We can all remember a call that sticks out in our minds, a crazy, messy, tragic call that has stuck with us over the course of our entire careers. I know I’ve had a few of these, but there’s one in particular I’d like to share that breaks from the norm and has stuck with me every day since.
One day, I was running a paramedic fly-car and was dispatched for a sick subject withdrawing from alcohol. It’d been a busy day already, and I immediately thought I could be used far better than responding to something EMTs could and should handle on their own.
I arrived before the ambulance and walked into this typical suburbia house, met by a lovely woman in her 40s who had clearly been crying. Tears were still visible on her cheeks, and her eyes were red. I found my patient sitting on the couch in the living room; he would’ve looked like any typical white-collar, well-dressed man in his polo and slacks except for the fact he was drenched in sweat, had flushed red skin, and had visible tremors so severe they were apparent while he was seated.
The patient related to me that he had been an alcoholic for over 15 years and, over the last 2 days, had been attempting to withdraw ‘cold turkey.’ Something had clicked in his mind, and he couldn’t bear to keep putting his wife through the ordeal of his addiction any longer. He also profusely apologized to me and was embarrassed and ashamed to be seen in his current condition.
Something about this effort of pure love and this man’s honorable intentions profoundly affected me in that moment. I evaluated him and found him to have all the warning signs of severe withdrawal, my assessment and evaluation placing him at a CIWA-Ar score of at least 17. I was concerned about his well-being and the severity of his presentation but also recognized no protocol even addresses this condition in my state.
As an aside, it's important to note that CIWA-Ar severity definitions vary throughout the literature, with some defining 15 as the cutoff for DTs, and some placing it as high as 20. I erred on the side of caution and treated the patient as a severe withdrawal.
Given the impact this call had on me at that moment, I chose to discuss a treatment plan with a physician as it required protocol deviations. I explained to the family that I was planning to give benzodiazepines to him, which should improve his symptoms; ultimately, the physician gave me the go-ahead.
Following 2mg IV Midazolam, a fluid bolus, and 8mg Zofran, we rode gently to the hospital with the patient’s wife accompanying me in the patient compartment. I spent the entire ride discussing the events that brought them to me and offering kind words and encouragement where I could. I ultimately followed up on him after a few days and then a few weeks later. I found that not only did he and his wife remember my name and my efforts, but the patient recounted several times how I treated him and made him feel like an actual human being for the first time since he could remember. As of writing this, the patient is still in recovery and has experienced no relapses.
It's important to remember that not all Benzodiazepines are built the same:
'LOT' Benzos (Lorazepam, Oxazepam, Temazepam) do not have active
metabolites and their half-life is not significantly prolonged by
hepatic dysfunction
Diazepam, Clonazepam, Midazolam are primarily metabolized via hepatic
CYP-mediated oxidation, and the half life in patients with hepatic
dysfunction such as chronic alcoholism will be substantially
prolonged, these three also have active metabolites.
Prolonged half-life is potentially beneficial as it may decrease need
for as frequent re-dosing, but results are unpredictable, use non-LOT
benzodiazepines with caution and careful consideration
Benzodiazepines are considered relatively equivalent in terms of IV
administration with 1mg Lorazepam being equivalent to 2mg Midazolam,
and 10mg Diazepam equivalent to approximately 3mg Midazolam.
While this seems like a relatively mundane call to most, there are a few things I want to call attention to:
Alcohol Withdrawal Syndrome (AWS) is one of the most frequent causes of death worldwide, more so than HIV, TB, and violence combined (Grover & Ghosh, 2018).
Historically, those battling addiction are treated poorly by healthcare professionals, which directly inhibits them from seeking or complying with care (Van Boekel et al., 2013).
Management of a severe withdrawal patient should be at the Paramedic level as these patients are pre-disposed to severe electrolyte abnormalities, prolonged QT intervals, Delirium, Seizures, and cardiac rhythm disturbances (2020).
Most EMS systems in the United States do not address any specific patient management strategy for these high-risk patients.
Early administration of Benzodiazepines addresses symptoms and can reduce mortality from as high as 37% to as low as 3% (Rahman & Paul, 2024).
Alcohol Withdrawal Syndrome is a blind spot in the majority of EMS systems. We historically have offered minimal, if any, treatment to these patients, and we can lose sight of their suffering as we are often not empowered to alleviate it. It’s essential to recognize that even when our protocols do not allow for a specific treatment, one act doesn’t require a protocol and is not limited by the scope of practice: compassion.
References:
Grover, S., & Ghosh, A. (2018). Delirium Tremens: Assessment and Management. Journal of clinical and experimental hepatology, 8(4), 460–470. https://doi.org/10.1016/j.jceh.2018.04.012
Gortney, J. S., Raub, J. N., Patel, P., Kokoska, L., Hannawa, M., & Argyris, A. (2016). Alcohol withdrawal syndrome in medical patients. Cleveland Clinic journal of medicine, 83(1), 67–79.
Rahman A, Paul M. Delirium Tremens. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482134/
Mihic SJ, Harris RA. Chapter 17. Hypnotics and Sedatives. In: Chabner BA, Knollmann BC, eds. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 12nd ed. New York: McGraw-Hill; 2011. http://www.accesspharmacy.com/content.aspx?aID=16663643. Accessed
November 7, 2013.
The Asam Clinical Practice guideline on Alcohol Withdrawal Management: Erratum. (2020). Journal of Addiction Medicine, 14(5). https://doi.org/10.1097/adm.0000000000000731
Van Boekel, L. C., Brouwers, E. P. M., van Weeghel, J., & Garretsen, H. F. L. (2013). Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug and Alcohol Dependence, 131(1–2), 23–35. https://doi.org/10.1016/j.drugalcdep.2013.02.018