A Tale of Two ER Patients

The blood came gush from the nose

Staining the floor and the clothes

But a Merocel pack

Slid from front to the back

Brought a stop to the flood, I suppose.

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia, to which we have returned. Any identifiable patient information has been included with permission.

A tale of 2 ER patients.

I find the process of transferring patients out daunting and frustrating. The remoteness of the community demands stewardship of the two ambulances with their crews.  Thus, when possible, I send  patients to Prince George via POV (privately owned vehicle).

Even then, the process of stabilize-and-transfer can involve an hour or two of ER time when I get to chat with a patient.

I got to talk with a chef, who gave me permission to write a good deal more than I have. His camp, with 120 workers, employs three cooks, each responsible for one meal a day.  We had a great time talking about gravy; we agreed that corn starch beats flour for thickener, and that a good broth or stock means more to the sauce than the drippings.

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I gave a different ER patient the reverse of my usual dietary advice. Eat three scoops of premium ice cream at bed time, I told her.  Don’t drink water, always make sure your beverage has calories, especially high fructose corn sweetener.  I described how the Iowa beef industry uses it to accelerate fat gain in cattle.   I told her not to eat anything without gravy, mayo, or a sauce.

At the end, I said, “I write a blog. I won’t mention name, diagnosis, or age, but I’d like to write about the eating plan I gave you, the opposite of what I usually give out, how poison for one person is life-saving for another.”

She waved her hand and said, “You can use my name if you like.”

 

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During my IHS time in New Mexico, I saw 2 or 3 major nose bleeds a week for 18 months.  In that time, I became skilled at packing the front part of the nose to stop the bleeding.  Most times I could get the stanch the flow, and when I couldn’t, I knew what to do to get the patient to specialist care.

But since then the nose bleeds I’ve seen were simple, easy to stop temporarily followed immediately by a touch with a silver nitrate stick for permanent resolution. .

But the problem of serious epistaxis (bleeding from the nose) relies heavily on equipment, and the equipment has changed in the last 30 years. Our hospital has specialized catheters with inflatable balloons (the Rapid Rhino), and sponges made of material that promotes clotting (Merocel).  We also have tranexemic acid, unknown in the 20^th century

For the time frame involved, I’ve seen more than my share of complicated nosebleeds this trip. I discovered that the closest Ears, Nose, Throat specialist doesn’t take call, and that most of the ER docs cheerfully confer by phone.

Cocaine, nosebleeds, and snakebites: lessons learned in a hurry and not forgotten.

Is cocaine the thing that you need,

When it comes to a nose that would bleed?

     Would some other med

    Do the same job instead?

It depends on the books that you read.

I did my residency in Wyoming.  Thirty years ago, I had a license and when I had a free weekend I could work where doctors needed help.  Most places paid fifteen dollars an hour; a seventy-two hour weekend could generate a lot of cash for a young man who had just finished twenty-one years of student poverty.  I soon found that the value of the learning experience exceeded the importance of the money.

In a large state with very few people, before the Internet, I found the pressure of dealing with medical problems outside my experience stimulated me to read, learn, and retain. 

Once, the ER where I was moonlighting got a call about a person who’d been bitten by a snake and would arrive within five minutes.  I had never seen a case of snakebite, but I went to the bookshelf, pulled down Rosen’s two volume Emergency Medicine, and read as fast as I could.  I looked up; no patient, but I had another minute before arrival.  I pulled down Harrison’s Principles of Internal Medicine and read what it had to say about snakebite.  The patient now three minutes late, I took a breath and started plowing through the books at hand.  Twenty minutes later, amazed at how much I’d learned in so short a time, I went to lunch.  The patient never arrived.

When confronted with a frightening nosebleed, Emergency Medicine provided me with a chapter that shines as a paragon of what medical writing should be: a review of the anatomy and physiology, elements of history and physical, proven techniques, and pitfalls, in a concise ten pages.

I faced an epidemic of nosebleeds at the Indian Health Service hospital where I worked fresh out of residency.  I could never determine if my hospital alone or if the area IHS hospitals in general had had their supplies of cocaine removed, nor for what reason.  I knew, for sure, that when I was confronted with the only legitimate use of the medication, nosebleeds, or epistaxis, I couldn’t get my hands on the drug of choice. 

We made do with 2% Lidocaine with epinephrine.  For a year and a half I saw a minimum of two major nosebleeds a week.  Most were the common variety, where the bleeding comes from the front part of the nose, but we also saw the terrifying bleeding from the back part of the nose.  I remember calling up the consultant in the big city at the other end of the highway and saying, “The patient has my best anterior (front) and posterior (back) nose packing job and he’s still bleeding, I’m afraid you’re going to end up ligating (tying off) his external carotid artery.”

“Nah,” he replied, “I haven’t had to do that for ten years.”

He called me the next day and said, “I had to tie off the external carotid.”

My experience with nose bleeds has stood me in good stead ever since, and yesterday I took care of two patients with that problem.  For one, I simply pinched the soft part of the nose shut for five minutes, and the bleeding stopped.  When I looked at the middle part of the nose, I found diffuse redness. 

The dry air in Barrow gets worse in the winter, and noses desiccate and bleed; most of those patients don’t need anything more than a little bit of Vaseline a couple of times a day.

When I looked at the other patient I found a snake-like varicose vein, the origin of the bleeding, about the length of an eyelash.  Numbing the area the way I’d learned in New Mexico, I touched bleeder with a silver nitrate stick for three seconds.  The nitric acid from the stick created a burn, and the vein stopped functioning as a blood vessel. It won’t bleed again.

It hurt like the dickens.  The Lidocaine hadn’t done its job as anesthetic, not like cocaine.