Chapter 491: Inexplicable high fever reaction, multiple sources of bleeding
After the patient underwent emergency gastroscopy, the situation was quite bad.
The patient's entire gastric mucosa looks pale, which means that the patient has gastritis and the condition is very serious.
This situation will only occur if there is erosion, ulcer, or inflammatory edema and exudation on the surface of the gastric mucosa.
No wonder the patient looked thin. The patient's father said that the child only knew how to play games and hang out all day, and rarely ate at home. With such severe gastritis, symptoms such as nausea, vomiting, indigestion, acid reflux, and heartburn will definitely occur.
In this situation, how can the patient eat?
However, the formation of gastritis is often caused by irregular diet, such as eating one meal hungry and the next full, or drinking on an empty stomach, eating spicy food, barbecue, etc.
In short, in general, gastritis is self-made.
When you are healthy, you don't take care of yourself in any way.
Eventually the organs most seriously affected can no longer bear the strain and begin to malfunction. This is when you become sick.
Gastroscopy showed that the patient had a linear mucosal old bleeding lesion on the posterior wall of the gastric fundus, superficial erosions were visible on the greater curvature of the gastric body and the ridges of the corrugated wall, and flocculent secretions and recent bleeding spots were attached to the surface.
The gastric antrum and duodenal bulb were normal.
A rapid urease test was performed on the patient and was negative.
At this point, the cause of the disease has been basically determined.
It's stomach bleeding.
After discussing with Zhou Can, Ai Li decided to use blood transfusion and intravenous drip of hemostatic drugs for treatment first.
Almost all responsible doctors will give priority to drug treatment when treating diseases. Only when drug treatment is ineffective will they consider surgical treatment.
Because any surgery will cause harm to the patient's body.
"Doctor Zhou, do you think batroxobin can be used as a hemostatic drug?"
"Using only one is a bit too weak. How about adding tranexamic acid!"
Zhou Can replied.
Batroxobin is an immediate hemostatic drug and is often used for emergency internal bleeding. Tranexamic acid has a long-lasting and powerful hemostatic effect. It is a drug that inhibits the fibrinolytic system and is mainly used for surgical bleeding and gynecological and obstetric bleeding caused by hyperfibrinolysis.
In addition, it has a powerful ability to pass through the blood-brain barrier, so it is often used to stop bleeding in the central nervous system.
After treating this patient, Zhou Can hurried into the operating room.
He told Ellie that if the above treatments were ineffective for the patient, they would discuss a new treatment plan then.
…
At around noon, Zhou Can finished the operation and went to the cafeteria to eat with his team members.
As I passed the triage desk, I was stopped by Dr. Ellie.
"Doctor Zhou, did you just finish the operation?"
"Yeah! There were a lot of emergency surgeries today, so the surgery was a little late."
Some surgeries need to be done as soon as possible and cannot be delayed.
For example, hemostasis and suturing of traumatic wounds.
Another thing is replantation of severed fingers.
The emergency department rarely received finger replantation surgery in the past because it required extremely high technical skills. Only Dr. Xu could perform it. And the operation took a long time.
If a patient who needs emergency surgery comes in while Dr. Xu is performing a finger replantation surgery, there will be a shortage of staff.
Emergency surgeries, especially wound sutures, dog bites, falls, and other emergency trauma treatments all need to be handled by the emergency department. If these types of patients are pushed to specialist departments, they will be scolded.
Don’t forget that a few years ago, Director Xie went directly to Vice President Ye because the emergency department performed a few extra surgeries.
In fact, Tuya never lacks patients for common minor surgeries .
For this famous tertiary hospital, which enjoys a certain reputation in the province and is also ranked among the best in the country, the number of outpatient and emergency patients is now increasing at an alarming rate every year.
All departments can be fully staffed. Even many specialist departments have to reject some patients with mild symptoms due to "indigestion" caused by too many outpatient and emergency patients.
Therefore, specialized departments now have a very contradictory demand: the fewer simple, mild patients, the better; and the more patients with medium or higher difficulty, the better.
If hospital departments want to generate revenue, they mainly focus on critically ill patients and those who are difficult to treat.
Because of this type of patients, the department's beds can be operated at full capacity to the greatest extent possible.
If the emergency department pushes some patients who can be treated with simple treatment to the specialist department, they will definitely be criticized. In the final analysis, it is all for profit.
Today, the emergency department's operating room has begun to flourish, with a general operating room, a Class 100 operating room, and an endoscopic operating room under construction.
The surgical team also expanded from the initial few people to twenty-five or twenty-six people.
Including more than a dozen surgeons and more than a dozen surgical nurses.
Now, even if either Zhou Can or Dr. Xu takes a vacation, the emergency department will not be unable to operate.
"Doctor Zhou, could you please help take a look at the patient with upper gastrointestinal bleeding? After a 1000ml blood transfusion, the patient has improved. However, the bleeding has not stopped, and the patient has developed a high fever, with the temperature rising to 39.4 degrees."
Ai Li made a request to Zhou Can somewhat embarrassedly.
She, a chief physician in her late 50s, had sought help from a resident in his twenties. This was the Nth time.
In other words, she had gotten used to it.
"Let me go with you to see the patient!"
Zhou Can can only put the patients first.
"Doctor Zhou, I'll prepare your meal and wait for you, okay?" Qiao Yu silently took care of Zhou Can in daily life.
It was already quite late, and she was worried that the food in the cafeteria would be sold out because it was too late.
"You guys eat first! I'll go get the food myself when I'm done."
Zhou Can realized that this patient with gastrointestinal bleeding was difficult to deal with.
It is not yet known how long it will take.
Why does high fever occur within just three or four hours after taking the medicine?
Following Ellie to the emergency room, I saw the patient lying on the bed, his eyes closed, his face still a little pale. However, compared to when he was first admitted to the hospital in the morning, his condition had improved significantly.
The amount of blood transfusion was as high as 1000ml, which is actually very amazing.
"Did you take ranitidine?"
After examining the patient's condition, Zhou Can asked Dr. Ai Li.
For this type of emergency patients admitted to the emergency department, the first-visit system is currently implemented. Whoever receives the patient is responsible.
Novice doctors are particularly afraid of receiving critically ill patients.
However, as long as there are attending doctors or above on duty, they will rush over and take over the patient immediately when they hear that a patient needs rescue. It is impossible to let a novice doctor rescue a critically ill patient and let the senior doctor leave it alone.
"Use it!"
Ellie nodded.
Ranitidine is commonly used to treat duodenal ulcers, gastric ulcers, reflux esophagitis, Zollinger-Ellison syndrome and other diseases with high gastric acid secretion. It is also sometimes used to treat Helicobacter pylori.
The cause of the patient's current fever is a major problem that bothers Ellie.
This is also the main reason why she asked Zhou Can to come and help with the consultation.
"The patient's other vital signs are relatively stable. He has no chills, only a high fever. It's really weird. We cannot rule out the possibility of an intestinal infectious disease."
Zhou Can frowned slightly and began to try his best to diagnose the cause of the patient's illness.
Blood transfusion cannot cause high fever, so this factor can basically be ruled out.
Ai Li was very cautious in giving medication to patients, and only used two hemostatic drugs that she had discussed with Zhou Can. Ranitidine, a commonly used drug for treating gastric ulcers.
In theory, the possibility of high fever caused by medication is also very low.
However, the patient did develop a high fever only after three or four hours of treatment in the hospital.
From the nurse's physical measurement of the patient, it can be clearly seen that the patient's body temperature showed a relatively stable sloping rise over four hours.
The fever didn't come on suddenly.
The first suspicion is still the medication problem.
Zhou Can's current pathological diagnosis is level five, close to the senior level of associate chief physician. His pharmacological differentiation is also level five, and he just reached the intermediate level of associate chief physician not long ago.
Compared with pathological diagnosis, there is a significant gap.
The patient received a blood transfusion of 1000 ml, and his hemoglobin level was barely restored to a relatively ideal level. However, his anemia did not improve significantly.
Zhou Can couldn't help but pick up the patient's emergency gastroscopy report again.
Logically speaking, the amount of bleeding caused by gastric mucosal erosion cannot be very large. Even if the bleeding continues for as long as a month, it is impossible for the patient to suffer from severe anemia or even sudden shock.
What exactly is the problem?
At this time, Zhou Can had begun to suspect that the patient's bleeding was not simply gastritis.
In addition, erosive hemorrhagic gastritis usually stops bleeding automatically very quickly, and the disease has good self-limitation. However, the patient continued to have black stools for more than a month, which is a contradiction between the two points.
It was further confirmed that the patient's bleeding was not simply gastritis.
His brain was working rapidly, wondering if there were other sources of bleeding in the patient.
It can cause severe anemia or even shock in patients, indicating that the amount of bleeding is very large.
If there is heavy bleeding in the stomach or duodenum, the blood will reflux into the stomach. At this time, the patient will vomit coffee-like stomach contents or even vomit blood directly.
For example, the Records of the Three Kingdoms records that Zhuge Liang scolded Wang Lang so much that he vomited blood and died on the spot in front of the battle.
The novel believes that Wang Lang died of a broken heart, which is definitely unscientific.
The heart is inside the chest cavity, so a ruptured heart vessel is unlikely to cause direct vomiting of blood. Usually, only bleeding in the upper digestive tract or upper respiratory tract will cause direct vomiting of blood.
Upper respiratory tract bleeding is more likely to present with blood foam.
For example, when encountering an emergency patient who suddenly vomits blood and falls to the ground, the doctor often determines the specific source of bleeding based on the color of the blood vomited from the patient's mouth and nose and whether there is foam.
Bleeding in the lungs, usually with blood foaming and coughing. Mainly coughing up blood.
If there is bleeding in the stomach or duodenum, the patient will vomit blood directly.
This patient did not have clinical symptoms of vomiting.
The possibility of massive bleeding in the upper gastrointestinal tract within a short period of time can basically be ruled out.
However, before the shock, the patient suddenly had nosebleeds, which is also a cause for concern.
The structure of the human pharynx and nasal cavity is very complex.
The nasal mucosa is rich in blood vessels, and people are very prone to nosebleeds when they have a fever or their nose is attacked.
Sometimes the amount of bleeding is so heavy that it's quite scary.
However, the patient and his family did not report frequent nosebleeds. This reason can be temporarily postponed.
The top priority is to quickly find out the patient's true source of bleeding.
Although the patient's vital signs are relatively stable after rescue, danger can occur in an instant if the real cause of the massive bleeding is not found out.
After the patient was admitted to the hospital, he received infusion and blood transfusion, which led to high fever symptoms.
Is this a coincidence, or is there another reason?
There are only three types of drugs for infusion. Whether it is ranitidine for treating gastric ulcers, or batroxobin and tranexamic acid used to stop bleeding, they will not cause the patient to have a high fever in a short period of time.
At least based on Zhou Can's clinical experience and knowledge of pharmacology, a high fever reaction is impossible.
Does blood transfusion cause high fever?
This is the first time I've heard of such a thing.
"Doctor Ai, please ask the nurses who are giving the patient IV fluids and taking care of him to come to the office to discuss the patient's condition."
Zhou Can first needs to rule out the possibility that hyperthermia reaction was caused by infusion or blood transfusion.
For example, there is a problem with the saline used for infusion.
This must be checked first.
Some saline solutions may have problems during storage or manufacturing due to various reasons.
For example, flocs appear in the bottle.
An experienced and careful nurse will not only check everything before giving an infusion to a patient, but will also shake the infusion bottle deliberately to see if there is any problem after the saline and medicine are mixed.
Normal saline is the most widely used medicine in hospitals.
When hospitals purchase, each manufacturer uses their own unique approach.
It is not ruled out that some unscrupulous manufacturers, after receiving orders from hospitals, sell substandard saline to the hospitals.
Of course, manufacturers are also afraid of accidents and want to do long-term business, so they will do their best to ensure quality, especially safety.
Workers who are just doing their job, or the manufacturer's technology is not up to standard, or the hardware facilities are outdated and faulty, which may cause problems with the brine produced.
Not every bottle has a problem.
If there is only one bottle with quality problems among ten thousand bottles, it will be a time bomb.
If used on a patient, that unlucky patient will most likely get into trouble.
In the office, the nurse who was giving the patient an infusion, Dr. Ai Li, and Zhou Can began to discuss the patient's condition.
Zhou Can is the leader.
"Did Mr. Zhao check the medicine bottle when he was giving the patient an infusion?"
Zhou Can would never ask such questions in front of patients and their families.
This is also the reason why Ellie and the nurse were called to the office.
"I checked it at the time and didn't find any problems. Director Niu repeatedly told us to be extra careful and attentive during clinical care and dressing changes, and to put safety first. We are especially careful when giving each patient an infusion."
Zhao Qian and Zhou Can are old acquaintances.
She really works hard.
I have been promoted to nurse, but I still have a long way to go if I want to be promoted to head nurse.
It is not easier for nurses to be promoted than for doctors.
It is relatively easy for a doctor to be promoted to attending physician.
Nurses who want to be promoted to head nurses now either have to accumulate experience or take the postgraduate entrance examination. Of course, those with connections are not included in this category.
Society is a society of favors, especially in my country, where favors are rampant in some units. For example, in a certain railway company or a hospital, management positions with high salaries and easy work are basically dominated by the second generation.
Zhou Can is quite familiar with Zhao Qian's working style.
She usually works seriously and hard.
Since she had checked carefully before the infusion and found no problems, it basically ruled out the possibility that there was a problem with the infusion medicine itself.
After much thought, Zhou Can felt that the patient was likely to have multi-source gastrointestinal bleeding.
What is multi-source bleeding?
It means bleeding in multiple places.
The patient's bleeding is likely to occur in more than just the upper gastrointestinal tract.
The small intestine and the upper part of the colon should be the focus of investigation. Gastric juice should also be monitored.
Because the patient has had black stools for more than a month, the possibility of massive gastric bleeding cannot be completely ruled out.
Medically, unless there is sufficient evidence for diagnosis, no possibility should be ruled out. At most, a certain possibility is higher and is given priority for investigation.
Especially these difficult cases that are extremely difficult to diagnose are often caused by some reasons that are easy to overlook.
The essence of difficult cases is that they involve relatively rare causes and symptoms and cannot be solved by using the content in textbooks.
Doctors need to make flexible diagnoses based on their clinical experience.
"Doctor Ai, I suggest that you first draw gastric juice from the patient regularly to monitor gastric bleeding. At the same time, use some auxiliary examination methods to further rule out the possibility of bleeding sources in the small intestine and colon."
Zhou Can gave specific further diagnostic suggestions.
