Wednesday, May 05, 2004
Smell
I'm lying in bed at last, reeling slightly as each wave of fatigue swells up and breaks over me.
Difficult to breathe. Everytime I inhale, I smell the dank, moist, sightly nauseating scent of blood.
Blood.
blood.
She - a pleasant old fogey - didn't look unwell when I was called in to see her. She'd dropped her b/p to 80/40 but she was alert and chatty and cracking jokes. And feeling well. Pale, slightly sweaty.
A, B, C, bang in the venflons and the fast fluids while chatting to her and making wisecracks. She laughs with me. Apparently she's collapsed after vomiting up a pint of blood 3 hours ago, just the once.
her b/p responds immediately to the fluids. 130/80 and maintained. not tachy. not pale or sweaty. not in shock.
I write her for 500 mls more over 30 min, then 500 mls over 1 hr and make an immediate medical referral as an upper GI bleeder. I warn the medic that she had been hypotensive but responded well to a fluid challenge.
When I come back several hours later it's to sheer and utter pandemonium. Apparently she's vomited again while waiting to be seen by the medics. about 2 pints this time. b/p is low and not responding as well. and she's clinically shocked now. although still chatty.
the medics have gotten fluids running in both drips. We bang 2 more in, and painfully raise her b/p back towards more physiological levels. anything is better than 60/30
she slides gradually, over the next four hours. we can see it happening before our eyes, even as the medics wage their campaign against the surgeons, and the nonexistent out-of-hours-endoscopists.
nothing is happening. The only reason she's keeping her b/p up is because of the fluid's we're running in. And the occasional bag of blood, as the X matches become available. Her blood has the consistency of coloured water, as she vomits it up, over, and over and over again.
At one point, the team flounders. Her b/p falls again to 60/30, and her GCS falls off. There is a pause, and suddenly I'm stepping forward to fill the gap. 3 bags of gelly, now please. b/p returns to 120/80.
Grimly, we battle on to keep her alive. She's been peri-arrest now for two hours. Her heart rhythm on the monitor changes a few times, but her cardiac output is maintained, thankfully. She was Nice. I knew her. For a while. She will live, dammit!! I press in the bloods manually, far faster than the pressure bags could possibly do. My arms are cramping up. But hell, she's still alive. Barely. Lab Hb returns 3.5... (the normal is >11)
The medics decide she has varices rather than an ulcer, even though she doesn't drink and has no stigmata of chronic liver failure. apparently her bloods suggest it to them. I suggest considering desmopressin if we can't get endoscopy, but the suggestion is swatted aside. We need to scope to make a diagnosis first.
Maybe we should consider a sengstaken tube. (But nobody here has done one. You could perforate the oesophagus!!)
But it might be lifesaving. She is going to die anyway, unless you can get her on the table instead of having to wait for an OGD in the morning. We can't possibly make her bleed faster than she is doing already.
My thoughts are ignored.
I suggest a central line for fluid monitoring. It happens two hours later. I should just have done it myself.
Four hours in, and the surgical reg has finally arrived reluctantly to assess her - by now, intubated and ventilated, and very nearly dead. With a hugely swollen abdomen, lying in a pool of melaena (which started halfway through the fracas).
The decision for theatre is made. And the team disperses.
I head for home at last. 2 hours after my shift ended.
Breathe. Breathe.
It's not blood I'm smelling. It's air. Really.
*****
Regret. I didn't foresee a re-bleed. I assessed her, found her stable and handed her on. The bare minimum. Group and saved, instead of cross-matched. Not enough IV access. No central line. Sure, the medics could have done that themselves, more quickly when she went off. But perhaps I should have done that all in advance, before she went off. Class II, bordering on III haemorrhage when I first saw her...
Difficult to breathe. Everytime I inhale, I smell the dank, moist, sightly nauseating scent of blood.
Blood.
blood.
She - a pleasant old fogey - didn't look unwell when I was called in to see her. She'd dropped her b/p to 80/40 but she was alert and chatty and cracking jokes. And feeling well. Pale, slightly sweaty.
A, B, C, bang in the venflons and the fast fluids while chatting to her and making wisecracks. She laughs with me. Apparently she's collapsed after vomiting up a pint of blood 3 hours ago, just the once.
her b/p responds immediately to the fluids. 130/80 and maintained. not tachy. not pale or sweaty. not in shock.
I write her for 500 mls more over 30 min, then 500 mls over 1 hr and make an immediate medical referral as an upper GI bleeder. I warn the medic that she had been hypotensive but responded well to a fluid challenge.
When I come back several hours later it's to sheer and utter pandemonium. Apparently she's vomited again while waiting to be seen by the medics. about 2 pints this time. b/p is low and not responding as well. and she's clinically shocked now. although still chatty.
the medics have gotten fluids running in both drips. We bang 2 more in, and painfully raise her b/p back towards more physiological levels. anything is better than 60/30
she slides gradually, over the next four hours. we can see it happening before our eyes, even as the medics wage their campaign against the surgeons, and the nonexistent out-of-hours-endoscopists.
nothing is happening. The only reason she's keeping her b/p up is because of the fluid's we're running in. And the occasional bag of blood, as the X matches become available. Her blood has the consistency of coloured water, as she vomits it up, over, and over and over again.
At one point, the team flounders. Her b/p falls again to 60/30, and her GCS falls off. There is a pause, and suddenly I'm stepping forward to fill the gap. 3 bags of gelly, now please. b/p returns to 120/80.
Grimly, we battle on to keep her alive. She's been peri-arrest now for two hours. Her heart rhythm on the monitor changes a few times, but her cardiac output is maintained, thankfully. She was Nice. I knew her. For a while. She will live, dammit!! I press in the bloods manually, far faster than the pressure bags could possibly do. My arms are cramping up. But hell, she's still alive. Barely. Lab Hb returns 3.5... (the normal is >11)
The medics decide she has varices rather than an ulcer, even though she doesn't drink and has no stigmata of chronic liver failure. apparently her bloods suggest it to them. I suggest considering desmopressin if we can't get endoscopy, but the suggestion is swatted aside. We need to scope to make a diagnosis first.
Maybe we should consider a sengstaken tube. (But nobody here has done one. You could perforate the oesophagus!!)
But it might be lifesaving. She is going to die anyway, unless you can get her on the table instead of having to wait for an OGD in the morning. We can't possibly make her bleed faster than she is doing already.
My thoughts are ignored.
I suggest a central line for fluid monitoring. It happens two hours later. I should just have done it myself.
Four hours in, and the surgical reg has finally arrived reluctantly to assess her - by now, intubated and ventilated, and very nearly dead. With a hugely swollen abdomen, lying in a pool of melaena (which started halfway through the fracas).
The decision for theatre is made. And the team disperses.
I head for home at last. 2 hours after my shift ended.
Breathe. Breathe.
It's not blood I'm smelling. It's air. Really.
*****
Regret. I didn't foresee a re-bleed. I assessed her, found her stable and handed her on. The bare minimum. Group and saved, instead of cross-matched. Not enough IV access. No central line. Sure, the medics could have done that themselves, more quickly when she went off. But perhaps I should have done that all in advance, before she went off. Class II, bordering on III haemorrhage when I first saw her...
