Reflection on a Tuesday: Drinking Under Tables and High Pressures

*written with patient's permission, although details changed to protect anonymity

"My blood pressure is still borderline? Man!"

"Yeah. . .and from looking through the chart, it was 150/96 on your admission. It's pretty much been that since you've been here give or take a few points. That's a little more than borderline, actually." I paused for a moment, realizing that I sounded a bit discouraging. "I don't think this would be hard to get under control at all, sir. I mean. . . you're such a motivated patient, you know?"

I studied my patient carefully. He was in his late thirties, although he could totally pass for a twenty-something all day every day. His skin looked like someone had grabbed him by the tip of his toe and uniformly dipped him in milk chocolate--not a single blemish anywhere. Although his complexion suggested that he was of some African descent, his fine facial features were more eurocentric than afrocentric. . . .the kind of look that gets you described as "exotic" or "striking"-- which for him would be spot on.

"I eat right and I exercise. . . .in fact, I'm a health nut! I'm really kind of surprised that my pressure keeps running high."

As for his self-proclaimed "health nut" status, his appearance certainly supported that claim. There was such little body fat on him that the veins popping off of his forearms looked like linear relief sculptures. I could see why these elevated blood pressure readings were taking him by surprise.

"You're not a smoker, no?" I queried while looking at the notes on my billing card. "No tob" was what I'd scrawled on the back of the card--short for "no tobacco use."

"Smoker? Eeew! Hells no. I hate cigarettes!" He gave a playful shudder and then laughed. His pristine white teeth were almost too white. . .their perfect alignment akin to what one might expect when seeing a tabloid celebrity up close and personal. He gave me a smirk and added, "Now my boyfriend? Hmmphh. That's another story. He smokes those nasty cancer sticks. Ugggh."

"Oh yeah?" I responded with a smile, "You'll have to get him in here-- before his lungs do." He shook his head and curled his lips in an unspoken gesture that suggested that the discussion of getting his partner to quit smoking was an old battle and a lost cause. I pictured him standing on the porch nagging his better half or covertly dumping half of a pack of Marlboros down the toilet. I raised my eyebrows in amusement.

For a brief second it dawned on me how completely unfazed I was by his reference to a "boyfriend" (as opposed to a "girlfriend" or a "wife".) I thought about how way back in medical school such inferences caught me by surprise, and then later in residency seemed to be almost a novelty. I'd find myself launching into these exaggerated "girlfriend" , finger-snapping interactions with such patients, that I now realize (as an older and wiser person) were probably deeply offensive. Anyways, I've since resolved that, in addition to growing up, that learning to accept oneself is the first step to better accepting others. And lucky for me, some of my favorite Grady doctors (like my friends David M. and Jason S.) have helped to really open my eyes to other variations of "normal."

"Now I bet a 'health nut' must be a total nag to a smoker!"

"Chile. . . .I know that's right!" he chuckled but became more serious when looked down at the blood pressure cuff still wrapped around his arm. "And wouldn't you know--his blood pressure is frickin' LOW! Go figure." He let out a frustrated sigh.

This patient was used to being healthy. He was young, active, and for the most part, in pristine physical condition. He'd come to us after a fairly soft admission for what the emergency department called community acquired pneumonia. The initial portable chest x-ray demonstrated a questionable infiltrate, but his follow up two-view films were essentially unremarkable. A slightly low white blood cell count of three thousand, seven hundred coupled with his endorsement of male sexual partners led to concern about the possibility of HIV. Upon further history, our team learned that this patient had been with his partner for nearly ten years, and was as boringly monogamous as it gets. The HIV antibody test was negative, and it was explained to him that lower white blood cell counts weren't unusual at all in African-Americans (to which he replied, "Yeah, I knew that already.")

At this point, it was time to discharge him. He looked awesome, and seemed like someone that would reliably follow up and do all that was asked of him. But his blood pressure just kept on reading a little to high for my comfort level. . . .not so high that he'd need to stay hospitalized, but definitely too high to keep referring to as "borderline."

"So you lead a pretty healthy lifestyle, right? I mean, it could just be what we call essential hypertension. That's when your blood pressure is high from, say, what you inherited, and not really because of what you're doing so much."

"I'm a vegetarian and I only eat organic ninety percent of the time. I work out, I ---" he sighed again. "Man, this is messed up."

"What about alcohol?" I asked remembering the lecture my friend and fellow Grady doctor, Joyce D., had recently given the residents on hypertension management. I recalled her teaching point about how excessive alcohol consumption can take your blood pressure up more than most folks realize. It was pretty much all I had left.

"I drink some. Not much, though."

"Oh okay. So like, what is 'some?'"

"Oh Lord, I don't know, Dr. Manning. Like a few margaritas here and there? Like a bunch of us love to hang out at El Azteca--that patio is so much fun--especially in the summer. So I'll have a few when I'm out there."

"I love El Azteca," I commented while thinking of the large outdoor seating area that, now that I thought of it, was always teeming with young attractive men who seemed interested in, well, each other. "Is that one of your summer hang outs?"

"Oh yeah, baby. That's the spot in the summer!" We shared a lighthearted laugh.

"You know. . . .I was just thinking. . . .when you go there or anywhere, what would you say is the most drinks you have?"

He sat for a minute and gazed skyward in thought. "Hmm, like . . .maybe three? Of the bigger ones not the tiny ones," he admitted. "But I'm always eating and never driving."

Whoa! I recalled one of the last times Harry and I had enjoyed a meal at El Azteca Mexican Restaurant in the heart of midtown Atlanta. I'll never forget it. . . .I ordered one lime margarita--the small one--and felt super-swimmy in the head before I could even finish it. Even Harry could "feel" his--so much so that we had to sit on that patio for nearly two hours drinking water so we could drive home. That day we both laughed at how little alcohol we could tolerate, realizing that (unlike when we were in college) drinking anything with a hefty shot of tequila was unusual for us these days.

"Ummm, okay. . . .so. . .tell me this," I asked, "If one of the large margaritas counts as two drinks, how many drinks would you say you have in a week?"

"A full week? Counting wine at night and stuff like that?"

"Sure, including everything."

He started counting his fingers and making funny expressions of exaggerated embarrassment. "If you count it like that, doctor. . . like . . . damn. . .eighteen to twenty. That's bad, huh?"

"Well, it's more alcohol that you probably realize, you know? It can make your blood pressure run higher, too."

"Shut up!" he exclaimed putting his hand over his mouth. "Really?"

"Yep. Like for a man, you really shouldn't have more than four drinks in a day and more than fourteen for the whole week. It's less for us girls."

"Damn."

"Another question--are you like . . . .drunk from the margaritas? I mean. . .they're awfully potent don't you think?" I recognized the irrelevance of the question, but couldn't resist asking. All I could think was, Lawd! How could he not be passed out from three BIG margaritas from El Azteca when he weighs easily fifty pounds less than Harry?

"You know. . . .I just have a high tolerance. I mean . . .I definitely get loose. ." he paused to giggle, "but I ain't falling down or cussing folks out or nothing. I definitely feel the buzz but it's manageable. I'm just chillin'. Plus we sit out there for a minute. . . talking, laughing, eating, you know what I'm sayin'?"

"Yeah. . .I hear you. I could tolerate more alcohol when I was younger and having liquor more regularly. Now I can't even take the little margarita at El Azteca. . . .and you know, I'm not picking on you. . .I just wanted to tell you. . ." I carefully spoke. "There's this saying that I think of when it comes to drinking alcohol. . ."

"What's that?" He hung onto my every word. I was glad that he seemed so interested in my opinion and what I'd say next.

"Basically it goes something like this--'The only way you can drink like that, is if you drink like that.' "

"Wow. . . ." he said nodding slowly first, and then mid-nod changing to head shaking.

I went on. "It's kind of like when my friend was telling me how to prepare to run a half marathon. I asked her what the key was to running long distances and she said, 'Here's the key to running long distance: Run long distances. The only way you can run long distances is if you run long distances.'" I smiled as I recalled my colleague Julie J-M telling me this little nugget during a very short-lived idea I'd had once about me running a 13.1 mile race.

"Wow," he repeated. It really seemed to resonate with him. Turns out that this health nut was doing something that wasn't so healthy after all.


In the end, we printed out a guide for alcoholic beverages and how to gauge what "one drink" is. He agreed to limit himself to no more than three equivalent drinks in a day and no more than seven in a week (he chose the seven over the recommended fourteen.) We started him on a low dose of an anti-hypertensive and also reviewed low sodium eating, too. (The other thing about El Azteca is that, like all yummy Mexican fare, it's SAL-TY.)

Today I'm reflecting on how easy it is to get into health problems from bad habits that we don't see as bad habits. I completely related to my patient and his surprise about how excessive his alcohol consumption was and its effects on his body. The points in my life where my friends and I took great pleasure in social drinking came to mind. . . . he isn't the only one who's ever felt the buzz.

Then there's all those sayings like "high tolerance" and threats to "drink you under the table." Funny how those references never sounded pathologic to me back then. . . .but now that I think of it. . .and my admitted participation in such antics. . . it really kind of is. There's no denying: The minute I stopped drinking like that, I could no longer . . .well. . .drink like that.

The other part is that I guess I always thought of heavy drinkers as staggering, boisterous, rabble-rousers. . .stumbling over tables and spitting while they spoke in their slurred speech. But as it turns out. . . .they aren't. Many of them look just like any of us. They hold jobs, are attractive, are romantically attached, and are functional folks. In fact, a lot of heavy drinkers are the picture of health--just like my patient.

Take home messages:

1. The only way to run long distance is to run long distance.
2. The only way you can drink like that (without face-planting on the asphalt, that is) is if you drink like that.
3. High tolerance: good for pain, good for running, good for exercise. Not-so-good for alcohol, capisce?

*Bonus side-bar take home message:

1. Regardless of your personal beliefs, you've got to know that men who prefer men can have just as boring sexual histories and every day lives as anyone. . . . and seriously, a same sex sexual partner does not equal HIV risk. (Easy mantra: It's behaviors, not boyfriends, capisce?)
   

***

"And no salt on the rim, right?" my patient called out to me as he and his partner passed me in the hallway on their way out.

I smiled and gave him a thumbs up from across the nurses station and watched him disappear down the corridor, confident that he would do exactly as he'd promised.