hello my name is dr. ed Norton Thoreau or dr. ent I'm an otolaryngologist surgeon I will be
reviewing three severe nosebleed scenes from three different popular TV shows Grey's Anatomy private
practice as well as one from the BBC called cardiac arrest the first nosebleed scene I
will review is the one from private practice not a bad representation of how an individual
with a bad nosebleed up and walks into a clinic or ER I'm a little surprised by how nonchalant
the patient is with her nose beat however which suggests she's had them before she was doing a
great job firmly pinching in those which is the right first step to take Karin i bleedin got a
lot worse check to CBC Hermetic Chris less than 30 less than 30 a shirt you mean there's something
really wrong with her yes there's something wrong with me it's a great time to walk out just great
her nosebleed is considered severe given her blood count has dropped significantly if he
blood transfusion is considered she would need at least two units of blood to get her blood
counts back to normal at this point simply pinching the nose as demonstrated in this as
well as the prior scene is simply not working the next best step would be to either try to
cauterize her nose or perform nasal packing the patient is amazingly composed when clearly
having an unusually bad nosebleed you have no idea who I am you only have Doug's side of the
story I'm the [ __ ] and he's in his unclear what exactly was done to stop the nosebleed in
the clinic but presumably nasal cauterization is performed as I see no obvious nasal packing and
her voice sounds normal but unfortunately her nose starts to bleed again coughing out blood
is common especially when it runs down the throat but with an act of bad news blade is
having someone else's blood splatter against her face realistic yes yes it is tipping the
head forward helps to minimize coughing up blood during an active nose blade you got something
called Wegener's disease it's a disease of the blood vessels that affects the ears nose throat
and kidneys Keshi nosebleed as the very first symptom of Wegener's is quite unusual usually
there will be other symptoms present and one normally would not run tests for Wegener's when
working up a bad nosebleed that said nosebleeds can occur with Wegener's due to an abnormal
hyper vascular and inflamed lesions of the nasal and sinus mucosa in this next scene from Grey's
Anatomy a patient presents to the ER in a similar fashion but with a dramatically different outcome
nosebleed huh let's hit a stop it it sounds like a rough night I've been there trust me FC okay you
want to apply pressure and keep your head forward come back to packet a fairly realistic example of
how a patient with a bad nosebleed presents to the ER appropriate first step of applying pressure and
keeping head tilted forward is demonstrated I think it's been long enough all right
initially the patient appears to have result is nosebleed but note how he has kept the
head tilted backwards which is why he stays he feels the blood running down the back of his
throat he probably also is constantly swallowing blood giving the false appearance of a resolved
nosebleed the true nature of the news beat soon becomes apparent when blood starts to
pour out of the nose and mouth which suggests an arterial source of bleeding at this point there
are two main arterial sources that can cause a severe nosebleed the dreaded Cimino Palatine
rd8 located in the very back of the nose and the anterior ethmoid already located near the
nasal corner of the eye I should mention that the severe nose but is quite realistically portrayed
in the scene yeah I got that why the hell's in stay already in a no arm let's go we need to
get him intubated open a central lines can't get some Oneg here right away yeah what's his
bleeding time clotting factors I don't remember oh I'm talking about you and pills at med school
letters labs did you even do a physical exam he'll last forever we're calling this patient been here
bleeding in the ER no my fault he was fine long as five hours dad can't visualize I can't build
us anything give me a crike kit and you go put the iris we don't stand by you now go go
the ER attending immediately recommends intubation which is not incorrect but I personally would not
pursue this right away rather I would immediately pack the notes and see if that's all it takes to
resolve this nosebleed emergency and rather than a central line which would take too long
I would have two large-bore IV placed instead keep in mind that the patient has been sitting
in the ER for five hours that's a long time to be actively bleeding and the patient is
at risk for severe hypovolemic shock once it is apparent that the patient rapidly decompensated
intubation is absolutely the right thing to do not sure why he is not able to intubate as only
blood would be present which should be able to be easily suctioned away but if he can't see
the early for whatever reason and emergency cricothyrotomy is perfectly appropriate in
a decompensating patient one can argue that bag mask ventilation should be performed but given
severe active bleeding one risks forcing blood into the lungs worsening pulmonary function I
can't get a readout on next symmetry what happened getting here I could use some help
from a grown-up when you double as this phenol Palatine artery and tell me what
you need to access the femoral artery I get the right side you take the left gun
what the hell happened eventual posterior nosebleed I tried to stabilize him in the
ER pack and Foley didn't work I got an IO line in but the blood is barely transfusing
damn it I can't get it hustles collapsed I'm gonna try it cut-down it stop compressions
Bell central access he's done old ah hold off stop compressions call it it's just a
nice plate a nosebleed that brings a person to the ER is never just a nosebleed in this final
scene the patient has suffered cardiac arrest from hypovolemic shock from significant blood loss and
ultimately passed away this particular scene shows CPR being performed quite timidly I should add in
order for chest compressions to be effective one needs to really push down on the chest
hard the ER attending stated he tried to pack the nose and even use the Foley without success
currently he is now trying to embolize this phenol Palatine artery by threading a catheter from the
femoral artery and the leg and advancing it up to the nose which is an appropriate next step
alternatively a possibly better option would be to endoscopically try to control the nosebleed
essentially women to run a tiny rigid camera into the nose to localize the source of bleeding more
precisely and perform more targeted nosebleed control measures compared to embolization and
the scopic nozbe control can be performed more quickly and can act as a tempering measure if
unsuccessful for invalidation to be tried later why embolization takes a long time to perform
time this particular patient does not have also it is nearly impossible to insert a catheter into
a collapsed blood vessel from hypovolemia when chest compressions are being performed
imagine trying to thread a needle if someone is constantly punching you in the arm ideally
chest compressions should be stopped briefly to allow time to quickly gain vascular access
let me take a wild guess yes well then let's get you into the recess in this particular
episode from the BBC TV show cardiac arrest one sees the now-familiar presentation of a
patient with a bad nosebleed the catch is that this particular patient is a hemophiliac which
means he does not have the ability to clot the implications of a hemophiliac
history is immediately recognized by the doctor who orders a factor
a transfusion which supplies the missing clotting factors required by the patient
Telos in my life it's the anterior distrust areas local switchboard says that the German
the general salient awkward I think it's getting worse no slacks today did have them to send out
the doctor realises that patient needs to be packed but has never
been trained to do so compounding this dangerous situation is the fact that the
hospital apparently did not have factored aid available which means the patient
will continue to bleed the way the severe nosebleed is portrayed is quite realistic
the actors quite accurately portray the panic of trying to save this patient's life without the
necessary tools and expertise the doctor tries the only thing she knows to do by inserting a
Foley catheter into the left nose and inflating the balloon to apply pressure this maneuver is not
incorrect and can indeed work when nothing else is available problem is based on what I see in
this scene I'm not sure which side the bleeding is coming from it could be just as easily be coming
from the right side if I were in her shoes I would place a Foley catheter in both sides
unfortunately placing a fully nasal packing in the left nose does not appear to be working as
he is still rapidly losing blood based on the canister he's lost about 700 milliliters of
blood in under one minute the doctor appropriately pursues intubation to
control the airway given the active bleeding which is clearly compromising the patient's
breathing basically he is drowning in his own blood the patient has gone into
hypovolemic cardiac arrest and CPR is now being performed the nose bleed appears to
have stopped but it is probably because their heart is no longer pumping blood effectively
question gentleman one milligram atropine three milligrams please as quick as you can please
still a sister ACLs protocol is now being pursued to revive the patient's cardiac rhythm
the patient ultimately passed away I hate to say this but the way this disaster unfolded is
quite realistically portrayed from the patient presentation to how the severan dose rate was
portrayed and managed the doctor truly did what she was able to do with the tools she
had on hand and I'm not sure if any non ent could have done it any better the only thing I can see
that the doctor could have done additionally that I already mentioned earlier was to pack
both sides of the nose given it was unclear of which side the bleeding was truly coming from
even if an ENT was present to stop being such a severe and notably in a hemophiliac patient
would have been challenging in summary these TV shows overall did a great job
in realistically portraying severe nosebleeds different treatment strategies may have been
pursued in real life but I cannot state what was shown was incorrect either thankfully death from
severe nosebleeds is exceedingly rare also I want to stress how frequently and commonly
nasal packing is performed to control severe and nosebleeds which is not readily apparent
in these scenes check out this video and how nasal packing is formally placed in a patient