Code Blue I

I often write about code blues where I run in, intubate a patient, transfer them to the ICU, and save the day. But this is a minority of situations; the real code, the helpless one, the one sometimes shown on TV, the one we all dread, is much harder to write about.

A 90 year old gentleman with a history of high blood pressure, atrial fibrillation on anticoagulation, coronary artery disease, heartburn, and osteoporosis comes in "not feeling well." He had an episode in the morning where he almost blacked out. In the emergency department, he has very low blood pressure and is witnessed to vomit blood. IV fluids are started and stat labs are sent which reveal a hemoglobin of 5 (normal 13-17) and an INR of 25 (normal 1). Meanwhile, the patient has vomited blood again and is having melena (black tarry stools) in the bed.

Immediately, more IV access is secured, but a large hematoma forms where someone tries to get a 16gauge IV in. FFP and blood is ordered and started. The diagnosis is clear: the patient has a "supratherapeutic" level of coumadin; for whatever reason, his home blood thinner for atrial fibrillation has become way out of control. The goal is an INR of 2-3 in atrial fibrillation, and here, his value is way above that, a reflection of how thin his blood is. If he bleeds, he cannot clot. And he is bleeding; the symptoms show exsanguination from the gastrointestinal tract. By textbook, he has an upper GI bleed with hematemesis and melena. ICU is called.

I rush down to admit this patient. When I see him, he is responding slowly to voice, saying "I just feel so weak and dizzy." His heart and lungs are unremarkable but he does have some abdominal tenderness and is having a black bowel movement concerning for blood. The ED resident is doing a quick ultrasound to look at the heart. Both of us spend a minute talking about how we'd like better IV access since we only have an 18g and a 16g IV. The blood products are hanging. In my mind, I know the most important first steps: get IV access, transfuse, secure an airway, and then see if interventional radiology or GI can intervene.

I step outside the room to check the EKG, and three minutes later, when I look back, they are putting the patient in Trendelenberg (head down to help blood flow), wheeling the bed out (a bad sign that the airway has been lost), and calling for help. It seemed that moments after he and I chatted, he stopped responding; I may have been the last person he talked to. The rest of the post tomorrow.