Hi everyone! I'm a 2nd year resident doctor in an inner city hospital. This is a blog to document some of the experiences I encounter as a training doctor, and some of the things that I learn in the process. After all, being a physician means that I'll be learning some fascinating topics for the rest of my career, and seeing how I can use those to help patients.
Let's get started with today's experience:
Thick blood!
There are quite a few reasons that we might sometimes have issues obtaining a sample of blood from a patient. Often they refuse blood draws (either they’re tired of them, scared of them, or don’t understand the importance of the labs we’re trying to obtain); other times, they have inaccessible veins making it difficult to draw blood; sometimes the veins are so calcified that it’s hard to even get into the vein to draw blood. An uncommon case is when the blood is so thick that even when there is available access, it can’t be drawn. I had such a case with a sickle cell patient who had direct access to her blood through a venous catheter.
Sickle cell disease and crisis
Sickle cell disease occurs when the red blood cells contain abnormal hemoglobin; hemoglobin being the component of blood that carries oxygen. It’s typically caused by genes passed down from parents; when both the Mom and Dad pass down the genes, their child will have the disease (it’s called sickle cell trait when only one parent passes down the gene). The abnormal hemoglobin causes the red blood cells to form in a C-shaped, otherwise known as a sickle. When a bunch of these sickled cells come together, they can cause many problems, largely stemming from clotting.
The sickle shape causes more clots to occur, resulting in problems such as sickle cell crisis (pain resulting from lack of blood cells moving to different parts of the body), acute chest syndrome (due to clots within the lungs), stroke (due to clots within the brain), splenic sequestration (red blood cells getting stuck in the spleen where they’re formed), bone pain (red blood cells getting stuck in the bone marrow where they’re formed), anemia (due to death of red blood cells), jaundice (due to release of components of the red blood cells when they die) and in the case of some men, prolonged erections (also due to clotting, which prevents blood from returning from the erect penis).
A sickle cell crisis occurs in patients who exposed to some external or internal stressor (sometimes as simple as a cold virus!). One of the most important treatments during such a crisis is the administration of intravenous fluids, or even just drinking a good amount of water. The reason that this helps is because the blood is clotted, thick, and doesn’t move around easily. Water is absorbed through the gut and into the bloodstream, where the red blood cells can absorb it. This helps expand the sickled red blood cells so they’re close to a normal round shape. This makes them less rigid, sticky, and thus it’s possible to break up the clot.
Getting that blood drawn
As you can predict from what I just wrote, patients who are in a sickle cell crisis are likely to have pretty thickened blood that doesn’t move easily. This can make it difficult to draw blood even when there is direct access. In the case of my patient, my coresident and I were momentarily stumped when we noticed that we could easily inject water into the catheter (that’s how we test if it’s working), but could not draw a drop of blood!
The importance of monitoring blood in these patients is to ensure that they’re not actively losing blood cells (which may require a transfusion if it’s very severe, although we try to avoid that because transfusions run their own risks, especially in sickle cell patients who are bound to sickle), as well as kidney function (which can be compromised because of dehydration and blood clots), electrolytes (which can be thrown of due to thick blood and poor kidney function), and reticulolytes (these are immature red blood cells; if their level is high, it tells us that new red blood cells are forming during a sickle cell crisis).
Well, we couldn’t get these values until we could draw the blood. What were we to do? Simple: hydrate our patient some more! It took about 3-4 days, but we finally managed to draw the blood when she was hydrated enough. We also made sure to give her some of the standard supplements and treatments that can hasten anemia if not given: hydroxyurea and folic acid. Her bloodwork came back showing an improvement, and she was able to leave the next day when she was able to tolerate the pain of her crisis.
I hope you've enjoyed this little snippet of an experience I had as a resident in an inner city hospital. I'll have many more stories and learning experiences coming in the future, so stay tuned.
Sources:
- https://lakesidemedicalcare.com/history-osteopathic-medicine/
- https://www.cedars-sinai.org/health-library/diseases-and-conditions/s/sickle-cell-disease.html
- Me 😊
Disclaimer: this blog is for entertainment (and possibly educational) purposes only. This is not medical advice. If you have nay questions or concerns about your own health, please contact a healthcare provider.
Here are the previous editions of this blog:
Chronicles of an Inner City Hospital Resident Doctor #2
Chronicles of an Inner City Hospital Resident Doctor #1