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CASE REVIEW | By James J. Augustine, MD, FACEP When It Rains, It Pours Blood thinners complicate a nosebleed ATTACK ONE RESPONDS to a call for a patient with a nosebleed. The caller is a senior-aged woman in her apart- ment, who presents to the doorway to greet the crew with her hand holding her nose and blood staining much of the front of her dress. As the crew enters, they introduce themselves and ask her to sit down in a chair to be more comfortable and avoid passing out. Once she's seated, one of the EMTs offers a gloved hand and asks if she can hold the patient's nose for her. Now sitting, the patient reports she is suffering from bronchitis and has been on several medicines for it. She had a coughing and sneezing spell, and suddenly her nose started bleeding profusely. She has no history of nosebleeds or nose injuries. Blood has also been coming out of her mouth. When it didn't stop after she applied an ice pack and pressure to her nose, she called 9-1-1. The Attack One crew chief asks the patient to lean forward so blood doesn't drain down her throat, and has the EMT hold fi nger pressure on the left side of her nose, the side that's bleeding. The crew obtains vital signs and collects her medicine names and bottles. With her nosebleed now under better control, the patient assists in giving the crew her medical history. She is having no pain and didn't do anything to injure her nose. She has been ill for about fi ve days and started new medicines about two days ago. She is also on a heart medication and a blood thinner she just started a few months ago. The patient asks if she can refuse care, since bleeding has stopped and she is comfortable in her apartment. "We would like to be able to leave you here and comfortable, ma'am, but we are very concerned that we have only temporarily stopped the bleeding, and it will happen again," the medic tells her. "Losing all that blood down the front of your robe has caused you to look awfully pale. Your pulse rate is high, and you are on a powerful new blood thinner. Especially in these cold months, it usually takes some additional treatment to get a nosebleed to stop. They can provide that in the emergency department, and can check your lungs and make sure your blood-thinning medication is working at an appropriate level. It really would not be safe to let you stay here alone." The patient is diffi cult to convince, Customer Service Opportunity The senior patient is often on numerous medications, may be trying home Copyright granted for this article for department use only up to 20 copies. remedies for fi rst aid care and may be embarrassed to have called for assistance. This patient demonstrated each of those characteristics. Although well-intended, some fi rst aid remedies are more dangerous than helpful, and in this case the patient had not been able to get the bleeding to stop. As with all patients, it is important to try to get a complete accounting for medications, and it is often helpful for EMS crews to collect all medications and bring them to the emergency department. The formal process at the hospital is called medication reconciliation and is a requirement of emergency care and documentation for patients admitted from the ED or discharged back home. The ED staff often fi nds it most helpful to have the entire collection of the patient's pill bottles to perform it. The elderly patient will often demonstrate modesty and an unwillingness to have someone make a fuss over them. This patient was uncomfortable in her blood- soaked clothing, but didn't think she would be able to change into something that was clean, dry and safe to wear to the hospital. The crew demonstrated foresight by having her change into clean clothes and bring clothing with her appropriate to wear back home. Her modesty was respected while the crew gained control of her nose. 18 FEBRUARY 2012 | EMSWORLD.com Initial Assessment An 81-year-old female with a severe nosebleed. ❯ Airway: Intact. ❯ Breathing: No distress. ❯ Circulation: Normal capillary refi ll but pale skin. Patient has an irregular pulse, which coincides with her history of atrial fi brillation. ❯ Disability: No neurologic defi cits. ❯ Exposure of Other Major Problems: Profuse bleeding from the left nostril. VITAL SIGNS Time HR BP RR Pulse Ox. 1530 24, irreg. 190/90 24 98% 1537 128 1545 104 180/76 24 99% 150/70 20 99% AMPLE ASSESSMENT ❯ Allergies: Penicillin, codeine. ❯ Medications: Patient is on lisinopril, dabigatran, thyroid supplement, azithromycin and a cough syrup. ❯ Past Medical History: No history of nosebleeds. Long history of atrial fi brillation. ❯ Last Intake: Lunch about three hours prior. ❯ Event: Profuse nosebleed in an elderly patient on a potent blood thinner. but the crew continues to offer her good explanations about why she would be better served by going to the hospital. Finally she accedes. The crew assists her in changing from her bloody robe into a clean one, and helps her clean the blood off her hands and out of her bathroom sink. They load her onto a cot and commence transport, being sure to keep her warm in the back of the ambulance. About two minutes from the emergency department, the patient has another bout of sneezing and coughing, and even with continued pressure on her left nostril, blood begins pouring out again. Emergency Department Management Having received the radio report when the bleeding was under control,