The Doctor in charge of this patient was so cooly in control he was able to fully explain exactly what was going on with his patient and what he needed from me to allow optimum care and management of this patients condition.... It made for a completely different experience.
The gentleman patient was a 55 year old Alcoholic presenting with a large GI bleed, he'd lost over 1500 ml of blood and was heading for theatres for an emergency laparotomy.
The team were well organised in that they had sent two sample for blood group and antibody screening.... In approximately 40 minutes I could supply crossmatched blood for this patient. This is the safest option and avoids using precious 'universal donor' O neg units.
Immediately after issuing 4 units of blood the doctor bleeped to inform me that he was activating the major haemorrhage protocol. This involves issuing 4x red blood cells, 4x FFP (fresh frozen plasma) and 1x platelets repeatedly until the patient is stable and the clinician in charge deactivates the MHP.
I asked the Dr the relevant questions (patients weight, medication, location), gave the Dr a projected time that the products would be ready and proceeded to prepare the FFP.
At the same time as this was going on a labouring lady of the same blood group was experiencing PostPartumHaemorrage and so I had issued my last set of A neg units to her.... In order to supply safe blood for the MHP guy I would have to issue O neg units - I wanted to avoid this to save these precious units. Here at PRUH we don't keep a stock of platelet so I needed to order some in, urgently. I also needed to replace the FFP that was thawing and order more A neg red cell units to see us through the night.
To give you a little back ground .... Clotting factors are the proteins in your blood that help to stop bleeding, these factors are produced in the liver. I mentioned that this patient was an alcoholic, and as we know alcoholism leads to liver damage reducing production of these clotting factors which contributes to greater blood loss in these patients. The FFP that I was thawing would replace these clotting factors and if the correct dose given, stem the bleeding. For effective management of bleeding patients it is important to monitor the patients haemoglobin, platelet count and clotting factors at regular intervals.
To calculate these parameters I rely on machines.....And this is where it gets interesting (I can say that with hindsight - at the time I was freaking out ) .......Analyser failure :-|
As I'd already issued 3 different products - blood, platelets and FFP....
Fibrinogen is one of the key clotting factors found in FFP but it is more highly concentrated in Cryoprecipitate. Cryo is another frozen product available for the transfusion lab.... But it is only issued to patients when their fibrinogen levels drop below 0.5g/L ..... But without a working analyser how were we to know whether the patient required this product. To blindly give this patient Cryo could cause more harm that good, to not give Cryo or delay transfusion if the fib had dropped could also be disastrous...... I was starting to panic at this point and feeling quite guilty.
I did manage to get some results to come thru by stopping and starting the analyser ... Prayers, relief, excitement, frustration .... But it didn't allow me to clear the back log.... When ever I have a busy shift like this or something extra to deal with it's really important that I keep on top on the workload as the bleep just goes nuts with doctors and nurses asking for results for other patients if I don't authorise result quickly. Which obviously holds me up further.
Communication is essential so I'd phoned the site coordinator to inform him of the situation and again spoken to the consultant in charge of the bleeding patient.....This is where I was most impressed, it was at this point that he relayed to me the status of the patient, he explained that they had been able to stem the bleeding in theatre but that the fibrinogen level would still be very useful. He thanked me!!! Yes the doctor thanked me the BMS for making such an effort to get these results to the ward, he also sympathised with the predicament I was in, understanding that I was doing my best. And he cooperated completely, even offering to phone the Denmark hill site to arrange for testing to take place there instead to allow me to concentrate on the rest of the work.
I would usually be very stressed and anxious in this situation but thanks the loveliest doctor, explaining the situation completely I managed to stay pretty calm!
Now obviously I didn't do anything differently, it wound be very unprofessional of me to change my actions because of a rude or uncooperative doctor but I definitely left work that morning feeling a greater sense of worth.......at the end of the shift this patients clotting result came back
fairly normal, his haemoglobin level was reasonable .... He'd stabilised.
Haemostasis had resumed the coagulopathy had been managed (thanks to the FFP) and I could leave my shift with the confidence that those patients would be okay :-D
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