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The Chronicles of Valentina - The Man with Court Cats

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Sometimes, you really do get to be a goddess.
Called to see a man on Monday, on the “Wellness” unit, which is the name for the unit for people undergoing substance withdrawal. He’d been drinking for 50 years, drying out for brief periods before starting up again.
“That means he started when he was six,” I said.
“So he says,” was the answer.
I decided that exploring that particular parenting issue was not a productive pursuit at the moment. But, ew.
He’d gone through detox three weeks ago, and started drinking as soon as he got out. He landed back in detox a week later, and was now apparently dried out. But he started to get weird again before the weekend. Thinking that for some reason, he’d resumed alcohol withdrawal symptoms a week after he was out of the danger zone, the “Wellness” staff resumed the CIWA (alcohol withdrawal) protocol, but he only got worse.
He was tremulous, with a wide intention tremor that was spectacular. He was hallucinating.
“There are court cats,” he said, pointing behind me.
“Court cats?”
“Yeah. Cats in ball gowns.” This part was lucky. Usually the hallucinations in this case are hideous visions of snakes and bugs and demons. He lucked out.
But the biggest “tell” was his eyes. Even if he tried to stare straight ahead, his eyes jittered and danced, and when he tried to look to the side, or watch someone move across the room, his eyes juttered in their sockets so violently I expected to hear a knocking sound. (I didn’t. he was hallucinating, not me.)
This wasn’t alcohol withdrawal. This was Wernicke’s syndrome.
Next, I tried instead to establish whether he was oriented. He knew his name. Every question after that produced answers that devolved into word salad and fantasy.
“Tell me where you are.”
“This is a place where they open and close and move and don’t have licorice whips.”
“What year is it?”
“19, 19, 19, two thousand barnacles.”
I point to the sitter who’s been with him all afternoon. “Have you ever seen her before?”
He looks at her in surprise. “No.”
Wow.
I told the Hospitalist, “You’ve got Wernicke-Korsakoff on your hands, here, and it’s the worst I’ve ever seen.” In fact, it’s the first full-blown case I’ve ever seen. Wernicke’s has all the symptoms this poor man had, but when they can’t remember something for more than two minutes, there’s a nastier problem. A permanent one. I’ve caught a couple of Wernicke cases before the dementia set in that graduated them to Wernicke-Korsakoff, but this guy had been at this for four or five days, and he was well on his way to complete mental breakdown. That worried me. The longer this goes untreated, the more permanent the damage.
“So we put him back on the CIWA protocol?”
“That’s for alcohol withdrawal. He’s not withdrawing. W-K is an acute vitamin deficiency. It’s a malnutrition syndrome. The last thing he needs is more benzodiazepines.”
“Vitamin deficiency?” said a nurse.
“Thiamine. B1. Drunks don’t eat right. And detoxing drunks in alcohol withdrawal don’t eat at all.”

As a matter of fact, W-K isn’t the sole property of drunks, although it’s the reason drunks of old wound up in insane asylums, drooling. Anyone with an acute malnutrition situation is at risk for this. The last case I’d dealt with was a young woman with hyperemesis gravidarum (that’s morning sickness with a vengeance). Poor thing hadn’t been able to keep more than saltines down, if those, for four weeks.
“I’m sure he got a banana bag,” said the hospitalist. That’s an IV with added B1, B6 and folic acid that we give alcoholics as a matter of course.
“That’s nice, but he needs to be flooded with the stuff. A bag gives him 100 mg of thiamine. We’re going to do 1500 mg a day.” And hope it makes a difference.
Hospitalist stared at me and then shrugged. “Well, it won’t hurt him,” he said.
No, it wouldn’t. Thiamine doesn’t build up in the system. You take too much, it gets filtered out by the kidneys into now-expensive urine.
I wrote the orders, warned everyone that sedating him won’t help and went on to the next patient, pretty skeptical that I would make much of a difference.
The next day, I ran into Hospitalist in the doctor’s lounge. “You are NOT gonna believe that guy!” he exclaimed.
“Uh oh. Is he all right?”
“He’s amazing! It’s like it never happened! I didn’t think you’d do it.”
All of a sudden I felt like Henry Higgins.
So I go to the Wellness Unit. And no, he wasn’t completely back to normal. I could still detect some tremor and memory glitches. But he was coherent. He could hold a glass and drink from it without splashing. The court cats were gone. And he was oriented.
Now I felt like a goddess.
I saved a guy from permanent brain damage with nothing more than massive doses of vitamin B1.
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