Blood has a very distinctive odor.

Blood has a very distinctive odor.

 Typically, “normal” blood has a metallic smell largely because of the iron. Iron is contained in hemoglobin which is a protein which carries oxygen to your entire body.

One of the things that is first learned when approaching a patient is that you MUST use all of your senses. Nose included, perhaps even (in my opinion) the most important. After seeing the various manifestation and appearance of blood, there are certain diagnoses that can be fairly accurately made just by having a whiff.  The blood I’m speaking of, of course, is blood that has already left the body. It’s either in the bed sheets, on the floor, in the toilet or spattered around the inside of someone’s car. Each of the aforementioned locations tends to bring with it, a different smell and a different diagnosis.

For example, if you respond to a car accident at 3am and the driver is dead but there are large amounts of blood on the seats or floor boards, the smell of the iron is nonexistent.  You can smell the alcohol in the blood on the seat.

Blood in the toilet or in other places on or around the patient that is dark and tarry is called melena. Melena is caused by a site in the (usually) lower intestines that is bleeding.  There is no mistaking the smell of Melena for anything other than what it is.

Ah, the nose.  We were dispatched to a “woman bleeding” in a very poor, very cold, 4^th floor walk up apartment. Women’s bodies are much more complicated than a man’s body. Their bodies have more sites to bleed from, and often, when they bleed, they BLEED! Any bleeding must be taken seriously. Any bleeding from a woman must be met with greater urgency.  I digress. On the 3^rd floor of this cockroach and bedbug infested home (no disrespect) our noses simultaneously did a quick sniff, smelled nastiness, and almost at the same time said “great”. Not in a good way.  Carrying our 50 or so pounds of gear another 13 stairs, already winded, breathing hard, made the aromatic and pungent air seem particularly unpleasant.

After knocking on the door and doing a quick assessment of our surroundings, we were introduced to our patient. I am a firm believer in the power of human touch and introduce myself each time, trying to get a handshake and touching the upper arm with my other hand. Touching is very important. It gives you an idea of the patients ability to follow commands, you get to feel their skin temperature to see if they are either hot, cold or normal and it creates a bond instantly that shows you care. Too many times I have seen EMS folks walk into a room, arms folded and simply begin firing questions at the patient. Who needs THAT! This patient no more wants you there to see her suffer in her embarrassment that you want to be there, trying to figure out how to effectively mouth breathe so your nose can take a break.

 Our lady today was a 50 year old woman with gastrointestinal (GI) bleeding as a result of years of drinking a fifth of vodka a day for more years than she can remember. Kids as young as 4 or 5 were trying to stay warm,   asking us for food, and begging us to help Nana so she wouldn’t die.

We were still holding our gear, with the help of the fire department, because one learns early that if you put your drug bag or airway bag or defibrillator on the floor, it goes without saying that a cockroach will wander into your gear, and you have now become a vector for disease.  According to the CDC  (http://www.cdc.gov/asthma/triggers.html) cockroach dropping are a trigger for asthma in kids and we don’t need to be introducing more distress into the community.

Nana was clearly sick. In fact she was probably hours away from stranding her grandchildren with only a memory and perhaps a few pictures.

Privacy is very important to patients. My partner took the kids into another room so I could get some concrete answers on the history and do a cursory physical exam. He kids don’t need to see or hear any of this. Nana is their link to the outside world and to diminish that by involving them, to me, is a sin.

She was frail, her eyes icteric (the yellow color of a yield sign), skin was cool and she was clearly dehydrated. The only medicine she took was for high blood pressure, which she should have flushed down the toilet, because she didn’t need them any more and you don’t want the children getting their mitts on them either.

This is not a complicated case, at least not any longer. Her blood pressure was terribly low, she had had melena on and off for a “couple years”, marked weight loss over the course of the past month, yet still kept drinking. Addiction can’t be fun. I’m not sure if the predisposition for some to become addicted to something, or anything, will be fully understood. At least in my lifetime.

Nana was in trouble, but we could stabilize her for the trip to the hospital where (I’m guessing) hospice and social services would get involved. Nana needed a few things. Oxygen, IV fluids to try to get her blood pressure to within reasonable numbers, Thiamine, and prayers. We tested her sugar and it was fine.  Her cardiogram was a mess and showed she had had heart attack in the past, but was way too fast. Not crazy fast, just a sign of her pain, stress and perhaps most importantly her illness and dehydration.

The oxygen was easy, and her oxygen saturation got better instantly. The EKG was easy, although on frail skin the adhesive can be tough but certainly not a contraindication. Accessing a vein would prove no easy feat. Earlier in Nana’s life she loved her heroin and lots of it. The access to her vasculature was impossible. My fear was that once we sat Nana up to move her, because her pressure was so low, she would pass out, which is exactly what happened. Eyeballs rolling back in the head, flaccid body except for the isolated focal seizure which happens and unconsciousness.  We laid her flat, feet elevated for a couple minutes while she came too. Last thing you want to do on a cold, poorly lit 4^th floor carry down is to do it with someone who is unconscious.

Typically we try to keep our “on scene” times to 20 minutes, but this took slightly longer. Nana needed fluid and the only place I could place an IV catheter was in her external jugular vein in her neck. I discussed it with her, told her the options and she said “Baby, if you can get a needle in my neck, you are a better junkie than I ever was”  Apparently she used her neck veins prior to using her arms, hands, feet and fingers. It was going to be uncomfortable for her for two reasons. This was going to be a big IV catheter and we had to really put her head down, as in almost upside down to get her neck veins to fill up with blood.  She tolerated it well, and I stuck the 14 gauge catheter in her neck without difficulty. We laid her flat again and started giving her some Saline. She was much tougher in body and soul than I.

You never want to take a 1000cc bag of saline in a patient with multi organ failure and give her all the fluid at once. Rather, we break it up into a smaller bolus to see how the tolerate it. After about 250cc, we sat her up. She stayed awake, but said the room was spinning. Progress. Reassessment of her lungs was fine. No gurgling. 250cc later she really perked up. I knew this was transient, but positive nonetheless. We sat Nana up and she stayed awake and was even laughing. Now don’t forget, my partner still has the kids in another room and she is still carrying her gear. I called for the kids so they could see Nana and give them some happiness and happy they were.

We got Nana to the hospital better than she was, and that’s the rewarding part.

To this day, I wonder what happened to those children. I know what happened to the late Nana.