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A Nose for Trouble
by Marc Auerbach
As I tapped the smooth piece of molding into place over the door frame, I felt a stream of liquid run down my right nostril. The physical sensation was not really different from that of a runny nose, but I didn't have to sample the stream with my finger to know that the liquid I felt was not translucent. I ran to the bathroom just in time to see the bright red line run off my lip and into the sink. I pinched the right nostril and within seconds I felt my nose fill up and the glistening fluid emerged from the left side. I grabbed it and my head filled up like some gruesome fish bowl, spilled over the top, down my throat and out of my mouth.
I've had nose bleeds before, but they meandered about, clotting up almost immediately and flowing like lava. This was not that kind of nose bleed. Blood was running like red ink, as shiny as new paint.
I held both my nostrils with one hand and dialed the emergency number with the other. It was the number I'd been given by the clinic that had performed routine nasal surgery on me on Tuesday. Now it was Saturday afternoon. The operator answered, and I, with a deliberate cadence I would have thought myself incapable of under the circumstances, calmly explained what was happening. The operator, with a disaffected air told me that Doctor P. was not on call that weekend, but that they would page Dr. T. I hung up and waited as I watched my life-force depart me and splash into the sink below. I was afraid I might pass out from the sight of it, and simply bleed to death on the bathroom floor; found later by concerned friends in a pool of congealed blood with my starving cat, Fang, meowing uncomprehendingly next to my stiff and rotting form.
How much blood is a lot? How much is too much? I don't know, I've
never been seriously ill. Certainly never been hospitalized or needed
a transfusion. No auto wrecks, no broken bones, no errant power tools.
It certainly seemed like a lot of blood to me. After an agonizing
several minutes, Dr. T. calls. He is patient and unfazed. He tells
me to meet him at the Urgent Care facility about 15 minutes away.
I live alone. I quickly call one friend and then another before I
find a ride. The conversation goes something like:
Hi it's Marc.
Hi Marc. How's it going?
Oh could be better. I need someone to drive me to the hospital right away.
Oh my God. I'll be right there.
It's funny what goes through your mind at a time like this. Rather than grabbing the white towel, which I knew would quickly look like a scene from Raging Bull, I grab a colorful beach towel. A bowl and a roll of toilet paper. Also, the slip of paper with the Urgent Care facility number on it.
My friend arrives. Not much is spoken between us. I find it hard to speak because my head is filled with blood all the way up the Eustachian tube to my ear. It is the same feeling that you get if you don't clear your sinuses after being on a plane. I even fear that blood may come dripping out the side of my head. All the while I've swallowing great quantities of it. Independent of how romantic Anne Rice may make it seem, there is no joy for me quenching my thirst with this sanguine drink.
I walk into the facility, and am ushered immediately into an examining room. My friend is left to fill in the forms. I explain my situation to the attending nurse, who is a pleasant blend of competence and empathy. This is not an emergency room, so this is quite an event. People seem to be walking by the door and peering in with the curiosity of those seeing the first new Volkswagen Beetle (spelling) on the street after having only read about it in magazines.
Shortly Dr. T arrives and is brilliantly laconic. Without the slightest sense of panic or concern for the less than surgically equipped center, he cobbles together the necessary pieces. As he is doing so we chat about my situation. How I had just had recent surgery that had gone exceedingly well. How I'd had the packing out of my nose on Friday with not a trace of bleeding, and the wonderful the intoxicating freedom of breathing was after having eroded so over the previous decade. And how, although I hadn't been totally sedentary, I certainly hadn't been out running, biking; hadn't sneezed or picked at my nose in such a way that would have opened up such a torrent.
He explained what he thought it might be, and that about once a year they get a patient from this sort of surgery that unexpectedly bleeds, and requires re-packing. As he talks he covers some strips of cotton bandages with Surgicil and lidocaine. He tilts my head back and sticks a long vacuum probe into my nasal cavity. Liquid blood, partially congealed blood, and other flotsam and jetsam are evacuated, relieving some of my discomfort. Then, as if he were laying out strips of carpaccio, he stuffs the anesthetically soaked bandages into my nose.
Perhaps some of us have explored our nasal passages with our fingers or a Q-tip. Perhaps we think that our nasal passages are a few inches in. After all, don't we need all that space for our highly evolved and massively large brains? Not really. There's a lot of space for rent in your head, as one quickly becomes aware of with nasal surgery. Long instruments disappear into your nasal cavity as easily as swords are swallowed. When I had had the packing out the previous day, two 3 inch long, tampon-shaped pads had emerged from their cave dwellings where they had comfortably rested for 3 days. And there was room for more. Of course, I had been packed under a general anesthetic. Here I was, about to be packed under only the most rudimentary local.
Dr. T. was smooth. After waiting a minute or two he followed the first batch with a second set. Driving the anesthetic deeper. The chemicals to control bleeding began to kick in and the flow seemed to abate. The strips were removed, and now came the packing. Since he couldn't tell where the bleeding as coming from, and since I'd had surgery in my middle sinus, he swiftly started packing this area. This is an unpleasant and unnerving experience as the packing is shoved hard under your eye. I grunted loudly, not in pain but more in fright at the sensation. Yelling at least kept me exhaling and thus not fainting. Next a long tongue depressor shaped, compressed cotton pad was run up along my septum which was somewhat painful. Again, acting with alacrity, before I could become fully aware of what was happening, Dr. T., with significant force, jammed the object the last half inch. A syringe loaded with lidocaine was then used to "inflate" the pad with liquid so it would swell up. I was spent. The chair was reclined as I caught my breath and tried not to pass out. The bleeding seemed to have stopped. Dr. T. packed up, gave a few words of encouragement to me, and a some brief instructions to the nurse, then he was off. Back to whatever my urgent call had dragged him away from.
No sooner did I sit up, but the blood ran through the heavy packing
and pooled on my upper lip where I once again caught it in a towel.
"I don't like the look of this," my nurse said with a not dispassionate tone.
Dr. T had only gone a few blocks when his pager chirped and he was forced to return. Good naturedly he told me he had done all he could here, and that he really needed to get me back on the table and find out where I was bleeding and either cauterize it or really compress it. Due to the local anesthetic that had passed down my throat I could no longer feel the blood flowing, but I could feel the need to swallow frequently. Dr. T. looked in my throat and concluded assuredly, "your losing some blood, but a young guy like you is making it just as fast, so don't worry about the blood loss." It was only the next day that I would learn that by the time they stopped the bleeding in O.R. around 9:30 that night, that I had lost one third of my blood volume.
I was transported by paramedic unit to a nearby hospital, and almost immediately into the operating room. Ironically, my greatest fear for the original surgery had been going under a "general." This was something I'd never done before, and yet here I found myself for the second time in a week putting my breathing in someone else's hands. Having had no difficulties the previous Tuesday, I was unafraid this time. I was happy to get to OR and get this over with.
I awoke in recovery with a wad of cotton on the end of my nose and a surgical tube called a "Foley" hanging out of it. When a wound bleeds, compression in advised. But how to provide compression in the narrow confines of your nasal passages? Stick a tube up there and inflate it with saline, then clip it off and wait. How long? Five days is typical, as I found out later. And five days it was. I didn't sleep that night. Although the nurses checked me every hour, I was my own sentry. Still as any Buckingham guard, lest any movement disturb what I imagined to be the delicate and damaged structures of my upper airways, I laid in wait. By morning, as activity on the floor increased, I gained confidence that the dam was holding. Fortunately, I had not had much ongoing pain from any of these procedures. It felt like the dull ache of a filling after the anesthetic wears off. Nonetheless, I asked for a painkiller because I knew it would make me drowsy and remove even the ache and let my blood depleted body sleep. I took the shot of Demerol and dozed off for a few hours.
It is easy to quickly lose the look of a normal human being. After a sleepless night, unshaven and unwashed, with a tube looping out my nose and pinned to a headband around my head, and an IV in my arm, I looked like a shipwrecked character on Deep Space Nine. My friends and family were horrified when they saw me. Although not truly a life threatening episode, it had all the look and feel of one.
I didn't have a private room, but for the first two days the bed next to mine was empty. On the third day a balding middle age man was rolled in and the curtain pulled around him. I overheard mention of how well the holes from his chest tubes were healing, and well the surgery had gone. He was angry. Angry that he was sick, in pain, and I presume, at the mercy of the care of others. Even though they kept talking about his going home the next day, he didn't seem eager to do so. The next day he was wheeled out on his bed, and I never saw him again.
The next night another person was rolled in next to me. He had had some sort of soft-pallet surgery, and had a ghastly device called a "trumpet" seemingly sewn into his upper lip. As I overheard, it was meant to be attached to some sort of suction unit. He was also supposed to be on oxygen for the night, and though he used neither, the vacuum pump and oxygen tank hissed noisily all night long. He also had high cholesterol and high blood pressure. Because the latter was not coming down, nurses were in every hour checking him. At this point I was sleeping in one-hour increments because I my throat became so dry it would wake me and I would have to drink some water. Every time I awoke my roommate would either be in or on the way to the bathroom, his IV cart rattling next to him. The antibiotics were giving him diarrhea. Between the blood pressure checks, and his trips to the toilet, it must have been exhausting. He was pretty stoical about it. In fact, I was fascinated to listen to the interplay between the doctor who would march briskly in with her students in toe, and ask a few questions. Because he was not very forthcoming, and she not very probing, it seemed to me that not very much information about his condition was really being communicated. "I've got diarrhea" is not the same as, "I've got diarrhea, and I'm having to go to the bathroom every five to ten minutes."
Between my IV and the water I was drinking, my kidneys were putting out quite a bit of fluid. Now if someone asks if I have a big or small bladder I will we able to answer more precisely, "my bladder holds 550 cc's before I need to urinate." That's a little less than two beers or the cylinder displacement of a decent sized motorcycle. How do I know this? Ones intake and output is meticulously checked. Everything I drank, from the pitcher of water at my bed to the carton of milk with lunch was tallied up. All my urine, whether I was in bed or able to go to the bathroom, was collected in a graduated, plastic urinal. With pride I would watch as the nurse held up my translucent bottle to the light and would then record 600 cc's on my chart. I was often congratulated for my accomplishment, and redoubled my intake in response. I felt like a star next to my beleaguered roommate who barely managed a few hundred cc's. Actually, peeing into a plastic, hand-held urinal. Has it's advantages. Rather than getting out of your tent, with it's -20 rated bag, and trudging out to the cold edge of camp, why not just pee into a bottle and stay warm and toasty? I admit that it might detract from the romance of sleeping in at a B&B, but it is eminently practical.
Dr. B would come in daily and examine me and hint that maybe Wednesday they would take the tube out. But on Wednesday it was decided to wait another day. The full five days. I was stronger now, and on the one hand wishing to depart, and on the other fearful that the bleeding would start again. In preparation, equipment started arriving for Thursday. A large vacuum pump, gauze, and to my horror, a freshly sealed, spare Foley tube. The prospect of being deeply repacked with a new tube while conscious was frightening. I was more than a little apprehensive but with that macabre sense of curiosity that compels people to do the stupidest things, I grabbed the new Foley tube and held it up to the one implanted in my own sinus cavity. Lining it up, I pinched the new tube at the base of my nose and pulled it away from my face. As I suspected, a good 6 or more inches seemed to be buried in my head. Strangely, the certain knowledge of it was calming, when compared to not knowing, and wild imaginings. Still, it was pretty deep.
The next morning Dr. B arrives. He has a brusque bedside manner, and though pleasant, and willing to wait the full five days, once he's decided to proceed, he want's to get on with it. Attaching a giant syringe to the tube, he attempts to suck the fluid out to deflate the balloon in my head. He is struggling, applying enormous force to the tube. Although I know it won't suck out my brains, I can't help dreading a sudden release of pressure. Not the least of these reasons is that I don't want the tube to be accidentally jerked from my head, dislodging some delicate membrane and causing me to bleed again. Finally he realizes that hidden in the cotton wad at the base of my nose is a clip. He works roughly around the base of my nose trying to free the clip even as I protest at the sudden movements. Finally he decides to just cut it. He applies a pair of clamping pliers ahead of the clamp and cuts it out. Then he releases the fluid. I feel the tube deflate inside my head and rest there like an overcooked string bean. Gently he pulls it out. It is a bizarre feeling to have something removed from your head live and in person. The tube is drawn out without incident. Next the packing. The forceps disappear up my nose, and like some magician's scarf trick, cotton packing emerges by the yard. This too is an unsettling sensation. Many people faint at this point. I think fainting is due in part to the strange sensation, and part to the flood of oxygen into these highly absorptive passages. Indeed, it is once again wonderful to feel the air circulating freely in the long closed right sinus. The packing is removed, and Dr. B announces that there is a second pack in there. I am not ready for this. I tell the nurse, and she points to the smelling salts strapped to her gown. I breath-groan-yell as the string of blood clotted cotton is pulled from the deepest regions of my nasal passages. Finally it is out. Dry as a bone. No bleeding, no pain. By noon, after some observation, I am showered and free to go.
There are more minor miseries to overcome on the way to full recovery,
but for now I am back on track. My first encounter with emergency
medicine and hospitalization has been a relatively positive one. But
I have learned the hard way that there is no such thing as "routine"
surgery. There may be surgeries that are performed innumerable times
but every patient is different. The illusion that we can fix people
like we fix cars has been shattered. I guess if I had thought about
it more in advance, I would have concluded that if we can't reliably
fix a machine that is entirely of our own creation, what luck do we
have with something as individual as a human body? We are all told
the risks in advance. Indeed we are required to sign our names to
the fact that we understand them. Yet we really don't. We don't want
to lest the knowledge of the possibility would prevent us from continuing
with the brave certainty that, "it won't happen to me."
There is quasi-cynical expression about surgeons that says, "the
chance to cut is the chance to heal." What may need to heal most
of all is the cut. More importantly for me now is the recognition
that the most important word to remember in this saying is "chance."
Copyright 1998. All rights reserved.