A hematologic emergency in the ER

I was on call over a holiday weekend and Friday night at 10 o’clock I was paged by the emergency department about a nosebleed. A man in his 30s had a bloody nose Friday morning and over the course of the day had developed red spots all over his legs. The ED checked his blood and his platelet count was near zero.

Blood looks red because of the oxygen-carrying red blood cells, but there’s a lot of other crucial stuff in there too. The bloodstream is the network of hallways by which almost everything in the body that needs to travel gets to where it needs to go. Most of us have the good fortune to go through our entire lives taking for granted that our blood stays where it’s supposed to be despite shuttling through a relatively leaky system of tubes thousands of times every day. That’s thanks to a meshwork of chemicals and cells that work together to let out what’s supposed to leave and keep in what’s supposed to stay. Platelets are part of that system — tiny cell fragments that constantly chip off,  swarm out, and plug up leaky spots in the bloodstream where they’re needed.

There are only a few actual hematologic emergencies, and this is one of them.  For one thing, spontaneous and potentially catastrophic bleeding is a major risk, but you also have to figure out why it happened, and it can’t wait until morning.

Thankfully hospital parking is easy at that hour. I found his bed in the ED and asked all the standard questions, and couldn’t find any obvious reason why his platelets were so low. Other than the rash on his legs (which was a classic low-platelets rash) he was fine. Under the microscope, his red blood cells, and white blood cells looked normal. He wasn’t on any new medications and wasn’t infected with anything.

If you can’t find another explanation for such a low platelet count, then the usual cause of this problem is because the immune system mistakes the platelets as something foreign and tried to get rid of them.  It’s one of the least scary reasons platelets drop like this and it’s one of the diagnoses we hope for when we get this phone call.

We admitted him to the hospital and started steroids, which is the easy part.  The next steps are, 1) wait; and, 2) pray that the very few platelets that are in there can keep his blood in the places where it’s supposed to stay.

Saturday morning I got in early to check on him, and his platelets were still critically low.  His wife and happy 10-month-old son were in his room with him and the general tone of the room was relief that nothing more emergent had come out of our workup.  It probably felt like we were doing a lot of nothing.  The whites of his eyes had bloomed red from hemorrhages, and he had developed a bit of a cough and was bringing up spots of blood.  Otherwise, everything was stable.

Sunday morning I got in early again to check on his labs, and there was still no improvement in his counts.   We added another med to try to  distract his immune system from the platelets,  then his oxygen level began to drop. A chest x-ray showed both lungs looked a little fuzzed out because he was springing tiny bloody leaks into the air spaces.  This isn’t common, and it terrified me. The relief I felt Friday night because he didn’t have leukemia was being nudged aside by a growing concern that his counts weren’t improving quickly enough.  He remained cheerful.

The reason this is so anxiety-provoking is that 1 or 2 out of every 100 people with his platelet count will bleed into their brain, and there’s very little to do about it.  It can be catastrophic.

Monday morning.  Platelets less than 10 again.  No new bleeding but still coughing.  More anxiety.

This patient is different from most of the patients I see.  He is young and he doesn’t have cancer. Prior to coming into the hospital, his life was normal. He wasn’t expecting to come into the emergency department and learn he has a condition that, while, hopefully, very temporary, is something that could end his life.

Something like this could happen to any of us, tomorrow.  Those of us who believe we take good care of ourselves and make healthy decisions and therefore will have no health problems are correct, until we’re not.  Which is, unfortunately, frequent.

When was the last time you expressed gratitude that your platelet count is normal?  How many other things in our lives does this apply to?  I started the weekend wishing it was someone else on call for the 84 hours of the holiday weekend.  I drove home from the hospital Monday night, got into bed slightly exhausted, and gave thanks for the reminder that while the things I consider problems may have short term importance, they are most often remediable and transient. The small things that nag at my attention and feed my frustrations are not the things that make up my life, they are distractions from my life.  My life  is constructed of a million small but crucial pieces that, given the proper recognition, can dispel the most pressing perceived deprivation.

It’s possible our lives are exactly as they should be, and our only mistake is not acknowledging it.

After the holiday weekend, my co-fellow took over the service and I went to a different hospital.  The man stayed inpatient for a few more days and his platelets were starting to creep back up towards normal by the time he was discharged later in the week.  His cough stopped and his oxygen levels got better.

I saw him in my outpatient clinic last week and the medications were continuing to work, his platelets back up to the normal range by then.  Rash disappeared, eyes clear white.  Same amount of happy as when they weren’t.  Two beautiful kids and his wife at the visit with him.

This may never be a problem for him again.  We’ll continue to check his labs and treat him again if necessary, but hopefully this will be the story he tells his grandkids about the long weekend he spent in the hospital with some blood problem that never came back.

It was a lot more than that, for me.

Kenneth D. Bishop is a hematology-oncology fellow who blogs at Out Living.

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