Ok, so here’s my best case from recent memory. Sorry for crappy phone formatting.
55M signed out from prior doc. Here for hematemesis, history of EtOH cirrhosis, had an EGD with banding of some varices done at hospital in Venezuela a few days ago. Stable, BP 110s systolic, O2 98%, not tachy, alert, pending admission at signout, GI says obs, outpatient scope after discharge. Enjoying his protonix and octreotide drips, complaining about NPO status.
Triage labs:
Hemoglobin 10.6
INR 1.8
Scattered electrolyte, renal, and hepatic findings consistent with CLD, but none markedly concerning.
About 7 minutes into the shift I peek over my desk and the guy is now covered in black emesis, unresponsive, O2 low 80s, and agonal breathing. BP now 90/50 and tachy 110s. Stat RSI, airway full of blood but luckily goes smoothly.
Recycle the BP and now it’s 70/40, call for Massive Transfusion Protocol, the nurse drops an OG tube, and it immediately begins pouring out mixed black blood, clots, and gunk. The OG is putting out this black trash so fast it burns through both of our suction canisters in about 10 minutes. I send the MS4 off to find “as many suction canisters as you can carry.” We start the first 2 units of PRBCs via level 1 infuser. After the first 2 units the BP is now 65 systolic, blood still pouring from the NGT, so we call for FFP, platelets, calcium, TXA.
Now 4 units of blood, 1 platelet, 1 FFP in and I’m Hammer paging GI, who is kind enough to inform us in person the guy is now too sick to be scoped, should go to ICU, they’ll see him if he makes it up there.
Total NGT output is now 4L, BPs still in the 65-75 systolic range. We decide to go for our Hail Mary and drop a blakemore tube. By some miracle we’ve got the one nurse working who actually knows where all the components are. We attempt to pass the tube but the dude has some weird oropharynx anatomy and it just keeps curling in his throat. NGT output is now over 5L of blood.
Suddenly I have an amazing idea! Let’s pass the blakemore like an NG tube. We get it through the guy’s nose but it keeps curling in his mouth. So I shoved my whole hand in this dudes mouth while the MS4 held the ET in place, grabbed the blakemore, and manually passed it into the esophagus. We inflate the thing, tie it to the wall for tension, and within a couple of minutes the bloody output stops and BP starts to creep up into the 90s. Me and the attending, who has balls of steel for letting me try that, high five all around.
All in all the gentleman went to the MICU with a total blood loss of 6 L, received 11 units of products (6 PRBC, 4 FFP, 1 platelet). Lowest hemoglobin, drawn during the resus, was 2.8.
Scoped and banded in the MICU, woke up Neuro intact a few days Later.
