Epistaxis II

This is the second part. Cautions for readers are the same as given in the first part. Any critical analysis is for introspection and not to malign image or reputation of any individual, doctor or hospital. Introspection should help all to perform better. No hard feelings. Take it easy. Here we go.....

Shift from Casualty to room was much faster than expected. In the same casualty little over six months ago, I had brought a old lasdy with hip bone fracture. The medical officer forced me to rush to the pharmacy to buy traction. It was indeed needed. I left the patient alone in the emergency, went to the pharmacy and got the traction. For next six hours in spite of repeated coaxing the patient and traction were lying in casualty. Ultimately after a wait of six hours with acute fracture pain the patient was shifted to the room and it took another hour to put the traction in place. With this experience and background, I was happy at my shifting to the room in less than one hour after arrival. The bed had electronic controls for reclining, altering the height of the bed and looked impressive. Unfortunately it was uncomfortable for me as these beds were designed keeping in mind patient’s maximum height to be of six feet. I am more than six two, so fitting in the bed was tricky. I had to sleep diagonally. While in casualty blood samples were drawn, IV cannula was in place at the back of my left wrist and x-ray chest was done. I thought I will have few hours of sleep before I go to the operation theater. However it was not to be so. I just dosed off and nurse walked in to record the ECG. Soon after that a ward boy came with hospital dress. There was a problem again. The largest size available in the hospital was tight for me. With no other option I slipped into what was provided and I was looking like a joker. Pyjamas were three inches short, sleeves were between elbow and wrist, many of the buttons refused to come closer to the button holes. I looked in the mirror and enjoyed my funny look. Then one after other someone kept on coming, from nurses to the anesthetist and surgeon as if there was a conspiracy not to allow me to sleep.

My younger son was travelling, he was called and asked to take next available flight back home. In any case he would not have made it before the surgery. He booked online and was to reach Vashi by 3.00 pm. I did not call my elder son in US as there was no point giving him the tension and in any case he can reach only when the emergency is over. By 9.30 am my wife and brother accompanied me when I was wheeled in to preparation room next to the OT. The final check was on to move me to the OT. The nursing staff was pushing the stretcher when the anesthetist asked me if I could walk to the OT. I said yes, I accompanied him to the OT. I took a good look at the OT. It was OK. I was in for endoscopy and cauterization. The position of the operation table was away from the monitor and thus the table and shadow less lamps were shifted accordingly. Anesthetist asked me usual questions, if I have dentures, addictions etc. He started Ringer Lactate drip, I saw him adding a sedative and in a moment I was fast asleep. I woke up when the procedure was in the final stage and the ENT surgeon was pushing the packs in my nostrils. In fact the pain of pushing 8 cm long packs in nostrils made me wake up from the deep slumber. The ENT surgeon looked to be happy at the job she did. I spent another hour in recovery room and later on was shifted to my room. The oxygen mask was making me uncomfortable. I did not certainly need the oxygen. I asked the nurse to check oxygen on pulse oximeter, it was 100. I asked her to remove the mask. On discharge I realized the need for the same for the hospital, as they had billed me for the oxygen and also for pulse oximeter. I could bought the pulse oximeter for myself with kind of charge billed. Rest of the day I was sleepy and uncomfortable. Nostrils were packed, breathing was through the mouth. With packed nostrils the post operative secretions, discharge was blocking the sinuses. I had to constantly sip water to keep dry mouth moist but even that was painful as nostrils were blocked. Block your nostrils and try to drink, you experience the discomfort. Lips developed cracks due to dryness. I had a restless night. Next morning some secretions dripped down the nostrils. ENT surgeon came for a round and looked satisfied with the progress. She suggested that packs could be removed after two days and I would be normal.

Things were not destined to be so. By 11^th afternoon I started bleeding again. The difference from earlier episodes and the fresh ones was that I was now getting a forewarning of the bleeding. The packs in the nostrils would absorb the blood and then blood would run down the nostrils. I was taken to the OPD to show her, as she did not respond to our request to visit the room. Now the ENT surgeon was worried. She prescribed me those medicines which she had asked me to stop when I met her first.  I had three episodes on that day. Next day the ENT surgeon was to take a look and see if she could remove the packs. She examined and suggested we should remove the packs on 13^th in the OT, so that if need be the cauterization can be again done. Bleeding was increasing on 12^th. The quantity was high and frequency was more. On that evening my brother saw me bleeding for the first time and then he realized the gravity of situation. The chairman of the hospital was informed of the condition, staff from ICU rushed to my room, we were given a choice to get another ENT surgeon of our choice from anywhere and we also made plans to shift if condition deteriorates. The night went by. Next morning on 13^th, bleeding was more profuse.  I went to toilet and nose started bleeding and once again the blood was splattered everywhere in the toilet to the bed. In between the bleeding would stop but things were taking a serious turn. By noon I was in the preparation room and while on the stretcher I once again bled profusely. That was the first time my younger son saw me bleeding. He could not believe that things could be so bad. I was moved to the OT with ice pack over my nostrils. This time the OT was different, but problems were same. The table had to be moved so it was closer to the monitor. The equipment was attached to the monitor. The cable was loose. It worked for a while and then the monitor went blank. I got reminded of AVG cable connecting the laptop with LCD projector not working in the management school that happened to belong to the same hospital group. The problem was somehow fixed. The air conditioning was on full blast. I requested the staff to increase the temperature. The poor fellow did not know how to respond to my request. I told the anesthetist to increase the temperature. He knew the problem and told the staff to switch off the AC. Apparently the thermostat of the AC was not working. Again it was similar to the problems I had in management school. I was readied for the procedure. This time I was not to be sedated but a mild tranquilizer was given. I was in full senses, local anesthetic xylocaine 4% was put in the nasal cavity and the pain was little blunt. In a short while the ENT surgeon walked in. She ordered IV cephalosporin. I stopped her and suggested that she gives amoxycillin and not cephalosporin. It was more than ten days I was on cephalosporin. She agreed but was tense.  I could sense her nervousness when I was in the preparation room and she was frantically trying to get some additional help, another senior ENT surgeon. She had a tough luck. No one was available at that moment. She called couple of her friends who advised her. Fortunately for me we had requested our octogenarian friend, a highly experienced ENT surgeon to be present in the OT. I was positioned for the procedure. She asked the table to be lowered. Unfortunately it could not be done. Then she asked for a stool, that was made available and then she stood on the stool to start the procedure. Eye drops were put in my eyes so that the vision gets blurred and a head towel was placed and tucked so that I could not see anything. She asked for the headlight, placed over her head and here again the connection was loose. The headlight stopped working. The wires were tightened and she was now ready. Our friend who was supposed to be there had still not come. The traffic jam at Airoli bridge had delayed him.  She asked me if she can start the procedure. I wasn't sure how much time my doctor friend would take and he was only an adviser  so I asked her to proceed. She removed the eight cms. long  packs that were placed little over 75 hours back. There was a friction and pain during the removal and soon after that there was gush of blood. The cauterization that she did on 10^th was disturbed and old wounds started bleeding. She was in a shock. She asked for assistance, ‘get the suction, Txxy, jaldi karo, it’s a profuse bleeding”, she applied the suction to suck out the accumulating blood. Either she was tense or was not used to the procedure, God knows. Ideally she should have put saline gauze over the bleeding surface and then used the suction. This minimizes the damage to the bleeding tissues. Putting suction straight on the bleeders is traumatic. Anyway while this was on, my doctor friend walked in and then I had my comfort levels. She put the endoscope in. I could feel the pain, it must be old model of endoscope as the new ones are just 2 mm in diameter.  This time she used RF for cauterization. It took almost twenty five minutes to finish the cauterization. The tip of the instrument emits high frequency waves and raises the temperature to about 70⁰ C that seals the bleeding points. She would cauterize one point and the bleeding would start from another point. At one point she used so much of force that I felt rupture in septum. This was confirmed later by another doctors when the healing process was on and old blood clots were gone. She was working on my nose as if she was playing a video game. She had to look at the monitor and make moves. The battle was over after nearly half an hour. With all these efforts she was feeling warm; she ordered to start the AC that had nonfunctional thermostat. Once again the blast of cold air swept my body. My doctor friend advised her not to pack but place gel foam, a old time tested dressing. The surgeon was not quite impressed with suggestion of an old timer but couldn't refuse and placed it in both the nostrils. I was wheeled out to recovery room. All looked relieved. The ENT surgeon patted me with assurance that all is well and went for another surgery. My wife, son, brother, doctor friend were around the bed with visible sign of relief. I blinked my eyes to assure that things are OK now. That happiness was momentary. I got the feeling that I am going to bleed. I told my doctor friend and asked the nurse to get the gauze. Before anyone could realize my nose started bleeding. The faces turned worried and helpless. The anesthetist and my doctor friends came close to me, ice was brought and once again my nostrils and face was covered with ice pack. The ENT surgeon was informed but was in the OT operating another patient. The two attending doctors and my brother said that nothing can be done at this stage. All that was to be done has been done. We have to wait and watch. Everyone looked helpless. I was wondering if it was a beginning of an end. Is this the way a healthy person has to meet his end. No it can’t, I said to myself and relaxed. The gel foam that my doctor friend had suggested worked. It soaked the blood and packed my nose. With pressure of soaked gel and it’s forming a film over the bleeding area the bleeding stopped. The cold compression was on. The ENT surgeon came after about half an hour and I am sure she must have silently thanked my doctor friend for his suggestion of gel foam. I was in recovery room for next two hours before returning to the room.

As there was no sedation, I was expecting a peaceful night, of course with the tension of further bleeding. By 11.30 in the night a resident doctor came and started explaining post operative primary and secondary bleeding. His knowledge seems to be from recent reading from some book. I asked him not to explain and let me relax. At four in the morning I heard some saying good morning, I looked at the wall clock it was about four ‘O clock. I lost my cool and fired the intruder, told him to come by eight. My son woke up to see what’s happening. The intruder left without further advance. In the morning my son told me that the person I gave a piece of mind was non other than the resident doctor. I felt bad, but certainly four in the morning is not the time to take a round. Night was otherwise comfortable. I could at least breathe through the nose. There was no further bleeding.

After the first cauterization I experienced nose bleeding may be due constipation. This time I decided to take complete bed rest and be on liquid diet for next three days and take stool softeners  It worked out well. I was doing well with liquids. On day two of operation, I started moving in the room and gained confidence. There was no fresh episode. I took discharge after two days. The ENT surgeon was pleased with her job, but not I. She asked me to see her in OPD after three days. I preferred not to. Two days after I was back home, my doctor friend came to my place and almost set up his clinic to examine me. We sterilized the instruments, got sterile gauze and dressing and removed the obstructing blood soaked gel foam. Net week onwards I went to my doctor friend’s clinic, who extended great help to ensure that I am comfortable.

I had tarry dark stools for over two weeks. My hemoglobin before this problem was over 15 gms. On the day I took discharge it was little above 10 gms. I lost almost 5 gms of hemoglobin in two weeks. One bottle of blood donation reduces the hemoglobin by about one gram. So was it equivalent of five bottles of blood loss?

Few questions are still bothering me. Why I got epistaxis to start with. It was from anterior region. I do not see any apparent cause. I was normal, did not venture in hot sun, did not poke the nose, nostrils were moist, no rhinitis, no coryza, no allergy, normotensive, no diabetes, no stress, nothing yet the profuse bleeding. A big question mark.  Why did the ENT surgeon stopped the coagulants and vitamin K? I just don’t understand. May be that would have helped.

Why did the ENT surgeon put me on third generation cephalosporin? Was it needed? I had no infection when I met her first. I was on IV cephalosporin postoperatively. I was getting hot flushes and had a feeling that cephalosporin is not suiting me. Was the epistaxis due to overuse of cephalosporin?

Was the first cauterization faulty or the packing was not correct? If the packing is right then there is adequate pressure and the chances of bleeding are remote. I was bleeding profusely even with nostrils packed raises doubt about the way packing was done? Why gel foam was not used after the first procedure? I am at loss to understand.

Was the ENT surgeon casual? Generally epistaxis can be a OPD matter. Maximum one day hospitalization if needed. I was in for six days. Was she not gentle in performing the procedures? I could feel her harshness many times during the procedure. Was the equipment not latest? The procedure has destroyed nasal villi. I will have to live with it for rest of my life.

With adequate knowledge of medical science, medicine and surgery, with adequate resources, with fair amount of doctor friends and some standing in the society, I have experienced the treatment related problems. What would have been the fate of common person on the street had this problem occurred to him/her?

I am limping back to normalcy. I am not supposed to bend down, exert, and lift weight etc for a while. Life will be normal again, but it was a phase of loss of mental peace, tension to family and friends and financial loss. The phase of fighting with mediclaim is on the cards, as they are paying only for two days of hospital stay whereas I was in for six days and there are many other unjustified deductions. This is the sad part of being ill.