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Bleeding Herself to Death

Posted Jan 07 2009 6:04pm
It was a rather ok night on-call yesterday. I wasn't too busy, but was kept going all night. However, my colleague, M, was quite stressed out with a really young lady, aged 33. She came in a few days ago with ascites secondary to alcoholic liver disease and menorrhagia. At that time, her haemoglobin was quite low at 6.1. Throughout the course of 2-3 days, she continued to have menorrhagia, and dropped her haemoglobin to about 5.3.

She has been relatively haemodynamically stable, as she has been receiving constant blood transfusions. However, yesterday afternoon, she deteriorated. She basically was bleeding profusely PV. My day colleagues (junior docs) tried to stablise her, and managed to get the SHO in Obs & Gyn to review her. However, they were not going to bring her into theatre or do any intervention as she was at risk of bleeding (her PT was 1.5). Having alcoholic liver disease was another reason.

So anyway, the only thing that my colleagues were advised was to continue with the blood transfusions. The poor lady was left to bleed all day until we night staff came on. Her condition further deteriorated, in which, her BP dropped quite significantly, became tachycardic at about 160 bpm, and was only saturating at about 80% on 2L oxygen. She was rigoring badly without a temperature. At that time, she has received about 11 units of RBC,a couple units of FFP and pools of platelets, and an infusion of Factor VII. All of us thought that she was going to go into a cardiac arrest. I was there to help M, as she appeared quite distressed about the whole situation. What happened was, she spilled the mixture of Factor VII on the floor while trying to prepare the infusion. It wasn't her fault, as these things happen especially at time of stress. The only thing about it was Factor VII is actually really expensive, think it costs a few thousand quid! So she asked me to prepare the mixture for her.

Our seniors were there to provide help. Almost everyone was involved, the consultant haematologist, consultant gastro, consultant O & G, ITU registrars, etc. It is SO TYPICAL that no decisions were made during the day, and only now, in the middle of the early hours in the morning, everyone begins to take the poor lady seriously. The registrar in Obs & Gyn was called in and she agreed that patient needed to be treated. She phoned her consultant who came into the hospital within 25 minutes. Unfortunately, he wasn't keen on taking her to theatre (her PT has dropped to 1.3). I mean I totally understand that she might eventually bleed to death in theatre, but are there just going to watch her bleed herself to death? Hysterectomy was not an issue as the patient was happy to proceed it with. What about something less invasive, like embolization of the artery?! I know I have totally no experience in this area, but I personally think it might be worth a shot.

So basically, the bottomline was we were pumping blood into her and she was losing it at the same time! Miraculously though, she stopped bleeding totally about 2 hours later and she told everyone that she was feeling great. I found out from M that despite improving marginally, there still wasn't any decisions made as to how to help this poor lady. She was eventually transferred to the O&G ward, where I am sure they could keep a close eye on her menorrhagia.
The cause of her menorrhagia was put down to dysfunctional uterine bleeding.

It is amazing how just ONE patient, could take up all your time and energy the whole night. M was totally knackered and I think the only thing that got her going was her engagement to her now fiance a few days ago. Congratulations to her.
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