She arrived by ambulance in the middle of the night, awake, alert, and bleeding like crazy. We’d gotten a call earlier in the evening that she was on her way from a small hospital about forty miles to the north. We were the big city hospital, and an attending physician had agreed to have her transferred for a life-saving procedure, in this case a shunt that might stop her bleeding.
People who bleed from their GI tract can fool you. One minute they’re sitting up and talking, the next they are unconscious and in shock. This one didn’t fool anyone. When I spoke to the transferring hospital, they told me that they’d already given her eight units of blood, and another was hanging in the ambulance. I suggested they take her back in immediately, but the ambulance was already on the freeway.
When it comes to active bleeding, you can give all the blood in the world, but without stopping the bleeding, the patient will die. From the vague report we received, she had cirrhosis of the liver and was bleeding from a broken vein in her esophagus. Supposedly, she was coming her to get a shunt that would stop the bleeding.
No one knew anything about her. She was in late-middle age and was soon unable to tell us much more. The attending physician who accepted the transfer had never met her and knew little more. Still we were able to get a radiology team in to evaluate her for a shunt.
There were two of us on call in the ICU, one making all the phone calls, the other helping the patient. She didn’t look all that bad, didn’t have all the signs we usually see in a long-term liver patient. But she was definitely still bleeding. Blood coming from the rectum has a particular smell that stays with you forever.
While we waited for our experts to respond, we “resuscitated” her which in this case meant placing large IV lines and pumping her full of blood and saline. We stabilized her enough to get her to radiology, but they told us that the procedure wasn’t going to help. Someone mentioned a weighted balloon down her throat but I can’t remember what happened to that idea.
What I do remember is a woman, lying in bed, in a place she’d never been, surrounded by strangers and the scent of blood, waiting to die. I stuck a needle into a vein in her arm to collect some blood, but it looked like cranberry juice, not thick, red, life-sustaining blood. At this point she was unconscious.
All of us in the ICU struggled to keep her alive, but watched as blood continued to flow into a vein and out her bottom. We all knew what would happen, each nurse, the doctors. We saw she was losing her life in front of us, her consciousness occasionally making a brief appearance before diving back into oblivion. When her heart stopped there was no need for CPR; our chest compressions were only circulating thin, pink fluid through her arteries and veins, carrying no oxygen, no life.
We watched her bleed to death before the sun rose.
“PalMD” is an internal medicine physician who blogs at White Coat Underground.
