I smiled a little bit when the nurse handed me the next patient’s chart.
An 18 year old had come in at 2 AM complaining of blood in his stool. Other docs may have yelled at him for waiting until 2AM to be seen in the ED for this “problem.” I just figured he’d need a little reassurance about some hemorrhoids or an explanation on how to manage a fissure. No big deal. A quick in and out.
I walked in and he was sitting on the bed smiling.
“How’s it goin’, doc?”
“Good, so tell me about the blood in your stool.”
“Well, the past few times that I went, there was blood there.”
“Do you mean stool with blood in it or do you mean that you’re passing blood instead of stool?”
“There’s a lot of blood there. I went in the toilet and left it there so you could look at it.”
That’s one of those things that is sometimes helpful but that down deep very few doctors want to hear. Right up there with “I brought my stool in a baggie for you to look at,” “the poopy diaper is sitting on the counter over there” and the one woman who was attempting to disimpact herself who held up her finger and said “its about that color” – referring to the stool still stuck underneath her fingernail.
“OK, I’ll check it after I get done looking at you.”
The tech was just finishing up her vital signs (which were all normal) and I asked her to get orthostatic blood pressures while she still had the blood pressure cuff in place.
Then a funny thing happened.
As the patient stood up, he started wobbling a bit. I thought he was kidding at first. Then he started to fall forward towards the tech. I reached over the bed, grabbed his shirt, and pulled him back onto the bed. He was out cold. His face was white and his lips were pale – never a good sign. His pulse shot up to 150 and his blood pressure dropped to 70 systolic. I ran over to the toilet and it was filled with blood. Definitely not a hemorrhoid. Got two IVs in and called for blood. We tipped the head of the bed back and soon he was back in the land of the conscious again.
“Did I just pass out?”
“Yes … yes you did.”
Got him a commode in the room and he ended up having a couple more bloody bowel movements. His hemoglobin was 9, which was low, but it was probably a lot lower than that after losing all the extra blood. Called in the cavalry who admitted him to the ICU. Ended up having an AV malformation.
The next time I went to the bathroom, I passed something a little strange looking, also. It looked like this (credit):
Gotta love the ED. Even when you think you’ve got a handle on things, you never know what’s coming through the door.