Issue #18: Coughing up blood on-screen is more ominous than it is in neonates...
Pulmonary Hemorrhages in neonates vs. in the movies
Coughing up blood in a movie is never good. The ‘bright red specks in a handkerchief’ trope seems to work so well as a foreshadowing technique because even non-medical people realize blood belongs in blood vessels, not spurting out of an adult’s mouth.
So what is the differential diagnosis of hemoptysis? In real-life, many of the causes are treatable. In children, lower respiratory tract infections and foreign body aspiration are often responsible for bloody coughs. In adults, bronchitis and pneumonia are major causes.
But on-screen that changes. For Jack Nicholson in The Bucket List, and King George in The Crown, blood in their phlegm was the first sign of an undiagnosed lung cancer. For Nicole Kidman in Moulin Rouge, it was a case of lethal Tuberculosis (not, unfortunately, her tight corset as she’d hoped). For Colin Farrell in Saving Mr. Banks, I’m assuming it was from ruptured esophageal varices secondary to chronic alcoholism. The blood spat out by Jared Leto in Dallas Buyer’s Club heralded the onset of AIDS.
And then there are all the traumatic causes for facial bleeding. There’s hardly a scene in Fight Club where somebody isn’t hemorrhaging. (Makes you wonder whether the first rule of Fight Club should be changed accordingly…)
A good samaritan’s cheek was torn off in The Good Doctor, leaving the entire orophraynx a bloody mess. There are endless war and horror movies where the amount of blood and gore dripping out of the mouth seems unnecessary, but I’ll spare you from those.
Basically- if you are an actor, and your script reads:
“Hacks dramatically into hand. Pauses, then inspects globs of blood dripping off palm…”
You should probably start looking for another job.
For neonates- a sudden, massive pulmonary hemorrhage can be life-threatening (mortality rates are quoted as being > 50%). But, more commonly, infants may have a trickle of bloody drainage or some pink frothy secretions which will (mostly) dry up if the baby is adequately managed.
We treat by:
Suctioning the ETT to make sure it’s patent
Increasing PEEP (or more generally the MAP)
Administering epinephrine 0.1ml/kg or~ 0.5ml down the ETT to aid in vasoconstriction
Ensuring good gas exchange (increase vent settings/ fi02)
Considering surfactant
Replenishing lost blood products (PRBCs, platelets, FFP, cryoprecipitate)
Supporting the infant appropriately
Our last video was on Pulmonary Hemorrhages- watch it here, if you haven’t see it yet.
If you’d like a helpful review on pulmonary hemorrhages, click here (no paywall).
Here is the PDF summary:
And a few questions on PH:
As an aside- a channel member (Dr. Hesham) asked for this video. Join our channel membership here, if you too want that sort of power (ha!)
And the rest:
A recent analysis by the AAP emphasized the importance of encouraging safe sleep practices for neonates while they are still in the hospital.
As a reminder, the last recommendations put out by the AAP on safe sleep guidelines to prevent SIDS was published in 2016.
Of note: the term SUID or Sudden Unexpected Infant Death encompasses all unexpected infant deaths in infants < 1 year of age.
SUID includes SIDS (Sudden Infant Death Syndrome)- which is the designation given when no obvious cause can be found for the infant’s death. If an infant was found to have been accidentally strangulated (for example) this is considered a SUID but not SIDS.
This (free) Substack newsletter is fantastic: Your Local Epidemiologist (YLE). It sums up all the relevant national and international health news. I love that it keeps us up to date with which viruses we should be most worried about (e.g RSV is climbing in the community etc.).
I highly recommend you sign up!
Ali Abdaal is a British YouTuber (wait, hear me out!) who also graduated from Cambridge medical school. While working as a physician he pivoted into time management videos and eventually published this book on productivity. I read it last year- then grabbed it again for a recent trip- and promptly remembered how much I loved it. In a nutshell, we are productive if we enjoy what we do. He gives lots of tips on how to actually enjoy tasks, too.
And remember: any commissions from your purchases will go to a neonatal charity- so have at it! (The book is on sale too!)
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Tala and Arianna
Love the movie references!!
Wow, great stuff! Is erythropoietin given to neonates too for anemia? https://drdov.substack.com/p/companion-guide-opinion-uncovering