is scared to give the Valium because she’s seen people die from too much Valium.
Tom H.: Right.
ZDoggMD: And sh- her shit’s on the line, too.
Tom H.: Yeah.
Tom H.: You gotta know, as the doc, which one is the correct drug to be giving so that you’re not stacking it up inside the-
(At same time) ZDoggMD: Exactly. Tom H.: -patient.
ZDoggMD: So this is what happens. They give the Valium 10, then tells the nurse, “Give the Valium 10.” At this point, the third dose of Valium, patient’s still jumping off the wall. The nurse is like, “Doctor, could you consider that maybe the patient has too much Valium?” “No, no, no, no. He’s still bouncing off the wall. Give him more Valium.” Well, he’s got florid liver failure. The next thing you know, he’s quickly unconscious.
Tom H.: Yeah.
ZDoggMD: And he vomits, aspirates, chokes on it, get’s pneumonia, ends up in the ICU, and dies.
Tom H.: Yep.
ZDoggMD: And so this- and- and sometimes that happens quickly, sometimes it stacks over time. And I’ve seen this happen. And the worst part is it’s often combined with other things like patient may be getting narcotics for something. Something else is going on, right?
Tom H.: Right.
ZDoggMD: He has a GI bleed so he’s what they call encephalopathic, meaning umm… he has a- a delirium caused by liver disease and it’s very common, but we’ll talk about it another time.
Tom H.: Yeah.
ZDoggMD: So all those things, you can kill a patient easily. So this is what I do. I give ‘em Valium, I give ‘em Valium. Okay, they’re still wide awake? I might alternate it with a little Ativan. ‘Cause Ativan is cleared through a different pathway. It doesn’t have active metabolites. It’s shorter acting. You can even give Versed which is even more short than that. And that way you can kind of watch and if that doesn’t work, maybe give them another Valium. And it- it- it’s a very hands-on process. And it depends on the nurse assessment, on your assessment, and your understanding of the overall picture of the patient.
Tom H.: But if it’s such a labor intensive, hands-on process, is the hospital the right place to be doing it?
ZDoggMD: There’s no better place. ‘Cause you can’t do it as an out- You can do alcohol detox as an outpatient, but not THIS. Not delirium tremens.
Tom H.: But do you need a- anoth- you need a sitter for them, like? Or do-
Tom H.: -you have to have the doc be there?
ZDoggMD: No, you probably need a sitter. The doc won’t be there. ‘Cause docs are stretched thin. The nurse will be with her five other patients-
Tom H.: Right.
ZDoggMD: -running around. The sitter will be in the room.
Tom H.: So who’s the- who’s the sitter?
ZDoggMD: Well the sitter may be-
Tom H.: Who does it?
ZDoggMD: It may be st- a-
Tom H.: Be a family member or-
ZDoggMD: CNA. It may be a family member although that’s not super smiled upon (laughter) depending on the institution. So that’s the trick. Everybody’s understaffed and you’re trying to take care of a very high intensity thing. So sometimes you’ll just have to bump them up to a higher level of care. A Step Down Unit. A ICU. Because then you have better staffing, right? So- and remember, guys, like, if you’re a doc- an- if you’re umm… an intern, there’s gonna come a point, there are criteria for this, where you’re gonna go, “You know what? This patient needs the ICU.” This patient needs 1 to 1 or 2 to 1 nursing. They need monitoring. They need cardiac monitoring as well because they’re- they’re having tachycardia, they could have an arrhythmia, their electrolytes are out of whack. All those things. And you’re trying to give these benzos and it’s getting behind. And when that happens, it may be getting time to intubate the patient, hit ‘em with propofol. There are other things you can do as well, right? We won’t get into. But the main points I want people to realize is if you get too behind, you can really- you’re spending the rest of the time catching up and it can be fatal for the patient. If you overdo it because you haven’t thought about liver disease and that kind of thing, you can cause death and harm. So generally- but the one thing I want to say is more often what I see are that people under do it. So they’re scared. They’re like, “I’m gonna give um-” I don’t know why I’m doing this voice, but- (laughter) “I’m gonna give, like, a milligram of Ativan because I don’t want anyone ta die.” And the patient’s jumping off the walls. And the nurse is calling and calling and calling saying, “Doc, the CIWA score is like 15 or whatever! This is not enough.” “Give him another 1 of Ativan.” Well Ativan is like- it’s spitting at a guy-
Tom H.: Right.
ZDoggMD: -who drinks a fifth of vodka a day. It’s like nothing. So you gotta go 10, 10, 10, 10, 10 of Valium or, you know, 50, 100, (laughter) like a shit ton of Librium. And I’ve given, like, 500 milligrams over a period of time of Librium. And the guy’s still wide awake, but he’s not withdrawing. And so, you can’t be scared of that. But you have to have experience. You have to call for help when you- you’re out of your depth on it. But you gotta get comfortable with it. Especially if you’re working in a county setting. Like UMC, that kind of thing. ‘Cause I see so many residents who under do it and then they’re wondering why every sh- all the shit’s hitting the fan.
Tom H.: It’s basically like tranqing a lion. You- you better have the right tranq-
Tom H.: -like, you better have enough.
ZDoggMD: But the thing about the line is you don’t- you don’t worry about over tranquilizing them.
Tom H.: Right.
ZDoggMD: In humans, the- everybody’s very stressed about overdoing it. Um… So that’s more or less- right- and you can get refractory delirium tremens and that’s when you’re really- you’re intubating people, you’re putting them on phenobarbital. Uh- dexmedetomidine. You’re putting them on propofol. Those kind of things. Now there are alternative ways to do this that the authors of the papers that I’m reading don’t like. One is giving ethanol, which we talked about. Like, straight alcohol. Not a good idea. The other are things like Haldol. So here’s a patient having hallucinations who’s jumping off the walls. A lot of times in the hospital for delirium that isn’t alcohol we give Haldol and Ativan in a combination. Well it turns out haloperidol, Haldol, is not the best answer for someone who’s in alcohol withdrawal. It effects heat metabolism so you- people who are having hyperthermia, which is one way you can die from delirium, you can get a fever so high you can die.
Tom H.: Ahh.
ZDoggMD: Um… because that’s one of the things. You’re disinhibiting the fever regulation is off. So Haldol which is an anti-
Tom H.: You know it’s interesting because part of the delirium tremens sound a lot like when people uh- freeze to death.
ZDoggMD: Yeah, except it’s the- uh- it’s the opposite.
Tom H.: It’s the opposite, right?
ZDoggMD: It’s temperature dysregulation.
Tom H.: But I can imagine- Yeah temperature dysregulation, the body’s under an extreme stress.
ZDoggMD: That’s what it is.
Tom H.: Similar.
ZDoggMD: That’s really what it is. You-
Tom H.: Not the same, but similar.
ZDoggMD: You’ve taken the brakes off the body’s autonomic system.
Tom H.: Yeah.
ZDoggMD: And everything goes haywire. And on top of that you’re not well to begin with ‘cause you’re a chronic alcoholic.
Tom H.: Right.
ZDoggMD: So it puts you at risk in many, many ways.
Tom H.: Well it sounds much more dysphoric to go through DTs than it does to freeze to death.
ZDoggMD: Yeah, yeah, yeah.
Tom H.: Hypothermia.
ZDoggMD: Yeah, well the thing is- Well here’s the thing. People go through alcohol withdrawal, generally if they hit the DT stage they don’t remember any of it afterwards.
Tom H.: Ahh.
ZDoggMD: But at the time they are suffering.
Tom H.: Yeah.
ZDoggMD: So it’s like tremendous suffering and then they- when they wake up at the end, they don’t remember anything happened. MOST people. So what do you think, Tom? Let’s go to some comments.
Tom H.: Hit me with, what’s a banana bag?
(At same time) ZDoggMD: Ah, okay the banana bag. Tom H.: ‘Cause a bunch of people were talkin’ about a banana bag.
ZDoggMD: Yeah, yeah. (laughter) There’s my boy, Yo Gabba Gabba Banana. So the banana bag, alright, is (laugh) and they call it a banana bag because it looks yellow. It’s a bag of IV fluids that they put a multi-vitamin in, thiamine, a little bit of glucose, etcetera. And people will reflexively give that to alcoholics in the emergency department and on the floor because they know that alcoholics are vitamin deficient, thiamine deficient, folic deficient. And they need a little bit of glucose.
Tom H.: It seems like a steroided version of like, “Have a Gatorade and a burrito, dude.”
ZDoggMD: It’s a ste- (laughter) It is. It’s a steroided version of the Hangover Heaven Bus that you-
Tom H.: Right.
ZDoggMD: -see around Vegas, right?
Tom H.: Yeah.
ZDoggMD: And the problem is, the authors in this particular article say, “It doesn’t do shit.”
Tom H.: Ahh.
ZDoggMD: So it’s actually- it gives you a placebo feeling like, “I’m doing something.” But really you gotta hit ‘em with good fluids. You gotta give ‘em thiamine. You gotta give ‘em glucose. You gotta give ‘em nutrition. And if you don’t do that- ‘cause these are malnourished people.
Tom H.: Right.
ZDoggMD: Already. And they’re dehydrated. And fluid abnormalities are one thing that kill people in delirium tremens because they’re vomiting, they’re sweating, they’re tachycardic, and they’re not drinking or eating. So you have to take care of that as part of it.
Tom H.: Ah, Sarah wants to know, “Why is Haldol bad?”
ZDoggMD: So Haldol is bad- and the authors here go into some detail on this. “Treatment with antipsychotics would only be appropriate when a decompensated thought disorder like schizophrenia coexists with alcohol withdrawal.” Right? Because otherwise routinely giving Haldol and other uh- you know, butyrophenones including Haldol. They lower the seizure threshold, so you’re more likely to have a seizure. Bad. And also they interfere with heat dissipation and don’t uh- sort of have any cross-tolerance with ethanol. So they’re not really helping the withdrawal directly. They’re- you’re putting a bandaid on symptoms of hallucinations, but you’re not treating the underlying cause which is alcohol deficiency at this point. It’s a GABA deficiency.
Tom H.: But it might be helpful in (laughter) Uh- people with schizophrenia or basically-
ZDoggMD: Ah. Right. So say you’re schizophrenic and an alcoholic and in withdrawal-
Tom H.: Right.
ZDoggMD: And you’re having crazy auditory hallucinations that are your schizophrenia. THEN it might be acceptable.
Tom H.: What about uh- PTSD. ‘Cause I can imagine a lot of the veteran community deals with that. Would that be on the same?
ZDoggMD: PTSD is- is different in the sense that if you’re not having these psychotic symptoms-
Tom H.: Right.
ZDoggMD: -auditory/visual hallucination, hearing voices, this kind of thing, you wouldn’t have an indication to give Haldol.
Tom H.: Okay.
Tom H.: Gotcha.
ZDoggMD: Now, and again, you’d- I’d defer to a psychiatrist because there may be some indications.
Tom H.: And then what’s Precedex? P-R-E-C-E-D-E-X?
ZDoggMD: So Precedex-
Tom H.: Precedex.
ZDoggMD: Is- is- uh- hang on a second because I want to make sure that we uh- we speak about this correctly because my anesthesiologist will get really pissed. And that’s dexmedetomidine which I talked about earlier. That- Dex as the anesthesiologists call it, is another kind of GABAergic sedative. And a- a lot of times they use it in anesthesia, in the ER setting, etcetera. And there was talk of using it in alcohol withdrawal- withdrawal settings. Including by one of my mentors, Jose Maldonado, back at Stanford. The thing is there’s not a whooole lot of evidence yet that it is- as a solo drug- a great choice.
Tom H.: Right.
ZDoggMD: So it may be part of the armamentarium and I mentioned it in passing when we were talking about phenobarbital, dex, propofol. So when you get anesthesia involved at this point or critical care, you know, they’re just snowing the fuck out of the patient.
Tom H.: Yeah.
ZDoggMD: Yeah. And so that’s one option for that.
Tom H.: And then hey, bro science break it down for me. It seems to me that people who do hard alcohol are much more likely to suffer severe alcohol withdrawal than people that just drink beer and wine. Is that- am I just totally of base here or-
ZDoggMD: It- it- it’s more that people who do hard alcohol uh- have found that hard alcohol shows less on the breath. It’s a quicker, easier way to get drunk, and they choose it because they’re harder core alcoholics. But you can be just as bad with wine. I’ve seen- I’ve seen- the worst alcohol withdrawal I see is from beer.
Tom H.: Oh, really!?
ZDoggMD: Ah, yeah. Beer.
Tom H.: Really?
ZDoggMD: So people who drink like a twelve pack a day on the regular. VA patients. And they’re, you know, they get sick, they stop drinking. Or they decide, “A’m just not gonna drink enymore, bro.” Next thing you know-
Tom H.: Yeah.
ZDoggMD: -they are literally- And it’s the craziest shit, Tom. ‘Cause they- they- they are insane when they’re withdrawing.
Tom H.: Dude, I- I used to drive- I used to take the train out to the metro out to the south suburbs of Chicago when I was living in the city in Chicago, to visit my family and I did it every day for about two weeks. Same construction worker got on every day with a thirty pack of PBR.
ZDoggMD: There you go.
Tom H.: Every day. And would drink five on the train on the way out to the south suburbs. And I gotta imagine he was killin’ the rest of the case at home. Every single day. It was crazy.
ZDoggMD: Wow. You know uh- name the movie. “Heineken?! Fuck that shit! Pabst Blue Ribbon!”
Tom H.: That’s Blue Velvet, mother fucker.
ZDoggMD: You are good. You are good. Uh- let’s read some comments. “My daughter just quit Friday,” says Lavon La Croix Kroger. Wow, her middle name is La Croix. I’m gonna drink for that. “No alcohol since. Was drinking fifth a quart a day. She seems not to have DTs. Seen doctor today. Gave her meds that make her sick if she drinks.” Right. So she’s getting the uh- getting that route. Uh- “Should I be concerned? Has it been long enough for her?” So let’s see, she quit on Friday and what’s today, Tom? Monday?
Tom H.: Yeah.
ZDoggMD: Friday, Saturday, Sunday, Monday. Yes. You can still be concerned. And this isn’t medical advice, Lavon. It’s just friendly entertainment advice. Which is that-
Tom H.: How many days would you be concerned for her?
ZDoggMD: So typically if you look at these paths 72 to 96 hours is generally the outset for the start of delirium tremens.
Tom H.: Yeah.
ZDoggMD: Prior to that you can get the other forms of alcohol withdrawal.
Tom H.: So after about five days you’re probably in the clear?
ZDoggMD: You’re probably in the clear. Now remember, almost all delirium tremens shows some sign of previous alcohol withdrawal before that. So if she’s awake and alert, nothing wrong with her, no alcohol withdrawal, it’s unlikely she’s gonna have DTs at day four or three. But it’s not impossible.
Tom H.: Right.
ZDoggMD: So constant vigilance, as Mad-Eye Moody once said, umm… Lavon uh- La Croix. Uh- let’s see. Yeah, see other people are talking about Lavon. “Just use Librium, hang a banana bag, and call it a day.” Ankeny Garcia. So Ankeny if you do that. If you use Librium, long acting benzodiazepine, hang a banana bag, give him fluid, and call it a day, as long as you’re watching him and you’re doing the CIWA protocol and you’re, you know, asking the questions, you can probably get away with that. But if it looks like it’s not working, you need to adjust really, really quickly. Umm… let’s read some more comments. (tongue clicking) “And how is this related to hypothyroidism crisis?” Laura Lynne. Generally isn’t. Umm… Oh, Catherine Mansfield, great point! “Plus with Haldol you can get a Long QT. Electrolyte derangements like low mag combined with tachycardia. You’re asking for arrhythmias. Haldol and alcohol is like using a super soaker to put out a forest fire in my opinion.” (laughter) Catherine that was fantastic. This is why I love the Zpac.
Tom H.: Would that be? Would that be similar for Seroquel also?
ZDoggMD: So Seroquel is another antipsychotic but it’s a lit-
Tom H.: Yeah. You feel the same way?
ZDoggMD: -we… Yes. But we often will give that at night for, like, people who are delirious in older-
Tom H.: Cause it puts you to sleep.
ZDoggMD: It’ll- yeah. You- it’s- Haldol is something you can give really fast and acute in the hospital and you can give it IV. Which is an advantage, right? When someone’s not eating. Now, let me unpack something Catherine said. Long QT. What she’s talking about is the Q-T interval on an EKG. And it’s- for people who aren’t savvy on this it’s just- suffice it to say, it’s a way you can look at the electrical tracing and go, “Ooo. Drugs, or metabolic derangements, or illness are causing a problem that can lead to a type of arrhythmia whi- especially when combined with low magnesium that Haldol can also cal- cause- called Torsades de Pointes. And actually, Dr. Harry and I did a song called “Doctors Today” that you can look up on our website uh- or on Facebook. And in that song, we were like, you know (singing) “The patient’s sundowning da da da da-” (not singing) I forgot what the lyrics were, but it was like (singing) “gave Haldol to stop him from falling,” you know, “checked the monitor it’s Torsades de Pointes.” (not singing) So we even sang about that particular complication with Haldol. And in alcohol, ‘cause it’s worse ‘cause their magnesium’s all effed up. Uh- So I love that comment Catherine. Let’s read some more. Umm… “Could you use Haldol for a quick PRN, as needed?” Ayrial Schnell. “Quick save just the wrangle the patient.” Ayrial Schnell. Well, that’s the thing, Ayrial. I wouldn’t do that. What I would do is I would hit ‘em with Valium or Librium or Ativan because that is treating the underlying cause and it is sedating them. You give them Haldol when they’re in alcohol withdrawal and you can have all those problems. So it’s not worth the risk. Whereas the other stuff is actually going to sedate them and treat the underlying conditions. So that’s why you want to go with that ideally. Umm…
Tom H.: Gloria wants to know, “How often do you think alcoholics should really be assessed and the CIWA scale-” Idolized? Itilized?
ZDoggMD: Idealized maybe?
Tom H.: Idealized.
ZDoggMD: Probably auto-correct-
Tom H.: Should there be a set frequency?
ZDoggMD: So it depends. And a lot of times uh- the authors of the article that I’m reading say- And I would tend to agree with this- you know, as often as half an hour to an hour. And I know nurses hate to hear this because they gotta go in and assess the patient and do this big questionnaire. But like, once if they’re- if they’re having fluctuating symptoms you have to at least get a sense. Now at least every hour you can- you can document a CIWA score, tell the doctor, and if there’s a protocol, you can give the Valium or the Ativan, right? And that’s gonna help a lot. (Tom H. waving arm like student.) Yes?
Tom H.: Z, I got a question.
ZDoggMD: Yes, Tom?
Tom H.: Yo, teach! Is it uh- unethical to force a patient to withdraw from alcohol if they came in for another complication and has no intention of withdrawing from alcohol?
ZDoggMD: What an interesting question. So Tom is asking, “Is it unethical?” So they come in there an alcoholic?
Tom H.: They’re an alcoholic-
(At same time) ZDoggMD: They come in with… pneumonia. Tom H.: -they have something else that’s wrong with-
Tom H.: Yeah.
ZDoggMD: Come in with pneumonia and they’re like, “I want alcohol. If I don’t get alcohol, I withdraw.
Tom H.: Yeah. And you’re like, “Time to go through withdrawals, mother fucker. You made some bad life decisions.” (laughter) Is that unethical?
ZDoggMD: Wow! You know I actually- so this comes up from time to time. This is how we handle it. Alright. We tell the patient this. “We can’t give you alcohol in the hospital because we think it’s- it’s unpredictably metabolized and it can interfere with your other treatment. What we can give you is benzodiazepines. So Valium, Ativan, Librium. To titrate to the level of your comfort. If you’re awake and alert, we can give you more. And so it’s kind of like our alcohol substitute. So we promise you we will do our best so that you do not withdraw, but we are not going to give you beer, wine, spirits.” That’s how we do it.
Tom H.: Listen up, bro. Alcohol? (tongue click) That’s Little League, son. We got them good drugs here.”
Tom H.: “You know what I’m sayin’?”
ZDoggMD: That’s what I- that’s what I, you know- as soon as the team leaves I’m like, “Check it out, son.” (laughter) “That shit that starts with a ‘D’? That’s my shit right there, yo.”
Tom H.: “Yer boy gotch you.”
(At same time) ZDoggMD: “I got yer back.” Tom H.: “I gotch you.”
ZDoggMD: “Who gotch you?” (laughter) (singing) Blame it on the de-de-de-de-de-demerol. Blame it on the deh-deh-de-de-deh-deh-de-de-demerol. (not singing) Umm… I don’t know, Tom. Couple more comments?
(At same time) ZDoggMD: These comments are great. Tom H.: Yeah, let’s do, like two more.
ZDoggMD: Yeah. Ummm… let’s seeeee. Ooo, Tess Dunaway. “Problem. Providers being judgmental, including nurses, instead of an objective assessment is a huge problem. Believing patients, and those who are withdrawing, are drug seeking even when the CIWA and the COWS protocol which are subjective are available.” Yup, Tess. I’m mean you’ve got- listen if 40% of the patients in the hospital have some kind of alcohol use disorder, you better just take it seriously, right? Umm… Oh, interesting. “In the 70s we had to just tie down people in delirium tremens. They didn’t use tranquilizers.” Deb Higgens. That may explain the 37% mortality rate, don’t you think? Umm…
Tom H.: Kristy Columbus says, “God, Zubin’s a good doctor. Totes. Real hearts.” This is why Zubin burnt out a lot quicker than other doctors. (laughter) ‘Cause he actually cares. (laughter)
ZDoggMD: Ohhhh. I don’t know if I’m laughin’ or I’m cryin’, Tom Hinueber.
Tom H.: Takes most doctors thirty years to burn out. Zubin did it in just ten.
ZDoggMD: I’m a gunner, son. I’m like, “You want a burnout? I can burn out faster than any other mother fucker on the planet.” (laughter) No, but seri- all joking aside uh- let us know, guys. If you think this form of teaching, which is fairly casual, lots of “f-bombs”, and actually, I really enjoy Tom and Logan’s uh- Bro inter- Bro-teruptions because they allows us to talk also to- Yes. Activated Gabba muggles- La Croix, bitches. Mmm. So, if you like this format, let me know. We’ll keep doin’ it. We’ll- hit me with topics you want to talk about umm… and- See the things I really am passionate about are often hospital related because that’s my speciality and training, but if there’s other shit, I’m happy to learn and talk about it. What I like to be able to do is give you my own, sort of, spin on it because, you know, a decade in the hospital doing that stuff, you learn a thing or two. And uh- you also learn some interesting stuff which is the way we practice medicine is a lot of seat of your pants. It’s a lot of intuition. And a lot of bunch of old guys sitting around a table saying shit like, “Don’t give alcohol for alcohol withdrawal.” or “Actually. Give alcohol for alcohol withdrawal.” It’ll change all the time. And uh- I think having the conversation and getting people’s input and- sort of crowd sourcing input is a good idea. So that’s my thought.
Tom H.: Heck yeah.
ZDoggMD: Wha chew think, Tom Hinueber? Any other good comments? Gabba gabba gabba gabba.
Tom H.: Uh- Danielle Hinueber says, “I love this education.” That’s ‘cause yer smart and pretty, girl.
(At same time) ZDoggMD: I think that’s a- Tom H.: Love you.
ZDoggMD: I think that’s a- the first time your wife has ever complimented the show. (laughter) ‘Cause bo- like my wife, they’re both like, “This show sucks.” (laughter) ‘Cause that’s what my wife says.
Tom H.: So true.
Tom H.: So true.
ZDoggMD: Which is great. This- that’s what keeps us pushing to try to make it better, guys. Oh! If you do love the show, we’d really appreciate if you go to patreon.com/zdoggmd and donate even a dollar uh- a week. Every week you get a summary of all the shows. If you sign up for our email list on our website, umm… zdoggmd.com, every week we send an update of everything we’ve done that week so you can pick and choose what you want to watch. And if you- if you donate enough, Doc Vader will make you a customized video. So if you have an organization or group that wants a Vader thing for their Christmas party, donate on Patreon and Vader will come correct- Correct, son! ‘Cause we will shill that Vader.
Tom H.: That’s right.
ZDoggMD: Wha chew think?
Tom H.: And listen up, people. When you booze, you lose.
Logan: I miss Shamu.
Logan: Remember Shamu?
(At same time) ZDoggMD: Ah, dare to keep Tom Hinueber off- Tom H.: The liberals shut down Shamu, man.
Logan: God damn liberals.
ZDoggMD: God damn liberals.
Tom H.: Tryin’ to keep big fish in a cage, Z. America.
Tom H.: Tryin’ to keep ‘im right in that cage.
Tom H.: Mmhm.
ZDoggMD: I hate you so much, Tom Hinueber. (laughter) Uh- We out.
Tom H.: FREEEDOOOM!
Logan: (singing) Freedom isn’t free.