I am a nurse who for 4 years worked on a Digestive Diseases Unit which included the care of alcoholic liver disease patients. This was almost 10 years ago so these recollections are based on my experiences at that time.
If I was to recount a day in the life of a nurse on this ward then this is how it would have been. After receiving hand-over from the night staff our first duty would be to do the drug round. Drugs played an important role in the management of liver disease whether we were managing initial withdrawal from alcohol, trying to correct vitamin and mineral levels with intravenous thiamine, folic acid and multivitamins or whether we were administering opiate based pain medication.
We had two types of alcoholic liver disease patients, the acute and the chronic. Though their disease was at different stages the life-threatening nature of it remained the same. The acute would include patients with pancreatitis. This is excruciatingly painful and because it is caused by inflammation of the pancreas has the additional risk to blood sugar management and therefore diabetes risk. Other acute patients included those who were just beginning the detoxification process and were at risk of epileptic fits, patients who were actively bleeding from gastric ulceration which meant they would vomit or defecate fresh blood or those whose blood pressure around their liver had become so raised that they would burst veins around their oesophagus and bleed out profusely, effectively internally drowning in their own blood. These patients would require intensive monitoring and blood transfusions if bleeding was extensive. Drinking affects the clotting mechanism within the blood and we would be vigilant for signs of additional clotting and bleeding. Observations of temperature, pulse, blood pressure and blood sugar was extremely regular as was monitoring and management of fluid balance, that is what we were infusing intravenously, or they were drinking, and what was being excreted either urine or other fluid loss, such as bleeding or removal of ascites.
Our chronic patients were those whose liver disease was more advanced. This would include patients with re-feeding syndrome, where they would need intravenous electrolytes and tube feeding as their digestive system was so disordered that they could not eat normally. Patients whose liver had stopped working and so fluid would collect in their abdominal cavity and would require drainage, called an ascitc tap. Patients who would come in comatose from toxicity and would require bowel management medication to clear the toxins from their gut. Patients who were confused, due to Wernicke-Korsakoff’s syndrome, or wet brain, where vitamin deficiency causes dementia. Finally we had terminal liver disease patients who were admitted for care and management in their death.
After the drug rounds, we would attend to the Dr’s round where management, progress and further treatment regimes would be discussed and implemented. From there we would help the patients to wash and dress if needed, provide food and drink if they were able to eat, although many could not. We would manage the tube feeds, drain their ascites replacing any fluid removed with albumin to rebalance their low protein levels. They would often be emaciated, with skinny arms and legs from muscle wastage with large rotund bellies from swollen livers and fluid collection. Many were profoundly yellow from jaundice and dehydrated and rehydration was a crucial part of their treatment.
There would be another drug round at lunch time and we would ensure that all our paperwork was accurate and up-to-date before handing over our patients to the next shift of nursing staff.
This was an exceptionally busy ward and we would have responsibility of between 2 and 7 patients depending on how acutely ill they were. Transfers and escorts to other units, such as endoscopy or intensive care were routine. Cardiac arrests were common and a shift would fly by as we were so rushed off our feet. It could be a depressingly sad place to work as many patients would be admitted repeatedly and it felt like a ‘revolving door’ much of the time with ‘frequent fliers’ who were unable to address their drinking becoming increasingly ill with each admission. Every patient was offered drug and alcohol counselling and support whilst they were in-patients with out-patient follow up but disappointingly many did not engage with this once they were discharged.
I felt very honoured to work on this ward and care for these patients but it left me with no illusions as to the harm that alcohol does both in the short term and the long term. I also wrote a guest post for Veronica Valli, which was published yesterday, that is my account of caring for a dying alcoholic that you can read here.