Thursday, January 7, 2010

All Bleeding Stops...Maybe

There are certain scenarios in life that you know are disasters waiting to happen. A date with a woman who has “love” and “hate” tattooed on her knuckles is one of them. So is a voice mail saying, “Hey, it’s Tiger. Whatever happens, you don’t know me.” Likewise, an atheist’s first view of heaven can’t be good.

Medicine has more than a few of these. One of them is the use of the drug warfarin (“Coumadin”). Coumadin is an anticoagulant drug that acts to “thin” the blood. Thinning the blood helps to get oxygen-carrying red blood cells through narrowed vessels and prevents blood clots. It’s an older drug, but still very useful in caring for patients who have suffered strokes, certain heartbeat irregularities (atrial fibrillation), or blood clots in the legs or lungs. More preventative than curative, it stops formation of blood clots that can be life-threatening within the heart, brain, and other sites. It works by inhibiting the Vitamin-K dependent clotting factors within the extrinsic coagulation pathway (Factors II, VII, IX, and X, for those who are keeping score). This is as opposed to another blood thinner called heparin, which acts within the intrinsic clotting pathway by preventing the conversion of prothrombin (Factor II) to thrombin (Factor IIa) through activation of antithrombin. The antithrombin not only blocks the conversion process by inhibiting the action of co-enzyme Factor Xa, but also by diretly inhibiting the action of thrombin itself on fibrinogen (Factor I) to fibrin (Factor Ia).

(No, its really not that interesting, is it? Amazing, complex, a masterpiece of evolutionary handiwork, but still boring. And before you give me too much credit, what I’ve written is all I remember of something that took me weeks to memorize in medical school. This is for two main reasons. The first is that permanent memories are established in the brain by repetition of specific neural pathways, and not once in 23 years since graduation has anyone come up to me and said, “Doc, it’s my extrinsic pathway…it hurts me so.” This is also the mechanism behind the extinction of any knowledge of the Krebs cycle, what fibrin actually is, and how to do a gram stain. On the other hand, I do still know that Trichimonas organisms look like Groucho Marx with a tail, so maybe those years weren’t a total loss.

The second is that, when faced with a choice of occupying my limited brain space with knowing where to find emergency flowers at 3 AM when you’ve really screwed up or remembering the coagulation pathways, I went with that which was most relevant and useful to my life. This is also why I know the names, stadiums, colors, division assignments, owners, head coaches, current won-lost records, playoff formulas, and cheerleader attire of all 32 teams in the National Football League at any given moment but can’t recall how many chambers the heart has. I think it’s between two and six.)

Coumadin is a great drug that, dosed and monitored correctly, does great things. And as long as nothing happens to you, life is good. When something does, however, Coumadin is a disaster waiting to happen.

Take Rocky Royster. Rocky is a mid-forties guy who was working in his kitchen. Basically healthy, he had some bad varicose veins which had developed some blood clots in the past. He was on Coumadin to prevent them from coming back. That December afternoon he was going about, minding his own business, when he slipped on a wet spot on the floor and cut his right leg on a sharp-edged piece of tile sticking up from the floor.

For most of us, what happens next is that we put some pressure on the wound with a kitchen or bath towel, the blood coagulates in the wound, and we drop into the ED an hour or so later to get the wound sewn up. (This, of course, is assuming that the injured party doesn’t pass out at the sight of their own blood. Lucky for me, I’ll pass out even before I see blood from the very idea of pain. This is why I have no fear of addiction to pain pills, as people who are unconscious do a poor job of swallowing tablets.)

But when there’s Coumadin on board, the bleeding doesn’t stop. Ever. Even though Rocky had been a Boy Scout and remembered how to tie a tourniquet around his leg, the paramedics guessed he had at least two liters of blood on the floor. Given that you’ve only got about five liters to start with, this is a major problem, especially when the bleeding shows no inclination to quit.

(While I applaud both the Boy Scouts and Rocky’s actions, paradoxically the tourniquet did not really help him. If the tourniquet is tight enough to occlude flow through the arteries, you can stop bleeding from a site beyond the tourniquet. But if it’s not, blood flow will continue to go down the leg past the tourniquet, but the band around the arm or leg will put pressure on the more superficial and less rigid veins, collapsing them and preventing the return of blood towards the central circulation. This results in more venous congestion in the affected limb and, if there’s an injury to a blood vessel, more bleeding that might otherwise occur.)

He arrived in the ED pale, cold, and clammy, drenched in sweat and semi-conscious. In one of those few moments when life imitates television (“Trauma: Life in the ER”), we dispensed with our usual chit chat and got to work. Respiratory therapy got oxygen on board. One nurse took vital signs; another hooked him up to a monitor; two more worked on finding more IV sites for the inevitable fluids and blood that would follow. My first job was to conduct a quick exam known as the “primary survey” and address any immediate threats to life.

Trauma courses treat us to evaluate patients using the ABC’s. In this case, A stands for airway. If someone doesn’t have an open airway, they can’t breathe, and no oxygen gets into the body. If that occurs, the game is lost. So airway management is the first priority. The B is for breathing, making sure the patient is getting oxygen into the lungs. Like airway problems, if there’s no oxygen getting into the lungs and out to the body death is imminent. C stands for circulation, to insure that the heart is pumping and that blood volume is sufficient to get oxygen from the lungs to the body tissues. We’re taught that when you find a problem, you stop, fix it, and only then move on to the next phase of care.

(The ABC system is, in many ways, backwards to the way most of medicine thinks. Normally when you see a patient, you would complete a full history and physical exam, order some diagnostic tests, and then initiate specific treatment. In this case, you treat the problem first and later figure out what caused it. Over time, you learn that the real benefit of the ABC system is that it’s not limited to trauma care, but that it applies to any patient in the ED no matter what the problem. You can do the ABC exam in 5 seconds. If you ask the patient a question, and they can verbalize a reasonable answer at a reasonable volume, you know that the airway is okay because air gets in and out of the lungs past the vocal cords; that breathing is good because they are able to move enough air to talk; and that circulation is okay because they’re pushing enough blood up to the brain to formulate and answer. That doesn’t mean that someone’s not ill or injured, but it buys you some time to do a more detailed history and exam. It can also be applied to the assessment of blind dates, but that’s another story.)

Rocky’s airway was open, and he was breathing. His oxygen levels, for the moment at least, looked good. He had no blood pressure to speak of, so in addressing his circulatory status it was our task to find the source of blood loss. It wasn’t hard, especially when there’s three pounds of bloody gauze and a hardend layer of duct tape over the leg.

While everyone else was hard at task, I enlisted a tech to help me remove the dressing. First we cut off the tape with those heavy medical scissors that actually will cut of a finger if you’re not looking. (I’ve seen it done.) You never want to rip a dressing form over a wound. If you do, you might also tear off any blood clot that might have formed, making the bleeding worse. The other reason is so that you can gradually peel away the dressing from the wound, looking for specific bleeding vessels as you go.

In Rocky’ case, there was no clot to beware of as the bleeding had never stopped. (That’s Coumadin for you.) The wound was a bloody mess, a seething pool of dark red sticky blood with no visible point where we could get control of it. But at that moment he twitched his leg just a bit, and suddenly we saw a spurt of blood come from the lower edge of the wound. Blocking the flow by compressing the skin just below it, we were able to get to bleeding to wane, and I was able to see the beveled edge of a severed vein. Letting up on the pressure just a bit, we saw the blood flow resume, saturating the towels we had placed beneath his leg; pressure again, and once more we were able to see the gaping inside walls of the vessel.

Now things became mechanical. Once you find the source of bleeding, you can usually tie it off. Taking a clamp holding a threaded needle, I looped the suture through the soft tissues around and behind the vein and brought it back around to the front. Using my own awkward version of a surgical knot, I cinched it down five times. (I’ve always placed five knots on top of one another when I do sutures. No idea why.) I placed a second suture a bit farther along the vein for good measure, and when we released the pressure the offending vessel stayed closed.

When a patient comes in bleeding, there are really two parts to their care. Part One is to stop the bleeding. (While it is a surgical truism that all bleeding stops… general it’s good form to stop it before it ceases on its own because there’s no blood left to ooze.) Part Two is to replace what’s lost. In patients with major bleeding, looking at an initial blood count really tells you nothing about real blood loss. The body will contract the smaller blood vessels in the periphery of the body in response to major bleeding, pushing more blood centrally. As a result, an initial blood sample may have an artificially inflated value for the amount of red blood cells present. So what you look for are clinical indicators of blood loss suggesting that the body is trying to compensate. Signs that the body is shifting blood away from the body surface and into the central circulation include cool, clammy skin, profuse sweating, and a pale appearance. The body also needs to circulate the remaining blood faster to the body tissues in order to meet demands for oxygen and waste removal, so both pulse and respiratory rates rise. Blood pressure finally falls when the body’s compensatory means are exhausted.

So with Rocky still looking like a soggy ghost, and no pressure that we could find, we sent for blood. Two units of the red stuff later, Rocky was looking good. Our physician assistant closed up his laceration, he had found to his delight that morphine is a wonderful thing, and he was peering through his glasses at the form he needed to sign so we had permission to treat him. (Mea culpa…we put patient care before the paperwork. Go figure.) His pressure was great, his skin was pink and warm. He leaned forward, hand outstretched. “Thanks, Doc,” he said, grasping me warmly. “You saved my life.” I remembered that the first time I had taken his hand in mine it was cool clammy, the grip of hypoxia, the feel of death. “No problem,” I replied. “It was our pleasure.” Which was, after all was said and done, probably the only thing I could say.

But the real feelings I had were not ones of comfort, teamwork, or accomplishment. In an environment where everything by definition is necessarily wrong, nothing ever really gets fixed, and even incremental success is the exception to the general rule, many of us felt more of an incredulous, “How did that happen?” And in reflection, even as we admittedly did truly save a life, it still feels odd. I didn’t do anything more than put medical duct tape on a garden hose. The stitch I used took ten minutes to learn two decades ago, and it’s still the only kind of technique I know because my hands can’t do the creative surgical knots. Boy Scouts with merit badges in Pioneering can do better than that. My medical degree didn’t make me any smarter, more aware, or more skilled than anyone else in the room. Maybe my discomfort is because all I did was happen to be in the right place at the right time, and I feel bad taking credit for that scheduling accident. Maybe it’s more ego, as we all know that patients who are in extremis usually never recall who saved their life, and always give credit to the first doctor they see after they’re stable. Or maybe it’s because I wish that luck would hold at lottery time so I could leave The Emergent Life and never be troubled with these feelings again.

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