When Ms. M walked into the hospital emergency department (ED) at 6 am to start her shift, the 42-year old nurse practitioner was hoping for a quiet day. Initially, that seemed possible. The waiting room was largely empty and despite the usual beeping and humming of medical equipment, the ED seemed fairly calm. 


Then, the nurse at the triage desk informed her that Mrs. B, aged 64 years, had come in. Mrs. B was a frequent visitor to the ED who would typically be brought in heavily intoxicated in the middle of the night and stay at the hospital until she was sober. Once she was released, the pattern would repeat. 


Ms. M had tended to this patient on several occasions. Mrs. B was a widow; her husband had died of an alcohol-related disease several years earlier. She said that she had a grown son who lived in another state, but Ms. M had never met any of Mrs. B’s family members. The pattern was always the same: Mrs. B would be found unresponsive on the street or in a bar and would be taken to the hospital. 


Ms. M checked in with the emergency medicine physician who had admitted Mrs. B. The physician, who was going off duty, told Ms. M that the patient had been brought in by ambulance at approximately 1:30 am. 


“She was very intoxicated,” the physician said, “but was in no acute distress and could be aroused by touch or by saying her name. This has all been noted in the chart.” 


The physician left, and Ms. M went to check on the patient. Mrs. B seemed to be sobering up. By 7 am, Ms. M noted that the patient could move her limbs, possessed motor strength, and could walk with a relatively normal gait. At 7:15 am, the patient was awake, responsive, and requesting food. 


“I think she’s good to go,” Ms. M said to another clinician. The paperwork was filled out, and Mrs. B was taken to the door. 


Ms. M hoped she would not be seeing the patient again for at least a month, but within 15 minutes, Mrs. B was brought back in. Hospital staff had witnessed her stumbling outside and having difficulty walking. 


Once back in the ED, Ms. M ordered a blood alcohol test, which was the first one for this visit, as no tests had been ordered at all earlier. The patient’s blood alcohol level came back as 0.261. Mrs. B was readmitted and placed in a bed to “sleep it off.” 


However, as the day wore on, Mrs. B’s condition did not improve, and it seemed to worsen. In addition to problems walking, the patient also seemed to be having problems speaking. No one thought much of this, however, as she often slurred her speech when she was drunk. No other tests were ordered.