About four o’clock in the morning, the ring down from the medics came in as “vomiting blood.” Though vomiting blood can be pretty dramatic, this ring down did not prepare me for what I saw when the patient rolled in the door.
He was a middle-aged man who woke up with blood gushing out of his mouth. The medics had no idea how to stem the dramatic bleeding, but they were wise enough to have him lean forward and use a suction catheter to keep the blood from filling his mouth and throat and choking him.
The patient was very anxious. Though he was doing his best to suction the blood as it gushed from his mouth, it was clear he was loosing the battle.
The first rule for controlling bleeding is to put pressure on the source. It seemed like the blood was coming from the roof of the patient’s mouth. So, I put on some gloves and tried to press gauze up there. This only gagged him and made him more freaked out. It did nothing to slow the bleeding.
I stepped back and took a look at the big picture. It was clear that, unless I stopped the bleeding, this man was either going to bleed to death or die from choking on his blood. Anything I might do could hasten his demise. Yet, doing nothing would have the same result.
I prepared to intubate the patient to protect his airway. Only then, could I focus on the bleeding. We gave the patient a quick-acting sedative. As soon as he went limp, I flattened the head of the bed, tilted his head back and, with a laryngoscope in my left hand, I used my right hand to suction the blood out of his mouth, trying to see the vocal cords through which my tube had to pass. I suctioned like crazy. Yet, whatever blood I removed was rapidly replaced by bright red blood welling up from somewhere deep in his mouth. When I finally caught a glimpse of the vocal cords, I dropped the suction catheter, grabbed the tube and passed it into his windpipe.
With the patient’s airway secured, I turned my focus to the bleeding. Though I could not see the exact source of it, I reasoned that applying pressure was still the best method to stop the bleeding. I repeatedly asked for gauze pads, which I crammed into the patient’s mouth, filling all the spaces.
For a moment, I felt some relief. But blood quickly soaked the gauze and started to run out of the patient’s mouth.
More pressure. I got more gauze and packed it into his mouth. I pressed as hard as I possibly could, adding more and more gauze, until, at last, the gauze stayed white. Only then, could I relax a bit and make arrangements for the patient to be admitted to intensive care.
I later learned the patient had recently had a CT scan that showed a tumor in the roof of his mouth. Apparently, as he slept that night, the tumor invaded an artery, which caused this massive, life-threatening hemorrhage. Had he not received care in the emergence department, he would have never lived to get treatment for his cancer.
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