It’s the start of the night shift. We’re getting sign out. “We should be getting a transfer soon,” the charge nurse tells me, “A head bleed”. Sounds straightforward. Call trauma surgery and neurosurgery, admit the patient. Have seen too many of these patients.
An hour later, I receive a call from the nurse that the patient has arrived. I walk into the trauma bay room. There is a young male, 22 years old, intubated. Not on any sedation, but not moving at all. GCS 1-1-2. There is a petechial rash over his extremities. That’s weird, I think.
Suddenly, this is not looking so straight forward.
I flip through his records from the outside hospital.
Healthy kid, had gone to urgent care THREE times this past week for vomiting. Each visit, he is given zofran and instructed on supportive care. He had even been given antibiotics on one of his visits. That did not seem unusual, we had been seeing a lot of acute gastroenteritis going around. I myself had seen multiple of those patients and sent them home with the same management.
I get to the part with the labs.
WBC >325k, H/H 10.5 / 33, platelets 44k,
Cr 2.7, trop 3, INR 2.4
I rub my eyes. Did I read that right or am I just really tired. That white blood cell count is ridiculously high.
Suddenly, this got interesting.
Per the outside records, the parents had found the patient altered and obtunded today. They brought him to the outside hospital where he was found to be GCS 5, with these lab abnormalities and a large intraventricular hemorrhage on CTH. He was transferred for higher level of care.
I send off a slew of labs. I call neurosurgery. Thankfully, it’s an actual neurosurgery resident on overnight and not the NP, and he comes down right away.
The lab calls. There are multiple critical values.
Among them, WBC 477k, 89% blasts. Hct 30%, platelets 42k. INR 2.5. Cr 4.3.
The patient is in blast crisis with hyperviscosity syndrome. Also disseminated intravascular coagulation. Also tumor lysis syndrome. We pan-CT scan him. There are lymph nodes everywhere. The intracranial hemorrhage is worse than on the prior head CT.
The neurosurgery resident is freaking out. He needs to place an emergent bedside ventriculostomy in the patient. But the patient is already bleeding from the DIC from multiple orifices. He asks me to stay, “for moral support”. If the neurosurgeon is scared, I’m shitting myself.
The neurosurgeon places the ventric. The patient starts bleeding from around the ventric. Blood soaks through multiple chucks at the head of the bed.
Do we give blood products? Or will that make him worse? What products should we give?
The hematology consult fellow isn’t calling back despite multiple pages. My attending calls the CMO of the hospital, who gets us in touch with the head of the department for guidance. The patient needs emergent leukapheresis. I need to place a large dialysis catheter for that. He is already bleeding from everywhere. I’m now freaking out even more. I’m about to stick a large bore catheter into the femoral vein of a patient that is already bleeding from everywhere. I’ve placed these before, but never when the stakes are so high. My attending stays with me. I’m grateful he is there to provide me that support. I am able to get the catheter in. The insertion site oozes and oozes. The tegaderm won't even stay in place. I admit him to the ICU and pray for a miracle. I can’t do any more.
The patient’s parents then arrive. I go in with the social worker to update them. How do I tell them? There are no right words to tell a parent that their son is dying. What I say, what they hear, are they the same things? They are in shock, disbelief, agony. Last week, their son was a normal healthy kid with his whole life in front of him. Now he’s dying. And there’s not much more we can do. They are inconsolable, his mother with audible heart wrenching tears, and his father holding it in, silently suffering.
I follow the patient’s progress in the ICU. They do everything. They try everything. But it is futile. He dies a few days later.
This case runs through my mind for weeks after. I can’t stop thinking. What should I have done more? What could I have done differently? Was there anything that could have changed this patient’s outcome? What if just one test had been sent on him during any of those urgent care visits, could they have caught this earlier and maybe it wouldn’t have ended like this? How many patients am I missing serious pathology on? How many patients am I sending home to die?
Share your "Hail Mary” story in the comments section below.
Subscribe to the blog by entering your email in the subscription box below. Don't rely on Facebook to get notifications for new posts. We only email when a new post is published. No spam. If you are reading this on your phone, just keep scrolling down to get to the Subscribe box.
Give us some love by sharing the blog. Forward the blog to people you think would like it. Post the blog on social media. Like and Follow our Facebook Page. Follow us on Twitter. Follow us on Instagram
