Dr Doctor he's vomiting blood again!

Last night I only had one particularly sick patient to deal with. A 77 year old gentleman who had come in with GI bleeding with a background of angiodysplasia (abnormal bood vessels in the GI tract that are likely to bleed). His haemoglobin (Hb) was 7.3 on admission and his INR was 5.7 (he was on warfarin for a metallic heart valve). He had been cross matched four units for transfusions which we started running into him. 

An hour or two later around 1am he had an episode of vomiting blood. His obs were all stable at this stage but he was a little anxious (which can be one of the first signs a patient is heading into shock) so I got further IV access just in case and made my SHO aware. An hour or so after that he vomited a rather larger amount of blood and dropped his systolic blood pressure to 80 with a heart rate of 128 - scary stuff! He looked really sick at this stage, was clammy, shaky and really anxious.

Put up 500ml of gelofusine stat and called the med reg. She asked me to ring blood bank to get four units of fresh frozen plasma (FFP) and cross match another 6 units of blood before she arrived. One of the other SHOs arrived put in another cannula and took a set of bloods. I ran to A&E with a venous blood gas which showed his Hb had dropped to 6.4. We started running in the FFP and blood stat while the med reg phoned the on call endoscopist and the on call anaesthetist and ITU.

The nurses rang the patient's family and while we were waiting for the patient to go to theatre he got to talk to them. It was quite heart rending to hear him saying his goodbyes as if it might be his last. 

In theatre they found several bleeding sites including one of the abnormal vessels that was actively bleeding which they injected with adrenaline (for vasoconstriction) and cauterised. He had a further 7 units of blood in theatre and the rest of the FFP. By the time he came back to MAU around 5am he was much more stable, his repeat Hb was 9.7 and his INR had come down to 2.2.

We saved this man's life.