Join internal medicine and rheumatology specialist Siobhan Deshauer, MD, and her husband, as they spend the day in a hospital covering for a physician shortage.
Following is a partial transcript (note that errors are possible):
Deshauer: Hey, guys. I'm Siobhan, an internal medicine and rheumatology specialist. Today I'm working in the hospital with my husband, Mark.
Mark: Hey, guys. I'm Mark and I'm going to be covering hospitalists this week in Sault Ste. Marie.
Deshauer: We fly up here to help out with a doctor shortage, so let's grab some breakfast and head to the hospital.
Mark: Sounds good. On the menu this morning is my personal specialty, proats. Okay. I realize this might not look like the most appetizing breakfast, but trust me, it's delicious.
Deshauer: Think fast.
Mark: ... Your workout in the morning. All right, time to go. You ready?
Deshauer: Yeah. Just about.
Oh, it's the hospital. Hi, this is Dr. Deshauer. Oh, 60 over 43? Did you repeat that like on the other arm? Okay, and he is still conscious? Okay. I'm not in the hospital right now. Can you start by giving him 1 L of IV fluid bolus? I'm going to call the ICU so they can be there right now and as soon as I get to the hospital I will come right to the bedside. Okay? Yep. Give me a call back if you need. Thank you so much.
All right. I'm just being put through to ICU. Hi! Yes, this is Siobhan. I'm currently covering Jim Yu. I'm hoping you can see a patient for me. I was just called about a patient who is hypotensive with a blood pressure of 60 over 43. I'm not currently in the hospital right now. I'm driving right now, but I'm wondering if you could see him. Thank you. Okay. I'll meet you at the bedside.
Oh my gosh. Okay. This feels so weird. I think this is the first time I have ever had like an acutely unwell patient when I'm called about them when I'm not in the hospital. It's just such an unsettling feeling not to be in the hospital right now and I'm really glad you're driving.
Mark: Yeah. It'll be just a few minutes.
Deshauer: Okay. I'm going to head right upstairs.
Mark: All right.
Deshauer: I'll meet you after.
Mark: Sounds good. Let me know if you need any help.
Deshauer: Okay. Thanks.
Rushing into the room, I find the ICU doctor and two ICU nurses at the bedside. They gave me an update. After 1 L of fluids, his systolic blood pressure was still very low, in the 70s. They gave him Tazocin, a broad-spectrum antibiotic, and sent off stat blood work.
Minutes after I arrived we get the results: high lactate, high white blood cell count, and a high creatinine. He is in septic shock, likely a complication from the procedure he had yesterday, a nephrostomy tube placement.
This is where a thin tube is inserted through the back and into the kidney. In this case, it was done because there was a blockage in the ureter causing a buildup of pressure in the kidney. Now we're giving norepinephrine to raise the patient's blood pressure and transfer him to the ICU for close monitoring.
Hooray. The patient is in the ICU and at least a little bit more stable. How has your morning been?
Mark: Oh, it's been actually quite interesting. I wanted to show you a chest x-ray. Let's go take a look.
Deshauer: Okay.
Mark: Yeah.
Deshauer: I'm so intrigued.
Mark: Yeah.
Deshauer: No way!
Mark: Yep. Yep. Out in the wild.
Deshauer: Okay, guys. This is something you read about and people quiz you out of medical school, but you never think you're ever going to see in real life, at least not me. This ... wait. Let's see if you guys can guess.
Look at this image. What is abnormal? This is something called dextrocardia. Dextrocardia with situs inversus is when the heart is on the right side of the chest rather than on the left where it usually is. It's like a mirror image and for some people even their internal organs like their stomach and liver are also on the opposite side. It's usually discovered when someone gets a chest x-ray like Mark's patient or when they get an ECG, which also looks slightly backwards.
Hali: Hi, Siobhan. I just had a concern about a patient. It looks like he keeps going into a rapid, irregular heart rhythm on the telemetry and converts back to a normal rhythm. It's very strange. I was wondering if you'd have a look at it with me.
Deshauer: Is he stable?
Hali: He is stable. He's asymptomatic. He said he feels great. Other vitals are good.
Deshauer: Okay. Yeah, yeah. Let's take a look. Which room is it?
Hali: This is 308.
Deshauer: Okay. That is such a strange rhythm. It doesn't look compatible with life. I need to go actually see this patient. This is the heart rhythm we see on the monitor. You can see a normal heart rhythm tracing followed by a shockingly fast electrical impulse and this keeps alternating back and forth.
Oh my gosh. You will not believe this. The patient was using one of those Dr. Ho's machine on his feet that's marketed to help with circulation and the heart monitor was actually picking up the electrical signal. I can't believe it. I have never even heard of that happening. I've got to find Mark and see what he thinks. I want to quiz him. Okay. Here it is. What do you think?
Mark: What?! That can't be real. It must be some sort of artifact.
Deshauer: Yeah. Okay.
Mark: What is it?
Deshauer: You will never guess what type of artifact. It's one of those Dr. Ho's devices. You know when you put your feet on it and?
Mark: Oh, the foot zapper. Yeah.
Deshauer: Yeah. Exactly. New thing on the differential diagnosis.
Mark: Hi, Dr. Weatherall speaking. I'll put in the orders for the potassium chips and I'll be right over.
This is a patient who came in and he was extremely dehydrated. He has what we call an acute kidney injury. Now when the kidneys aren't working as well, then potassium can build up in the blood and that causes a fatal arrhythmia. That's really what we're trying to prevent here.
The first and most important step is giving IV calcium to stabilize the heart muscle. This doesn't actually lower the potassium, but does prevent fatal arrhythmias like this one. Then Sydney is going to give some medications to lower the potassium.
Sydney: Yeah. We're using 50 mL of dextrose first over 5 minutes and then 10 units of insulin right after. Then we're going to do a Ventolin nebulizer and then she's going to drink this Kayexalate to now shift her potassium back down.
Mark: I'm really hopeful that his kidneys will perk up with the fluids that I'm giving him. But if not, we're going to have to consider dialysis.
Siobhan Deshauer, MD, is an internal medicine resident in Toronto. Before medicine, she was a violinist, which is why her YouTube channel is called Violin MD.