haemolysis

Blood, sweat and tears

You can’t choose which patients live.

It doesn’t matter how much you try, how much medical knowledge and care you provide, some things are beyond your control and there’s not a single thing that you as a clinician can do to turn them around.

I had a patient that was spectacularly trying to die: diabetic ketoacidosis with intravascular haemolysis from secondary hypophosphatemia and a marked hypokalemia on top of all that.

For the less medical in the audience, this is the simple version: diabetic dog doesn’t get enough insulin for a prolonged period, so blood is full of glucose. That excessive glucose gets turned into ketones, which acidify the blood. Acidic blood denatures the body’s proteins, sort of like the change you see when you marinate meat in lemon juice, and can kill the dog.
So you give insulin to transport that glucose into the cell where it can be used. Next problem is that the glucose takes potassium with it when it crosses the cell membrane, so all that glucose entering cells drags potassium with it. As the blood potassium is used up, the heart slows down, and will try to stop. This is as bad as you expect it to be,
AND THEN the glucose, finally inside the cell, gets turned into energy. On a molecular level, that’s turning molecules called ADP (with two phosphate molecules) into ATP (with three phosphate molecules) where does the cell get all that extra phosphate? From the blood. What happens when the blood phosphate levels drop too low?
All the red blood cells decide to explode and become useless. Hello severe anaemia. So there are multiple ways the patient is trying to die.
Oh, and it was pancreatitis in the first place that triggered the whole catastrophe. (I’m not kidding when I say don’t feed them bacon,)

And here I am, sweating over this patient, desperately trying to find a source of intravenous phosphate that I can have RIGHT NOW, because our supplier wont have any for two days, by which time the patient would be nicely frozen in our cadaver storage.

A whole week I spend micromanaging this patient, trying to control all these factors and trying to get the patient back into any kind of balance. That included two nights in ICU at the 24 hour clinic, and one of me checking him at the clinic during the night. Mate, was this patient a lot of work. I was dreaming of his supplement calculations.

He even received a blood transfusion from my parent’s dog when his phosphate dropped to 10% of its normal level.

Until two days after his transfusion, when I was finally starting to hope, he crashed. He was put to sleep.

He had the blood, sweat, and now the tears.

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Day 5/100 - 24th Nov - 20:20

Today has been pretty productive. I had a practical in biochemistry today. We did haemolysis of blood cells - and general osmotic fragility. I then had a career planning meeting and she said she couldn’t really tell me much more, but she gave me some really useful tips on how to create some professional networks so I’ll defo be doing that. I then came home and made some revision notes on data handling. My exam is in Jan, but we don’t have that much to cover - it feels really weird. I feel it should be harder than it actually is. I have a mock exam in that module in 2 weeks tho so we will see :)