Internist Bashes EM doc on Huff Post

[BAM!]

What do y'all think of this article? I hate to see doctors publicly bashing other doctors, especially in the press.

I'm A Doctor Who Almost Died Because My Own Doctors Refused To Do This 1 Basic Thing

My take:
-pt is likely annoying and difficult, which didn't help his situation
-EM doc likely had poor bedside manner, albeit maybe not as bad as pt says (one sided story)
-EM doc actually did the right thing and got the GI doc to see him in person in the ED
-GI doc didn't take him to the colo suite, and pt was OK with this?!
-pt is psych-splitting, hates the EM doc even though GI doc made the wrong choice
-likely there's more missing to the story --> pt tried to sue with 6 rejections from malpractice attorneys

Do you think if you're life threateningly hypovolemic with an underlying physiologic tachycardic response, would the beta blocker reduce your HR to 60? I don't.

Don't get a retiring GI doc to do your procedure on the day of his retirement!!

---

Members don't see this ad.

 

[EMhawkeye]

He was backseat doctoring from the time he was triaged.
I doubt one single event like that caused his CHF or ckd stage three. The interactions he described. He wanted to go from 0 to 100 in the first five minutes of the encounter. I think we all would’ve been putting the brakes on.

 

[EMhawkeye]

I think a type and screen and a repeat cbc perfectly reasonable management. Obviously, this doctor doesn’t know too much since he wanted to overly hemodilute himself with IV fluids in a G.I. bleed. Maybe he read that new study we missed about saline oxygenating tissues

 

[Dr Mantis Toboggan]

I’ve heard that plaintiffs attorneys despise having doctors or a doctor’s spouse etc as a client.

 

[pkwraith]

So the patient physician wanted the nurse to just start fluids with a doctor even got in the room. Then he wanted PRBC and platelets immediately with normal vitals before blood work. And this is an internal medicine physician? I understand how a lay person would expect it... but I doubt he practices medicine like this.

 

[WorkNoteEmergency]

I’m sure he was real popular on the ward in 1970 when he ordered nurses to measure volumes of bloody stool.

 

[DeadCactus]

"I checked in at the desk and a few minutes later, a nurse opened the door. 'Dr. Mieczkowski? Come on back' she told me."

Everything you need to know, right there.

 

[WorkNoteEmergency]

So the patient physician wanted the nurse to just start fluids with a doctor even got in the room. Then he wanted PRBC and platelets immediately with normal vitals before blood work. And this is an internal medicine physician? I understand how a lay person would expect it... but I doubt he practices medicine like this.

Probably the crux of the whole issue. Guy likely hasn’t worked in a hospital in 20+ years. His story is probably what he imagines happens when he sends his patients in for a GIB.

 

[skougess]

How about how he slips in at the end that he was rejected by SIX malpractice attorneys.

This guy is the patient we all hate, he just happened to go medical school too.

 

[Emapp20177]

The "one basic thing" was listening to this guy? He wanted a platelet transfusion that would increase his mortality. No wonder he can't find a lawyer to represent him, he doesn't know basic medicine.

 

[Birdstrike]

It’s his opinion that they messed up. He had a bad outcome. He’s likely to be a persuasive witness when he sues. He’ll probably get some money.

But there’s an entire other side of the story we haven’t heard. So, he may be right or he may not be.

A jury of plumbers, school teachers, retirees, bankers, Walmart greeters (and maybe a nurse, if he’s lucky) will decide.

He’ll be more comfortable in retirement. The accused doc will continue working, will order more tests and admit everyone who farts sideways.

Life goes on.

 

[JacobMcCandles]

1.) People are terrible estimators at the amount of blood lost. I suspect he is no different.
2.) I don't know why he was hung up on IVF. Any acute care doc knows that a patient with significant blood loss needs blood and not IVF.
3.) I'm shocked the GI doctor did a repeat colonoscopy. I feel like many places would have recommended IR.
4.) He seems insufferable.

 

[thegenius]

Probably the crux of the whole issue. Guy likely hasn’t worked in a hospital in 20+ years. His story is probably what he imagines happens when he sends his patients in for a GIB.

This!!

 

[EMhawkeye]

This!!

Yeah his opinions on what management should have been make me question his clinical acumen.

 

[BAM!]

1.) People are terrible estimators at the amount of blood lost. I suspect he is no different.
2.) I don't know why he was hung up on IVF. Any acute care doc knows that a patient with significant blood loss needs blood and not IVF.
3.) I'm shocked the GI doctor did a repeat colonoscopy. I feel like many places would have recommended IR.
4.) He seems insuffereable.

our shop would have done repeat colo.

 

[BAM!]

Probably the crux of the whole issue. Guy likely hasn’t worked in a hospital in 20+ years. His story is probably what he imagines happens when he sends his patients in for a GIB.

I originally saw this article from a Doximity link. What saddens me is reading all the support he has from Doximity doctors of varying specialties. Mostly outpatient. They have no idea of what an unstable patient looks like. Sad to see them throw another doctor who followed standards of care under the bus so quickly.

 

[BAM!]

Pro tip: if you really want to get the physician's attention, splatter a copious bloody diarrhea onto the floor in your room. This will accentuate the volume and get you an admission right away.

 

[WilcoWorld]

If I need care, please don't send me to Dr. Mieczkowski - dude's got no idea what the evidence supports.

 

[thegenius]

I did have a pt once with post-polypectomy bleeding. Even though his H&H was OK and his vitals were OK too...he looked so pale and was dizzy and was farting blood every 20-30 minutes. We repeated a hemoglobin and it went down like 1 (maybe 11.5 ->10.5 IIRC). He was like trying to pass out in front of us. I told the pt and family he was probably vagaling and they didn't seem to buy that.

Pt and wife had a similar conversation. I called GI and he said it's very hard to find active bleeding on colonoscopy because the entire colon needed to be prepped. I said "so basically he will be transfused for 24 hours while doing a colon cleanse?" he said yup.

IM did give him a unit of blood when his H&H was > 10 with no objectionable change in vital signs just based on how he looked.

Pt did just fine the next day.

 

[thegenius]

And WTF is this nonsense that his severe bleeding resulted in a cardiomyopathy and dementia? WTF is up with that?

I've never seen an etiology of cardiomyopathy from acute blood loss. Nor dementia. Did he get dementia from innumerable of tiny ischemic stroke from anemia? He's probably demented to begin with.

 

[southerndoc]

You know, I find it often easier to just go along with them. IV fluids aren't the end of the world, and I'm sure he would've been fine with a repeat CBC and monitoring over immediately ordering blood. I'm sure the guy was anxious because he was suddenly the patient.

It's a lot easier for me to consider their requests, sometimes act on them, than to spend a ton of time arguing with them or worse yet defending myself if they end up being right. The ED doc did seem overly reassured by the low heart rate and didn't factor in the beta blocker. If I have someone who is actually bleeding as much as he describes (who knows if he is exaggerating), then yeah, I probably would order blood for him.

On another note, I had to be cardioverted in the ED recently and received extraordinary care. I didn't demand anything. Felt sorry for the crew that had to bag me for 5 mins because I'm a lightweight and can't handle my propofol though. LOL Woops! I don't even drink alcohol. I'm a cheap sedation.

 

[JacobMcCandles]

On another note, I had to be cardioverted in the ED recently and received extraordinary care. I didn't demand anything. Felt sorry for the crew that had to bag me for 5 mins because I'm a lightweight and can't handle my propofol though. LOL Woops! I don't even drink alcohol. I'm a cheap sedation.

Glad you're doing well but I'd like to be the first to apologize about the cardiomyopathy and dementia that you're going to develop because you weren't cardioverted 2 minutes earlier.

 

[smq123]

If I need care, please don't send me to Dr. Mieczkowski - dude's got no idea what the evidence supports.

"“Dr. Woods, I’m on a high dose of a beta blocker for my blood pressure"

...so he doesn't know anything about primary care, either. This guy seems like a real treat.

 

[CoolDoc1729]

It’s crazy how all day he lost a couple pints of blood twice an hour and he is still alive. Dr woods is a hero! /s

 

[emergentmd]

Medical care is all over the place depending on your community.

If I were a patient at my well functioning community, it would have been IV+IVF+Hematochezia/melena/lots blood on rectal+Labs+admission+Serial Labs+GI Consult. HR, BP, H/H early on is meaningless and doesn't change what my rectal tells me.

In my previous locums crapshow ER, older/sicker pt, tachycardia, anemia, chronic medical issues was admitted to the hospital floor under a hospitalist APC care. If I were the family of this pt, I would have gone Ape $hit b/c this was clearly not standard of care.

Hard to know what the real truth is without looking at the records.

 

[GassYous]

I agree with everyone here and that the management was appropriate. The ED doc's job is to look at the clinical picture, labs then transfuse and consult as necessary. Can't see well on a scope in a non prepped patient. Was he even NPO? There was no clear indication for a transfusion or a rush to the GI lab on initial presentation. Even fluids have risks in a guy with chf and ckd. They would also dilute out the clotting factors. Anesthesia is risky in patients like this as well. He could aspirate, get hypotensive, have an mi etc. etc.

We do a ton of these doubles on patients with a significant drop in hemoglobin and find nothing.

 

[ShockIndex]

Plenty of people with severe hemorrhagic shock have normal hemoglobins and vital signs…until they don’t. Yes, you can absolutely bleed to death from post-polypectomy hemorrhage - especially when it’s arterial in source. I believe that the author was reporting 250-500 cc of blood loss out of his ass every hour or so. Things like IVF, hemoglobins, and hospitalists shouldn’t factor in the decision making with that volume of blood loss.

 

[GassYous]

Self reported blood loss. It wasn't known to be arterial on presentation. Blood loss is difficult to quantify. I watch people bleed and give blood products all the time and I still can't give you an accurate estimate of ebl like a suction machine can.

 

[JacobMcCandles]

As someone else mentioned, the fact that he has had six (6!) malpractice attorneys refuse to take his case should tell you something.

 

[Kryptocoin]

The guy claimed to be in shock and yet was never objectively hypotensive. That amount of blood loss would have dropped his SBP. The beta blocker would have accelerated it since his compensatory mechanism was restricted.

No wonder six malpractice lawyers rejected him. The guy has obviously never treated anyone in hemorrhagic shock.

 

[GonnaBeADoc2222]

The guy claimed to be in shock and yet was never objectively hypotensive. That amount of blood loss would have dropped his SBP. The beta blocker would have accelerated it since his compensatory mechanism was restricted.

No wonder six malpractice lawyers rejected him. The guy has obviously never treated anyone in hemorrhagic shock.

Having reviewed cases, I know that the bar is pretty low for a malpractice attorney to take a case.

6 said no.

This case is trash.

 

[SXMMD]

My mother sent me this article. I nearly had a GI bleed reading it at work. I sat my mother down and talked her through the case and why this guy isn't a clown 🤡 but the whole damn circus.

My favorite is the line about his shock giving him dementia, CHF and ckd... He was taken for procedure over night, discharged during day, all less than 24 hours from hitting the ER in apparent hemorrhagic shock with multiorgan dysfunction in setting of GIB? He didn't have a problem with hospitalist discharging him in that situation? 6 malpractice attorneys missed out on winning the lotto here.

I googled him, is he an endocrinologist? Doesn't sound likes he has practiced primary care since like residency 40 years ago tbh...

Dr. Lawrence Mieczkowski, MD - Internal Medicine Specialist in Dayton, OH | Healthgrades

Dr. Lawrence Mieczkowski, MD is an internal medicine specialist in Dayton, OH and has over 41 years of experience in the medical field. He graduated from University of Cincinnati / Main Campus in 1982. He is affiliated with medical facilities Kettering Health Main Campus and Kettering Health...

www.healthgrades.com

 

[gutonc]

Also, this guy has a Bernedoodle, so **** him. He's clearly a terrible human being based on that alone.

 

[smq123]

My mother sent me this article. I nearly had a GI bleed reading it at work. I sat my mother down and talked her through the case and why this guy isn't a clown 🤡 but the whole damn circus.

My favorite is the line about his shock giving him dementia, CHF and ckd... He was taken for procedure over night, discharged during day, all less than 24 hours from hitting the ER in apparent hemorrhagic shock with multiorgan dysfunction in setting of GIB? He didn't have a problem with hospitalist discharging him in that situation? 6 malpractice attorneys missed out on winning the lotto here.

I googled him, is he an endocrinologist? Doesn't sound likes he has practiced primary care since like residency 40 years ago tbh...

Dr. Lawrence Mieczkowski, MD - Internal Medicine Specialist in Dayton, OH | Healthgrades

Dr. Lawrence Mieczkowski, MD is an internal medicine specialist in Dayton, OH and has over 41 years of experience in the medical field. He graduated from University of Cincinnati / Main Campus in 1982. He is affiliated with medical facilities Kettering Health Main Campus and Kettering Health...

www.healthgrades.com

The entire article is so tiresome, and he is so clearly full of bull .

"My condition worsened and after undergoing tests locally and at the Mayo Clinic, I was diagnosed with congestive heart failure, stage III kidney failure and chronic anaemia."
- First of all, you shouldn't need to go to the MAYO CLINIC to be diagnosed with 3 of the most common diagnoses of all time. A reasonably good internal medicine/family medicine resident should be able to diagnose you with them on their own. Why did he feel the need to get a second opinion at Mayo?

- He has an acute GI bleed but is now left with "chronic anaemia." What, his bone marrow was permanently affected, too? Diffuse permanent ischemic bone marrow injury? WTF.

 

[gutonc]

The entire article is so tiresome, and he is so clearly full of bull .

"My condition worsened and after undergoing tests locally and at the Mayo Clinic, I was diagnosed with congestive heart failure, stage III kidney failure and chronic anaemia."
- First of all, you shouldn't need to go to the MAYO CLINIC to be diagnosed with 3 of the most common diagnoses of all time. A reasonably good internal medicine/family medicine resident 3rd year med student should be able to diagnose you with them on their own. Why did he feel the need to get a second opinion at Mayo?

- He has an acute GI bleed but is now left with "chronic anaemia." What, his bone marrow was permanently affected, too? Diffuse permanent ischemic bone marrow injury? WTF.

FTFY.

And yes, this guy is ridiculous.

 

[Rekt]

Plenty of people with severe hemorrhagic shock have normal hemoglobins and vital signs…until they don’t. Yes, you can absolutely bleed to death from post-polypectomy hemorrhage - especially when it’s arterial in source. I believe that the author was reporting 250-500 cc of blood loss out of his ass every hour or so. Things like IVF, hemoglobins, and hospitalists shouldn’t factor in the decision making with that volume of blood loss.

We’re obviously aware of that but you know that isn’t the case with this clown.

 

[Tenk]

“Sure, we’ll start a bit of fluid and type and screen you while we wait for the hgb to come back. We don’t want to flood you with too much fluid since it doesn’t bind oxygen which of course you know already, HA HA HA *forced laughter while thinking how much I hate myself.*”

The guy is dumb for a lot of reasons but this approach would have kept things going in the right direction without derailing the train. Sometimes you just gotta know when to play the part.

 

[Mount Asclepius]

Agree with many comments above. Physicians and occasionally PLPs or RNs do get VIP treatment and unnecessary care sometimes to their own detriment. I'm guilty of this because it's easier even if not entirely right. The principles of non-maleficence and beneficence conflict with patient autonomy. Anyone practicing for a while knows that frivolous patient complaints are soul and time sucking. Not worth the fight. Especially coming from someone in the medical community, particularly if you might have to interact with them professionally in the future. Our job is hard though and we've all had times where our comments or even our tone came out less than ideal even if not terribly inappropriate.

We all know that in acute hemorrhage that either doing nothing or giving blood is almost always better than giving IV fluids. However, it's not worth fighting over IVFs (or just some small amount of MIVFs) or even a pint of blood in this scenario if requested and perhaps not indicated.

Additionally, H&H lags in significant hemorrhage. Don't make the mistake of chasing your tail for a truly ill patient (not saying this patient was). The patient could have been experiencing class 1 or even class 2 (lack of tachycardia given beta blocker) hemorrhagic shock, but suspect would have been more likely to develop hypotension without compensatory tachycardia. However, I think the lack of hypotension would have made us all unlikely to transfuse with a normal H&H and visualization of only a mild to moderate amount of hematochezia. Certainly EBL is hard to quantify for patients, non-acute care physicians and even intermittently for acute-care physicians. Any hemorrhage is also often overly alarming to patients and non-acute care physicians. I suspect this patient overestimated the EBL, although it's certainly possible it was underappreciated by the EP.

If I was reviewing this case in peer review, I think care was appropriate within the standard and not grossly negligent. In many cases, GI isn't going to emergently scope acute hemorrhage in the middle of the night. I can count on one hand the number of times I've seen a Gastroenterologist in the ED. So the fact that they came in (let alone after a retirement dinner) and then that a repeat colonoscopy was done is beyond in my opinion what typically happens. Granted it was a post-colonoscopy bleed rather than random undifferentiated lower GI bleeding and so there is higher likelihood of requiring requiring intervention for post-polypectomy hemorrhage. The fact they scoped him does give a little credence to the idea that the patient may have been correct regarding the amount of blood loss. Sometimes though the progression of illness in the inpatient setting necessitates intervention that wasn't perhaps initially indicated in the ED. That's why we admit patients instead of having them followup closely - in case their illness experiences more rapid decompensation.

It's reasonably possible that you could develop an AKI from acute hemorrhagic shock secondary to GI bleeding that could progress to CKD exacerbating underlying CHF or cause some cardiomyopathy. However, I don't think the lack of IVFs and a blood transfusion in the setting of normal vital signs in the ED is specifically causative. Not sure why it would take the Mayo Clinic to figure that out. I suspect the patient was physician shopping just like he attorney shopped. The fact 6 malpractice attorneys declined the case also indicates that it's hard to fault the EP or even the Gastroenterologist for the patient's outcome. That doesn't mean the patient won't continue to attorney shop and eventually sue resulting in a settlement because it's easier to settle than litigate even if not at fault. That's the major problem with our mediolegal system.

My only hope is that the patient has given up on litigation using publication to seriously self-reflect and process as well as improve care for other patients if viewing in a positive light, or equally likely using a cynical lens they are lashing out at others because health isn't for granted and often not in our control despite access to medical care.

Anyone else picture @southerndoc receiving cardioversion in the ED mid shift still providing EMS medical direction over the phone as the Propofol is going in? Ha. Obviously not that there is or should be a need to be that macho. Makes it more exciting though.

 

[nVictus]

admit yourself to the floor if you want to tell honey badger what to do, honey badger dont care.

 

[WilcoWorld]

Anyone else picture @southerndoc receiving cardioversion in the ED mid shift still providing EMS medical direction over the phone as the Propofol is going in? Ha. Obviously not that there is or should be a need to be that macho. Makes it more exciting though.

I had an attending in residency with intermittent a fib. Comes on on shift, so he checks in, gets etomidate-->joules-->back to work.

 

[Pudortu]

I had an attending in residency with intermittent a fib. Comes on on shift, so he checks in, gets etomidate-->joules-->back to work.

Stories like this sound badass but really if something bad happened to a patient he would be in big trouble for a moderate sedation and practicing medicine so soon. Easily lose malpractice cases or even a board complaint. I once had an appy on shift and refused any narcotics despite every step being excruciating until I signed out my 10 active patients and I time stamped the documentation and made sure the doc didn’t order it until Signout was done. I would have tried to wait but it was a weekend and OR team was ready to go according to my surgeon.

Anyways, I know this isn’t the topic of our thread but we put too much “badassery” to these type of issues.

 

[JacobMcCandles]

I had an attending in residency with intermittent a fib. Comes on on shift, so he checks in, gets etomidate-->joules-->back to work.

What kind of wimp needs sedation for that…?

 

[ShockIndex]

We’re obviously aware of that but you know that isn’t the case with this clown.

It doesn’t sound like the gastroenterologist who punted him to the hospitalist knew that. I assume that the EP had nothing to do with that call since the author lays that gem at the feet of his gastroenterologist.

Admitting someone to the floor (at 7 PM nonetheless) who is producing multiple pints of bright red blood out of their ass in the ED is a great way to screw over your partners who are covering night call.

 

[JAFERD_MD]

"Nurse practitioners (NP) and physician assistants (PA) have similar outcomes as physicians, often have more time to spend with their patients and have high satisfaction ratings."

Sigh....but maybe this guy gets his next colo by a Hopkins trained NP!

Also, this is yet another article that lambasts doctors and increases the hostilities between patients and physicians. Except this one is worse, because it's doctors doing it against other doctors. Why do physicians keep doing this to each other? And the media will never publish articles about all the times doctors were right and the "I know my body" patients are wrong.

 

[southerndoc]

Anyone else picture @southerndoc receiving cardioversion in the ED mid shift still providing EMS medical direction over the phone as the Propofol is going in? Ha. Obviously not that there is or should be a need to be that macho. Makes it more exciting though.

I did go for a walk the next morning and worked the next afternoon.

 

[JacobMcCandles]

Also, this is yet another article that lambasts doctors and increases the hostilities between patients and physicians. Except this one is worse, because it's doctors doing it against other doctors. Why do physicians keep doing this to each other? And the media will never publish articles about all the times doctors were right and the "I know my body" patients are wrong.

Because that’s how the media works. They don’t want to hear that the crazy patient is actually crazy. That isn’t what gets clicks and likes. They want the extreme 1 in a million times where the crazy person who comes to the ED 5 times a month is finally right. They want to hear about the bad outcomes that are going to happen to a certain percentage of the population so they can blame the physicians and hospitals. Our society rewards a victim mentality. The more we give these people our time and attention the worse they become.

 

[Brigade4Radiant]

Stories like this sound badass but really if something bad happened to a patient he would be in big trouble for a moderate sedation and practicing medicine so soon. Easily lose malpractice cases or even a board complaint. I once had an appy on shift and refused any narcotics despite every step being excruciating until I signed out my 10 active patients and I time stamped the documentation and made sure the doc didn’t order it until Signout was done. I would have tried to wait but it was a weekend and OR team was ready to go according to my surgeon.

Anyways, I know this isn’t the topic of our thread but we put too much “badassery” to these type of issues.

True but the same thing would happen for you as well. if you make a mistake. It’s not looked well regardless of what you’re going through

 

[ShockIndex]

Self reported blood loss. It wasn't known to be arterial on presentation. Blood loss is difficult to quantify. I watch people bleed and give blood products all the time and I still can't give you an accurate estimate of ebl like a suction machine can.

The whole story is self-reported and there are a lot of reasons to believe that this author is full of crap.

Having said that, I’m deconstructing this case into the basics of a guy comes in to the ED reporting BRBPR, and then proceeds to pass multiple episodes of BRBPR in front of my staff every hour or 2 with each episode being “a couple of pints.” In that circumstance, my response is not to start some IVF, check serial hemoglobins, and admit to the hospitalist. That kind of thinking at 6PM results in things like 1AM colonoscopies or visits to IR which is what reportedly happened here…if we believe the author.

I suppose my larger point is that some patients surprise us by looking pretty good from a vitals perspective but then go on to bleed at a fair clip. Putting these patients with unrelenting bright red blood loss from any orifice on the floor at night with a hospitalist is risky at most hospitals. They generally warrant an ICU admission if not a more expedited interrogation of the blood loss. The floor is where you put people with reasonable certainty of hemostasis.

Again, I don’t fault the EP. We all get surprised by these patients. It’s the GI who made the call to put this guy on the floor with ongoing BRBPR.

 

[WilcoWorld]

The whole story is self-reported and there are a lot of reasons to believe that this author is full of crap.

Having said that, I’m deconstructing this case into the basics of a guy comes in to the ED reporting BRBPR, and then proceeds to pass multiple episodes of BRBPR in front of my staff every hour or 2 with each episode being “a couple of pints.” In that circumstance, my response is not to start some IVF, check serial hemoglobins, and admit to the hospitalist. That kind of thinking at 6PM results in things like 1AM colonoscopies or visits to IR which is what reportedly happened here…if we believe the author.

I suppose my larger point is that some patients surprise us by looking pretty good from a vitals perspective but then go on to bleed at a fair clip. Putting these patients with unrelenting bright red blood loss from any orifice on the floor at night with a hospitalist is risky at most hospitals. They generally warrant an ICU admission if not a more expedited interrogation of the blood loss. The floor is where you put people with reasonable certainty of hemostasis.

Again, I don’t fault the EP. We all get surprised by these patients. It’s the GI who made the call to put this guy on the floor with ongoing BRBPR.

I'm with you here, except that you accept the report of loosing a pint of blood every hour for several hours. Of course, if someone is loosing their entire blood volume in under 10 hours, IV fluids and watchful waiting are insufficient. But the outcome described in the piece seems incongruous with this. It looks like he got transfused one unit and was discharged the next day. If that's the case, then I don't believe he was actually bleeding as briskly as he thought he was.

Stated otherwise: I completely agree that we should not wait for someone with ongoing massive hemorrhage to fully decompensate before we take action. I think the author of this piece did not actually have ongoing massive hemorrhage.

 

[JacobMcCandles]

I'm surprised he didn't try to show the ED doctor a picture from his phone like EVERY patient tries to do with regards to blood in the stool. I believe you, man, I don't need to see a picture of it and I certainly don't need you to hand me a Tupperware container full of it so I can turn around and throw it in the trash.