Mr. Reynolds is a vivid 83 year old who lived alone at home. He walks everyday int he morning first thing before he has a small cup of coffee. His kids bought him an ipad and he uses it to browse the Washington Post, the Wall Street Journal, and the Pittsburgh Post Gazette while eating breakfast.
Every morning it’s the same breakfast…toast with honey and a small cup of yogurt. Then he’s ready to start the day, just when the rest of his neighbors are waking up.
Today however, he ate hist toast and his stomach grumbled, louder than usual. He thought to himself that he’d better get to the bathroom quickly… and he was right.
I met him an hour later in a gurney with the chief complaint of ‘bloody diarrhea’. He looked great to me, comfortable, normal blood pressure and heart rate, he wasn’t pale, no pain at all. The only finding was maroon colored stool.
I sent off a bunch of labs thinking he had one of 3 main intestinal related issues…bleeding ulcer, bleeding polyp / diverticula, or hemorrhoids. Hemorrhoids were less likely since the blood is usually bright red. Likewise lower intestinal bleeding is often still bright red since there’s a short distance for it to travel and the bright red color is maintained. Hmm…that leaves a bleeding ulcer from the stomach. int he stomach the blood is exposed to stomach acid, which turns the iron black. Black stool is a bad sign..but maroon stool is even more ominous, as the blood is accumulating quickly enough to let some bright red blood mix with the blackened blood turning it a dark shade of maroon.
But Mr. Reynolds looked great. Many bleeds are brief and stop on their own. He’d had no further episodes since the first one.
After an hour his labs came back. His hemoglobin was 9.4. A little on the low side but not overly concerning. I looked up old labs and only had ones from years ago. His old, presumably “baseline” hemoglobin was 14. But I had no way of knowing how quickly he had become anemic. For all I knew it could have been gradual over years or a few months. Surely he’d not lost 5 units of blood since this morning because his blood pressure and heart rate were normal and he felt fine.
Then his nurse grabbed me. “Doc Shazam,” she said forcefully. “Mr Reynold’s blood pressure is 90/50”. “How does he look?” I asked. “He still looks fine.” Reluctantly, due to the IV fluid shortage, I asked her to start a 500ml fluid bolus. I hesitated because lots of folks when they are relaxing in the ER, especially if they’ve taken home blood pressure medicines, may develop a blood pressure a bit on the low side. I’d hoped that was his case, but this nurse is good. She’s not one that comes to me for every little thing and she’s a great problem solver. IN this case her problem solving included telling me his pressure was on the low side.
“Let’s add a lactate and redraw his hemoglobin,” I called towards her desk. She heard me. “OK,” she smiled and strutted away to draw some labs. She seemed happy with my orders, i think they were in line with her concerns. But I still thought I was overreacting, wasting resources, wasting a half-liter of precious saline and the bag it comes in.
15 minutes later, I learn his lactate is 6 and his hemoglobin is now 9. “That can’t be right,” I told her. His lactate can’t be 6…he looks FINE, I told myself for the umpteenth time. But that hemoglobin…could be lab error I thought.
I started putting the pieces together and while the patient looked fine, and had responded nicely to the fluids with a pressure now of 114, I’ve seen enough patients get very sick, very quickly once they cross a threshold. Unfortunately they don’t come with gauges that tell us where that threshold his.
I decided if it was my family member in that room, I wouldn’t want the doctor to wait until he turned downhill, scrambling to replace blood and calling in resources exigently.
I ordered a unit of packed red blood cells and a pack of platelets since he was on aspirin and plavix, called the admitting team who had already seen him and updated them on what I’d learned and what my concerns were. He thanked me and was in the ER within 5 minutes to assess the patient himself. His repeat lactate was 5.3 suggesting he’d begun responding to fluids and blood and his repeat hemoglobin climbed to 10.
When I went into his room the GI team was there and they took him to the GI lab a few hours later.
Fast forward to the end of my shift and the hospitalist came down to give me an update.
“You were absolutely right with Mr. Reynolds. The GI doc found bleeding varices in his stomach that they had a hard time controlling. I did a CT and found cirrhosis and signs of portal hypertension. We’re transferring him to tertiary care for a TIPS procedure.”
“I had an instinct,” I told him. I’m so glad I listened to it. It was subtle but in retrospect it was absolutely the right thing to do.
“Instinct is learned behavior,” he proclaimed. “You’ve seen it before and you knew the right course of action. Thank you for helping him.”
It made me appreciate that medicine really is a practice. You can know the right thing on paper and on board exams, but in the real world, cases don’t present like books and numbers and vital signs don’t follow the right patterns. The wisdom of experience only comes from seeing many previous patients crash quickly and rebound slowly.
Mr Reynolds was lucky he came when he did and that it wasn’t my first year on the job. I went home humbled and scared that I’d taken his case too lightly, but ultimately I’ve learned again and strengthened that clinical instinct.