James B. Naidich, MD, FACR
Prisoner of North Shore Hospital
Blood has the almost magical property of remaining a ﬂuid within the circulatory system, but also has the ability to turn solid when extravasated. When blood clots within the circulatory system, this is disease: thrombosis. When unclotted, blood ﬂows freely outside the circulatory system; this too is disease: hemorrhage.
One evening during a weeknight call, my patient acutely clotted an arterial bypass graft. My goal was to dissolve the clot. If I could position a catheter in the clotted graft, I might then be able to instill thrombolytic drugs, reverse the clotting process, dissolve the clot, reestablish ﬂow through the graft, save the patient from surgery and maybe save his leg.
But reversing a patient’s natural protective ability to clot blood is dangerous. The danger is hemorrhage. The patient must be monitored closely. By around 6:30pm with the catheter properly positioned, I was waiting for an ICU bed to open. I wanted to explain the set-up to the ICU nurses, and then I could go home.
By 8:30pm, the patient was tucked away securely in an ICU bed, and I was free to go. At that moment, the hospital conducted a ﬁre drill, prompting a secretary to shut all the oﬃce doors. As luck would have it, my car keys were in my oﬃce, and I was locked out. I thought, “All my residents have master keys. If I could ﬁnd one, I could escape!” Someone mentioned the residents were in the Nuclear Medicine section of the hospital.
Approaching Nuclear Medicine, I found the residents tending to a patient with hematochezia. I wasn’t leaving the hospital so fast. “Great,” I thought to myself, “Now I have my keys, but I also have a new patient!” The patient was a young alcoholic with gastrointestinal hemorrhage. I experienced the surrealistic, nightmarish sensation that I was never going to escape the hospital.
Although alcoholic patients can bleed for a variety of reasons, in this case the bleeding scan localized the hemorrhage to the left hemicolon. Calling my nurse and technician, we were ready to perform the procedure at about 10:30pm — to place a catheter into the inferior mesenteric artery, ﬁnd the bleeding branch artery and plug it with a coil, which we did. Finally, I left the hospital at 1am.
The next day, the patient was stable with no further signs of hemorrhage.
About one week later someone asked, “Did you hear what happened to the patient?” Something in their voice suggested I did not want to hear the answer. The risk to the ﬁrst patient was hemorrhage, but the risk to the second patient was that by obstructing the blood ﬂow through an artery, I could infarct the bowel.
This did not happen, thankfully, but what actually happened was worse. The alcoholic patient was lucent upon arrival to the hospital. But when deprived of alcohol — the patient suffered withdrawal symptoms, including delirium tremors and hallucinations. Rather than medicating the patient, he had been physically restrained. The hallucinations can be frightening. The patient broke his restraints, and using an IV pole, broke out the fourth-ﬂoor window, escaping the hospital.