Student Scene
 Ellen Rothman Photo by Graham Ramsay |
A Quandary in Caring for Alcoholic Patients
On first impression, I thought Johnson was a loser. He had been in a wheelchair for five years since becoming paralyzed in a car accident, which, although he had never admitted it to me, I strongly suspected was alcohol-related. He wore his unwashed hair short on top, while the bottom hung in strands to his shoulders. His thick, fleshy features had a faint oily sheen, and he smelled distinctly of urine from his leg bag, tinged green from long-term use and held in place with a ratty strip of elastic."Oh, don't ask Johnson," his primary care physician said when I mentioned that I was thinking of inviting him to speak to a group of Navajo high school students. "He'll be a disaster."
Although the Navajo have chosen to outlaw alcohol, it remains a significant problem. As physicians, we feel the ebb and flow of the monthly cycle. The first of the month with its paycheck or benefit check brings intoxication and assaults; alcohol withdrawal creeps in insidiously as funds wane toward the end of the month.
The pattern of alcoholism is different on the "rez" than in other places I have worked. No one drinks quietly at home in the evenings. Instead, people tend to go on dramatic binges, disappearing from their homes only to reappear in emergency rooms across the reservation days later. Most of the drinkers are men. Women tend to stay sober at home, struggling to hold the family together. As a result, there are surprisingly few Navajo children suffering from fetal alcohol syndrome. But the younger girls are starting to drink just as hard as their male companions.
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I don't know yet exactly what alcohol means to the Indians, either to those who drink or to those who welcome the drinkers back into their homes time and again. --Ellen Rothman |
One of my patients laughed at my written discharge instructions when he finally sobered up enough to leave the ER. "'Please stop drinking,'" he muttered. He was still chuckling as he walked out. I knew he probably wouldn't stop drinking just because I wrote it, but I wanted to acknowledge the primary issue that had brought him in that night.
Telling About the Crash
Johnson wasn't actually my personal patient. I had seen him several times in the emergency department for urine infections. Against my better judgment, I offered him a $50 stipend to spend an hour with my students talking about his experience as a paraplegic. I didn't expect him to show.Much to my surprise, he arrived at the clinic 30 minutes early for his session. He had washed his hair and put on a clean sweatshirt. He smelled pleasantly of aftershave, without even an undertone of stagnant urine. He was using a rickety wheelchair that was missing one footrest. As a result, he sat crooked in the chair with both feet crammed on the remaining rest.
When Johnson spoke to the students, he was candid about the role of alcohol in his accident. He and all his buddies were drunk on the night of the crash. They rolled their vehicle just beyond the only traffic light in town. The front passenger was killed instantly, and Johnson was thrown from the vehicle. The driver was still serving a 25-year prison sentence. Johnson spent the next six months in a rehabilitation hospital in Albuquerque, more than 300 miles from his home.
The Gift Wheelchair
The students were so captivated by his experience that they took it upon themselves to write to various agencies requesting donations to purchase Johnson a new racing wheelchair. At rehab, he had especially enjoyed wheelchair sports. I suggested that perhaps an alcohol awareness project or seatbelt promotion might be more generally useful, but they insisted on the wheelchair. The students succeeded in raising $500. This sum was nowhere near the amount needed to buy a new one, but they were thrilled nonetheless. They begged me not to divulge their secret to Johnson until they had raised the full amount.As I started to ponder the logistics of purchasing a new chair for Johnson, I went for advice to our Community Health Nurses, who are hired by the tribe to visit patients in their homes. This system is necessary because more than 70 percent of our families do not have a phone, and with no local mail delivery, many do not check their town post office box routinely. The nurses knew Johnson well. It turned out that they had obtained a new wheelchair for him just a few months earlier. He had lost it in jail a few weeks prior to his session with my students, when he was in detention for public intoxication. I couldn't bear to tell the class. Instead, I quietly funneled the money into a support group for patients with spinal cord injuries. They never garnered enough funds to purchase the wheelchair anyway.
I don't know yet exactly what alcohol means to the Indians, either to those who drink or to those who welcome the drinkers back into their homes time and again. Maybe more years on the rez will reveal the reason. Until then, I am frustrated, pained, saddened, and sometimes annoyed by the role of alcohol among the Navajo.
This spring, it was time for Johnson to attend his yearly spinal cord clinic. I pulled his chart to send him an appointment slip, only to learn that he had died. His grandmother told one of our nurses that he had gone out drinking with his buddies last winter. His friends had abandoned him, and somehow Johnson fell out of his wheelchair. Alone in the wintry desert night, Johnson froze to death.
--Ellen Rothman, HMS '98, now practicing in northern Arizona on the Navajo Reservation
All patient names in this column are pseudonyms. The opinions expressed are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.