“Do you have any belly pain?”
“You guys keep asking me that.”
“How about this?” I gently pressed a hand into his stomach.
“OK, OK that hurts some, but not bad.”
Blood can be highly irritating to the abdomen’s lining, so if the excess fluid was blood, Mr. Dexter should have felt more pain, but following gastric bypass surgery, he no longer had a normal abdomen.
With low blood pressure and possible blood in the belly, this patient was now an official emergency. “Call the surgeons—now!” I ordered. “Make sure he’s typed and crossed for four units.” More nurses swarmed in.
An intern entered, waving a slip of paper: “His hematocrit is 26.” That’s a low—but not critically low—red blood cell count.
“I’ve been a little anemic in the years since the surgery,” Mr. Dexter offered.
“What’s your usual level?” I asked.
“Don’t know. Sorry.”
Don, one of our surgeons, came charging down with his team. “Odd thing is,” I told him, “his belly’s not tender, but look at this.” I passed the ultrasound wand over the black band again.
“I see it,” Don said. “I believe you.”
“Could he have a PE?” the chief surgical resident mused, referring to a pulmonary embolus, or blood clot in the lung. “The gastric bypass puts him at risk. Or maybe a suture line eroded or there’s a perforation leaking stomach contents.”
The list of possibilities seemed endless. With no time to spare and Mr. Dexter too unstable to undergo a CT scan to image the lung, we would have to decide on an operation based on our own judgment.
“Why should a healthy man suddenly bleed into his belly?” Don asked. “And then not be tender? What if it’s a PE and we operate, then have to anticoagulate him? Nightmare.”
“His oxygen level’s not bad,” I said.
“It’s like he has half of everything,” the chief resident observed.
“How about we look at his heart with a bedside echocardiogram?” I suggested. “If the pulmonary artery is corked by a clot, we’ll see a dilated right ventricle.” Echocardiograms create images of a beating heart, to help doctors spot problems in cardiac structure and function. Mr. Dexter’s results were normal.
“We’ve wasted enough time. Let’s go,” Don ordered.
Suddenly the monitor beeped: Blood pressure was now 110 over 60. Mr. Dexter was in safer territory now.
I held Don back. “His blood pressure’s better. Maybe something clotted off. Why don’t we sneak a CT scan on the way up?”
Fifteen minutes later, everyone crowded into the radiology suite. The scan showed blood everywhere.
“What’s that?” Don tapped the lower pole of the spleen, where an odd lesion that resembled a bull’s-eye lay at the center of the bleeding. “Aneurysm? Tumor?”