Morning guys. I'm Siobhan, a 3rd year medical resident. I'm just going to the hospital and today I'm bringing you into the cardiac care unit.
All right.
So each morning we start out by meeting as a team and making a plan for the day,
find out what happened overnight. As you can see we have a big team today.
Moe, Wasim and Mike are 2nd year internal medicine residents.
Justin is our cardiology fellow, he's a 5th year resident.
And then dr. Ainsworth is our attending physician. And what seems to be the last patient on our list. Yeah, sure.
So we'll probably meet back here in about an hour.
we have
grand rounds virtually, I'll send you guys a link. Okay? Okay.
Okay, so we've got 2 patients in the Covid ICU that we're following.
So I'm just gonna head there now to see them before we start rounds.
Okay, so this is the patient that I actually admitted overnight when I was on call. And at that time
we really weren't sure, the x-ray looked terrible. We weren't sure if it was a heart problem or if it was a lung problem.
So that's why she was admitted to the Covid ICU, because we thought maybe it was coronavirus.
Walking into the room, I'm amazed at how well she's doing. This morning
she was extubated and she's only requiring a small amount of supplemental oxygen now.
Her chest x-ray looks a lot better than when she first arrived at the hospital,
but there is still extra fluid on her lungs and her blood work shows there was significant damage to her heart.
Now that I finished my assessment, let's head back up to the CCU and discuss our plan with Justin the cardiology fellow.
Hey Justin, can I chat with you about one of the ICU patients? Yeah, of course what's up?! Okay, more and more I'm thinking this is cardiac.
So just to update you her troponin level was really high, she has like some
ECG changes now and her pulmonary edema is on both sides of the chest x-ray, so I'm sort of leaning towards cardiac.
Okay. Yeah, I mean...
It sounds like it's more cardiac from what you're saying for sure. Yeah. Ehm...
Maybe I was thinking maybe an echo.
Yeah, let's go ask. What do you think Dr. Ainsworth?
Let's head down to the ICU and we'll do a point-of-care ultrasound while we're waiting for the formal echo
and then we can review all of that together. Is the ultrasound downstairs? Yeah, it's downstairs. We'll do right at the bedside.
Okay, perfect!
So the echocardiogram shows how the heart is moving and
her echocardiogram at the bedside
doesn't look very good. So it doesn't look like her heart is pumping very well,
which again makes us think: Did she have a heart attack?
And actually we should go in with an angiogram and look at her coronary arteries to see if there are any blockages that we can fix.
Hey guys, are you ready to start rounds? Yeah, sounds good. What bay do you want to start at? We're gonna start at bed 1. Sounds good. Awesome, let's go.
After seeing our patients individually,
we meet for team rounds with the medical team, pharmacist, bedside nurse and charge nurse.
For each patient one of us will summarize the patient's course in hospital so that we're all on the same page.
Then the bedside nurse provides a head-to-toe assessment and brings up any issue they're concerned about.
My other issues for you guys would be to restart the metformin, the senokot like I mentioned and then
heparin has been off since she went to the cath, so whatever we want to do with the anticoagulation. Then we go through
everything thoroughly: lab work, imaging,
medications before making a final plan for the day. Rounds are also a time when we get a lot of teaching and
we often find ourselves having long discussions about the most recent literature and medical trials.
So has anyone heard of MINOCA?
Yeah. Yeah.What is that? So it's kind of
the various causes of
like a troponin rise and fall over the 99th percentile that aren't due to necessarily acute plaque rupture. Yeah, exactly.
Do you know what the
potential causes, some potential causes are? Yeah, so we can go through like there's in-stent thrombosis,
there's vasospasm as well.
So in medical culture a lot of teaching is by asking questions and sometimes people get pretty nervous.
So we actually call that getting pimped: Put In My Place.
Usually more for... It's meant to be for learning, but it can be nerve wracking. Justin doesn't make it nerve wracking.
It's actually, it's a great environment here.
So this patient had an out-of-hospital cardiac arrest, secondary to a myocardial infarction.
3 Stents were placed and this morning the patient was extubated.
All right. Luckily a family member was present when he had the heart attack and his heart stopped and CPR was started
right away.
So after the blocked artery was opened at the hospital,
he was transferred to the CCU and we cooled his body temperature to reduce the chance of brain injury and
now he's awake.
So we're focused on optimizing his medications to improve his heart function and to prevent a future heart attack.
Time for lunch now and then we'll get back to work. There might be some new patients coming.
So last night a patient was admitted with
retrosternal chest pain. He said it felt like someone was sitting on his chest and that got worst when he went upstairs.
Now that gives us a clue that it's probably a
cardiac issue and then on blood work we can see that his troponin level was up.
Now that's an enzyme that we can measure in the blood and when the heart is under strain and stress, it goes up.
So we see those 2 things, plus on physical exam
he has a murmur and so we've done a bunch of imaging and now we've got all the results back.
So I'm just heading to dr. Ainsworths office, he's the attending physician.
We're gonna look at all the imaging and actually make a diagnosis and figure out what to do next.
So the first thing we're gonna look at is an angiogram and this looks at the coronary arteries to see if there's any
blockages that are leading to lack of blood supply to areas of the heart.
During an angiogram procedure a catheter is inserted into the heart and dye is injected so you can see the blood vessels of the heart
called coronary arteries. The main artery that goes to the left side of the heart has a
significant narrowing at the first part of the artery and this is likely compromising blood flow to that part of the heart.
So next we're going to look at his
echocardiogram or ultrasound of his heart, which tells us if there's any valve problems or any other structural problems related to the heart.
The aortic valve is the valve between the heart and the aorta and on this echocardiogram
it looks very tight and narrowed down, probably compromising blood flow out of the heart to the rest of the body.
I know it can be really difficult to tell what you're looking at on an echocardiogram,
so let's compare it to a normal heart. This is actually the heart of one of our 2nd year residents.
Look at the normal valve on the left.
You can easily see the three leaflets of the valve and you can see that it's opening fully.
In comparison, the patient's valve is so thick and calcified that you can't see the different leaflets and it's barely opening.
Now with this view, the green jet shows you the turbulent blood flow through the aortic valve and
it's turbulent because the valve is so narrow.
The next thing we wanted to look at was to see if there's any other structural abnormalities of the heart, specifically if that
narrowing in the coronary artery that we showed before was leading to pumping abnormalities of the heart.
And here we can see that there's an area of the heart muscle that's not pumping well at all,
suggesting lack of blood supply to that area.
And again, it's a lot easier to see how poorly the heart is pumping when you compare it to a normal heart.
So given all of those problems, the valve problem and the narrowings in the coronary arteries,
the best solution is likely heart surgery and form of a bypass surgery and a valve replacement.
So I will give our cardiac surgeons a call to see what their thoughts are. All right, so we've got our answer:
Cardiac surgery.
Okay, let's head back to the CCU and see what else is going on.
Hey Siobhan, do you have a second?
Oh yeah, for sure. Yeah, so the guy in 4 keeps having runs of VT. What do you want to check his mag or something?
Uh, so how long are the runs of VT? So they've been about 10 to 15 seconds here or there.
Okay, so why don't we draw some extended electrolytes. We'll see what the magnesium is
and if it's low we'll top it up and then if it's happening more often, just let me know. It sounds good.
Okay, so this center is the regional center for PCI. So basically when a patient has a heart attack,
they will actually be sent here so that we can do a procedure called an angiogram to go up and look inside the heart and
if there's a blockage to actually open it up and put a stent in there.
And so you can imagine there's a lot of patients from the area that come to this hospital.
So as soon as the procedure is done,
within you know 24 hours, they get transferred back to their hospital that's closest to where they live. And so the patient
that I saw in rounds, the one that had the out of hospital cardiac arrest,
that patient is actually stable and ready to go back to the other hospital.
So we need to go do the paperwork and get things all set up.
This is a discharge summary from the Cardiac Care Unit.
So that's a typical day in cardiology.
I really want to thank the team and all of their work and help on this video.
So the nurses, the doctors, the pharmacist, I want you guys to see how we work as a team together.
So if you guys have any questions or comments, leave them in the comments below. I'd love to hear from you guys,
even if it's just to say hi. So anyway, I'll be seeing you in the next video. Bye for now!