Morning Rounds: Alcohol & Poor Judgment; A Source of Job Security for Emergency Physicians
To Your Health —
Thursday, November 19, 2015 11:45 AM
When I was a medical student working in St. Paul, Minnesota, an 18-year-old kid arrived in the emergency department in the early morning hours with two broken legs. Bilateral femur fractures (both legs broken at the thigh level) are impressive injuries which require a great deal of force to accomplish.
Our patient had that sheepish expression of somebody who understood he had just done something very, very stupid. At first he would not tell me what had happened. But eventually, he copped to it.
He had been drinking with his girlfriend and their relationship was not going well. At some point during the evening, his girlfriend announced that she was going to commit suicide by jumping off a nearby parking garage.
She left in dramatic fashion and after a very short time, the young man followed. When he reached the third story — and luckily the garage only had three stories — she wasn’t there. Either because she was not quite as drunk as he was, or maybe because she had just gotten lost, she ended up on the second floor.
Leaning out over the third floor of the structure, the young man discovered his girlfriend was about 12 feet below him leaning out of the second-floor opening. Naturally, he decided the quickest way to save her was to jump from the third floor and, then, just sort of swoop into the second-floor opening below.
Of course, this kind of thing only works in cartoons and martial-arts movies, and when he missed the turn, he continued on down to the asphalt three stories below, where he broke both legs. He was very lucky to have survived the fall.
One of the truisms about emergency medicine is that everybody wants an emergency department in their community but nobody wants to be the one who has to use it.
That’s especially true when you know that the reason for your visit is that you have exercised extremely poor judgment.
Unfortunately, bad judgment accounts for a surprisingly large number of emergency department visits and, from one perspective, it is actually the greatest source of job security that emergency physicians have.
Medical science is getting better at managing conditions like asthma and heart disease that were once a bigger source of emergency department business. And, health care systems are working harder to make sure everybody has a primary care provider who can ensure people with these conditions have access to the therapies, medications and relationships they need to stay out of the emergency department.
In my wildest dreams, I can imagine a time when the majority of people with high blood pressure and diabetes can live their lives without ever having to visit the emergency department.
One thing I don’t see any hope of curing anytime soon is poor judgment. For pretty much all of us, making the occasional bad call is just part of being human. But when you add alcohol, especially a lot of alcohol, a plan of action that is just plain silly in the sober light of day can begin to make a lot of sense.
When you consider that the young man I talked to willingly jumped off the third floor of a building, when he wasn’t actually trying to commit suicide, you realize that what he did went beyond stupid.
Our brains are designed to prevent us from doing things that could result in our death. Our neural wiring includes natural inhibitions to prevent us from doing things like, for example, jumping off a parking garage.
Alcohol works as a depressant in the brain, inhibiting those neurological circuits that prevent us from doing stupid things at the same time that it is depressing those synapses that allow us to walk in a straight line and talk without slurring our words.
When it comes to the decision-making process, especially in the still-maturing adolescent brain, which is already short on impulse control, drinking large quantities of alcohol is like imbibing highly concentrated bad judgment.
But here is a little good news:
About five years ago, Lincoln County, where I live and work, had some of the highest levels of alcohol and binge drinking among youth in Maine, according to the OneMaine Community Health Needs Assessment.
Roughly 42 percent of high-school-aged people in Lincoln County surveyed by the University of New England’s Center for Community and Public Health in 2010 reported that they had used alcohol in the past month. About 25 percent had engaged in binge drinking (five or more drinks) within the last month.
Those are scary statistics to anybody, but to somebody who works in emergency medicine and has had the opportunity to talk to people who have committed emergency-department-worthy bad judgment calls, those statistics are daunting.
More recently, the Maine Shared Health Needs Assessment and Planning Process released results of a survey that indicated that in 2013, only 12.5 percent of high school students had reported binge drinking within the past month.
Two data points is not a trend, but even the possibility that alcohol use in high school is moving in the right direction is exciting. As a parent and a physician, I would much rather have a little less job security and a lot fewer conversations like the one I had with that young man in St. Paul.
Mark Fourre, MD, is an emergency physician and Chief Medical Officer of LincolnHealth. He also serves on their Board of Trustees. Prior to joining LincolnHealth, Dr. Fourre was an attending faculty at Maine Medical Center where he developed the Emergency Medicine Residency Program and served as Residency Director.