If it Bleeds, it Leads………

This is our 1st case in a case series exploring the care of patients with GI related illnesses in the Emergency Department.  Similar to our "Out on a Limb" and "Sepsis Smackdown" case series, the case presented is followed by a series of questions, with a discussion in the comment section facilitated by the post authors.  In approximately 1 month, the authors of the post will conduct a combined simulation/small group session reinforcing the learning points from the posts during Grand Rounds.  Around this time, they will also curate the comments from the discussion and publish a post highlighting these learning points.  Looking forward to a great discussion!

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Case by Jessica Nelson, MD

It’s late on a Saturday night and you are moonlighting as the single provider at a community hospital about 15 minutes from UC. You’re trying to disposition five current patients when a new patient is brought in by EMS with a complaint of vomiting blood. The patient smells of alcohol and states that he drinks daily, though he may have “overdone it” the last 2-3 days since he has had friends in town. He is 48 years old and denies any past medical history. He agrees with your records showing that he has not seen a doctor in more than 5 years. He denies taking any medications and does not have any allergies. His initial vital signs are: Temp 98.1°F, BP 105/45, HR 125, RR 24, O2 saturation 98% on room air. Your exam reveals the following abnormalities: dry mucous membranes, tachycardia, a diffusely tender abdomen, and melena on rectal exam. Labs are significant for:

• CBC: wbc 13.1, hemoglobin 8.9, platelets 120
• Basic metabolic panel: Na+ 127, Cl- 90, K+ 4.5, CO2 10, BUN 56, Cr 1.7, Glu 230,
• VBG: 7.15/30/-10    Lactate: 11.7
• Hepatic panel: Bili 4.5, Direct bili 1.2, AST 894, ALT 560, Alk Phos 90, Albumin 2.4
• Lipase: 124
• INR: 1.5

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When responding you need only respond to 1 or 2 questions (leave some fodder for others!) and please begin your response with Q1, Q2, etc, denoting to which question you are responding.

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Question 1:

What additional work-up and initial treatment would you like to do for this patient?

Question 2:

Repeat labs after your initial resuscitation show a hemoglobin of 7.1, lactate 14.3, and VBG 7.12/30/-10. The patient has not had any significant change in his vital signs. Your hospital does have a MICU, but it is staffed overnight by residents and a tele-ICU attending only. There are no specialty services in house overnight other than surgery, and GI will not be available for endoscopy until tomorrow (if the case is emergent) or the following day (it’s a weekend after all). Do you admit or try to transfer the patient? If you transfer the patient, what type of service do you choose for the transfer (i.e. air, mobile ICU, ALS, or BLS) and why?

Question 3:

The patient has two, large volume bowel movements in the ED which are consistent with melena. He also has one episode of vomiting which results in a small volume of coffee-ground emesis. Does this change your management? If the patient then vomits a significant amount of bright red blood, how does this change your management? If you are going to do any procedures, please explain how you are going to carry them out and what key resources you will need (meds, personnel, equipment, etc.).

Question 4:

Secondary to his illness and worsening mental status, the patient has been unable to provide you with any information about family or emergency contacts. His girlfriend eventually shows up in the waiting room. What do you tell her about the patient’s condition and prognosis? If you find out that she and the patient have been together for years and she states that she is his common law wife, how does this change her status as a potential decision maker for the patient? What is the legal hierarchy for surrogate decision makers in Ohio?