"Please help me. I was brushing my teeth this morning and started bleeding a ton from my mouth." Sam pointed to a bucket next to his bed. I was horrified to see close to two pints of blood in it. With gloves on, I pulled out my penlight and a new tongue depressor.
"Open your mouth wide for me, Sam. I need to see where you are bleeding from." I clicked the light on and with my other hand started exploring around his upper and lower gums. I lightly pressed various areas inside his mouth with no bleeding. There were no mucosal lesions either. I only saw dried blood over his teeth and oral cavity. I couldn't find any signs of the source.
"Is this the first time you've bled like this?"
"First time, sir."
"Any history of bruising?"
"It looks like you do have some small bruises on your arms over here."
"Oh, those? I didn't notice, but yeah, those weren't there before."
"Do you have any family members with bleeding problems?"
"Nah, my parents are pretty healthy. So are my brother and younger sis. Actually, sorry, my dad mentioned to me once that he had gum bleeding. But I'm not exactly sure."
Possibilities started running through my head: hemophilia, scurvy, Von Willebrand disease, maybe one of the platelet function disorders. I took more of Sam’s history and completed the physical exam.
"Were you given any medications since coming here?"
"One of the nurses gave me a mouthwash to use, she said it would help stop the bleeding."
"And you haven't bled since using the mouthwash?"
"Not since, thank god."
"I think I have everything for now Sam, I will be back soon with my boss."
"Please don't go, sir, it's just me here."
We were in the last emergency room bed next to the emergency door. Sam was a young Hispanic boy who loved playing basketball (and supposedly had handles like Kyrie Irving).
"Are your parents coming to visit you later today?"
"My mom just left to go back to work. I haven't heard back from my dad yet."
"They'll be here as soon as they can."
"I hope so …"
As I was saying goodbye to Sam, my attending tapped me on the shoulder.
"Looks like you both were having a good conversation!"
"Oh hey, Doctor! Yes, this is Sam. May I present him to you?"
"Have at it."
"Okay, so Sam is a Hispanic male who came in with acute onset oral bleeding. While brushing his teeth this morning, he started to bleed profusely into the sink. His mom immediately took him here and since arrival he has bled two pints of blood. Oral cavity exam is unremarkable; I was unable to locate the source of bleeding. There are some small bruises on his upper arms, but otherwise negative physical exam. He denies any trauma, bleeding elsewhere, shortness of breath, chest pain, trouble swallowing, choking, or other symptoms. No past medical history of easy bruising or similar bleeding episodes. He mentioned that his dad had gum bleeding in the past. No smoking, drinking, or illicit drug history. Sam doesn't take any medications and is otherwise active and eats a balanced diet."
"Good, thank you, T.J. Hey Sam, how are you feeling buddy?"
"I'm feeling okay, sir."
"Is it okay if I also examine you? I'll be doing what T.J. just did."
"That's okay with me, sir."
My attending did a thorough physical exam, also checking Sam’s feet, scalp, and ears.
"I'm sorry about your bleeding, but since this is the first time it's happened to you, it may be because you were brushing your teeth too hard."
"My mom tells me that every day."
"Listen to your mom; I think you'll be just fine. Any questions for us, Sam?"
"I don't think so … does that mean I get to go back to school?"
"If your mom or dad can pick you up, yes, we'll wrap things up and get you on your way."
Sam looked like a million bucks and was ready to leave the emergency room. But I had serious doubts about him leaving so soon. Maybe it was looking at the blood bucket several times or hearing his story … I told myself there must be a medical reason for Sam’s bleeding, and I asked my attending to admit Sam to the inpatient floor for overnight observation so we could run some tests (e.g., an iron panel, ascorbic acid, and coagulation studies).
"You want us to admit him to the floor instead of discharge?"
"I feel that strongly, yes, and it would give more assurance to Sam and his parents. Also, he did have some very subtle bruises on his arms and mentioned that his dad had bleeding gums."
"Alright, sounds like appropriate reasoning to me. I will admit him for observation in a few minutes, let me know if something changes with his condition."
"Thank you, Doctor."
The remainder of the day was uneventful and Sam seemed to be doing quite well. But as he was eating his dinner, the bleeding returned in full force.
My attending and I rushed to the emergency room bay as soon as we got the call. People were surrounding Sam’s bed, checking his vital signs and mental status. Sam had his head down and was sitting upright holding a bucket in his hands. Bloodied bed sheets were being changed out for new ones.
"Sam! Are you okay?"
"Oh hey, T.J. … I started to bleed again while eating my sandwich. I'm sorry for making a mess …”
"Don't be sorry, we’re here for you. I called your parents earlier and they will be here soon. You'll stay overnight upstairs, but we'll keep a close eye on you and make sure that everything is okay."
My attending consulted Hematology as I spoke with Sam and within the hour he was transferred to their service.
What was the final diagnosis?
Several months before this experience, which occurred during my Internal Medicine rotation at the local trauma hospital, I had the chance to speak up for a patient from a different team. After I saw this patient, I felt strongly that he should not be discharged. I chose to stay silent because I told myself, “I am just a medical student and I should fall in line.” Never again. Whether you are a medical student, a resident, or an attending physician, it is always an honor and a privilege to see and take care of patients. This privilege does not only require rote application of medical knowledge. We must also be our patients’ advocates, and doubly so when patients cannot advocate for themselves.
Ton La, Jr. is a MD/JD candidate at Baylor College of Medicine and the University of Houston Law Center applying to Internal Medicine residency programs Fall 2020. He sits on the American Medical Student Association Board of Trustees as the Vice President for Membership.