The Tale of 5.9. Part 6. Expectations.

What will happen to this lady who is hemorrhaging out?
Variceal bleed. Massive transfusion protocol initiated. 2.5 liters suctioned out into the cannisters. 2 units of fresh frozen plasma in 2 units of packed red blood cells. No platelets yet until I get to 4 of prbc and ffp. No whole blood transfusions are available here.
Patient is sedated on precedex drip without bolus. And being given fentanyl or dilaudid ivp as needed for analgesia. She opens her eyes to voice. She nods and shakes her head when asked questions. I hadn't paralyzed her with Rocuronium or Vecuronium. She recognized me and I updated her on her ordeal that she was very sick.
I have to explain to the husband of the patient that I don't have GI to scope here and band her known varices, and my acute care surgeons can do upper endoscopy but dont have the training to band these varices. Patient not stable enough to get a TIPs procedure by interventional radiology. Plus we dont have that service at my hospital. No icu beds here plus we dont have in house intensivists. I have to transfer her. I make phone calls locally. No icu beds at close hospitals more than 1 hr drive each way. Perhaps 25 minutes if flown by helicopter.

I don't have my hail mary for massive upper gi bleed, the Blakemore or even Linton tube.
Only placed them once in a live patient and the rest of the time in a simulation lab. That one patient lived. A surgeon and em doctor had to insert one. To be honest, I watched really. I didnt insert it myself. Instructions had to be read before it was inserted in an upper gib in a liver cirrhotic patient from hepatitis b. Not a drinker. Fortunately that Blakemore tamponaded the large gastric ulcer she had. Tamponaded enough for the ulcer to clot off as per GI who scoped her in the ed and removed the Blakemore tube. He had never inserted one in his training or career.

#resuscitation #emergencymedicine #expectations
#massivehemorrhage #gib #uppergibleed #emergency #hemorrhagicshock #massivetransfusionprotocol
#ruralmedicine #locumtenems #locumslife