Two-Way Flow

     "He was bleeding! Like, bleeding all over the place!"

     The wife is highly upset and looking pale herself. Her husband had survived surgery for colon cancer, but now is lying pale and sweaty on the couch. The Attack One crew was dispatched for "a man hemorrhaging," but it looks more like a shooting. The front room is covered in blood, and it trails into the bathroom and toilet.

     The male patient has no complaint of pain, and in fact has suffered no injury of any type. His colostomy was done about a month ago as a result of the cancer surgery. He's recovered uneventfully, and even received good news that the cancer was contained and he would need no chemotherapy or radiation therapy. The surgeons hoped his colon could be repaired and the colostomy closed in about six months. He's had no other problems. He was sitting on the couch at the end of a busy workday when he noticed a little blood in the colostomy bag. He called his surgeon, but the office had closed, and the answering service was still trying to page the physician. As the couple sat on the couch, his colostomy bag felt full, and he opened his shirt to find the bag full of blood. He felt too light-headed to get up, so his wife tried to take it off and empty it in the bathroom. It was so full, it spilled along the hallway, and worse, the patient was bleeding bright red blood from the stoma site.

     The man had placed a new bag on the stoma, and now it was almost full with the same bright red blood. And again the patient was too light-headed to stand.

     The Attack One crew is familiar with stoma care, but not with situations where bright red blood is flowing from the opening. The patient reports no pain at the site or anywhere in his abdomen. He's not on any blood thinners. He has a blood pressure that's only palpable, at about 80 mmHg. He is tachycardic and appears to be perfusing poorly.

     The crew starts an IV line with a large bag of saline, then contacts medical control. The emergency physician asks the crew to try to localize exactly where the blood is coming from—with bright red blood, it has to be somewhere close. It will require a team effort to find the site and avoid a mess. All three crew members don gloves, goggles and gowns. The wife provides clean towels, an empty trash can and a Chux absorptive pad to place under the patient. He is placed on his side on the couch.

     One crew member removes the stoma bag and hands it off. Another provides light and suction. The third has the dressings, adhesive materials and hemostats. As the bag is removed, there's a pulsatile flow of bright red blood out of the stoma, into the air and onto the gowns. With suction and the rapid cleaning off of some clots, the pulsating site is localized, then controlled with pressure using a 4x4 dressing.

     More cleaning uncovers no other bleeding sites. The bleeding appears to be from a small artery at the edge of the stoma surface, where the skin and the edge of the colon would be sewn together. Once apprised, the physician asks the crew to apply direct pressure and a small amount of IV line dressing material to the wound to stop the hemorrhage. With the patient having at least a liter of visible blood loss, the crew will bolus him with two liters of saline. It's cold outside, so a crew member asks if the saline can be warmed in the couple's microwave.

     The direct pressure is working. The crew and wife quickly clean the blood off the patient, couch and floors. They leave the colostomy bag off for now. The patient can keep light direct pressure on the bleeding site with one finger, and observe for any more bleeding. He keeps a Chux pad over his abdomen.

     The crew starts an initial fluid bolus, and the paramedic specifies that the fluid be pressure-infused. Through the large-bore IV needle, the first infusion is started out of the bag at room temperature. The second bag, warmed to about 104ºF in the microwave, and IV line are cleared of air. The first bag delivers around 300 cc before the second bag replaces it and is placed in a pressure infuser, which rests against the patient under the blankets as he's wheeled toward the transport medic. This keeps the warm fluid infusing and out of the freezing cold evening air.

     In the medic unit, the crew rechecks the patient and finds no further hemorrhage occurring. The fluid system is hung up, and the second warm liter of fluid delivered after the first. The patient reports feeling much better, and his perfusion improves, including a reduced pulse rate and warm, pink skin.

     Transport to the hospital where the surgery was performed takes about 20 minutes, and the emergency physician who delivered medical direction is there to greet the patient. No further bleeding occurs. A total of 2,000 cc of saline are delivered, and the patient's vital signs normalize.

     The patient was examined by the physician immediately, with the crew present, so the exact bleeding cause could be determined. The source was at the edge of the colostomy stoma, from the colon. There appeared to be a small artery at the surface of the colon that for some reason had just opened up and started bleeding. There was no sign of trauma or, importantly, cancer. The emergency physician had contacted the surgeon while the patient was en route, and the surgeon was concerned that the patient had bled from another potential spot of cancer. With that not present, the emergency physician cauterized the bleeding site with an electric cautery, the stoma site was cleaned, and the stoma bag put in place.

     After a couple hours of observation in the ED, the patient was able to get up and walk around, ate a meal and experienced no further bleeding. He was released home.

     The patient was managed using direct visualization and then direct pressure to control bleeding, then restoration of perfusion using warmed intravenous fluids administered in a bolus. EMS infused two liters before hospital arrival, and this allowed the patient a rapid recovery. This incident illustrates rapid volume infusion when the bleeding site is controlled. There is considerable controversy now regarding the infusion of fluids in patients with uncontrolled internal bleeding, as is the case with many trauma patients. In cases where bleeding is not controlled, follow local protocol for fluid management.

     It is now common for patients to leave hospitals with medical devices in place on their body or available for use for a broad range of problems. When they malfunction, EMS may be called. A broad variety of "holes" can be placed in the body that connect cavities within the body to the outside. These are called stomas, and they require ongoing home care and medical supervision. A stoma can be placed in the airway (tracheostomy), stomach (gastrostomy), bowel (colostomy), ureter (ureterostomy) and bladder (suprapubic catheters). There can be others. Any of these sites can suddenly have problems, such as occlusion, bleeding, injury or failure of a device that's supposed to be in the stoma. EMS providers should be comfortable asking the family, primary physician or medical direction for assistance in dealing with emergencies involving these devices. With the growing number of devices in the home, it's difficult to be comfortable with all of them, but the experienced provider can apply basic principles to manage emergencies until someone familiar with the device or stoma can provide definitive care.

     This incident occurred with a stoma that was new for the patient and his spouse, and those are situations where the patient may not be as experienced or helpful. Call for medical direction, or even assistance from the physician most familiar with the stoma or device. Many devices used in the home (oxygen delivery systems, nebulizers, CPAP devices, etc.) are maintained by commercial companies that have 24-hour emergency phone lines. Those sources can provide guidance.

     Administer fluid boluses for blood loss with pressure infusion, using either a commercial infusion device or the EMT's hands. There are commercial devices for fluid warming that can be used in medic vehicles, or fluids can be warmed in microwaves. Standard medical literature calls for warming intravenous fluid for resuscitation to 40–42ºC/104–107ºF. This takes about 90 seconds in a microwave. Only administer it if the fluid temperature is comfortable against the EMT's skin.

     Fluid boluses are appropriate as delineated by medical protocol or online medical direction. "Dripping" in a bolus of fluids is not considered resuscitation, and will prolong the time needed to deliver the bolus.

     James J. Augustine, MD, FACEP, is deputy chief-assistant medical director for Washington, DC, Fire and EMS and a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, OH, as well as a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.

     Middle-aged man with severe bleeding from stoma following surgery for colon cancer.

     Head: No trauma or abnormality.

     Neck: No tenderness.

     Chest: Clear, equal breath sounds.

     Abdomen: The patient has a thin abdomen with a colostomy bag in place. The 500cc bag is completely filled with bright red blood. The bleeding site is on the edge of the colon surface and the abdominal wall.

     Extremities: Moves all four; distal pulses not present.

     Skin: Pale and diaphoretic.

     Neuro: No focal neurologic findings.

     Basic principles for emergencies involving stomas:

• Apply direct pressure to control any visible bleeding.
• If the hole is supposed to be open, try to keep it open.
• If it's supposed to be draining, let it drain.
• Keep tissues moist.
• Keep the patient in the position of most comfort.
• When the patient is comfortable doing so, let them provide routine care to their own device.
• Family members are often very knowledgeable.

     If the appropriate care of a patient calls for a fluid bolus, pressure infusion of the fluid through the intravenous device is usually appropriate. Rapid fluid administration, as long as it's not cool, will provide more rapid volume replacement. This will result in fluid administration at appropriate amounts before arrival in the ED, and allow perfusion of critical organs. Fluid resuscitation should be directed by medical protocols, and online medical direction when necessary.