Medical questions about blood and blood loss, pretty please! :-)

Los Pollos Hermanos

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Hello and happy Saturday, good people of AW!


I’m plotting my next two crime novels whilst waiting to see if any literary agents bite for the trilogy I’ve finally started to send off (fingers and toes crossed, and all that). I’d greatly appreciate it if any medical-type folks could help out with some blood-related questions for one of them. At no point in the story does any kind of bloodbath occur, btw!

Big thanks in advance!

1). A character loses two pints – we’ll say around one litre as I know UK and US pints are different – of the red stuff (no sparkly vampires involved). He’s forty years old and in good health, around six feet tall and of medium build. Within twenty-four hours he has a blood test carried out for something unrelated. Even if he appears perfectly healthy after all this, would the results of the blood test show that he’d lost this specific(-ish!) amount of blood recently? As I understand it, the plasma and white cells are replaced quite quickly but the red cells take many weeks toget back to normal levels – hence the rules for the minimum intervals between voluntary blood donations.

2). If there is a detectable difference, what sort of values would be detected? Imagine two doctors are discussing the character’s blood test results. Ideally, I'd like them to be a bit confused by some sort of discrepancy.

3). The character appears none the worse for wear after losing a litre of blood.
a). Would he feel different? Maybe a little light-headed or tired?
b). Would he look paler than usual? He’s a white Englishman, and they tend to look pretty pallid even when healthy!

4). My googling has supplied plenty of information about what would happen if he then lost another litre of blood (no giant leeches involved either) soon after. I can write the hypovolaemia scenes clinically, but if anyone has any authentic snippets they could share it would be a massive help. Either from a doctor, nurse, paramedic or patient perspective is fine.

Erm… I think that’s all. Again, humungous thanks as I face my having to write medical scenes demons. Bloody (pardon the pun) well hate ‘em – you’d think I’d have learnt by now.

Cheers,

LPH.
 
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Pegster

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I can't speak entirely to human symptomology, but from a veterinary perspective, the hematocrit would be reduced. Two pints would probably induce signs of hypovolemia (dizziness, exhaustion, thirst), particularly if, unwitting, he consumed a diuretic like coffee or chocolate afterwards.
 

Silva

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So, I'm female and very small, therefore I expect that numbers would be a little different for a taller male, but when I hemorrhaged (enough that they were urging a transfusion) my hemoglobin count was at seven. In a healthy person, it would be somewhere like 13, or perhaps 14 or 15 for a healthy male.

Hematocrit is another thing they might look at and you'll notice from that link that healthy percentages for a male are also higher than for a female.

Mostly people just talked about my hemoglobin levels, though--they drew blood for a CBC which includes hematocrit as well as hemoglobin and other things, but it was always this or that about my hemoglobin and no word about my hematocrit except once from someone other than my doctor. This may have to do with what the doctor's preferences for what he likes to look at; perhaps a medical professional can chime in on that.

I don't remember being particularly thirsty (I was on an IV, so I don't know), but there was extreme muscle fatigue, some mental fuzziness (but not a lot, I still felt very alert), and I felt cold easily. I was very, very pale (EMT said I looked like an angel, because that was nicer than saying I looked like a ghost, lol) and dark circles around the eyes are not uncommon, but I'm not sure if you'd see that in sudden blood loss as much as long-term anemia. I also had zero appetite for the couple days directly afterwards, but I'm not sure if that's related.

It took me a couple months to work my way back to a normal (for me) hemoglobin count of 12, while taking iron supplements, sublingual B12 tablets, folate, etc., as well as a diet high in those things.
 

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Registered Nurse in an American ER here.

1. We don't track blood loss in the field, they do in surgery (where we use the metric system btw). Ultimately we're less concerned about how much blood was loos and what your Hematocrit and Hemoglobin shows. Our medical guidelines say that blood should be given on a restrictive basis, not a liberal one, so typically speaking your Hemoglobin needs to be below 7 to 6.5 grams per deciliter in order to have RBC transfused. Men tend to run in the 14 to 17, it depends what the blood work shows.

2. I don't know about anything surprising. He could be asymptomatic but still have a low H&H but there's really nothing in your basic blood tests that's going to confuse an MD. They're going to run a Complete Blood Count (CBC) and a Basic Metabolic Panel (BMP). What tends to be more confusing is when your chemistry odd, like when the Potassium is high or low for example.

3. Yeah, he could be showing the signs and symptoms of anemia for a few days, low energy level, dizziness when standing that sort of thing.

4. Hypovolemic shock is an incredibly dangerous condition and thankfully pretty rare. In my experience they've been involved in a car accident, or a shooting and have lost a lot of blood in a short period of time. They're cold, their lips are blue, typically they're not conscious and it can be very hard to start an IV. That's the most nerve wracking thing is that they need IV access and typically you have two or three nurses working on different arms with large bore needles and if you can't get one in about five minutes or so you try intraosseous access, which involves either you or your charge nurse grabbing a drill and literally drilling a catheter into their femur, and that's not a sure thing either. That's what sticks out to me the most, the stressful fight for IV access.
 
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GeorgeK

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It would depend on the starting point for his Hgb and his activity. For men that's probably going to be in the 12-16 range so if say he went from 15 to 13 the lab would officially still be within normal range and would not suggest a problem. It's the trends that are more more important rather than any individual lab result. Depending on his activity level he could be asymptomatic if he's basically sedentary or may have dizziness, mild confusion, blurred vision, tachycardia, shortness of breath etc if he's doing anything even moderately vigorous. If he tried to go out running he may not get very far before having to turn back. Even if his Hgb is officially still in the normal range, it's not going to be normal for him. If there is normal health and nutrition otherwise there'd already be some improvement the next day and depending again on activity should be better within a few days to a few weeks. As far as pallor goes, most likely the doctors wouldn't notice it at that level of blood loss, but someone he lived with may, or he may notice it in the mirror.

The doctors may or may not notice a left shift in the CBC (complete blood count). That's something two could argue/discuss. A left shift is usually in reference to white cells but a loss of red cells will also have an impact if you know what you're looking for. It's an increase in immature cells being released to deal with the drop in oxygen carrying capacity. At only 1 liter and less than 24 hours and no obvious trauma it'd be a subtle pick up and since most labs do automated (computer read) differentials rather than manual (prep a slide and look at it under the microscope) it would probably get missed. At least in America it's mostly automated and in my experience they never do a manual diff unless it's specifically ordered.

If the patient has complaints the normal thing would be to recheck the labs in a few days. Since he's healthy and whatever caused the blood loss is gone there will likely be a slight rise in the hemoglobin and a drop in immature cells. This is a normal thing in isolated questionable results. It's called regression to the mean.
 
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Los Pollos Hermanos

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Many thanks to you lovely people for all the bloody good info!
(Yeah, thankfully I don't write comedic stuff)

So... if my character usually had a haemoglobin value of 15, what could it drop to after he loses a couple of pints (in everyday parlance we measure essential liquids like blood, milk and beer in pints!) of blood? That link suggests a male's haematocrit would average out around the high 40s %. Say his haematocrit was 50% before, what could it drop to after losing two pints/one litre of blood? This is just for doctor conversation, btw. He has regular medicals at work; not sure if these would include blood tests (so there'd be a baseline to make comparisons), but I could try to find out.

Could losing two pints of blood in one instalment mess up his blood chemistry to some degree?

Also, would having a beer or two (with alcohol being a diuretic) after this first incident of blood loss exacerbate his symptoms, or have any additional effect(s)?

The thought of someone drilling into a femur with a Black & Decker (famous UK power tool brand) is giving me jelly legs! I'll make sure he doesn't end up that badly ill. I need him out of the way in hospital for a few days, albeit not on death's door.

Cheers m'dears! :D

Edit: I need him to feel off-colour, but not realise it's down to losing two pints of blood. He needs to be as baffled as the doctor... I might have to do something else unpleasant to him! Any ideas?!?! :evil

p.s. PEGSTER - Is that Winter Park in Colorado?
I had an immense Kobe beef burger and sweet potato fries at a grill house there a few summers ago.
 
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MaeZe

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The average adult has about 5 to 6 liters of blood. If you lose one liter rapidly, you will have symptoms of thirst, weakness and a fast pulse. When you donate blood they take a pint. That's enough to make me nauseated the rest of the day because of the vasovagal response, but most people don't have any symptoms at all.

As you noted, in a few hours (or less) your body will dump enough fluid into the bloodstream to correct the volume, but that serum has no red blood cells. However, until the volume is compensated, you will not see a drop in the hematocrit which is a percentage of fluid to red cells, not a direct measurement of blood loss. In the timeframe of your story, the volume will have equilibrated so the H&H will reflect blood volume loss.

This paper has some good insights about symptoms and blood test measurements: The blood loss analyzerA new way to estimate blood loss
Blood loss in adults is divided into four categories, primarily based upon the clinical symptoms that are exhibited by patients who have suffered such blood losses. An estimated blood loss of 500- 700 cc is considered minor, representing approximately 10-15% of an adult's total blood volume. Patients with minor blood loss may experience a rare vasovagal syncope. A moderate loss is one of 750-1500 cc, approximately 20-30% of the total
blood volume. A patient in this category with a loss of less than 1000 cc may experience a decrease in pulse pressure and a slight tachycardia, tachypnea and postural hypotension.

A major loss of anything above 1200-1500 cc in adults may constitute a hemorrhagic shock. These patients not only experience shock with a drop in systolic pressure and cold clammy skin, there is also a decrease of urine output to less than 30 cc per hour. At this point, a drop of 50% below normal systolic pressure occurs in these patients. A loss of greater than 45% may be irreversible, and a patient at that time becomes hypoxic and totally unresponsive.1

There are formulas to determine blood loss by drop in H&H (provided there has been time for volume correction) so you can just reverse the math.

http://perinatology.com/calculators/Calculated Blood Loss CalculatorO.htm

If that one doesn't work for you, just Google 'estimating blood loss by hematocrit'.
 

GeorgeK

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There are many variables, mostly depending upon his state of hydration, and activity. The better hydrated the less cardiovascular / hemodynamic effects. The less activity, the less impact on oxygen requirement. Generally blood donors are recommended to go light on alcohol for a couple days, partly due to the diuretic effect and most people also report they get a bigger kick from the alcohol itself after donating blood.

A hematocrit of 50 probably correlates to a hemoglobin of roughly 17 which is borderline for polycythemia which would be treated by therapeutic phlebotomy as a short term measure at least. A Hct of 45 is probably in the roughly 15 Hgb. I prefer to go by hemoglobin because it's closer to but not exactly a 1:1 correlation between pints lost and lab values observed. So if he went from 15-13 that'd be again, roughly a hematocrit drop of 45-high 30's. But again, there are many variables. In a surgical patient there's usually a bigger drop because of the wound itself chewing up additional blood. I'm assuming this was the result of phlebotomy or a slow bleed. He could have lost the cells to lysis from hypervolemia or infection but those would not be subtle in the least. A deep finger laceration could do if if he didn't realize it for a while. That actually happened to me while butchering a pig and I didn't realize it was my blood draining out
 
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GeorgeK

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The average adult has about 5 to 6 liters of blood. If you lose one liter rapidly, you will have symptoms of thirst, weakness and a fast pulse. When you donate blood they take a pint. That's enough to make me nauseated the rest of the day because of the vasovagal response, but most people don't have any symptoms at all.

As you noted, in a few hours (or less) your body will dump enough fluid into the bloodstream to correct the volume, but that serum has no red blood cells. However, until the volume is compensated, you will not see a drop in the hematocrit which is a percentage of fluid to red cells, not a direct measurement of blood loss. In the timeframe of your story, the volume will have equilibrated so the H&H will reflect blood volume loss.

This paper has some good insights about symptoms and blood test measurements: The blood loss analyzerA new way to estimate blood loss

There are formulas to determine blood loss by drop in H&H (provided there has been time for volume correction) so you can just reverse the math.

http://perinatology.com/calculators/Calculated Blood Loss CalculatorO.htm

If that one doesn't work for you, just Google 'estimating blood loss by hematocrit'.
The only caution I'd suggest is that infants don't respond the same as adults. They don't have the reserve and so crash faster, but they also don't have the bulk and so can bounce back faster
 

Los Pollos Hermanos

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I didn't know there were online calculators - my googling skills are slipping!
Thanks for the links, and for that article, which I'll print out and peruse at leisure later.

I used this:
https://www.easycalculation.com/medical/allowable-blood-loss.php
to work out that a 75kg male with a starting haematocrit of 45 and a final haematocrit of 38 could lose 937.5ml (a little over two UK pints) of blood. Am I correct in rearranging that to say that he could start at 45, lose a couple of pints of blood, and end at 37.5? The reason behind the blood loss is classified information, I'm afraid. ;)

And... some more adjustments said that to go from 45 to 32 would be a blood loss of 1,625ml. Would that be enough to give him some pretty nasty symptoms, but not enough to end up with a drill in his femur?!
 

MaeZe

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The only caution I'd suggest is that infants don't respond the same as adults. They don't have the reserve and so crash faster, but they also don't have the bulk and so can bounce back faster

The link was for calculating the mother's blood loss, not the infant's.
 

Pegster

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Brrr! No, it's in Florida (Orlando, effectively).
Does he have to know how many pints he's low, in the end? Like he saw two ruby bottles driving away, then later realized those were his? If the volume just has to be substantial, it might give you more leeway for HOW it was lost, or wasn't, and why he feels poorly. Flu versus gastric ulcer, broken coffee maker versus flying hypodermic needles, or whatever. Maybe the doc's incompetent and overlooks the anemia? Did all the labwork come back, or get lost in the fax?

Was it a weekend? Did the doctor go golfing and leave him to sweat it out until Monday? That happened to me once.
 

Los Pollos Hermanos

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My best bud just got back from Orlando (I hope she's brought me some grape Jello and a bottle of Walgreen's ibuprofen) and our chilly-damp weather was a rather rude welcome! Quite depressing to know we've got another four or more months of it.

He won't know how many pints he's lost, but by the time he ends up in hospital the medical bods will want to know - and so will the police.
 

GeorgeK

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The link was for calculating the mother's blood loss, not the infant's.
ok. I saw perinatal and mistakenly assumed they meant the infant, just one of those days
 

Pegster

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The ibuprofen I can understand, but grape jello? Grape, when there's lime?
 

Los Pollos Hermanos

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I love that synthetic never-seen-a-grape-in-its-miserable-existence taste. :Shrug: Much better than our blackcurrant-flavoured stuff!
 

Tsu Dho Nimh

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He won't know how many pints he's lost, but by the time he ends up in hospital the medical bods will want to know - and so will the police.

The lab would get involved ... a major suspect would be Gastrointestinal bleeding, so they would send feces to the lab to test for hemoglobin.

If he denies vomiting or coughing up blood or nosebleeds, they'll still check for bleeding esophageal blood vessels (laryngeoscope), stomach ulcers (gastroscope) and do an X-ray looking for signs of lung problems.

A rare but potentially lethal way to lose blood from circulation without any signs of it externally is to have a blood vessel in your abdomen rupture. The blood is contained, and until the body starts removing the clots, there would be no sign of it in the blood chemistry (then the bilirubin would rise). The CBC would show low H&H with an unusually high population of immature red cells. That would get MRI and/or ultrasound looking for masses and signs of an aneurysm.

Cancer can produce some astonishingly low RBC counts, but it is a slow decline.
 

O-shin

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Oooh, something I can answer!

So basics: what you're defining is 'hypovolemic shock', meaning the body goes into a compensatory state because there is less blood in the body- 'reduced organ perfusion'. Doctors just say shock and most know what that means. There are other types- neurologic, septic, blah...
It can either be due to open trauma, or as the poster above me said, internal bleeding. Usually open trauma is easier to treat, faster to notice (it's there, man).Internal bleeding, depending on what artery is involved is a bit different, but usually goes at a slower pace (say 4-6 hours before death in spontaneous hemoperitoneum, that is described above)

So first *rubs hands happily* vitals and systemics! Blood pressure will be low, heart high, maybe a fast respiratory rate (so hypotensive, trachycardic, taychpnea). Conjuctival pallor (pale lower eyelids, works for any ethnicity) reduced capillary refill (a test you do, press on the fingernail and see how fast the white turns to pink, again, works for any ethnicity)... then there are a lot of other symptoms but no doc is gonna hang around to check them all out. If the patient had head injuries, esp for road accidents, we will do a Glasgow Coma Score.

We will first start IV isotonic (0.9%) saline solution, or Ringer's lactate. Stop any open bleeders, using sutures or compression bandaging. We will take blood for cross matching, and send blood for CBC and electrolytes. We will also put a catheter and check for any reduced urine output (which is bad). All this will also prep him for surgery if need be, and usually we will send for HIV and Hep B testing as well (in case we operate). We don't infuse blood until the results return- unless of course we get the CBC first and the hemoglobin (Hb) is terribly low (I'd say 5mg/dl, but for a tall white guy, make it 8mg/dl to be safe. Normal adult male: 16mg/dl) and then we'd raid our fridges for O negative blood.

Other values we look at are total RBC count (reduced), MCV, MCH MCHC, and hematocrit. All would be normal except hematocrit, which will be low

Like someone pointed out, you got lots of blood in your body. A rule of thumb is 1l per 10kg of body weight. Assuming our guy is 60-70kgs, he'll have a min of 5l of blood. Even then, the physiology of our body is designed to compensate for this loss, until you get help.

Usual symptoms of shock- lightheadedness, fatigue, confusion, being aware of your heartbeat, and I've personally heard a drumming, pulse like sound in my ear before I passed out. If internal bleeding- usually dull, generalised abdominal pain (or wherever blood is being collected. even if blood is collected in the pelvis they describe it as lower abdominal pain.) Sometimes if they lie down they might feel a sharp, shoulder tip pain. This usually happens in women, in ruptured ectopic pregnancies)

1). A character loses two pints – we’ll say around one litre as I know UK and US pints are different – of the red stuff (no sparkly vampires involved). He’s forty years old and in good health, around six feet tall and of medium build. Within twenty-four hours he has a blood test carried out for something unrelated. Even if he appears perfectly healthy after all this, would the results of the blood test show that he’d lost this specific(-ish!) amount of blood recently? As I understand it, the plasma and white cells are replaced quite quickly but the red cells take many weeks to get back to normal levels – hence the rules for the minimum intervals between voluntary blood donations.

No, maybe a very slight decrease in Hb, but really negligible- you don't have any previous reading to compare with anyway! And I think that answers the rest of your questions, except for Q4

2). If there is a detectable difference, what sort of values would be detected? Imagine two doctors are discussing the character’s blood test results. Ideally, I'd like them to be a bit confused by some sort of discrepancy.

3). The character appears none the worse for wear after losing a litre of blood.
a). Would he feel different? Maybe a little light-headed or tired?
b). Would he look paler than usual? He’s a white Englishman, and they tend to look pretty pallid even when healthy!

4). My googling has supplied plenty of information about what would happen if he then lost another litre of blood (no giant leeches involved either) soon after. I can write the hypovolaemia scenes clinically, but if anyone has any authentic snippets they could share it would be a massive help. Either from a doctor, nurse, paramedic or patient perspective is fine.


I must disagree about the immature blood cells. This would indicate a chronic pathology, not something that would happen in a day. Blood cells are produced everyday, and the cells die every 120 days, so you got time. If you have defective erethropoesis (defect in producing red blood cells), then yes, you'll have different lab values, the reason for it being anything from a lack of vitamin B12 in the diet to cancer- and that's another kettle of fish.

Sorry for the long post!
 
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MaeZe

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The lab would get involved ... a major suspect would be Gastrointestinal bleeding, so they would send feces to the lab to test for hemoglobin.

If he denies vomiting or coughing up blood or nosebleeds, they'll still check for bleeding esophageal blood vessels (laryngeoscope), stomach ulcers (gastroscope) and do an X-ray looking for signs of lung problems.

A rare but potentially lethal way to lose blood from circulation without any signs of it externally is to have a blood vessel in your abdomen rupture. The blood is contained, and until the body starts removing the clots, there would be no sign of it in the blood chemistry (then the bilirubin would rise). The CBC would show low H&H with an unusually high population of immature red cells. That would get MRI and/or ultrasound looking for masses and signs of an aneurysm.

Cancer can produce some astonishingly low RBC counts, but it is a slow decline.

Just a couple nitpicks. If the blood loss is rapid and from the GI tract, you don't need a lab to tell you there's blood in the feces, it's obvious. You test feces for blood when it is 'occult' which would mean a very slow bleed over time.

If you are bleeding from esophageal varices, it's rapid, like an arterial rupture even though varicies are technically veins. They are unique veins. If, on the other hand, it is a smaller bleed from say an esophageal erosion or tear, but enough you lose 2 pints, blood is a strong emetic. You will usually vomit and if you are in the health care setting, it would be obvious there was blood in it. The would do and endoscopy if bleeding was suspected and the source was unclear.

Internal abdominal bleeding is going to be a major event, not something you don't notice until there is clot absorption.

You don't use a laryngoscope to examine anything, you use it to intubate a patient. To look in the lung you use a bronchoscope and an endoscope to look into the upper GI track. There are many different kinds of endoscopes depending on what one is going to look at. There is an endoscope called a gastroscope used to look in the stomach. Looking for an upper GI bleed, you would likely use a longer instrument so you could look at the esophagus, the stomach and the small intestines.
 

GeorgeK

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Just a couple nitpicks. If the blood loss is rapid and from the GI tract, you don't need a lab to tell you there's blood in the feces, it's obvious. You test feces for blood when it is 'occult' which would mean a very slow bleed over time.

If you are bleeding from esophageal varices, it's rapid, like an arterial rupture even though varicies are technically veins. They are unique veins. If, on the other hand, it is a smaller bleed from say an esophageal erosion or tear, but enough you lose 2 pints, blood is a strong emetic. You will usually vomit and if you are in the health care setting, it would be obvious there was blood in it. The would do and endoscopy if bleeding was suspected and the source was unclear.

Internal abdominal bleeding is going to be a major event, not something you don't notice until there is clot absorption.

You don't use a laryngoscope to examine anything, you use it to intubate a patient. To look in the lung you use a bronchoscope and an endoscope to look into the upper GI track. There are many different kinds of endoscopes depending on what one is going to look at. There is an endoscope called a gastroscope used to look in the stomach. Looking for an upper GI bleed, you would likely use a longer instrument so you could look at the esophagus, the stomach and the small intestines.
You beat me to it MaeZe. The only additions I have off the top of my head, it's been a very long time since stool was sent to the lab to test for occult blood. A Guiac test at the bedside has been the standard since...have to think about it...late 80's at least. Also rapid GI bleed patients can be identified from the hallway before the patient is in sight just by the smell. The smell wanders down the hallway. It sneaks around invisibly and then reaches down through your nose and tries to pull your gonads up into your sinus cavities. As you point out they will be vomiting, but beyond that there is a characteristic smell of the GI bleed patient a mix of undigested blood, partially digested blood and ketones/ammonia that the patient breathes out as a result of having digested a significant amount already. It's also not unusual for them to be having diarrhea and they are too sick to get to the bathroom, so that adds to the smell.
 
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I have no laboratory experience with this at all. My experience is from what happened to me in the war. I have a rare blood type. The surgical hospital called me over because they had a patient with my blood type that had lost a lot of blood. When I arrived they were losing the patient and they just hooked me up to the patient, directly!. After 30 minutes they unhooked me and told me to take tomorrow off, and drink plenty of liquids. My major never got the message to take the day off and so he sent me on a mission for 3 days. I went. I didn't notice any difference in my performance, and no one said anything. And, the patient lived.
 

Los Pollos Hermanos

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Thanks for the extra info, folks. I should be able to cobble together enough medical detail for the relevant scenes (when I eventually get round to writing them), but may come begging again if I'm struggling with anything.

Bloody well hate writing medical scenes - haha! :cry: