Vomiting

SPEAKER_00 0:12

Hello and welcome to a new episode of Home of Medicine Podcast in association with the Royal College of Physicians, Edinburgh. I am Ben Lovell. I am a consultant in acute medicine working in the UK, and you all know my co-host. Hello, Amy, how are you?

SPEAKER_02 0:27

Hello, I'm good. I am very hot. Um obviously we're in the middle of a heat wave and this is extraordinarily warm, but we're here. Brave message.

SPEAKER_00 0:40

Well, you know, maybe when this episode is released, the temperatures will have normalized and we will be complaining about the rain and how cold it is. Although I did say to you just before we switched on the recording, I'm never gonna complain about being cold or wet ever again in my life. I just leave this to it. Yeah. But um, let's be brave and we'll crack on with the episode today because I've got a case for you. Bop, go for it. All right. Acute medical take. 74-year-old man presents with severe vomiting of very acute onset, less than 24 hours ago. And the vomiting has been severe and it's been all night long, and this is now the morning. There's been some mild diarrhea, but the main thrust has been vomiting associated with terrific epigastric stabbing pains, and this all came on all of a sudden. Uh, hasn't had this before and um hasn't noticed any fevers and has come into ED because he says he was gonna breathe it out at home until the last two vomits he did at home, which he said were black. And uh he says he believes this is because just before he'd drunk two cans of these to settle his stomach. And for the audience at home, I'm holding up a can of coke. So he says he thinks the coke gate came back up again. But ChatGPT told him black vomiting, you have to go and be assessed by a doctor in the emergency department, and he can't keep fluids down at the moment.

SPEAKER_02 2:25

So we have two cans of other brands are available, by the way.

SPEAKER_00 2:29

Um two brands of cola of generic cola.

SPEAKER_02 2:32

Generic cola, roller cola. Yeah, um, okay. So um, I'm going to try and put that into my head. So you've told me that, and what I'm gonna do now is um represent that problem back to you. So 74-year-old man, acute onset of vomiting associated with diarrhea and sudden onset of epigastric pain with no associated fever. The previous two vomits have been black in nature. I am going to park the Coca Cola because I think that is a distractor, a red herring, a bias introducer. But I'm going to keep it in my mind. That's it.

SPEAKER_01 3:31

Okay.

SPEAKER_00 3:33

On further question, he says, My wife had this two days ago. She was sick as a dog for 24 hours and she got over it. She didn't have any of the black vomiting. She was very ill with abdominal pains, severe vomiting, and feeling dreadful, couldn't keep fluids down. It lasted about 24 hours and then she slowly recovered. And so I thought I've got the same, but the black vomits frightened me. And I'm sure that's the coke that I drank that's coming back up.

SPEAKER_02 4:02

So it's the black vomit that he's worried about. Okay. Um, I want to ask you some questions about the vomit. Number one, did he take a picture of the vomit?

SPEAKER_00 4:13

He did not, and he was quite bamboozled that one would ask for such a thing. Oh, yeah. Why would you take a picture of your own vomit since I don't have them to do? So no, he didn't.

unknown 4:22

Okay.

SPEAKER_00 4:23

But you're right, that would have been useful.

SPEAKER_02 4:25

Was the black, was the whole vomit black, or was it clumps of black within the vomit?

SPEAKER_00 4:31

It was a uniform black liquid mixed in with sort of bilious liquid liquid contacts.

SPEAKER_02 4:39

Okay. Did it taste like coke?

SPEAKER_00 4:43

Um, I didn't ask that.

SPEAKER_02 4:45

You know, sometimes you vomit, and if you thought it was the Coke, it would have tasted, didn't it? It tasted like the Coke? I don't know.

SPEAKER_00 4:52

Okay, that's on me. I didn't ask.

SPEAKER_02 4:54

Okay. Was there any fresh red blood within the vomit that he noticed?

SPEAKER_00 4:58

There was not.

SPEAKER_02 4:59

Okay. And what I want to understand is has he passed any dark tary stools?

SPEAKER_00 5:06

Negative. He has not.

SPEAKER_02 5:09

Okay. So I guess what I need to do is I need to. There's two things I want to do. First of all, I want to aside from the examination and stabilization, what's going through my head is is this black vomit anything? Is it is it a bleed? So is this black vomit an ulcer, a perforated ulcer? Is it esophagitis? Is it varices? I don't know about his past medical history yet, but I want to identify is this blood, is it coke? It could be, I don't know. I mean, it's not something I have to say I've seen very often, if at all.

SPEAKER_00 5:47

Um, coke?

SPEAKER_02 5:49

No, vomiting coke. Oh, okay. Okay, no, no, coke. Um, but also the question is has he had um D and V, diarrhea vomiting that he's had from gastroenteritis that maybe caught from his wife? So I'd want to find out, is there been any recent travel? Have they eaten anything differently? Could this be noravirus? Is it infected? Has he vomited so much that he's ruptured his esophagus? So that sort of thing would be going through my head. Um, and I guess that's where I am at the moment. So I'm a bit all over the place, but I I guess my ultimate decision is is this man seriously unwell with a ruptured esophagus or PGI bleed, or has he vomited coke due to gastroenteritis?

SPEAKER_00 6:36

Very good. That's sort of where I was really. I didn't know what to make of the coke. Um, and uh I thought, yes, look, severe retching and vomiting, and then he brought up some blood blood. So you think is it a Mallory Weiss? Mallory Vice tears, you tend to bring up some fresh red blood, but I thought maybe if it bled and it's sat in his stomach and it altered for a bit, it could come up as as di partially altered blood. Um, yes, but the coke the coke was was sort of the the strange attractor in this one, which sort of brought your thinking towards confusion for me. Um it did smell, I meant to smell as it's sort of metaphorically, not actually smell, but it's meant to probably smell it a bit like gastroenteritis and the fact that his wife went through something um a couple of days before and now he's got it. Um and the vomiting and abdominal pain and the bit of diarrhea were sort of matched with that. But of course, the question is has he had an aperture, right? Um and is he vomiting autumn blood or not? Exactly. So I think we're on the same page there. So what's next? What do you want to know?

SPEAKER_02 7:32

Um so I want to know. Um, I guess I'll do a general history. Um vomited, did he inhale any of this? Is he um aspirated at all? Which I find tends to I find that it's more likely the older you get. Um when was the last time he vomited? Has it settled down now?

SPEAKER_00 7:54

Um so the vomiting has uh settled a little bit, but he still couldn't know, couldn't face eating anything at all. He felt dreadful. Um he thought he was keeping sip, he was keeping sips of water down.

SPEAKER_02 8:09

Uh-huh. Okay.

SPEAKER_00 8:10

Yeah.

SPEAKER_02 8:11

Um was he dehydrated?

SPEAKER_00 8:15

Oh, so on examination he did look a bit dry, yes.

SPEAKER_02 8:18

Yeah. Okay. Um, we've talked about abdominal pain. Is he passing urine?

SPEAKER_00 8:24

Uh small amounts of concentrated urine.

SPEAKER_02 8:27

Okay. Any chest pain?

SPEAKER_00 8:30

No, no, just epigastric.

SPEAKER_02 8:32

Okay. Um, has he had any recent travel?

SPEAKER_00 8:36

Nope. No exotic travel, no.

SPEAKER_02 8:38

Okay. Has he um changed medications recently?

SPEAKER_00 8:43

He had not changed any recent medications, no.

SPEAKER_02 8:45

Okay. And has he eaten any food that's very different to normal from like a takeaway or something that couldn't think about food poison?

SPEAKER_00 8:54

I asked about that because I said, gosh, if you've both had it, what have you eaten? And the only thing he and his wife could think of was um a couple of days before, they'd had a bit of yogurt, which was technically past its sell-by date, but looked fine, and they used it to make a kind of a dip. Um, then they both had some of that. And it's the only thing they could think of, but it was over its best before date when they ate it.

SPEAKER_02 9:15

Hmm. I mean, I guess that wouldn't really worry me unless it was like months past the sell by date. Um, but it wouldn't. Hmm. Okay. Any past medical history?

SPEAKER_00 9:27

Yes. Um, hypertension.

SPEAKER_02 9:29

Yeah.

SPEAKER_00 9:30

Aroxysmal atrial fibrillation, for which he takes riveroxidan.

SPEAKER_02 9:35

Ooh, okay. Any other past medical history?

SPEAKER_00 9:40

Umsteoarthritis, and that's okay.

SPEAKER_02 9:44

Does he take regular anti-inflammatories for the osteoarthritis?

SPEAKER_00 9:48

Great connection there. And of course I asked that because I'm thinking about NSAID gastropathies and ulcers, but no, he doesn't.

SPEAKER_02 9:54

Okay. Any any other over-the-counter medications?

SPEAKER_00 9:59

No.

SPEAKER_02 10:00

No. Okay. Um, so he takes riveroxaban. Anything else for the blood pressure?

SPEAKER_00 10:04

Perendapril and amlodipine.

SPEAKER_02 10:08

Okay. Um, any other thing?

SPEAKER_00 10:10

He also takes ameprasol, so he takes ameprazole as well.

SPEAKER_02 10:13

And why does he take ameprazole?

SPEAKER_00 10:15

Because he gets occasional gastroesophageal reflux.

SPEAKER_02 10:18

Okay. Has he ever had an OGD?

SPEAKER_00 10:22

Oh, he has actually. Years ago, I think sort of 15-20 years ago, he had it due to severe gourd and it did not detect pepticulcer disease.

SPEAKER_02 10:31

Okay. Fine. Okay. Um, medication-wise, you've said riveroxaban, pyrindropyl, amylodopine, and a PPI. Any allergies?

SPEAKER_00 10:40

No allergies.

SPEAKER_02 10:41

No, okay. Um, does he smoke?

SPEAKER_00 10:45

Never smoked.

SPEAKER_02 10:46

No, any alcohol?

SPEAKER_00 10:48

Very minimal because he found that that can trigger a paroxysm of AF. So he's cut right down the last year to maintain sinus rhythm. And according to his smartwatch, he has maintained sinus rhythm for the last year, which he's very pleased by.

SPEAKER_02 10:59

Has he ever been a heavy drinker? And by that I mean a daily drinker or drinking.

SPEAKER_00 11:05

I think not heavy. I think um before he was diagnosed with AF, he might have had a glass of wine at night with a meal or a whiskey at bedtime, um, but not a heavy drinker, no.

SPEAKER_02 11:15

Okay, and job-wise, you said he was 74. Is he still working?

SPEAKER_00 11:19

No, he's retired. Uh, but he's a very, very active chap who gets to go on cycling and walking holidays, and plays golf several times a week in his hours and out a lot.

SPEAKER_02 11:29

Okay, so very active then.

SPEAKER_00 11:31

Yeah.

SPEAKER_02 11:32

Okay. Examination-wise, you said that he looks dehydrated. What are his observations like?

SPEAKER_00 11:37

Yeah. Heart rate's 98.

SPEAKER_02 11:40

Okay, so blood pressure.

SPEAKER_00 11:42

Go on. Yeah, it's all lineage. Uh blood pressure is 131 over 74.

SPEAKER_02 11:48

Yeah.

SPEAKER_00 11:49

Respiratory rate is uh 16. Saturation is a 99% on Rhimair. And he's A febrile at 36.9.

SPEAKER_02 11:59

Was his pulse sinus rhythm or AF?

SPEAKER_00 12:01

He was in sinus today.

SPEAKER_02 12:03

He was in sinus rhythm. Okay, fine. Okay. Um, chest.

SPEAKER_00 12:07

Chest completely clear.

SPEAKER_02 12:09

Yeah. Anything orally? Any evidence of vomit or blood or anything in the mouth that you could see?

SPEAKER_01 12:15

No, no.

SPEAKER_02 12:16

No, okay. I love looking in people's mouths. Not why because I think you can tell a huge amount about a person from their mouth. So you can tell about their oral hygiene. Do they brush their teeth? Do they get lots of sweets? Have they had lots of fillings? Have they got oral thrush? What does their tongue look like? And I think we often overlook things like the teeth and the toes. I like toes and the toes.

SPEAKER_00 12:40

You know what, as well? I think I've got no evidence for that stuff. I think patients quite like it.

SPEAKER_02 12:46

Um looking in their mouth.

SPEAKER_00 12:48

Uh yes, I think it looks like thoroughness. I think it looks yeah, it sort of it sort of matches old, maybe for older patients, it sort of matches the the old-fashioned doctor who'd come and visit you at home and they put a hand on your forehead and and guess, ah, and look at your tongue. And I think it sort of fits. I still do that better. No, I think you should. I think it sort of fits some kind of stereotype, which I think I think I get the impression some patients find it a little bit reassuring, like, okay, this this doctor knows what they're about. They're giving me a good assessment here. Yeah. Anyway, just that's that's that side.

SPEAKER_02 13:20

Okay, you mentioned that you have epigastric pain. So, what was the abdominal examination like?

SPEAKER_00 13:27

He was he had a soft abdomen. He was tender when you did deep palpation, the epigastric region. That that hurt, it was sore, but certainly the abdomen was soft. So no signs of guiding or rigidity, no signs of peritonism.

SPEAKER_02 13:41

Chest.

SPEAKER_00 13:42

I said it was clear.

SPEAKER_02 13:43

Oh, sorry, my apologies. Okay. Um the reason I'm asking about the chest is esophageal rupture. Um, I mean a borehover syndrome. Borhava syndrome, yeah. Yeah. But I mean, if you've got an osophageal rupture, you're probably not going to pick up anything on clinical examination of the lungs. You're going to need to do a chest x-ray, aren't you? Or scan the lungs or something. Okay.

SPEAKER_00 14:08

Well, you might pick up um widespread subcutaneous uh prepitus emphysema. Yeah, you might do.

SPEAKER_02 14:12

Surgical emphysema, yeah.

SPEAKER_00 14:14

Yeah.

SPEAKER_02 14:14

Any surgical emphysema that you picked up?

SPEAKER_00 14:17

No.

SPEAKER_02 14:17

No. Okay. Okay. So um calves. I always examine the calves.

SPEAKER_00 14:25

They were soft, they were uh no pedal edema.

SPEAKER_02 14:29

Okay. So actually, from what you're telling me, I've got quite a well-looking man. He's a bit dead on the higher side of normal for his heart rate. But aside from that, oh, not really much to hook onto at the moment, to be honest. The question I need to ask myself is, is this man well or is he unwell? So when you first saw him, what was your you know, you have that end-of-the-bed assessment, and you can look at someone and go, they look really bad, or you can look at someone and go, they look well. What did you think?

SPEAKER_00 15:09

He looked like someone who had experienced four 24 hours of nasty stomach flu, you know, absolutely miserable, dehydrated, fed up of being being unwell and vomiting, hasn't he had a nice cup of tea, you know, let alone a solid meal? Um yes, that would that was sort of the end of the pedagogram.

SPEAKER_02 15:29

Okay. Can I have a VBG, please?

SPEAKER_00 15:33

Yes. But would you like uh the full chiavan?

SPEAKER_02 15:36

I want the yeah, because I want to know potassium, and it's a quick way of getting that he's vomited a lot. So is he hypokalemic? I want to know if he's acidotic, and I want to know his lactate and his hemoglobin, please.

SPEAKER_00 15:48

Okay, so his potassium is 3.9. His hemoglobin is 135.

SPEAKER_02 15:56

Okay.

SPEAKER_00 15:58

Lactate is 2.1. His bicarb is 23, and his base excess is one.

SPEAKER_02 16:06

So all normal, pretty much.

SPEAKER_00 16:08

Yeah, yeah.

SPEAKER_02 16:10

I mean, the hemoglobin of 135 reassures me, but also I'm not 100% saying he hasn't bled because it's quite an it's quite a recent VBG, and actually you might not have had the hemoglobin drop. So um, and the potassium is okay, you know, nothing's wildly abnormal on that. Okay, um white cell count, please.

SPEAKER_00 16:32

White cells, white cells, white cells. White cells were normal actually at 10.4, and neutrophils were 5.1.

SPEAKER_02 16:39

Okay. Hey, uh, we've got HB platelets because 349 plotting.

SPEAKER_00 16:46

Calculation, INR was 1.4 and remained a normal.

SPEAKER_02 16:51

Which is expected. I often see that on a doak. So although you know, I know we don't use it as a marker of when somebody's on a doak, but you often find that the INR is around 1.4, 1.5. Okay. Use an ease, please, because he's been vomiting. Has he got an acute kidney injury?

SPEAKER_00 17:06

So sodium's 141, potassium is 3.9, as we mentioned, urea is 13.5.

unknown 17:12

Okay.

SPEAKER_00 17:13

Um, with a keratinin of 59.

SPEAKER_02 17:17

Liver function?

SPEAKER_00 17:18

Liver function tests, all completely normal.

SPEAKER_02 17:21

Normal. Okay. So, okay. The only thing that I'm starting that makes me feel a bit like twitchy is the urea of 13.5. Now let's go back to his medication. He's not on any medication that would cause that urea. So he's on perintropen and amylodopene, but that wouldn't necessarily auto-usenease, the river oxpan wouldn't, the PPI wouldn't. So a urea of 13.5. I'm starting to think about dehydration, but then we've got a creatine of 59, so it could be acute. Also, I'm thinking about blood, upper GO bleeds can increase your urea. But then that's normally a more chronic result from the 13.5. So I would have expected the hemoglobin to drop at the same time as the urea goes up. But that worries me, the urea. I'm stuck. What do you want from me?

SPEAKER_00 18:23

Well, I've written down thoughts here, and it's almost like an angel on one shoulder and a devil on the other shoulder. And um the devil, all right, let's nice to come back. Let's call Ben One and Ben You. Ben One is saying, you have an older gentleman who is on a powerful anti-coagulant drug. He's presented with chip episodes of jet black vomiting, um, which is hematemesis, surely, until proven otherwise. He's got an elevated urea, which is the normal creatine, which is a clear um correlation with acute upper GI bleeds. Um, could he have a malle-riced hair? Could he have a bleeding peptic ulcer? Um, either way, this is a very unwell man who needs to have some urgent discussions about endoscopy, uh, potentially holding or reversing his doac and stabilization. On the other hand, Ben 2 is saying this is a man who's got severe gastroenteritis, who drank some Coca-Cola and vomited back up again. Let's not turn this into a GI bleed just because he's on River Oxaban. Um to which Ben 1 says, I think you've got premature closure. Um, the coke is making you falsely reassured. But at the but now I have to make a decision about what to do next. So I think I was in a similar mindset to you.

SPEAKER_02 19:33

Yeah. Do you know? I actually quite like Ben One and Ben Two. I've just imagined, like Paul, you know, like the little birds sitting on your shoulders, one named Peter, one named Paul. And actually, maybe that is a good way of when we think about making clinical decisions and clinical reasoning, is I've got Amy one saying this, but Amy two saying this. So instead of just being Amy, I've now got two persona. I quite like that, two personas. Oh, right. And start to refer to Amy one says this and Amy Two says that. People might start to be slightly concerned about me. Yes.

SPEAKER_00 20:07

Um there's an internal dialogue, I think it's internal.

SPEAKER_02 20:11

So the question is admit, not admit, scope, not to scope.

SPEAKER_01 20:17

Yeah.

SPEAKER_02 20:19

PPI, IV, or not to IV, PPI.

SPEAKER_00 20:23

Yeah.

SPEAKER_02 20:24

Stop driver Oxabam, not stop river Oxabam.

SPEAKER_00 20:27

Yeah.

SPEAKER_02 20:28

So I think that's what we can break down the decision processes into that.

SPEAKER_00 20:34

Do you know that's really funny? You've almost exactly, it's like you read off my sheet. I've got down here questions. One, admit or ambulate. I, you know, it's discharged via you get. Two, reverse, stop, continue with Roxaban. Number three, OGD question mark. So I think we actually had the same thought processes going on.

SPEAKER_02 20:53

And you know what's really fascinating? And actually, when we hear from listeners, they often say this, they can tell that we are two very different physicians who always come to the same very similar conclusion and diagnosis, but the way that we get there is often through different routes, and that's okay.

SPEAKER_00 21:12

Um there are many paths to the top of the mountain.

SPEAKER_02 21:15

Exactly. I think I take the circuitous route, and you sometimes you take the pretty way, you take the train. Yeah. Okay. I'm going to admit this man because he's 74, he's on a doac, his urea is high. I cannot 100% say that this isn't a GI bleed, actually. So, do you know what? I'm going to admit him. I'm going to stop his river Oxabam. I'm going to give him Ivy access. I'm going to give him IV PPI. I am going to give him some fluids because his heart rate is a bit high. And I'm going to do an OGD. I'm going to speak to my gastroenterology colleagues.

SPEAKER_00 21:54

Well, I admire you for sticking your colours to the mask like that because that's what we have to do ultimately. We have Make the call on the post-the water and we can't go. Oh, I don't know, I don't know. We have we have to make a call and what we think is the right thing to do. So you said you'd admit I agreed, that's what I did. Um, the next question, Market, I was going to ask emergency OGD today or or watch and wait for a bit.

SPEAKER_02 22:19

I something's just come into my head. Number one, we need to do a digital rectal examination, and number two, we need to group and save. So that's just in my that's just popped up.

SPEAKER_00 22:29

Yeah.

SPEAKER_02 22:29

Um did you do a DRE by the way?

SPEAKER_00 22:32

No Melina on Melina.

SPEAKER_02 22:35

Okay. I don't think this man needs an OGD today because he's hemodynamically stable.

SPEAKER_00 22:40

Okay. Does it does it influence that if I say that um if this were to be an apogee bleed, his Blatchford score would be five?

SPEAKER_02 22:48

Yes, yeah, yeah.

SPEAKER_00 22:49

Yeah. How would that change your your ideas?

SPEAKER_02 22:52

I'd I'd scope him within 24 hours.

SPEAKER_00 22:55

But in 24 hours, but maybe not right now.

SPEAKER_02 22:57

I wouldn't scope him. Um I would I would get my I would get my gastroenterology. And you know what? When these situations, we've got the guidelines there, the nice guidelines, we've got Blachford score, but actually things aren't often black and white, they might be grey, and sometimes it's worth having a conversation with a gastroenterologist on call to say, look, this is a situation, I'm not quite sure what to do. What do you think?

SPEAKER_00 23:23

And ultimately they they hold the ring on on prioritizing people with endoscopies, and they will make the call based on the information I give them, or anyone gives them. So you've got to make sure your information is accurate. And I thought, I'll call gastro now. They're going to ask me, well, was it was it hematemesis or not? And I can't give them a sort of a half bait, but it might have been a Coca-Cola. Um, and I really tried to nail this down. And what occurred to me was when you're asking about coffee ground vomit, because that's a language we use, isn't it? Did it look like coffee, ground coffee? I don't think people know what that looks like. What is it?

SPEAKER_02 23:56

Exactly.

SPEAKER_00 23:57

And I've got a confession to make, Aidan. When I learnt at medical school about coffee ground vomit, I had no idea what they were talking about for years because I'd never had ground coffee. Um, I know, but I I didn't drink coffee. And if I saw coffee, I saw instant coffee. So in my head, I kind of imagined instant coffee granules and water, but that's not right. And it wasn't until you know I sort of went to Posh people's houses and they sort of made you a cafetiere, and you'd see what the sludge at the bottom of it, and you'd go, Oh, that's coffee ground vomit, is it? I had no frame of reference for this, so I didn't know. I hope you there's other people out there nodding and saying, you know, I didn't know either.

SPEAKER_02 24:35

Do you know? I completely agree actually, because you know, until recently I did think it was Nes Cafe. Like I did think coffee ground.

SPEAKER_00 24:49

So it's just until you've just said when you said until recently, do you mean until just this moment? Because that's really there's no shame in that because I didn't know either.

SPEAKER_02 25:04

Do you know what though? Coffee ground vomiting. I've I well, I've clearly I've never understood it until just and I love coffee, but I've never put two and two together. But if somebody tells me, I've never ever asked the question, have you got coffee ground vomiting? Because that means nothing to me. So therefore, why would it mean anything to them? So I would ask them, have you vomited? What colour it is? Was there any blood? Was it dark? Do you have a picture? Can I look at it?

SPEAKER_00 25:30

Yeah. Yeah. So um I I bought a bit of a bee in my body about coffee ground vomiting because I don't think it has much currency. Um and I'm talking I'm talking about doctors, not clinicians, but patients as well. And I don't think your average patient's going to have a have a reference for that. So what else does it look like? Could we say it looks like? I mean, could you say, does it look like wet, wet soil in liquid or something? I don't know. We've got to find a substitution, guys, because I don't think coffee involved. I literally looked back before we did this recording and thought, when did this come from? This is an old reference when there was it was before the existence of instant coffee. And apparently the oldest reference I can find was in a medical textbook in 1925. So I think back in the day when the only way to drink coffee was to grind your beans and put it in a cafetiere, that's when doctors went, Oh, that looks just like my patient who had a hemorrhage and gastric ulcer, you know, that's what they brought up all over my shoes. And that's how the connection was made. And I think we have to find an alternative explanation because as you demonstrated so beautifully, coffee ground vomiting doesn't really mean as much as maybe it did in the 1920s.

SPEAKER_02 26:36

So maybe we'd need to do an experiment and we need to get coffee ground vomit and have a look at it and then look at the pictures, and then what else could it, what else does it look like? You know, is it soil, is it compost, is it chocolate flakes? I don't know.

SPEAKER_00 26:52

Please write in and tell us what you think the new coffee ground vomit for the 21st century should be when we're asking patients to describe potential hematamasis.

SPEAKER_02 27:01

Do you can you remember being told to dipstick it?

SPEAKER_00 27:04

Never.

SPEAKER_02 27:06

So I remember being told if you wanted to identify if there was blood in your in in um vomit, you would dip it. And if you dips if you dipped it with a urine, well, the pH would be different if there was blood in it.

SPEAKER_00 27:22

I've never had that. That doesn't sound right to me. Otherwise, we'd be doing that all the time, wouldn't we?

SPEAKER_02 27:26

I might have made that up as well. I didn't make it up, I'm sure I didn't.

SPEAKER_00 27:29

I'm gonna look it up afterwards. No, I it sounds like the kind of thing that we'd be told to do, and then when you dig down, there's no evidence for it. It's one of those things that we just do with the other.

SPEAKER_02 27:39

Yeah, exactly. But maybe we could dip it for Coke, Coca-Cola. I'm not sure. Anyway, we digress quite a lot.

SPEAKER_00 27:45

We digress. That's my coffee ground band. So um, okay, let's make um oh yeah, I was gonna say talking to the gas revenge. So yeah, I tried to nail down what it looked like, and the patient just said, I don't know what to tell you. It looks like it looked like black liquid. I've never born a setup before. I made the assumption it was coke, uh, but I I could promise you it was coke. And he he's on a he's on River Oxfam, which is a potent anti-coagident. So um, post-tate wardround note for you. You said number one, admit, number two, cross match, three, PR exam. Yeah, number four, what was your number four?

SPEAKER_02 28:18

Um PPI.

SPEAKER_00 28:20

Okay, IV PPI. Do you like cantoprazole IV?

SPEAKER_02 28:23

We well uh tended to use a metrazole, but that was just okay. What was a baby?

SPEAKER_00 28:29

80 milligrams IV ameprasols IV. 80 milligrams, okay, yep. What's point number five?

SPEAKER_02 28:34

Uh was consider stopping the riveroxabam.

SPEAKER_00 28:37

Stop riverox, okay, fair enough. Point six.

SPEAKER_02 28:40

Point six was intravenous fluids.

SPEAKER_00 28:42

Okay, yeah, very good. Hydrated. Nil by mouth.

SPEAKER_02 28:45

Nil by mouth.

SPEAKER_00 28:46

That urea could just be dehydration, couldn't it? It hasn't quite reached the AKI phase yet. So it's just the elevator. Okay.

SPEAKER_02 28:52

And actually, if I'm thinking about dehydration, I'm gonna stop his perindropyl.

SPEAKER_00 28:58

Good point, yeah. Um what about the amlodapine?

SPEAKER_02 29:01

Yeah, I mean his blood pressure's on the lower side that I'd like. Well, it's one three one over 74. Um, he doesn't I I'm not, yeah, I don't think he necessarily needs a perindropyl and lodipine for a day or two anyway. So let's just withhold those medications.

SPEAKER_00 29:15

Fair enough. And then the last point is discuss with the gastro-redge about timings of OGD. Okay, we had really, really similar plans. Then what about this question about the river ox band? You're happy just to hold it, then I guess. You're not thinking about reversing it.

SPEAKER_02 29:29

Uh, I still don't have evidence that this man is actively bleeding. I'm gonna stop it. Um, I'm gonna observe. I mean, if there's further vomiting, because he still feels unwell. You know, if he vomits again, we're gonna have a look at the vomit. I'm gonna dip it. No, I'm not gonna dip it, um, dipstick it. Um, you know, I'm gonna keep an eye out for any um Melina. I'm gonna also keep an eye on his hemoglobin. Does that drop? Um that would suggest he keep blood loss. Um he's in sinus rhythm, although he does have paroxysmal AF. So I am happy to stop that. Would I give him subcutaneous 40 milligrams of inoxoparin? Uh yes, I would.

SPEAKER_00 30:10

Okay. I didn't. I stopped liverox pan. I had a conversation with myself about reversal. Um, you can reverse a doac using uh there is a reversal agent. Yeah, um, it's called andexinet alpha, and I think it costs many, many thousands of pounds.

SPEAKER_02 30:26

Thousands, isn't it? Yeah.

SPEAKER_00 30:27

It could have to be authorized by an on-called hematologist, so you know they don't let an acute physician like me get my hands on it. Um, and I think you can only use it in life-threatening or uncontrolled hemorrhage as someone who has a doac. So it wouldn't be clearly applicable in this case. Um, pro-thrombin uh uh concentrate complex, um, is a pro-hemostatic agent. There are some local guidelines to that, but as you uh as you say, I I don't even know this is an apogee bleed yet before I start using some very expensive interventions, switch off as riveroxaban, which is he's taking to prevent him having a stroke um for a good reason.

SPEAKER_02 31:00

Would you give him vitamin K or tronic semic acid?

SPEAKER_00 31:03

Uh neither of the above.

SPEAKER_02 31:05

Yeah, me. Yeah, I wouldn't either. I'm just yeah. Tedopress.

SPEAKER_00 31:09

Negative, no. This is I doubt this be a varacile, I believe.

SPEAKER_02 31:13

Yeah, exactly.

SPEAKER_00 31:14

So um, yes, I spoke to Gastro, um, who said, I tell you what, keep him nil by mouth, admit him, recheck everything in the morning. Um, make sure he's got two large ball cannulas just in case things go south during the night. Good point. Um let's check his HB, his renal function tomorrow, and if there's any melina, because if he has had an upper GR bleed, it should have worked its way around to the bottom end by tomorrow. And then we'll rediscuss and keep him fasted, and we can scope him tomorrow morning if there's a strong indication for it. So he was admitted to the AMU. Um, and the next day his urea had normalized to seven, his um creatinin stayed normal, his hemoglobin stayed completely on the level 135 to 134, um, and he had no melina, and his vomiting is settled, and no further um episodes of vomiting of any colour. Um so we spoke to Gastro, and the decision was does he need a scope after all?

SPEAKER_01 32:12

No. Go on.

SPEAKER_02 32:16

I am happy that this gentleman does not have an acute upper GI bleed. He's had no melina, he's had no further vomiting, his hemoglobin's stable, he hasn't dropped any further, he's urea stabilized, he's hemodynamically stable. I don't necessarily believe that I need to put this gentleman through a procedure at present. However, I will safety net. So I wouldn't just say, see uh I would probably give him open access to SDEC or whatever whatever service it is where you work, and say, you know, if you have any of these signs or any of these symptoms, please come back to see us straight away.

SPEAKER_00 32:57

Would you have to restart I don't think it's the right answer? Would you have to restart the river Oxaman?

SPEAKER_02 33:02

I would.

SPEAKER_00 33:03

Yeah.

SPEAKER_02 33:04

Again, I don't know whether that's the right or wrong thing. And I think the restarting of a doac, aspirin, cloppy dog will is really difficult. And I think it's about balancing the risks and benefits of stopping it, starting it, not being on it, being on it for many reasons. But if he's got PAF, he's got a high risk, well, he's not he's got a higher risk of a of a cerebral infarction, of a stroke compared to somebody who doesn't have PAF, and the reason he's on a doac is because of that. Am I stopping it because he may, may have had a bleed, although I've got no evidence of it? I do have evidence of PAF. Do you know what you don't know I'm gonna speak to the patient?

SPEAKER_00 33:48

Okay.

SPEAKER_02 33:50

What does he want to do? I'm gonna say, look, this is a situation because what we often forget is to involve the patient in these decisions. So I think let's have a shared decision. Often the patient will say, I don't know, I'll defer to you, but I think it's really important that we involve them in those decisions, those discussions, and explain the risks and the benefits of either option.

SPEAKER_00 34:12

So the patient was this was explained to the patient. The patient's main desire was to get home and get out of here. Very unpleasant, uncomfortable night on the AMU in an open bay, wants to get on the driving range, wants to get back to comfortable surroundings and back to normality, and just wanted to get out.

SPEAKER_02 34:31

I'm gonna send him home. I'm gonna say start your doac tomorrow because you've had an octopar in today or last whatever it was. Um, and he's open access to STEC. If you have any of these signs or symptoms, please don't hesitate to come back and see us.

SPEAKER_00 34:45

That is so spooky, Amy. That's exactly what happened. And the patient went home and remained well. And the next day was hitting golf balls on the driving range back to his normal life. Okay, and I know this because the patient told me this because he gave me his consent to talk about this case today, because the patient was my dad. Oh dad. Little happened to him last week.

SPEAKER_02 35:12

Really?

SPEAKER_00 35:12

And of course, I was very worried about my dad, but I was um I thought, wow, this would be a good case for the old podcast. Really, isn't it? Please do.

SPEAKER_02 35:22

Because I know that your dad listens to it, doesn't he?

SPEAKER_00 35:24

He does, he does. Um, my dad isn't medical, he's not a doctor, but he's a big admirer of the pod. And um, he'd be very excited to be on it. And I thought it was a really interesting case because it was about doubt um and uncertainty, and about trying to make sometimes what feels like binary decisions in the face of um lack of complete information. But of course, you and I know that actually they're not binary decisions, there are shades of grey there and nuances, and we can do some middle road things, which may be let's watch and wait and see what happens, or let's do what seems to be the safest option for now, and then tomorrow will present us some new data and we can make another decision based on that.

SPEAKER_02 36:05

Can I just check? You mentioned that your dad checked Chat GPT, yeah, yeah, yeah. And what is that what he uses for his medical advice?

SPEAKER_00 36:14

He does at four in the morning, yes. He's welcome to ring me because when he rang me and he said, I've been vomiting and I and I've got this River Oxpan and then I've vomited black liquid. I said, Dad, you've got to go to AE said, Oh, you sound just like Chat GPT. That's what it chat to told me to do in the night. So it's good to know that ChatGPT and I are on the same page, medically speaking. Um, and just to reassure people out there who think I'm ethically uh treated my own father, I wasn't his treating physician in this particular case, but um I uh I I know who was, and that's how I've got all these these bits of information. Um, so yeah, so I thought that would be an interesting story, really. And uh and when I when I'm trying to make decisions, and maybe we could do another episode in the future about when it's someone that you know, a family or a friend who's the patient and how that affects your decision making. Does it make you more risk-averse or more risk tolerant? Um, that's sort of an episode in itself. But I thought it was interesting because this wasn't a case of an apogee hemorrhage, which in many ways is a protocoled decision. And we we we do things a bit quicker and a bit faster coming to our ultimate decision making. It was uh, I'm not quite sure if it even is an apogee bleed or not. And when that's your starting point, you're sort of groping in along a little bit outside or alongside a protocol, but doing things your own way and using the protocol to inform your decision making, but not direct your decision making because because you're not sure if the protocol is truly applicable and appropriate.

SPEAKER_02 37:40

Do you think that the vomit was Coke, Cola, Cola?

SPEAKER_00 37:44

I still think he had a bit of a bleed. I think he either had a small malurie vice or a bit of gastritis due to a really nasty bout of noro or something like that.

SPEAKER_02 37:52

Which does happen, doesn't it?

SPEAKER_00 37:53

Yeah. Um, I I think he probably did have a little bit of a bleed, but fortunately no more than a mild one.

SPEAKER_02 38:00

Yeah. Really interesting. And often you learn so much um about medicine and decision making from cases that aren't about the really complex diagnosis, they're about vomit, or they're about a doac, or they're a you know, and it's often I find these cases challenging the management of doac or no doak, and you know, and that sort of I hope your dad's not offended by the fact that I was concerned about the yogurt that he'd eaten it when he was out of date.

SPEAKER_00 38:31

Not at all. And he'll be very pleased that neither of us referred to him as elderly, which he would have hated. I said older gentleman, very specifically.

SPEAKER_02 38:37

Yeah. Really interesting. Um, really interesting case, actually. I think good. Yeah, some really interesting thought. And what I'm really like is when we talked about coffee ground, and I think we do bring into medical language things that have been used for 100 years that are no longer relevant.

SPEAKER_00 38:57

Yeah.

SPEAKER_02 38:58

So the coffee ground vomiting, you know, and also we use clinical signs that are no longer relevant, like you know, um Brodzinski's signing meningitis. You know, what even does that mean? What's its relevance anymore?

SPEAKER_00 39:10

Um, and I think the wide descent of the JVP.

SPEAKER_02 39:14

Yeah, well, quite. And I I do wonder whether we need to an update. A bit of an update, yeah, absolutely. And I I did, while we've been talking, I have done a bit of a search on dipping. I found something on um the webinar vet. So um, in fact, maybe that's not the appropriate um thing for me to look at because it tends to come up um on veterinary cases. Do you know what? I'm gonna have a look round and we can talk about it next time, just as a bit of an update about the utilization, but it is on there, so it was a thing. Um, obviously should no longer be a thing. Yeah.

SPEAKER_00 39:56

Um, and please let us know and write in if you've got a good idea for a substitution for coffee ground vomits, um, which we can use in our conversations with patients, and it turns out amongst ourselves, so we actually know what that looks like so we can identify an appearanid accurately. Hurrah. Well, that's the end of the episode. Thank you so much for going through this episode with me, Amy. I hope you enjoyed it. And I hope you enjoyed listening at home. Um, people who do write in, they say that they like to put on in the car or when they're going for a run and can guess along with us and sort of make decisions along with us. So I hope we manage to uh scratch that itch for you today. The podcast is really going nuts. We're we're we're shooting up all of these charts and everything, which is um very gratifying for two job consultants who work. You know, this isn't our main job. We do these recordings from our bedrooms, and uh I think it just really helps if you do like this podcast to leave a little star rating, even a comment or wherever you listen to this, and just let other people know that we exist and they might get something out of it. Do you know it maybe it's a dream, but one day we could be number one. We cracked top ten in the UK, didn't we? Yeah, we did.

SPEAKER_02 41:00

Yeah, we are in fact we are today, actually. So um what? Um we are I think we're number 10 today. Number 10.

SPEAKER_00 41:06

Oh, okay, fine, not number one.

SPEAKER_02 41:07

But then I think when we're looking at the charts, we're looking at the ones above us are um medical podcasts for the general public.

SPEAKER_00 41:14

So like so that you know they're not educational.

SPEAKER_02 41:18

They're for like, yeah, exactly.

SPEAKER_00 41:20

So we're number one in our field, is what you're telling.

SPEAKER_02 41:22

Yes.

SPEAKER_00 41:23

Yes, okay, I'll take that. That'll keep me warm tonight. Oh my saying it's a heat wave. Um but yeah, please do take on board and and and pass on to other people if you think we're worth a listen. And on that note, have a great rest of the day, whatever you're doing. Amy, I'll see you next time.

SPEAKER_02 41:38

Thanks for listening. Bye bye.