Blood Warmer

One of the many functions of the human body is to warm the blood. A couple times in casualty my body has warmed someone else's blood.

The first patient was too weak to stand from the wheel chair and his friend could speak enough English to tell me that he had vomited blood. The bottoms of feet are not supposed to be the color of the sheets and when they are it is a bad sign. Not having a blood pressure is another bad sign. Yet anotherbad sign for a system is that this man had waited to be seen long enough for his old record to be on his stretcher. In that old record was evidence that this man had esophageal varices(enlarged veins lining the wall of the esophagus, prone to bleed because they are close to the surface and not designed to carry large volumes of blood). He had schistosomiasis which is a parasitic infection caught from exposure to water(fishermen on Lake Victoria and children who play in infected water) and a subset of people with this infection get scarred livers and abnormal circulation in vessels outside the liver.

I ordered O negative blood immediately for emergent transfusion along with two large bore intravenous lines with saline running wide open. The casualty nursing director worked on this patient along side me and ran to the blood bank for the blood. We transferred him to intensive care where his low blood pressure was causing confusion and he had to be restrained with sheets tieing his limbs to the bed. I stood beside him squeezing the cold blood bag with my warm hands. He is still alive.

The second patient came in today and was too weak to sit or stand. She was on a stretcher between the 4 beds in the women's ward of casualty. Her feet were pointed in the other direction but her eyelid linings were white, her pulse was thready and the nurse had written "unrecordable" where blood pressure numbers are placed on the chart. Her abdomen was tender in the lower half and up the left side. She told us her last period was August 20th. But there are not too many things that present like this in young women. I told the gynecology intern in the department that I thought this patient had an ectopic pregnancy and ordered O negative blood and 2 lines of saline wide open. For the second shift in a row I found myself at a patient bedside squeezing a cool bag of blood. This time the lab had no O negative blood so I had walked to the lab to explain that I needed a rushed blood typing and 2 units of type specific blood along with 4 units of cross matched blood. In the meantime there was some discussion about sending the husband to the pharmacy to purchase a pregnancy test. The second on-call gynecologic surgeon wanted to see the results of this test. I posed the hypothetical question that in a woman who had no bloody vomitus or bloody stool, had a tender abdomen and no blood pressure, what would they do if the pregancy test was negative. I didn't get an answer to my question. A few minutes later the pregancy test came back positive and two and a half hours later this woman was taken to the operating theatre. The intern told me afterwards that there was about three and a half liters of blood in the woman's abdominal cavity.

Both of these patients survived their time in casualty. Each is an example of the lifeboat approach to care to which I have alluded in a previous post. A whole host of questions arise about systems, culture, training and case management as a result of these two cases. Some of these questions I am ill fitted to ask, much less answer. I share these experiences and have not entirely succeeded in withholding judgment in their telling but withhold judgment I must. A greater understanding is required. For now I am a blood warmer.