Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, M.D.
5 July 2006

I.                   WHAT IS HEPATIC COMA?

II.                COLUMNS ON THE INTERNET

            The lady was recently admitted to the hospital very confused, unkempt, and with extensive bruising from multiple falls that had occurred at home.  She had abrasions on both knees that she acknowledged were quite painful.  She indicated that they had come from crawling back and forth between her bed and the bathroom because she was unable to stand or walk.  Her loss of ability to walk had occurred over several weeks’ time.  Unfortunately, she was an alcoholic who had been drinking heavily.  Her family volunteered that they brought her a 12-pack of beer every two days and friends brought over unknown amounts of wine.  The past two days, she had been unable to “keep anything down” and was brought to the emergency room by her family because they thought she was dehydrated.

            She was very confused, asking where she was, who we were, and what we were doing.  Answers would be given in as comforting a way as possible and then she would ask the exact same question two minutes later.  Intermittently, she would fall off to sleep.

            History obtained from the family indicated that the patient had been alcoholic for many years and had previous liver damage.  She has been given medications to help with this, but had ceased taking them several months ago.

            This lady had hepatic coma.  Her liver had failed so badly that she was unable to clear naturally occurring toxins and waste products from her blood.  One of the liver’s main functions is to purify the blood and remove waste products and any toxic materials that are absorbed from the bowel.  When the liver can no longer do this because of cirrhosis, those products build up and cause the confusion and eventual coma.

            The patient’s family wanted to know what was wrong and it was explained to them what the liver problem represented and what could be done to help.  Specifically, the most important step in helping is to avoid further alcohol intake.  Unfortunately, this is very frequently difficult to achieve as alcoholism is a terrible addiction.  However, in this lady’s particular case, there were many facilitators who brought her alcohol even though she could not walk out to get it herself.  Her family said they knew that the alcohol was bad for her, but she became very demanding and angry if it was not provided so they brought her what she wanted.

            If and when a person decides that they want to change the alcohol habit, there are medications that will help remove the waste products from the blood when the liver can no longer do so.  The important steps in care in this situation are to provide a low protein diet so that the number of toxic waste products produced in the body are decreased.  Secondly, a product called Lactulose is provided to combine with the waste products and allow them to be expelled in the stool.  Unfortunately, this causes a diarrhea problem which is very bothersome to patients who use this.  Thirdly, an antibiotic called Noroxin can be provided to cut down the number of bacterial waste products in the colon.  With these three steps, patients who have liver damage can be effectively treated to reestablish relatively normal mentation and avoid the confusion of hepatic coma.

            I never cease to be disappointed and very puzzled by the self-destructive behavior that patients perpetrate upon themselves.  At least as disappointing and puzzling is the way families support and facilitate a relative’s self-destructive behavior.  One of the most frustrating aspects of the healthcare profession is our inability to save patients from themselves.

COLUMNS ON THE INTERNET

             During a recent clinic visit, a patient asked about one of the columns that I had written in the past.  I told her that they were on the Internet and she could access most of those that were done since the year 2000 at the Medical Associates Clinic web site.  She said she lived with her daughter and 11 year old grandson.  She knew that the grandson had a computer, but she didn’t have a clue how to use it.  I asked her if the grandson would let her use his computer if she wanted to and she said that he better because she bought it for him.  I told her, “Here is what you do:”

1.      Turn the computer on.

2.      Wait for it to warm up and then go up and double click with the mouse on the symbol for whatever Internet source he had.  It might be AOL, or Net Zero, or Yahoo, or MSN, etc.  If she had trouble with this part, ask her grandson to help her.

3.      When the Internet screen finally displays, there will be a section on it called SEARCH.  Take the arrow and put it up in the SEARCH box using the mouse.  At this point, I am sitting with the patient in front of my computer showing her how this is done.

4.      Type in small letters www.macpierre.com and then move the arrow out to the little box that says GO or SEARCH.

5.      Pretty soon there comes up a list of web sites that fulfill the search request.  Right at the top will be one that says Medical Associates Clinic, Pierre, SD.  I showed her how to move the arrow up on to that site where upon it turns into a little blue hand.  Once this occurs, double click again and the Medical Associates Clinic web site will appear.  She had never worked with the Internet before and when all of these different screens kept coming up, she just thought that was wonderful.

6.      When the Medical Associates Clinic web site appears there will be a picture of the new Medical Associates Clinic building.  On the left hand side of the screen there will be some headings starting with “Contact us”.  Move the arrow over to the far left hand side of the screen and place the arrow over “SD Medical News”.  The arrow will turn into a hand.  When you left click with the mouse, “Central South Dakota Medical News” appears.  Pick out any year that you want to examine and click that.  Then there will appear a menu of the columns for each week in that particular year.  By putting the arrow over the date you want to read and click that site, the column for that date will appear.

7.      When you are through with the column that you are reading, you can go back to the menu to find other columns that might be of interest.

The patient just thought this was wonderful at this point.  She had never worked with the Internet before and said she wanted to go home and try this out.  I pointed out that she could access these columns from any place in the country or the world just by getting through the above steps.  She could send something to her friends any place she wanted.  Then I pointed out how to print out one of the columns she was interested in and she was hooked.  I told her that I was going to print out these instructions and put them in one of the columns in the future and here it is.