(Transcript is automatically generated)

Matt: [00:00:00] he turns his head to the side and it was like, it was like horror movie.

Erik: He had an appendicitis in. Oh, he had a necrotic appendix. That's actually what ended up being his worst problem.

Matt: Okay. And that's why he was vomiting.

Narrator: You are listening to EMS with your hosts, Erik Axene and Matt Ball.

Matt: I'm actually unsure about this whole leech idea.

Erik: Yeah.

Matt: That you come up with.

Erik: Well, so it started with that Vitology book from the standard medical practices mm-hmm. Of the, uh, of the 19th century in the 18 hundreds,

Matt: which side note is from, for the us old people.

From the Vitology album, from Pearl Jam from the early nineties.

Erik: That's

Matt: right. Most of the young kids are out. They're like, what's a Pearl Jam? What's Vitology?

Erik: Right, right.

Matt: But anyway,

Erik: sorry. I own that album. That was good. That's a great album. And so when I saw the cover of this book, I was like, that's where the cover came from.

I didn't know that. That was cool. [00:01:00] But uh. The, um, the, the cool, the cool part about, um, the leeches, it's actually two things I think that are pretty cool about the leeches. Uh, back in the 17 hundreds, even earlier in Egyptian, you know, medicine mm-hmm. They would use leeches mm-hmm. Uh, for bloodletting.

Matt: Yeah.

Erik: And it became the standard of care for medicine.

And in fact, it was so associated with, with medicine. That, uh, in old English, the word for doctor, they derive from leech.

Matt: Really?

Erik: Yeah. Le I can't, it's a weird spelling, but it, I guess they have, there's a common word, you know, you know, origin? Mm-hmm. In the old English, uh, ese or something like. That. Mm-hmm.

Which was really because of the association people made with leeches and medical care for,

Matt: It should have been more for attorneys that they would be associated with leeches, not doctors. Just kidding.

Erik: Just kidding. Well,

Erik: but you know what's interesting too, as I was reading about it, they actually, it, it created almost these, these leeches almost went extinct.[00:02:00]

The, the scientific name is Hirudo medicinalis, or something like that.

Matt: Medicine Alice.

Erik: Which reminds me of the second reason. I think it's interesting, not only that they've been used in medical practice for centuries, but, and that they're still used today. Mm-hmm. Which we'll talk about. Mm-hmm. Uh, but the other is the Hirudin, I think it is.

It's the, it's this compound in their saliva that is an anticoagulant.

Matt: Yeah.

Erik: Um, just to facilitate the, the blood from the host, if you will.

Matt: Mm-hmm.

Erik: Um, and in the saliva they've got peptides that are an, like an anesthetic. Mm-hmm. So it numbs the, the, the host. Mm-hmm. So they don't know that they're there.

And then there's also, um. That another peptide that in really increases blood flow. It stimulates histamine and uh, so you got the increased blood flow, the anesthetic, the anticoagulant, and these leeches, that's how they, that's what they do. They suck that blood out. So what is the use today?

Matt: I don't know, you tell me.

Erik: Well, [00:03:00] micro surgeries, so, uh, I had a patient once he'd, uh, cut his thumb off in a dump truck door accident. Okay. The dump truck doors that slammed down. Yep. His thumb was in there and that thousand pound door just took his thumb right off.

Matt: And that's a bad appendage to lose your Opposable thumbs. Separates us from the primates.

Erik: That's right. That's right. So he was, he was, he was a gorilla for a while and he became a human again because of these hand surgeons.

Matt: Because of the leeches.

Erik: Yeah. Well, the leeches are very important after surgery.

Matt: Uhhuh.

Erik: So when you take, uh, when a micros surgeon, a like a hand surgeon Yeah. Uh, or the microvascular surgeon.

Right. All sorts of different names for things. But the point is when you repair vessels mm-hmm. Reattaching your thumb. Mm-hmm. You gotta, you know, obviously there's gonna be some structural things that need to be attached and there's gonna be some, uh, you know, blood vessels mm-hmm. Mm-hmm. That need to be reattached too, right?

Mm-hmm. So those micros surgeons will reattach those, uh, the arteries. Mm-hmm. Arteries start pumping [00:04:00] blood to the thumb right away. It's not a problem getting blood. To the thumb. Oh, the problem are the veins. The veins take a while to heal and to start working. Mm-hmm. And so you'll get blood to the thumb.

Mm-hmm. But the blood's not getting removed from the thumb, so you end up with a congestion problem. Oh,

Matt: okay.

Erik: And so they put the leech on the thumb to remove, to pull blood out, to keep the circulation going. So the leeches have really become really crucial, um, to the healing process of. Of these, like, of that thumb for example.

Mm-hmm. That reattachment of the thumb. Hmm. Um, and so leeches have a place in medicine today. Really important. That's interesting. A lot of people have that gentleman that I've got to see. Um, his thumb was reattached. Mm-hmm. And so, um. Postoperatively, they keep the room warm. You got lots of like cotton gauze around his hand just to soak up the, the blood.

And they keep replacing the leeches. Leeches will work for 15 to 60 minutes.

Matt: Okay.

Erik: Um, and I'm not, I don't deal with the inpatient [00:05:00] management of these things. Right. But, uh, there was, uh, very interesting to see the leeches saving that man's thumb. That's pretty,

Matt: that's crazy.

Erik: So we decided, because of all of

Matt: this, well, what's, what's this?

We. You decided,

Erik: well, you know, well, you and I agree that we, we like to find an engaging sort of a,

Matt: well, GI bleeds isn't the most interesting topic

Erik: either.

Matt: No, it's not. Yeah. It's

Erik: so in yesteryear medicine.

Matt: Yeah. Yeah.

Erik: They would use leeches to treat GI bleeds.

Matt: Mm-hmm. Crazy. And where would they put those bleeds, Eric,

Erik: around the anus and on the abdomen.

Um, and the, the thought was back then is that the GI bleeds were caused by blood congestion, so they wanna remove blood.

Matt: Mm.

Erik: Um, to fix the GI bleeding. And as we know, right. As you're losing blood.

Matt: Yeah.

Erik: Pulling more away is really the answer.

Matt: Yeah, exactly.

Erik: Uh, so I thought that was interesting when I learned that, when I read that Uhhuh.

So I thought what a cool, uh, idea for our lectures to pull the medicine from yesteryear.

Matt: Yeah. I [00:06:00] wished I would've now answered that call when you called me the other day and I was at work about, Hey, I got some cold open ideas so I could have maybe hedged this off. Oh yeah, that's right. Yep. Too late now.

Erik: Well, there are other things too they did to treat GI bleeds. Uh, beef broth enemas. Uh oh.

Matt: Lovely.

Erik: They, they believed, well, even the causes, they believed it to be, uh, anxiety or, you know, being, uh,

Matt: the, the cause of a GI bleed.

Erik: Yeah.

Matt: Okay.

Erik: It's like, like mental things and spiritual things, right? Yeah. That were causing the bleeding.

Um, the, um. And some of the other treatments I thought that were kind of interesting too, is no, like they put you in a dark room mm-hmm. With no sound, very quiet and no stimulation. They felt like that had a lot to do with the bleeding to treat a GI bleed.

Matt: Hmm.

Erik: Uh, just kind of ridiculous stuff back then.

It wasn't ridiculous though. Yeah. Standard of care. Uh, that, that, that, I mean, that was the, the medical practice journal of the day.

Matt: Yeah. Right, right.

Erik: That's what

Matt: they did. [00:07:00] So. We're talking about GI bleeds.

Erik: Yeah.

Matt: Did I ever tell you my GI Bleed story?

Erik: No, let's

Matt: hear it. And it's not, it wasn't a patient. It was I was the patient.

Erik: You were the patient.

Matt: I was the patient.

Erik: Let's hear it.

Matt: Yeah. This was,

Erik: did you use leeches?

Matt: I did not. Thankfully.

Did

Erik: your doctors use leeches?

Matt: I wanted to use anything. 'cause I can tell you the pain was not fun. Uh, yeah. This would've May of 2020. Uh, we had actually had a. Um, get together at the house. We had several members of my crew, we had some police officers, whatever.

Anyway, we had a big barbecue at the house. Good, good. Friday night, whatever. But May of 2020. So we are right at the beginning of COVID, right. So, you know, hospitals and everything. We probably would've got shut down 'cause we had people over our house anyway, uh, everything's fine, feel fine. Everybody leaves, you know, go to bed at whatever, midnight or whatever.

And I wake up and I've got this like knot in my stomach. Not abnormal, you know, happens. Right? Feel a little bit nauseous anyway. Go in, don't really, don't really get sick. [00:08:00] But then I get this like surging pain. Hmm. So it's like, or it, it like comes and goes. And when the pain comes, I mean, it comes on strong.

It's like an eight or nine outta 10

Erik: knocks you down.

Matt: It's a, well, I'm laying in bed and I mean, it's like,

Erik: okay,

Matt: like, oh, like a real bad gas pain. Mm-hmm. But painful and it gets worse, and then it'll kind of go away. It's like, okay, it's gone away. Or good. 10, 15 minutes later comes back again. Oh, here comes again.

Erik: At this point, did you have an idea what you thought it was?

Matt: I had no idea.

Erik: Did you have any thought? You're such a smart guy. I thought, no.

Matt: I'm

Erik: just like, what the heck's going on?

Matt: No. I just knew, I thought, you know, a gas bubble or just Okay. I mean, I had no idea what was going. On so it progressively gets worse.

Well then I feel an urge to go. The other, not vomit, but not to be graphic, but the other way, right? We've all been there with some medical podcasts. We can talk about these things. So I go into the bathroom and whatever and this progresses. I have never. Sweated so much in my life. I'm [00:09:00] not kidding you. When I say I was balled up, this is like two, three in the morning.

Now I am balled up on my bathroom floor. I am literally sweating from the top of my head to my feet. Every inch of me is just soaked in sweat. My wife comes in. Or knocks on the door like, Hey, are you okay? I'm like, I'm fine. You know the typical male answer, right?

Erik: You are not okay.

Matt: I'm fine, I'm fine. Uh, do I need to call 9 1 1?

And I'm like, not just know, but heck no. Calling 9 1 1, I'm gonna

Erik: die before

Matt: you call 9 1 1. I'm not calling them out here at three in the morning for my belly ache anyways.

Erik: Actually, probably should

Matt: have, but I probably, well, I didn't realize it at the time. Yeah, but I probably, so this progressed. Uh, on and off for four or five hours.

Just this pain. Oh, that long. I didn't believe you were there that long. Oh, yeah, yeah, yeah. I was on the floor bathroom. It would subside. Okay. Maybe it's bad. I thought it was just something I ate or whatever.

Erik: Mm-hmm.

Matt: And so finally it was around, up around five o'clock or so in the morning. And I kind of felt like it's, the pain started to [00:10:00] go away and I thought, okay, maybe it was just something, it got outta my system.

I'm good now, and I didn't wanna keep waking up my wife, so I just went out and laid on the couch. Yeah. I, I'll just sleep. I'm exhausted at this point from mm-hmm. Just not sleeping and the physical trauma that I just went to for the last five hours. Right. That's what

Erik: happens when you're in shock

Matt: and I'm dehydrated.

Right. I'm totally dehydrated. And so now I just have this dull ache in my stomach, but it's manageable. It's like two or three. It's manageable. I can lay down and kind of get comfortable. Well, then I feel the urge to go again and I go, and this time as I'm cleaning up, it is nothing but blood. Bright red blood, and I'm like, well, that's not good, right?

That's when I realized like, oh, this is not good. There's something. So that's when. I didn't wanna freak my wife out, but I went in and I woke her up. I'm like, Hey, I think you might need to take me to the hospital. And she's like, oh my God. 'cause I don't ever, like, if I say I'm gonna the hospital, like it's, I've chopped my arm off bad.

Erik: You basically told your wife, you think you might die?

Matt: Yes, pretty [00:11:00] much so she, we get loaded up and she's kind of panicking, but I'm like, I'm fine. And, and now the pain's starting to come back a little bit and I'm like, okay, yeah, there's something definitely going on more than just a stomach ache. This is not just something I.

We get in the car and we're trying to decide. 'cause the hospital that you were at, the hospital where she worked at was about a 45, 50 minute drive where the hospital that's a little bit closer was like a, I'm like, just go there. I'm like, I've, this pain has gotta stop. I am in excruciating pain and I want it to end.

It takes me to the hospital. It's COVID. She can't come into the er. So I literally like walk in, doubled over into the ER and I'm like, Hey, you know my stomach's hurting. And they're like, okay, there's nobody in the waiting room. Right? It's like six, seven o'clock in the morning. They were very good.

Hospital staff was great. I was sat there for like 10 minutes. They come, got me, guy comes, gets me, does a triage, gets me right in the room. Doctor comes in and. Uh, you know, kind of does a quiz, quick assessment, what's going on. And so I tell him the story and he's like, okay. He goes, well, you know, we need to get you back to [00:12:00] make sure it wasn't an ischemic bowel to where it was twisted, because that's like immediate surgery is what he was telling me.

Mm-hmm. That's the biggest threat, right? Yeah. So that's what they wanted to rule out immediately. So he's like, let get some orders put in, I'll get you some pain meds. Cool. The nurse came back in, guy nurse came back in and he is like, okay, we're gonna get a line on you. And he goes, and the doctor's ordered you, ordered you 10 morphine.

And I was like. 10 of morphine, like I'm not a big guy and I'm thinking that's a lot of morphine. 'cause I've given people like two milligram doses of morphine. So I'm thinking, dang, that's a lot. I'd never had. I'd never had IV narcotic pain meds at all. Well, I can tell you, I know why people get addicted to

Erik: it worked.

Matt: Oh my gosh. He pushed that in and I mean, this is, at this point, I'm like seven hours into feeling a lot of pain.

Erik: Yeah.

Matt: And he pushed that. And immediately as it pushed into my face relief, I felt this warmth just come up my spine and just like everything, just relax. Like, oh, oh, that feels so good. It's just like this warm sensation, pain goes away.

Anyway. Ended up having [00:13:00] ischemic colitis. I got admitted to the hospital for four days. COVID wife couldn't come visit me. Sat in a hospital room for four days. Um, don't, he said I probably just got dehydrated and for some reason. This just happened. He's like, I don't, he didn't really kind of follow It didn't

Erik: twist.

It didn't

Matt: twist. Did not twist. Yeah. It was not like, yeah, did not twist. It was just a ischemic colitis is what happened. But that was not pleasant.

Erik: Well, if there's a doctor listening right now, they're going to, they, I know. I'm thinking, uh, the classic. Board exam question is a lot of pain. Like the worst pain in your life.

Mm-hmm. But not tender. You push on it. It really doesn't hurt that bad to push on it. It's, it's that the pain You have this sky high. Yeah. I

Matt: had no tenderness.

Erik: Do you remember? No. Yeah, that's classic. I don't remember

Matt: having any tenderness.

Erik: See, that's a big warning for us. You get a patient that comes in with this awful abdominal pain.

Matt: Yeah.

Erik: And then you push on 'em. Nah, it doesn't hurt. Hm, but that's terrible pain.

Matt: That's for what? What's that? The

Erik: ischemic is, oh, ischemic is bowel disease. Okay. Yeah. Ischemic, ischemic bowel. [00:14:00] Yeah. You get the lack of blood flow to the gut. It's extremely painful, but not that tender. This is painful.

Matt: Yeah.

Erik: So pain out of proportion minus any tenderness on exam, which is atypical, right?

I mean, right. You get somebody with a bad diverticulitis or it's appendicitis. Yeah. Right. You get those peritoneal signs where it's a lot of pain, but

Matt: hit the heel.

Erik: Exactly. Hit the heel. Touch 'em. It's just a lot of guarding and a lot of, what's

Matt: the point called mc, not

Erik: mc, mc

Matt: burn's.

Erik: Okay. For appendicitis.

Matt: Yeah.

Erik: So you had that, so ischemic bowel, and you were in the hospital for a number of days and that, that gi bleed, you had a lower GI bleed.

Matt: Mm-hmm. Yes. Bright red blood.

Erik: Yep. So they would've, and yes, your year, they would've put some lees on my leges, on your anus and, and, uh, on your abdomen. We joke, but that was the standard of care.

Yeah. That's what they thought. That's what they thought. Yeah. And that would obviously not have helped you

Matt: treating cancer. I mean, can you imagine like a hundred years from now, they're probably gonna be like, you know, when you got cancer, they used to give you chemo and radiation. I think about some that like the poison that we

Erik: C-collars.

Matt: Exactly. Right. I think about that sometimes. Like, you know. You [00:15:00] look back a hundred, a hundred years ago, like cars were just invented.

Erik: Oh, I know.

Matt: Right Now look at all the technology. Just imagine. Anyway, we're getting off topic, but it's interesting leeches.

Erik: Yeah. So GI bleeding is a common thing that we can see.

You can bleed from lots of different areas. Mm-hmm. But the GI system is a commonplace, very vascular. Mm-hmm. I think I read 20% of our cardiac output goes to the. The mesentery, the GI system's, blood supply. Mm-hmm. And we need it too. Right. When you eat something, the body's gotta reabsorb and deliver the nutrients from our GI system.

It's always active.

Matt: Yeah.

Erik: So there's a lot of blood interfacing with our GI system. So you have a problem with the GI system.

Matt: Yep.

Erik: You know, you can, you can bleed pretty bad potentially.

Matt: And it's not always. Out the back. It can come out the front's or out the, the, uh, yeah. I guess one's an in hole. One's an out hole.

Not to be graphic that's, but it can come outta your mouth.

Erik: Yep.

Matt: You can get a lot of bleeding and that can be GI bleeding. You get esophageal varis, which can be horrific. Bleeding those patients

Erik: Yes.

Matt: [00:16:00] Bleed like crazy from, uh, an inflamed liver. Right. And then it. Blocks, backs up the,

Erik: usually it's usually a cirrhotic liver.

Yeah. Like from alcohol. It doesn't have to be alcohol. There's lots of causes for it. Right. Um, and it causes a lot of increase of portal pressure, blood pressure, the, the, the veins within the portal C the liver circulation mm-hmm. Called the portal circulation. Mm-hmm. Uh, causes a backup of blood, which can cause those, those esophageal.

Veins. Yep. Uh, to and get it really engorged and swollen and create varis. Yeah. It's like a pouching of blood. Yep. And then, uh, you can burst. It can burst and you can bleed a lot. So you can bleed out your mouth. You can bleed out your anus. Yep. And, uh, there are two colors, black and red.

Matt: Yep.

Erik: So typically the blood that comes out of the mouth, that's black, it's like a coffee ground mm-hmm.

Material. Mm-hmm.

Matt: It is, yeah.

Erik: Yep. And that's usually from some sort of a bleeding within the stomach. Yep. That's nice and slow, typically chronic. Yeah. And then as it, it sits, it. Yep. And as it sits there in the, in the stomach, that acid creates a, a. A metabolite that's [00:17:00] black. Mm-hmm. It breaks down that iron.

Matt: Mm-hmm.

Erik: It's in the hemoglobin into a black, um, substance. Yeah. It looks like coffee grounds. Yeah. And so you get this patient that's been vomiting up coffee grounds.

Matt: Yeah. '

Erik: cause blood's really irritating to the stomach. Mm-hmm. And you vomit up that, those coffee grounds, that's a sign that you got blood in your, your stomach.

And that's one form of. An upper GI bleed. Yep. And you can also vomit blood. That's red.

Matt: Yeah. Bright red.

Erik: And you can also vomit up like a maroon color blood, like a dark red. Mm-hmm. Which would be like what you get from a variceal bleed from an alcoholic, for example. Mm-hmm. But I had a patient wants to tell you a story.

Okay. This guy, he came in, I'm, I'm taking a history from him. He came in for vomiting blood.

Matt: Okay.

Erik: He and I were having a conversation just normal. Mm-hmm. Just like you and me. Mm-hmm. And, uh, he was feeling nauseous. We got him some Zofran and we're, you know, I'm a new doctor. Mm-hmm. This is 20 years ago.

Matt: Mm-hmm.

Erik: And I'm asking him questions and, and all of a sudden he said, I need to vomit. And so I got him a vomit basin and [00:18:00] he. One of those crescent shaped like a moon. Oh yeah. Yeah. Crescent, moon shaped vomit basin. Like the mid pants

Matt: almost.

Erik: It was not enough to hold the blood. He was about to vomit. He almost like projectile.

Yes. Bright red blood.

Matt: Yes.

Erik: And I said, oh my goodness, this is not good. This is not good. Yeah. And so. My nurse was in there. She got the attending physician. I was in residency at the time.

Matt: She said, this guy doesn't know what he's doing. Get somebody.

Erik: I was like, this guy was so sick.

Matt: Yeah.

Erik: Anyway. Was he jaundice?

Uh, he was a little pale. Yeah. But not jaundiced. No, not jaundiced. So he had. Undergone some, some radiation from some, uh, some surgery, some cancer. Mm-hmm. That he had had, he wasn't that old, he was probably in his fifties. Mm-hmm. Very young. But he very young, had young, some sort of a throat cancer anyway. And some of the radiation that he was getting mm-hmm.

Caused an erosion between his esophagus. Mm-hmm. And I think it was actually. Way down an esophagus. I think there was a communication with the aorta. So it's called an aorta. [00:19:00] Esophageal fistula.

Matt: Mm-hmm.

Erik: And so that

Matt: tunnel between the aorta and

Erik: the tiny, it's almost like a pinprick. A pinhole.

Matt: Yeah.

Erik: Spray of blood from the aorta into the esophagus.

Wow. Going down into his stomach. Yeah. And the stomach would fill up with blood, irritate the stomach, and then he would vomit it up.

Matt: Which by the way, is why you do not tilt your head back when you have a severe nosebleed.

Erik: Uh, that's, uh, that's right. 'cause

Matt: you swallow it. Yeah,

Erik: that's, and so, well, for this guy super sick, he vomited up anyway, he, he got altered and my attending and I decided this guy needs to go to the or we're intubating him now 'cause he's vomiting so much blood.

Mm-hmm. I think that little aorta, esophageal fistula, the connection between the aorta of. Great vessel. Mm-hmm. And the esophagus, your food hole. Mm-hmm. Uh, food tube. Food tube. Uh, not a good, not a good place to put blood. Yeah. Uh, we intubated him and I can remember that I had one Yankauer whatever.

Yep. You know? I could not suck uc, the blood up fast enough.

Matt: Right.

Erik: And so we put two of them in there from the other neighboring trauma bay, and I got him [00:20:00] intubated. Got him to the or they needed, needed some fast repair. He needed blood.

Matt: Yeah.

Erik: And so we were able to transfuse him and. Get 'em fixed up. But anyway, that was a a, a bright red blood.

Yeah. So that's probably like, it was arterial art from the aorta. Yep. And that's so brisk and so fast that the, the, the stomach doesn't have a chance to really turn that stuff black. So bright red blood is usually a cute brisk bleeding. The maroon color or the dark red colors probably a venous bleed from like a.

Of, like we said, of varices.

Matt: Mm-hmm.

Erik: The, the, and then the, the, uh, coffee ground emesis

Matt: old bleeding,

Erik: old bleed. But sitting there for a while,

Matt: we had one very similar to that. We, we had actually been on this guy before. He was a basketball coach, big, tall guy,

Erik: Uhhuh.

Matt: And we'd run on him before, I can't remember if he had cancer.

What? But anyway, we went to his house and showed up and the truck had got there before I was on the medic. We got there right after the truck did, and we walked in and the captain on the truck walked out and he goes. It looks like [00:21:00] somebody slaughtered a pig in that bathroom. And I'm like, what? And the guy's on the truck come walking out.

Like I said, this guy was like 6 5, 6, 6. Big guy. He comes walking out and this guy is bright yellow, jaundice.

Erik: Oh no. I mean, he

Matt: is. And I'm like, oh man. And he just looks sick. And I'm like, oh man. So anyway, get him on the. Get him out to the ambulance. We're getting our vitals and everything. I'm looking for a line, same thing.

Your guy

Erik: vomited up,

Matt: I'm gonna throw up, I gotta throw up. And I'm like, okay. And there was no time. I'm sitting here bright red blood, or he turns his head to the side and it was like, it was like horror movie. Like it wasn't even vomiting. He just opened his mouth and it just poured out. I mean, again, I'm not trying to be graphic.

Erik: Yeah.

Matt: And it, I was just like, oh my God. And it was bright red. Just

Erik: Oh, bright red.

Matt: Yeah, bright red. Just, and I'm like, what is going on? And we tried to get a line on this guy. We could not get an iv. He was so sick.

Erik: Yeah.

Matt: Um, we thought about, I own him, but he was still conscious. Anyway, we [00:22:00] ended up getting to the ER and they were like, oh, I'm, I told the docs, I'm like, you might have to io this guy, put him down.

Oh, no, we'll, we'll get a line. I'm like, okay, bro. Like, I've been doing this a little while. We're pretty, I'm pretty good at IVs and I'm telling you. This guy's got nothing.

Erik: He needs a centralized

Matt: knees. Yes, exactly. Well, anyway, they ended up sticking him multiple times. Still couldn't get a lane on him.

Finally, the doctor comes in and he starts freaking out. We need to get an io. I'm like, oh, okay, Mr. Smart Guy. That's what I told you 10 minutes ago. But yeah, I think that guy ended up. Uh, passing away. I don't remember what the underlying issue was. I will, but I will never forget him turning his head to the side.

And all I can remember is like horror movie. Yeah. Level vomiting. And I mean, it took us two hours. And

Erik: he was yellow.

Matt: He was yellow. He was bright yellow. Yes. And it took us two hours to clean

Erik: the, I mean, we're talking like bright, bright red. I don't have anything red

Matt: on it. Yeah. Oh no. I, I, yeah. Bright red.

Okay. Bright red. Yeah, just it was crazy. But yeah. So it's [00:23:00] important as a EMS provider, you know, you go in these, you're gonna get called out to an abdominal pain call, right? Yeah. Those are important questions to ask, like, have you been vomiting? Have you had any diarrhea, loose stools, anything like that?

And then ask them, you know, was it bright red blood? Did it look like coffee grounds? That's a good way for a lay person to understand. Mm-hmm.

Erik: Right.

Matt: You know, say, did you have bright red emis? Like what? I don't know what that is. Like

Erik: Yeah.

Matt: What did it look like? That's, those are important questions.

Sometimes you look, especially if it's vomit, go look right. Maybe take a picture of it to show the ER doctor. Like that's very valuable information. 'cause that can tell you a lot of what might be going on with your patient.

Erik: You know, the, uh, the most common form of an upper GI bleed. And by the way, the definition is above this thing called the ligament of Treitz, which is right around the liver.

Mm-hmm. Anything north of that is an upper GI bleed. Anything south of that is a lower GI bleed.

Matt: Is it upper intestine? Lower intestine?

Erik: It's, it's, it's, yeah, it's up. Yeah. It's, it's the, it's past the duodenum.

Matt: Yeah.

Erik: Um, it's really high on the, most of the intestines are lower [00:24:00] GI believe. Yeah. But, um, the most common cause of an upper GI bleed is a peptic ulcer.

Matt: Mm-hmm.

Erik: So, uh, you, you get, uh, you've been taking too many NSAIDs, too much Motrin or ibuprofen, um, steroids can do the same thing. Mm-hmm. You, you basically end up. Um, uh, well, the true cause, well, I guess I should back up. It's really interesting. Your stomach acid can eat through the block of an engine. The metal of an engine, I mean, it's hydrochloric acid.

This stuff is really powerful stuff. Mm-hmm. You might wonder, well. Why in the world would we want that in our stomach? Well, we want it to be able to digest food. Mm-hmm. We really need that stomach acid, especially with proteins, to break them down, break those peptide bonds. So we need hydrochloric acid secreted by those parietal cells in our stomach.

Mm-hmm. They make it. Mm-hmm. Mm-hmm. Right. But we also have goblet cells. Within our, our, our lining of our stomach secreting a mucus. So we constantly are regenerating that mucus layer. As the acid breaks the [00:25:00] mucus down, we make more mucus. Mm-hmm. It's just like, it's amazing. Yeah. The system in the stomach to protect the tissue of the stomach and the muscle and stomach.

From the acid. From the acid. Yeah. Well, when you take Motrin, you slow down because of prostaglandins. You slow down the mucus making process. Mm-hmm. So you're, you're, you're kind of, uh, hamstringing your, is that the right word? Hamstringing, like, like limiting the ability Yeah. Of your stomach to make mucus.

And you do that long enough, you can actually get an A ulcer. Mm-hmm. You can, the acid can break through and, and eat at the lining of your stomach. And if you happen to get that ulcer over an artery,

Matt: mm.

Erik: You can bleed pretty heavily in your stomach. You can also perforate the stomach and create a hole in the stomach with a bad enough ulcer and that creates another problem with air in the belly.

Mm-hmm. All that to say these things can bleed. If it's a slow bleed, you get black, you get the, the coffee ground emesis, right?

Matt: Yeah.

Erik: You get a guy that you see 'em vomit into the bag and it's like, that looks like coffee grounds.

Matt: Yeah.

Erik: Right. And you're [00:26:00] looking at him, he looks pale. Yeah. He's been bleeding for a while.

Matt: Yes.

Erik: The scary ones are the bright red. Mm-hmm. Or the, even the dark red ones. You, you can bleed a lot of blood from a risi Yes. From liver disease. Um, but those are the, the different ways you can bleed outta your mouth.

Matt: Mm-hmm. Mm-hmm.

Erik: Risk factors for those things. Obviously, you know, chronic, he said use alcoholism is big.

Um, and, and then boy, you see any bleeding and a patient's on a blood thinner.

Matt: Mm-hmm. Yes.

Erik: We talk a lot about that in our lecture of blood thinner

Matt: and a beta blocker. Yeah.

Erik: Stuff the leech makes, right? Yeah. And we've learned a lot from those leeches making, uh, in fact, uh, it's a thrombin inhibitor, so it's very similar to the blood thinner we would take called Pradaxa.

Matt: Mm-hmm.

Erik: Um, most of the blood thinners, we, they act in a different area of the coagulation cascade.

Matt: Mm-hmm. Yeah. Right.

Erik: But

Matt: yeah, warfarin and Coumadin are kind of a broad spectrum. Would you put that term on it? They kinda,

Erik: yeah.

Matt: They're all the factors. Were these other ones, Eliquis and mm-hmm.

Erik: They act, yeah.

They, they are affecting the, the vitamin K dependent co-factors made by the liver, and then they're the, some of the [00:27:00] other ones like Eliquis. Mm-hmm. They hit factor 10 A. Right. I mean, anyway, point is more

Matt: targeted type

Erik: quality. Yeah. More targeted. That's right. And then you got heparin, you got, uh, yeah, Lovenox.

There's a lot of different anticoagulants. Yeah. Uh, the aspirin hits the platelets specifically.

Matt: Yes. Platelet aggregate.

Erik: Um, so. Anyway, um, the point is, you know, the blood thinners, that's another risk factor. Yeah.

Matt: So you have that GI patient, you have that abdominal pain patient that says they've been vomiting or said they've, you know, had some rectal bleeding.

That's, those are two good questions to ask when you're doing your sample history. That's

Erik: right.

Matt: What kinda meds do you take? And then mm-hmm. Do, do they take a law medication?

Erik: Yeah.

Matt: Or do they take a anticoagulant?

Erik: Right.

Matt: And even like, do you have AFib? Well, if they have AFib and it's diagnosed probably not thinner, they're probably on a blood thinner.

Erik: I'm glad you brought that up. It's good to know like the different medical problems that are associated with needing, it's very good anti anticoagulant. So just ties it all. AFib is a big one.

Matt: Yep.

Erik: Um, probably the most common reason why somebody

Matt: Definitely the most

Matt: common. Yeah. Out of hospital. Why somebody's on a anti.

Yeah,

Erik: absolutely. Um, [00:28:00] sometimes, uh, you get a patient, uh, that's, uh, like a valve heart. Patient. Mm-hmm. Or has

Matt: clotting issues. Yep. That's

Erik: right.

Matt: They have DVTs a lot. Mm-hmm. So they get

Erik: put on, but they make, 'cause it, you know when our body makes clots Yes. And breaks clots. Yes. It's a balance. Yes. And we wanna be balanced.

So if you have an I nr

Matt: Yeah.

Erik: Or if you're balanced, it'll be one.

Matt: Yeah. Right. If you're too low, then you have Yeah,

Erik: exactly. So if you have a risk like AFib Yes. And you, we wanna decrease our likelihood of making a clot. So we, we Right. We tip the scales towards clot breaking. That's by taking an anticoagulant.

Matt: So you don't throw a clot.

Erik: But if your grandma or grandpa and you're falling a lot, we don't want a head bleed. So the risks, ah, maybe we balance it out. 'cause the risk of AFib forming a clot. Mm-hmm. You know, falling, hitting your head.

Matt: Mm-hmm.

Erik: So there's all sorts of risk tools in medicine to determine what we should do based on the literature, but that's.

That's not important for us to know in an ambulance, but knowing, um, that a patient's on a blood thinner is important. Yeah. Now we talked about the upper GI

Matt: bleed. Mm-hmm.

Erik: So [00:29:00] about rebleeding and

Matt: I said, and I said upper and lower intestines. I meant large and small.

Erik: Smaller.

Matt: Somebody's gonna be like, is the upper and lower intestines idiot?

So

Erik: I would never call you an idiot. Well, we all knew what you're talking about. Yeah. Because you've got, you've got the upper intestine, which is the small intestine, a small

Matt: intestines en large.

Erik: Yeah. And, and some of the upper intestine or the small intestine is part of an upper GI bleed.

Matt: Exactly.

Erik: And then, and then most of it, most of it is part of the lower GI bleed.

Yes,

Matt: yes.

Erik: Um, but most though, most of the GI bleeds that come out of the anus mm-hmm. Uh, those lower GI bleeds. Like you can actually have blood from your anus and be an upper GI bleed too.

Matt: Oh, okay.

Erik: Yeah. Because if you're not vomiting it up, you could swallow it and it could get down into your GI system.

And then by the time it gets to the anus, it's one of the forms of a GI bleed called melena. Mm-hmm. Which is a black tarry material, very characteristic odor.

Matt: Mm-hmm.

Erik: Um. Of, of, of, uh, blood in the stool. Mm-hmm. Melena, it's like tar.

Matt: Mm-hmm.

Erik: And so you get a real brisk bleed up top. [00:30:00] It can form a gi, like a black tarry stool down below.

Matt: Yeah.

Erik: Typically the, um, those types of bleeds. Well, it can go either way. Right. But if you have a black stool, it, it, it's probably an upper GI bleed.

Matt: Yeah. Right.

Erik: Um, coming out the anus.

Matt: Yes.

Erik: Um, most of the most common lower GI bleed though. Um, is probably like a hemorrhoid, I was

Matt: gonna say. Yeah.

Erik: Internal or external hemorrhoid.

Um, fissures can lead to fissures. Yes. Those, those anal rectal problems. Mm-hmm. Um, but uh, you can also have, uh, diverticula mm-hmm. In the colon mm-hmm. That can bleed. Mm-hmm. Uh, colon cancers can bleed. Mm-hmm. I had a patient once in his thirties, um, who. Came to the ER because of rectal bleeding.

Matt: Mm-hmm.

Erik: And, uh, he never got a colonoscopy.

He had risk factors all over the place for colon cancer. Never got it. Should have gotten it.

Matt: Like family history and stuff.

Erik: Yeah. He had, uh, rectal cancer.

Matt: Mm.

Erik: And um, he just came in, he said, doc, I woke up [00:31:00] feeling warm and wet. And I looked, I was red blood everywhere.

Matt: Mm.

Erik: And he came straight to the er and the, the CT scan that I got showed, uh, he had a, he had a rectal mass.

Matt: And isn't that, what's her, what's the famous actress? She was the model back in the day.

Erik: Oh, got colon cancer or

Matt: rectal cancer? Rectal cancer. And, and she died. What? What's her anyway, sorry. Uh oh, she was the famous she blonde. Like your typical California,

Erik: Like I'm thinking,

Matt: Oh my god.

Erik: Kristy Brinkley.

Matt: No, it wasn't Kristy Brinkley.

I think she's still alive.

Erik: Uh, Kathy Ireland?

Matt: No, she's not blonde.

Erik: Oh, I, I don't

Matt: know. I'll dog on it. I'll remember it and it'll come back to me. But yeah, she got, uh, I'm so bad at movie. Was it Farrah Fawcett? I think it was Farrah Fawcett. I think it was Farrah Fawcett. She got rectal cancer and. I mean, she's been, she passed away several years ago, but that's what, okay.

Yeah. I mean, sad. Terrible way to go. I mean, cancer in general, period is, is terrible. But,

Erik: but two colors. Yeah. Two colors of bleeding. Well, really three, but red or black? Red, black tar. We talked about that. The red ones, uh, it can be maroon or red.

Matt: Right?

Erik: Um, you get a, [00:32:00] a nice variceal, I'm sorry. Uh, like a, well actually a hemorrhoid basically.

Basically a varix, right? In the rectal varices Yeah.

Matt: Same.

Erik: Um, and you bleed that way. But you can also have a bright red bl blood from your anus too. Mm-hmm. Hematochezia.

Matt: Mm-hmm.

Erik: And that's, um, not a good bleed either. It could be just as life threatening as an upper GI bleed.

Matt: Mm-hmm.

Erik: Uh, coming out the anus.

Mm-hmm. So you need to, you need that, uh, GI doctor to find the bleed. Yeah. So we can stop it.

Matt: Yeah.

Erik: But oftentimes we have to transfuse these folks, in fact. Yeah. Where we've started the blood program

Matt: mm-hmm.

Erik: Uh, we've actually given a surprising amount of blood. To medical bleeding like this, like we're talking about that need the blood.

Matt: Probably a lot of OB patients, I would think. OB hemorrhaging.

Erik: Yep.

Matt: Yep.

Erik: So we've talked about the two upper and lower GI bleed. Mm-hmm. Uh, presentations.

Matt: Mm-hmm.

Erik: Um, and we've talked about some of the risk factors for them.

Matt: Mm-hmm.

Erik: Um, and uh, we've, um, but we really haven't talked a lot about management.

Matt: Yeah.

Erik: I mean, again, and assessment really

Matt: Too.

Assessment, we talked about assessment, [00:33:00] but obviously you want to ask. How long has this been going on? Are we vomiting? Do we have diarrhea? Was it. Bloody, what did it look like? Was it bright red? Was it coffee ground? Yeah. Did it look like black tarry stool? All those important questions that we learned through paramedic school and EMT school.

Erik: Let me paint you a picture, Matt.

Matt: Paint me

Erik: picture. I'm your patient. Okay? I'm your patient and, uh, I'm nauseous. Okay. And, uh, um, I'm feeling lightheaded. Mm-hmm. And I've been vomiting up these, this coffee ground material.

Matt: Mm-hmm.

Erik: And I show it to you

Matt: mm-hmm.

Erik: In, in my house when you come in to pick me up.

Matt: Mm-hmm. Mm-hmm. Sometimes they save it for us. Yeah. Thank you very much.

Erik: Vitals look. Okay.

Matt: Okay.

Erik: You know, kind of borderline, uh, border, maybe a heart rate's a hundred.

Matt: Okay.

Erik: Blood pressure's a hundred over 60.

Matt: Mm-hmm.

Erik: Um, I'm talking to you on a, I'm a A oh four GCs 15. Mm-hmm. But I'm feeling a little bit lightheaded.

Matt: How's your skin color?

Erik: Um, I look pale.

Matt: Okay.

Erik: Um, what are you gonna do?

Matt: Uh, well, obviously, like you said, full set of vitals.

Erik: Full set of vitals, definitely. Anything else you want? What, what did I give you? Did I give you everything?

Matt: Uh, I [00:34:00] think, uh, blood sugar, probably. Blood sugar's

Erik: a hundred

Matt: temp,

Erik: uh, 98, 6.

Matt: Yeah.

So I'm gonna get you on the cot.

Erik: Yep.

Matt: Definitely thinking. Okay. He's got some sort of a bleed going on, right? Yep. Definitely gonna get a prophylactic id. Mm-hmm. Iv. Excuse me if he's been vomiting blood or, yeah, you said vomiting.

Erik: Yeah. I, I, yeah. Vomit blood. I've had a vomit and I, I, I saw these black. Uh, coffee grounds.

And I've been told that that's blood. Yeah. And I was worried. I called 9 1 1. Well, my wife was worried. Right. Yeah,

Matt: yeah, yeah.

Erik: That's usually the way the story goes.

Matt: Exactly. I don't need to go. Yeah. Yeah. So definitely gonna get some Zofran or something on board. Mm-hmm. For the

Erik: nausea. Fran's good.

Matt: Um. You know, because the vitals are okay right now.

I'm not overly worried, but I also wanna know his past medical history and med, what medications he's on.

Erik: Yeah, great question. Yeah. Getting that. Yeah. If I'm a blood thinner, that makes you a little more concerned.

Matt: Blood thinner for sure.

Erik: Yep.

Matt: And then as he on a beta blocker.

Erik: Yep.

Matt: Right, because we know. Signs of shock, what's the first thing the pump's gonna speed up to try to maintain pressure?

Right? Yep. Yep. And so we're at a hundred, which is probably not his normal. No. He's probably 70, 80.

Erik: Mm-hmm.

Matt: Right. So his pump's already [00:35:00] sped up a little bit.

Erik: Yep.

Matt: So I want to know, like, and he probably, he probably wouldn't even be at a hundred if he was on a beta

Erik: pump. Right.

Matt: Definitely wanna get a good history.

Yeah. Has this ever happened before? Do you have any family history of any GI problems? Um, all those kind of questions

Erik: and, you know, we're not really trained to think. Uh, positively about these patients. We're trained to plan for the worst, right?

Matt: Yeah. Right.

Erik: This guy's lightheaded. I agree with you. I wouldn't necessarily,

Matt: I'm not freaking out.

Erik: No,

Matt: I mean, his vitals are stable. Right. But I do recognize that, hey, this guy could be bleeding internally and he needs to go to a hospital.

Erik: You would feel different. Mm-hmm. If. I vomited like that guy did. Yes. A bunch of bright red blood. Oh yeah. Filled up a basin and all over. Right. I mean, that's a different form of a bleed.

Yes. That's more concerning to us.

Matt: It's in a more acute get to the hospital. Yes. And I can't do anything if you're bleeding out of your femoral artery, I can put a tourniquet on you.

Erik: Well, you got blood. In, you're like, if you have blood, if you,

Matt: if you have access to blood,

Erik: right? You might, yeah, you can give blood, which is good.

Matt: And saline. What about saline? Should we give 'em saline or ringers?

Erik: Oh, of [00:36:00] course. Dilute the blood out and no, no. Yeah, yeah. Well it's a good question,

Matt: But I mean, if my car runs out of gas, wouldn't I just put water in the fuel tank, wouldn't that help me? Absolutely.

Erik: It's a great idea.

Matt: Yeah. No.

Erik: Yeah. No. Yeah.

And, and we know now not to do that. Yeah. Yeah. Uh, so the blood pressure's falling because he's losing, he's losing blood.

Matt: Yeah.

Erik: Uh, now it's interesting though, if I back up and look at the coffee ground emesis. So what's really neat about it's, it's neat about the body's compensation. Mm-hmm. We haven't talked about this much, but the body makes a compound.

Two three BPG. Don't need to know what that is. But that actually increases the body's ability to offload. So these offload blood off hemoglobin mm-hmm. Uh, changes the oxygen dissociation curve.

Matt: Mm-hmm.

Erik: And so people who are chronically anemic mm-hmm. Can actually build more and make more two, three BPG, so they can compensate and live in a much lower hemoglobin concentration than you and I would be able to survive on.

Hmm. Because they offload more. It creates a [00:37:00] problem though, because if they have an acute bleed, they don't have much margin.

Matt: Yeah, right.

Erik: But that's how a guy can come into the ER with a hemoglobin under two.

Matt: Oh geez.

Erik: He looked like Casper, the friendly ghost. Yeah, I bet. And his blood looked like Kool-Aid.

But he had been diluting,

Matt: which, if a nursing school, uh, serves me correctly, I wanna say the average for male is like 13 ish.

Erik: Yeah. 15.

Matt: Probably 15. Okay.

Erik: 13 to 15. Maybe

Matt: female was 13. I think females are a little bit lower.

Erik: That's exactly right. Like 12 to 14. Yeah. I'm, I'm spitballing here than, yeah.

Matt: Right, right.

But,

Erik: but men typically have more blood. Yeah. A higher. Concentration. Remember hemoglobin. The hemoglobin we measure that is a concentration of blood,

Matt: right?

Erik: It's right. If I bled out all my blood right now into the floor into a five gallon make need

Matt: blood,

Erik: that last drop Yeah. Of blood in my body mm-hmm.

That I left there would have a normal hemoglobin.

Matt: Exactly. Exactly. It's

Erik: the concentration.

Matt: And your SPO two would be 99% I'd

Erik: be dead. Yes.

Matt: Yes. But yeah, just to put that in, you know, [00:38:00] uh uh, what am I trying to say? So people understand a he hemoglobin of two context. Thank you. A hemoglobin of two is extremely low.

Erik: Very low.

Matt: Yes. Extremely low. That's gonna get everybody freaking out, like mass transfusion protocol right now.

Erik: Yes. But what's interesting, he actually came in, brought in by his mom.

Matt: Yeah.

Erik: Um, he was very orthostatic. He could not stand up without passing out. Mm-hmm. Uh, he just, he didn't have the oxygen carrying capacity he needed altered.

Uh, it was in bad shape, right? Yeah. Yeah. But the only reason he could even survive at that low of a hemoglobin level was because of that two three b pg, where he's just offloading every ounce of oxygen off the hemoglobin he had left. Interesting.

Matt: That's crazy.

Erik: And so these people that have coffee ground emesis have been bleeding chronically.

Mm-hmm. So they're compensating not only with their heart rate, but they're constant, they're able to, because it's a chronic bleed, they can actually compensate bio. Mechanically, like, I'm sorry, with like the biochemistry of the blood. Mm-hmm. They can change and add the two three B pg. So, [00:39:00] um, so if you do have that patient with the coffee ground emesis, you can, it doesn't mean you don't have to be concerned, but that's more of a chronic bleed.

Matt: Yeah.

Erik: It's more concerning with that bright red blood.

Matt: Yeah. Now with the bright red blood. Because a lot of paramedics, maybe like my department, we do not have blood yet. Mm-hmm. But we do have TXA.

Erik: Yeah.

Matt: I've got a bleeding patient, what I want.

Erik: No. TX a.

Matt: No

Erik: TX

Matt: A. No TX A for the GI bleed.

Erik: Absolutely not. Yeah.

In fact, literature has come out. In fact, five years ago I taught this differently. I said, I know. Yeah. TXA. Okay. The call has changed. Yes.

Matt: Yep.

Erik: So now, yeah. Yeah. It's tempting 'cause you think, uh, TXA might help. But,

Matt: and just to, for again, context, what TXA does for those that aren't familiar is, like you said earlier.

We, our body clots forms a clot over the wound. And what TXA does is it, it, it slows down the breakdown of that clot. Right? It stabilizes it. Yeah, it stabilizes it so that that clot doesn't go away, right? Mm-hmm. And that's why we don't give fluids. We give a bunch of saline 'cause that will blow those clots out.

Erik: That's right.

Matt: Which is gonna increase bleeding. So TXA does [00:40:00] not stop bleeding. It helps the clot stay there longer to plug the hole until we can get 'em to somebody that has blood.

Erik: You're right. And by giving, like you said, the IV fluids make you bleed easier. Yeah. It increases vascular permeability, which makes 'em more leaky.

Matt: Yes.

Erik: Uh, it makes your, your clotting factors, you got even more dilute. Yes. I mean, it's, it's, uh, there's a place for fluids, right?

Matt: A little bit. Yep.

Erik: And I think. I haven't seen the literature in the last year or so, so I could be off on this, but I think a Cochrane review that I looked at said that 250 ccs of blue, blue, 250 ccs of blood, I'm sorry, two 50, lemme try this again.

I don't wanna confuse anybody. 250 ccs of crystalloid, whether it's NS or LR. May not cause harm,

Matt: it's not gonna have a positive impact, but it's not gonna have a negative

Erik: impact. Maybe not,

Matt: but you go to 500 like we used to do when I went to paramedic school, A

Erik: leader.

Matt: Oh, it was,

Erik: yeah.

Matt: Two large bore IVs wide open.

Yeah. I mean, that was, the trauma care feels good of the day. Oh, I've, it's C [00:41:00] collars. I was checking the box.

Erik: Yeah.

Matt: Uh, we were gonna. Makes some people mad. Lets,

Erik: I'm glad you asked about TX A though, 'cause it's not indicated

Matt: well, and again, people would think, well, bleeding's bleeding. Right? I mean, if, if somebody's got a traumatic injury, I would give them TX a if they're hypotensive.

Mm-hmm.

Erik: Well, what's the TXA? Is it, it increases the stability of clots, right? Mm-hmm. So the, but it's been shown in the literature not to have any sort of benefits to mortality for a GI bleed, for

Matt: a GI

Erik: bleed, GI bleed, so, right.

Matt: If you had the hemorrhagic OB patient.

Erik: And then, well then I hope you have Pitocin, that's the first line.

Yes. Or oxytocin.

Matt: Yes.

Erik: Uh, or, or, um, uh, TXA would be appropriate, but that would be appropriate

Matt: for those. Yeah. Yeah. 'cause we don't carry, I don't think a lot of flight services probably carry Pitocin.

Erik: You know, one thing that I don't think we really hit on hard enough mm-hmm. And I think this is one of the greatest values we have for these GI Bleed patients is determining whether or not they, it, they would be a.

Candidate for blood. Mm-hmm. Are they far enough down that, that hemorrhagic shock [00:42:00] pathway where blood actually would have a benefit for them?

Matt: Yeah.

Erik: Because we don't wanna give blood to every patient that's bleeding. No. 'cause we have compensatory mechanisms. Yes. In our, with va, you know, vasoconstriction mm-hmm.

Is certainly in our heart where we have clotting

Matt: factors.

Erik: Yeah. You know, I don't think there'd necessarily be a survival benefit for some patients. Right. So just get Get 'em to the hospital.

Matt: Yeah.

Erik: But there are some.

Matt: Yeah.

Erik: How do we determine, like what do we look for, uh, in the pre-hospital environment? The back of an ambulance.

Indicate a transfusion.

Matt: I like things easy. I like the shock index.

Erik: I do

Matt: too. Right. Heart rate divided by systolic blood pressure.

Erik: Mm-hmm.

Matt: Right. And if it's greater than one, you've got a positive shock index.

Erik: Yeah.

Matt: Right.

Erik: I think and when we teach this, it's like you, you're, you're in hemorrhagic shock until proven otherwise.

Yes. I like to add one thing to that.

Matt: Okay.

Erik: Ultra mental status.

Matt: Okay.

Erik: You know, you get, you get, because see if I'm tachycardic and hypotensive. But I'm able to perfuse the metabolically active brain cells. Mm-hmm. That I got. Mm-hmm.

Matt: And you're still doing okay.

Erik: [00:43:00] Yeah. And I think depending upon the clinical picture too.

Mm-hmm. I mean, if you just saw me vomit up a liter of blood into a basin

Matt: mm-hmm.

Erik: And I'm tachycardic and hypotensive. The next time he vomits, he's probably going be altered, right?

Matt: Yeah. Right.

Erik: Let's, let's, let's act now. Yeah. Oh yes. So I agree with you. It depends

Matt: on the context. Anybody that's vomiting a liter of blood, you need to act now.

Yeah. Let's just, yeah.

Erik: If you have it, if you have it,

Matt: well yeah. You gotta do something. Right. And, and either, whether that's getting en route. 'cause a lot of, a lot of places do not carry blood, so. You gotta get moving.

Erik: Let's see if you can read my mind. This is unfair, Matt. Okay. So if you don't get it, it's totally okay because I'm, you can't read my mind, but, okay.

But I'm gonna, there's a compensatory mechanism that we have in our bodies that we can actually capitalize on, whether you're a BLS provider or an LS provider and it's our legs.

Matt: Mm-hmm.

Erik: What am I thinking right now,

Matt: Berg?

Erik: That's right. Lift the legs up. Yeah, because we store most of our blood in those big capacitance vessels in our legs.

We've

Matt: talked

Erik: about that before. You lift them up above the [00:44:00] level of the heart, all that blood flows out of the legs to the heart. And it's like a, it's almost like a transfusion.

Matt: Yeah.

Erik: Right there.

Matt: Exactly. Uh,

Erik: so

Matt: let gravity work in your favor.

Erik: That's right. So there's a lot you can do and hopefully your transport times aren't very long.

Matt: And if they are, you know, call for a flight.

Erik: Yep.

Matt: You know, they'll probably have blood. Mm-hmm. They'll probably have, you know, the ability to do a little bit more. Especially if you're A-B-B-L-S provider out in rural nowhere and you've got an hour long transport times. We get these calls all the time for abdominal pain.

Yeah. And we kind of think like we don't. Well then another abdominal pain call. Yeah. And then you show up and somebody's really, really sick.

Erik: Yep.

Matt: Those patients are just as sick as your STEMI patients or your trauma patients that are bleeding out. They are bleeding out. Mm-hmm. It's the same thing that's happening.

And so yeah, you really gotta be aware that, don't take it for granted that you're just going on another abdominal pain call. You gotta be paying attention.

Erik: And I think a lot of the cases that we've talked about are pretty, pretty obvious. Mm-hmm. And I, and I don't think those are the ones that really separate a good paramedic from an excellent paramedic mm-hmm.[00:45:00]

Or EMT or whoever. Mm-hmm. Because, uh, he, I think some of the subtle presentations are the ones that are really, uh, the ones where you really are an excellent. Provider

Matt: for sure.

Erik: One of the things I don't think we think about enough is chest pain.

Matt: Mm-hmm.

Erik: It's not uncommon to have chest pain because of a GI bleed.

Yeah. The patient's been having black stools, but he or she didn't understand that that was blood. Mm-hmm. But as they lose more and more blood, the heart's gotta work harder now to maintain that oxygen carrying capacity. Mm-hmm. At our tissue levels. Mm-hmm. To maintain perfusion. And so as the blood gets more and more thin or anemic

Matt: mm-hmm.

Erik: The heart's gotta work harder and harder and harder. You get an older patient that doesn't have that kind of cardiac output ability mm-hmm. Or capability. Mm-hmm. They will present with chest pain. The heart's working so hard, they call 9 1 1 for chest pain. So you're thinking. Yeah. Cardiac. Cardiac 12.

Cardiac 12.

Matt: 12 leak. Yeah.

Erik: Don't forget to ask about bleeding.

Matt: Mm-hmm.

Erik: [00:46:00] Because, interesting. These old folks are having chest pain. This patient's tachycardic. This patient looks a bit pale. Remember we talked about it in our le our, you know? Mm-hmm. We'd should mention this here. A window to your hemoglobin.

Mm-hmm. Look. Conjunctiva.

Matt: Yeah.

Erik: If they look pale, you're probably anemic. Look at the lips, the tongue, the, the, the, the, the loss of the palmer creases. Those things we talk about in our lecture. Yep. If you have a patient that's calling for chest pain, don't forget to do a thorough exam and ask about some of those GI bleed questions.

Yep. It just takes a few seconds.

Matt: Yeah.

Erik: And that might actually be the life-threatening problem.

Matt: Yeah.

Erik: Heart's actually. Okay. It's just that. Uh, it's that we're bleeding to death.

Matt: Yeah. You run the 12 lead, there's nothing on there. There's sinus attack. Yeah. Like, okay. They're not having a heart attack. Well, they might have some other life threatening condition that we're not thinking about.

Yeah.

Erik: Here's another case, Matt, that I thought was a really good case. I was on a ride out and we walked in. You could smell the urine.

Matt: Mm. The

Erik: older person, I saw a urine bag under the pajama pants.

Matt: Is this nursing home?

Erik: No, it was at home, actually at his home. Okay. [00:47:00] They're called to his home. Um, the wife was there to explain, he was just released for treatment from a UTI.

Okay. Smells like a UTI.

Matt: Sepsis,

Erik: sepsis. They, they called us because of altered mental status.

Matt: Okay.

Erik: He's in AFib, RVR.

Matt: Okay.

Erik: And I'm thinking, okay, well this is a classic setup for an infection, like a u sepsis.

Matt: Mm-hmm.

Erik: Yeah. Uh, some sort of a septic. Patients that triggers the AFib, it's not uncommon. Yeah. In fact, you should treat the sepsis before you treat the AFib

Matt: because

Erik: that Cardizem is not the initial treatment there.

You give 'em fluids. Yes. Oftentimes that'll fix the AFib, but point was he was an AFib. RVR. Yeah. Everything was screaming sepsis. I mean, he's tacky in the one seventies.

Matt: Hypotensive, uh,

Erik: hypotensive, crappy end-tidal. He was altered. That's why they called. Yeah. Um, the leg bags there, it smells like urine. He wasn't febrile, but mm-hmm.

Um, certainly looked like, but he had a presumed s

Matt: source of infection. Yeah.

Erik: Well, when we were doing our physical exam and we were so [00:48:00] focused on sepsis. Yeah. And it was just screaming ssis.

Matt: Yeah. We put the blinders on.

Erik: But I noticed some coffee grounds around his lips.

Matt: Mm.

Erik: And I said, sir, have you been vomiting blood?

Have you been vomiting? Or whatever? And he said, yes. And he said he'd been having these black little bits in his vomit.

Matt: Mm-hmm.

Erik: And so I'm thinking, well guys, this may not be sepsis. This could be a GI bleed. And so I use this as an opportunity to teach my paramedics about anchoring on a diagnosis. Yeah, like sepsis, when you could miss a GI bleed.

Matt: Yep.

Erik: It's funny, I, I was wrong again,

Matt: it was sepsis.

Erik: No, it wasn't sepsis. Well, actually it kind of was. Lemme explain.

Matt: Okay,

Erik: so I get there, I'm thinking UTI sepsis.

Matt: Okay.

Erik: And then I see the coffee grounds around his lips. Okay? So I'm lecturing my guys. I'm not angry. I totally anchor

Matt: as, as you're anchoring.

Erik: I totally anchored on the second diagnosis.

Right? I forgot that it could be a third. So we're, we're transporting this guy and every bump, he's like,

Matt: did he have tobacco in his mouth?

Erik: No. Good. I [00:49:00] could. Do you have, do you wanna guess? What do you think it might be? You won't guess it. We've actually already talked about this diagnosis.

Matt: Now you're challenging me.

I won't guess it.

Erik: We, we talked about it already.

Matt: Today,

Erik: McBurney's point, he had an appendicitis in, oh, he had a necrotic appendix. That's actually what ended up being his worst problem.

Matt: Okay. And that's why he was vomiting.

Erik: I was so focused on teaching my paramedics about not anchoring on the first diagnosis.

Matt: Well, you were still kind of right. 'cause at least it was in the abdomen.

Erik: But every bump, the guy, he, he was using profanities every time the ambulance hit a bump. And I remember thinking, oh, is he having belly pain? So I'm pushing on his belly while he is sitting up.

Matt: Oh,

Erik: and I, I'm pushing on his belly and he's, you know, yeah.

I wasn't impressed. Yeah. And so I just kept talking about how not to anchor on whatever. Anyway, we get there and, um, I called the PA that was treating the patient. I said, Hey, what was the hemoglobin on that guy? It was like six.

Matt: Yeah.

Erik: So I was like, Hey, we're right. Right. Uh, and then he says, but that's not what.

The worst thing was the CT scan showed a necrotic chronic bad appendicitis.

Matt: Wow.

Erik: So he had to go to [00:50:00] the OR to fix his appendix and get that thing removed. So that ended up, was that a friend pa?

Matt: Which one?

Erik: Uh, be.

Matt: Oh, Bey. Okay.

Erik: I love him. Yeah, he's a great pa. That's

Matt: funny.

Erik: And uh, he, he called,

Matt: I was there when he first got his first two, remember?

Erik: Oh

Matt: yeah, I brought that patient in.

Erik: Oh yeah. Oh, that's right.

Matt: I remember. He was so nervous and you were standing there coaching him through it Anyway, uh, so well that's a, yeah, that's an interesting case. Yeah. So

Erik: don't anchor.

Matt: Very important not to anchor on a diagnosis. Yeah. See

Erik: Yeah. You get that chest pain patient.

Just remember to ask the questions about a potential GI bleed. Yeah, I think that's a good skill,

Matt: especially if you find nothing on the 12 bleed.

Erik: Right.

Matt: There's nothing that's pointing you to this as a cardiac issue. Yeah. Besides maybe the heart rate's a little bit elevated.

Erik: Yep.

Matt: Right.

Erik: Yeah. And there are other problems.

It could be too, I mean, the medicine's complicated, but just remember not to diagnose, I'm sorry, anchor on that diag that initial diagnosis.

Matt: Yeah.

Erik: Um, but GI bleeds can, can rum quickly on you. Yes. So if you do have a bad GI bleed. Identifying it's important. Identifying the risk factors. How bad is it?

Matt: Yep.[00:51:00]

Erik: What do the vitals look like? Shock index.

Matt: Yep.

Erik: Determining whether or not they're a candidate for blood. If you carry blood.

Matt: Yep.

Erik: If you don't carry blood lift, lift their legs

Matt: up. No, TXA. Give 'em a little bit of fluid. No, TXA, some Zofran for the nausea, vomiting, or rein, whatever you. Yeah. Um, I can't think of anything else you would give them.

Erik: No, that's pretty much it. I think, uh, elevating the head of the bed. I think, uh, you know, well the, the well airway management's big, right? So

Matt: Right. If they start getting really altered or go unconscious on you 'cause they bled out.

Erik: That's correct. Your patient, that's correct. And I've had to intubate patients, GI bleed patients that get also altered, they.

I can't protect their airway anymore. And they're vomiting. Uh, that's bad. You gotta intubate them. Yeah. So airway management's really important. Um, I think, uh, the blood's important. Uh, we're not gonna be able to reverse any anticoagulation in the ambulance, but no, being aware of the blood thinners is big, like you said, just asking about it.

Matt: And beta blockers. Yeah. If you got the laws, well, for more information, go to our. Website, [00:52:00] get the course. We go into way more detail, have a lot more graphics, and you'll get to see the leech experience. The leeches,

Erik: Yeah. We're not doing leeches here, but we'll do leeches there. It's gonna be a great course.

Matt: So yeah, I'm really excited about it.

Well see you on the next one.

Erik: Be safe out there.

Narrator: Thank you for listening to EMS, the Erik and Matt Show.