Frank Blood

Sorry it's been so long since my last post... it's been a very, very busy winter.


Ugly and I respond to one of the local nursing homes for a hemorrhage. Hemorrhage calls are most often for people who think, incorrectly, that they are vomiting blood. This was not to be one of those calls.

We enter the room to find a man, in his 60s, with his wife. His wife smiles when we enter the private nursing home room. It's the pained smile of a spouse who has been at the side of their partner through years of illness; a sign that this is nothing new for her. She quickly rattles off the story, and closes with a summary of his medical history and medications--an oral report fit for med control.

The man suffers from hepatitis, and although he's in his sixties, his 6'4" body is withered, his jaundiced skin stretched tight over frail bones. His wife says his ammonia levels must be elevated; he tried to get out of bed while alone in the room. The staff found him on the floor, on the side of the bed opposite where his foley bag was hanging. I wince a little, and can't help but cross my legs a little bit. After putting him back in bed, the nurses noticed that the bag seemed to have a significant amount of blood in it. They removed the foley catheter, only to find that he was still bleeding from his urethra. Falling away from the foley bag must have tugged on the catheter, lacerating something internally. They put a towel under his diaper, the wife tells me.

I try to talk to the patient, but he's out of it. He can't answer orienting questions well. His eyes appear fixed on a distant object somewhere above the ceiling.

"Is this his baseline mental status?" I ask the wife.
"No, he's usually normal and talkative, like you or me."
I throw Ugly the "package" look, and he goes out to get the stretcher, backboard, collar bag, headblocks and straps. In the meantime, I ask the dispatcher to send an additional EMT to the scene. The patient's unwitnessed fall with altered mental status, complex medical history, and question of internal bleeding will certainly merit evaluation in a critical care room when we get to the hospital, and without another EMT, I can't perform advanced life support. Also, although he's emaciated, the patient is tall, making boarding him with two people difficult. I put the man on oxygen, take a set of vital signs, and apply a collar before my "backup" arrives. L1, a lieutenant, and the person who taught me most of what I know about taking care of people, helps us get the patient on the board and out to the truck. I give her the story as we work.

The more astute medically trained readers will have noticed that I haven't yet inspected the bleeding site.

"We should probably look at the bleeding, huh?" I ask her.
"Oh, I assumed you already had," she replies.  Duh.

As I lift the diaper and towel, I'm momentarily confused by the image in front of me. Glancing down, I see what appears to be a bright red stick extending from the patient's penis. It takes me several seconds to realize that the "stick" is actually a stream of blood, continually flowing, at a rate similar to urine's typical exit from the body. I look up at L1; "This changes things."

I tell Ugly not to waste any time, and he pulls out of the nursing home. L1 spikes a bag of saline while I wrap a tourniquet around the man's right bicep. After a moment, I run my gloved fingers up and down the inside of the man's elbow, pausing to gently press against the areas where I know there should be veins. Areas where there should be accessible veins, but there aren't. Visible scars on the surface belie the mess of scar tissue I can feel below the skin. I flip over the man's arm, looking for veins in the hand. A network of tiny, wiry veins are the only thing I find.  "I'll try, but it doesn't look promising, why don't you look on that arm?"

We go to work.  I think I feel something in the AC, and gently glide an 18 gauge catheter underneath the skin.  Nothing.  No satisfying "pop" of the needle invading a vein wall, no flash of crimson blood in the chamber.  I weave the needle in and out, angling its razor edge, hoping that it will find its target.  I pause for a moment and use the two fingers of my left hand to relocate the vein I had been aiming for, but the soft spongy spot I had felt before is nowhere to be found.  L1 meets similar frustration in the other arm.  I angle the needle slightly deeper and advance it one last time before giving up.  I shake my head, and secure the needle inside the plastic safety.  Click.  I cover the site.  "Nothing over here."  Click.  "Here, either."

I take a minute to recheck vital signs and mental status.  The blood pressure is holding, and he remains responsive despite being disoriented.

Back to the arm.

I try a new trick MTM told me about, and wrap a second tourniquet above the first.  L1 toils over the other arm.  Now I can't find anything.  I feel the soft spot just below and outside of the end of the biceps where I know there should be a vein.  I clean it with an alcohol wipe, and push another 18 gauge catheter through thick off-white scar tissue.  Nothing.  I pull the catheter back and change the angle, aiming deeper and towards the outside of the elbow, and push forward.  I suddenly feel slightly less resistance, and see a small amount of blood in the catheter's flash chamber.  I advance the needle a few more millimeters.  My index finger pushes gently on the catheter hub, trying to coax the plastic straw over the needle and into the vein.  It won't budge.  I push slightly harder, and something gives–in a bad way.  I know it won't be a good line.  Click.  I pull the needle, and leave the catheter and hub in place just to be sure.  There is no trickle of blood out of the IV.  I pull the catheter and cover the site.  Click.  L1 drops another spent catheter into the sharps box, shaking her head.

We're only a few minutes away from the hospital now.  I call in and give a quick history while L1 gets another set of vitals.  We make one last attempt at an IV, finding frustration, but no veins.  

At ambulance triage, I recount the story to the triage nurse.  I tell her that there is or was a stream of blood coming from his penis.

"Frank blood?" she asks me.

Hundreds of jokes about her choice of words run through my head.  Defeated by impossible veins, however, all I can say is "yes."

The patient is moved to a trauma room.  I don't know what his hospital course involved, but I know he survived to be transported by MTM from the same nursing home the next month.