Congratulations to Dr. Charles Murchison for our save of the month!
A 75-year-old man with history of HTN and BPH presented with a single episode of rectal bleeding. His exam was notable for hemorrhoids, and his hemoglobin was at baseline. Previously, the patient had been discharged home, but he passed out while walking out of the hospital and was brought back into the ED. This is where the hero of our story, Dr. Murchison, comes in.
Dr. Murchison immediately re-evaluated the patient and noted that his left leg was larger than his right.Dr. Murchison then immediately performed a bedside ultrasound, which revealed a large proximal DVT extending distal to the popliteal vein. With this new information and a stable repeat hemoglobin, he was concerned that the syncopal event was not due to a GI bleed, but rather a PE. He started the patient on a heparin drip and ordered a CTPA.
Shortly thereafter, while the patient tried to push himself up on his stretcher, he immediately developed respiratory distress and became unresponsive. He was transferred to the resuscitation room with repeat HR in the 120s and BP of 70/40. Concerned about a massive PE, Dr. Murchison started IVF, and after some short deliberation about thrombolysing a patient with a GI bleed, administered half-dose alteplase over an hour. A few minutes into the alteplase infusion, the patient started speaking and reported that he felt better. The CTA chest/abdomen, hours after thrombolysis, confirmed multiple PEs and no active GI hemorrhage.
Kudos to Dr. Murchison for not letting himself fall victim to anchoring and premature closure, making a tough decision regarding thrombolysis in a patient with a “GI bleed”, and saving a life in the process!
Noah Berland
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