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Which would surprise you first....

Discussion in 'Emergency Medicine' started by roja, Jul 30, 2006.

  1. roja

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    42 yo female sent in for vaginal bleeding and 'looking pale'. Per triage, pt looks 'a little pale'. VSS (ie, not tachycardic, not hypotense, pulse ox okay). Pt with compliant of feeling tired but no CP/SOB/focal compliants. Sister says she has been bleeding for 'months' and dragged her in (pt doesn't like doctors)

    Intern goes to see her and tells me, 'I think the patient is a virgin, I think her hymen is intact'.

    Me: Is she a nun?
    Intern: no. Just never had sex.

    Gyn laughs but then concurs (hymen indeed intact(


    And the drum roll is: Hgb of 2

    Got a hysterectomy yesterday for a fibroid :thumbup:
     
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  3. DrMom

    DrMom Official Mom of SDN
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    How was she functioning with a Hgb of 2?!? I know that she'd have had a slow chronic Hgb decline, but still.
     
  4. roja

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    Trust me... Thought the same thing... How the hell?


    and then the perseveration of being in your 40's and having an intact hymen.....
     
  5. DrMom

    DrMom Official Mom of SDN
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    To each her own, I guess. ;)
     
  6. Dane

    Dane New Member

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    Had pt with cervical CA, complaint of SOB, h/o anemia.
    Hgb 1.4 unfortunately transfused and ended up in the MICU with TRALI.
     
  7. stoic

    stoic "Time you enjoy wasting, was not wasted"
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    jesus. hgb of 2 and looking pale. not but a month ago i saw a new mom with some retained placenta and heavy post-partum bleeding start getting into hypovolumemic shock (hr 160's bp 60/35ish) with a hgb of 6.5 - and that chick looked white as a new snow. gotta love the bodies ablility to compensate during chronic phys distirbance.

    per her hx, how much was she bleeding/day? was she working or at all active?
     
  8. bulgethetwine

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    Was it still intact after the speculum exam??
     
  9. spyderdoc

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    Apparently doctors aren't the only thing she doesn't like...


     
  10. Hard24Get

    Hard24Get The black sleepymed
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    My aunt is about that age and she is still a virgin, too. (not in NY, though ;) ). Wants to, just never got around to it....

    Interestingly, she also has massive fibroids and needs a hyster (case study, anyone?)......
     
  11. DropkickMurphy

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    If she's good looking, send her my way.... ;)
     
  12. leviathan

    leviathan Drinking from the hydrant
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    Maybe the lab results were off?
     
  13. DropkickMurphy

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    I don't care how stupid the lab tech was.....no one would turn out a result of "Hgb- 2" without running it at least twice if not more (this coming from the son of a lab tech who will be a medical technology major after his transfer)
     
  14. southerndoc

    southerndoc life is good
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    Wow, Hgb of 2. What did the blood sample look like when someone drew her blood? It must have looked like Koolaid.
     
  15. DropkickMurphy

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    The only case I've seen that bad was a lady in septic shock from some weird form of Clostridium perfringens or a similar bacteria.....basically the bacteria produced some form of toxin that produced massive hemolysis. Wildest thing I've ever seen.....her blood literally looked like cherry Kool-aid with little clots in it.
     
  16. USCDiver

    USCDiver Percocet-R-US
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    It may not have been lab error, blood drawn from a vein above an IV running wide open with NS can give you markedly reduced Hgb and Hct.
     
  17. BKN

    BKN Senior Member
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    Seems to be news to you all. I agree it's extreme, but you can function at a low level with a Hct of 6, if it happens slowly. Blood viscosity drops, rheologic qualities change and it's much easier to push around. Southerndoc, imagine the difference between pumping jello and kool-aid. Interestingly, I've read the O2 delivery doesn't change much between hct of 40 and 20, since cardiac index rises.

    We see folks from Mexico with this level of anemia a few times each year. they aren't feeling good, but they can walk and mentate sort of.
     
  18. southerndoc

    southerndoc life is good
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    Well, O2 delivery does change a lot, but the body can still handle it without strenuous activity.

    delivery of O2 = CO X [ (Hgb X 1.34 X SpO2%) + (0.003 X paO2) ]

    So let's assume paO2 is not significant (for calculation purposes). Oxygen saturations are 97%.

    With a normal hemoglobin of 14 g/dL and a cardiac output of 5 L/min (stroke volume of about 75 mL/beat at 65 beats/min), the delivery of O2 would be 90. With a hemoglobin of 2 g/dL and a cardiac output calculated with a stroke volume of 85 (the heart will be hyperdynamic) and a heart rate of 120, the DO2 is about 28.

    So even with severe compensation, you are still only getting a third of the delivery of oxygen to the tissues with such a low hemoglobin.

    The body can still survive on this, at least with normal living activities and not with some sort of strenuous exercise. I'm not even going to go into the VO2 equations for this. (I think I've proven I'm nerd enough with this post.)
     
  19. BKN

    BKN Senior Member
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    No, you're not nerd enough:D ! I used to know soemthing abut this many years ago, this is my recollection.

    Poiseuille's law is what I was talking about, not the co = sv * rate equation. I'm going to have to use bad symbols since the greek and math sets aren't available:

    Q = pi*deltaP*r^4/8*nu*L where q = flow, deltaP is change in pressure across the vessel, r is the radius of the tube, nu is the viscosity and L the length of the vessel.

    So, flow is proportional to the 4th power of the radius (and I assume that vessels will dilate maximally under these conditions) and inversely proportional to the viscosity. End result is I think that the increase in cardiac output could be higher than the doubling that you posit.

    Second issue is that the important stuff is not delivery, but extraction. Normally delivery is 20 ml O2/100ml blood, but only 5 -6 ml used. With a Hgb of 2, perhaps 3 ml O2 ml/100 ml blood but if extraction near total (is that possible?) and a doubling of CO then oxygen extraction very close to normal basal usage. Thus as long as patient doesn't exert, may not feel too bad or be too acidotic. Did all that make sense?
     
  20. Annette

    Annette gainfully employed
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    SouthernDoc and BKN, you are both super nerds! ;)



    NO. Do you have a powerpoint on that??? :laugh: :laugh: :laugh:
     
  21. southerndoc

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    Yea, it did. I didn't think to factor in Poiseuille's law. It makes sense. A less viscous material will flow more easily. So the stroke volume could increase, although I don't have the willpower (or the brainpower) to calculate it.

    Alas, I am not nerdy enough. Geeky, yes, I have that one under control, but not nerdy.

    Maybe I should've paid more attention in physics instead of waking up at 4 am to freshly learn the material before my exam at 9 am every week!!
     
  22. DropkickMurphy

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    Actually you're confusing a couple of related parameters.....normal O2Del is 1,000 mL/min, assuming a O2 content (CaO2) of 20mL/dl and a CO of 5L/min.

    O2Del = Ca02 x CO x 10

    Now assuming this lady has the 97% SpO2 that SouthernDoc used, and an Hgb of 2 g/dL that's:

    2 x 1.34 x .97 = Ca02 of 2.56 mL/dL

    In regards to cardiac output, let's operate under the assumption that this lady has a hematocrit of approximately 6% (figuring that 7 g/dl = 21% HCT), and bear with me because I haven't formally had physics yet, but assuming that that's a 86% reduction in her hematocrit (assuming 42% as normal) and I'm assuming viscosity decreases non-linearly to an unpredictable degree given the data at hand (due to the multitude of factors that go into it.....including not only the hematocrit, but the pliability and elasticity of the RBC's, the behavior of individual cells or groups of cells within the flowing fluid, etc, etc, ad nauseum.....I hate non-Newtonian fluids :smuggrin:).

    But the answer to the question about oxygen extraction , well, assuming normal C(a-v)O2 is 5mL/dL and has been documented to go above 10 mL/dL in cases where CO is bottomed out (half normal (2.5L/min) in the reference I recall), given a normal CaO2 so I'm assuming that the same would be true if you reversed the scenario to an abnormally (in this case, freakishly) low CaO2 and a normal if not supranormal CO. Basically I don't believe there is anything explicitly prohibiting the extraction of the entire O2 content of arterial blood at the cellular level, so long as the proper gradient exists.
     
  23. leviathan

    leviathan Drinking from the hydrant
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    Yeah, but you'd be surprised to what depths of stupidity a human can travel to. (This is coming from the nephew of a lab tech, who has seen that kind of behaviour in his lab. :D )
     
  24. leviathan

    leviathan Drinking from the hydrant
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    Naw, that was a really informative post. I showed the DO2 equation to my class of EMTs during a training session about oxygen therapy and I know they all just laughed at me behind my back. :smuggrin:
     
  25. DropkickMurphy

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    Point taken.....
     
  26. BKN

    BKN Senior Member
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    Yea, I know. I just didn't do the multiplication, I just chose to talk about the amount delivered per 100 ml.
     
  27. DropkickMurphy

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    OK.... just checking....I figured that was the reason, but I was bored decided to occupy myself for a few minutes :laugh:
     
  28. roja

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    Sorry, been out of comission working, writing lectures, IRB's, etc.....


    1.Pt had been bleeding 'a long time'. (she was VERY embarrassed to talk about it)
    2. She was not very active. She was 'tired' alot
    3. No speculum was inserted
    4. There was no IV when the bloods were drawn.
    5. blood did look a little thin...
     
  29. EM2BE

    EM2BE Elf
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    This forum and all you who claim "nerd" have now successfully made me say :eek: . And orientation starts next week...I guess it's about time for that feeling to come around!
     
  30. BKN

    BKN Senior Member
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    Embrace your nerdity. But some contraceptive glasses and tape the bridge.
     
  31. EM2BE

    EM2BE Elf
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    I'll get right on that... :D
     

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