I know I posted an entry just the other day but after what happened today I felt like writing about it. It´s definitely healthcare related in nature, so sorry for any jargon that dosn´t make sense...and if the thought of blood makes you nauseated you might just want to disregard this post.
A 45 year old man came into the emergency department this morning with an altered level of consciousness. The Masaya bomberos (firefighters) had brought him in after someone had reported seeing the man sitting in his car and having cognitive trouble. When he got to the hospital we took his vitals, which showed a blood glucose of 421 (we had glucose sticks today!), a low blood pressure and a rapid pulse. The man could state his name but was mostly incoherent and unable to open his eyes fully.
We gathered what medical history we could from him given his state and not having any family or close friends present. He said he was diabetic (and the multiple large ulcers on both feet were probably a result of this) and had a history of alcohol use. The docs did a rectal exam which showed a back up of black tarry stool, meaning he probably had an internal bleed somewhere. IV fluids were started and then one of the doctors inserted a nasogastric tube, a large bore tube inserted through the nose into the stomach. We also had no lubrication available today so the tube was inserted using water as a lubricant, instead of something to make the passage a little easier.
The tube went into the stomach okay, but the next minute we were draining over 1000cc of blood from the tube. What probably happened is the man had esophageal varices (http://www.mayoclinic.com/health/esophageal-varices/DS00820) which ruptured when the NG tube was placed. This is something you would normally screen for by asking the patient (this person was not cognizant enough to understand the question), or performing an endoscopy or CT scan to check for varices (resources we do not have), since a rupture can be life threatening. But now the damage was done, all we could do was try to drain the rapidly accumulating amount of blood from his esophagus and replace fluid IV at the same time.
Due to the amount of blood being lost a blood tranfusion was started and another doctor was notified to insert a ballon tamponade. Essentially this is just a smaller tube which is again inserted into the esophagus (after the NG tube is removed). There is a long balloon that can be inflated once the tube is inserted that puts pressure against the esophageal wall in an attempt to stop the bleeding. The tube was inserted, but by this point the man was in unimaginable distress, coughing up blood and bits of tissue that I can only imagine were parts of tissue from the varices. Aye...que puede hacer?
During this time I got called away to help deal with other people coming into the hospital, like a young kid who had accidentally cut one of his wrists open with a machete. But when I returned to see how the man was doing he was surprisngly still alive, with IV lines wide open. But somehow it seemed like the bleeding had either stopped or slowed down significantly. The baloon tamponade had been removed and he was no longer coughing up blood, he was just curled up in a fetal position as his mother, who had shown up at some point, made sure he did not inadvertenly fall off the narrow bed without side rails as he tossed around in agony.
Before I left that day he had been transfered to a med-surg unit since he was going to need longer care then what we provide in the emergency department, but I hope he makes it through the day.
That is all, just felt like I had to vent that in some way...