Code blue.
Hey guys. I'm Siobhan, a 3rd year medical resident. I'm heading to the hospital right now and I'm gonna be starting a night shift.
So we're gonna be down in the emergency department, seeing patients who need to get admitted to the hospital and
we're covering the code blue pager. So any emergencies in the hospital, we're gonna be managing them.
*Pager beeping*
So the general surgery team has asked us to go and see one of their patients.
They just came out of the operating room and now they've become quite short of breath.
So since I'm the senior resident,
I'm gonna go and see them first,
get a sense of the patient and then I'll get one of my junior residents to do the full consult.
We'll review it after and then make decisions together.
So this is what happens in teaching hospitals where we work in teams.
Walking into the room, my first priority is to make sure that the patient is stable and that it's not a medical emergency.
So I'm relieved that she's sitting comfortably in bed and only requiring 2 liters of oxygen through her nose.
And then otherwise her blood pressure and her heart rate are normal.
Listening to her lungs, she does sound crackly and her legs are quite swollen as well, but luckily she's not having any chest pain.
So what I'm gonna do is get an ECG,
some troponins, a chest x-ray,
get some more information so that by the time the junior resident is up there taking a look at the patient,
we'll have some more answers.
So I just heard from general surgery, they've got a patient who's really short of breath after the OR.
-Okay.
Yeah, so I'm hoping you can see what you think is going on.
-Yeah.
And you can let me know.
-Okay. How stable are they looking right now?
So, stable. Stable enough. They're on 2 liters of oxygen,
blood pressure is fine. -Yeah -But I'm still a little bit concerned so I've got a chest x-ray, ECG sort of brewing.
Um, they're probably getting done now. So if you take a look, let me know. I've got a couple consults to see down here.
-Yeah, yeah, sounds good.
So I'll go take a look and then come back and let you know.
Yeah and if you're worried like just call me and I'll come up and meet you. Okay?
-Okay. Sounds good.
Okay, so now I need to see 2 patients in the emergency department.
Both patients have been seen by the emergency doctors.
So now we, from Internal Medicine, have been asked to see them
to help with their diagnosis and to probably be admitting them to the hospital for further management.
So medical student Sally just called me and asked me to come upstairs.
There's a patient who has a very low blood pressure and she's really worried about her. So let's go meet her now.
Hey Sally.
-Hey, thanks for coming up.
So the patient has a fever. Her blood pressure is 64 over 42.
Her respirate is 30. She's been in the hospital for a really long time.
I'm worried that she might have like a hospital-acquired pneumonia or sepsis. -Mm-hmm
With such a low blood pressure, we immediately give a bolus of IV fluids and continue to monitor the blood pressure for improvements.
So I completely agree with you, I think pneumonia big concern. Probably a source for sepsis. And so I like your plan: fluids,
let's get a chest x-ray, we're getting blood cultures, we'll do some other blood work and then we're gonna be starting antibiotics.
-Okay. -Alright. So let's put that on the computer. -Okay.
Since this patient is so sick,
we're gonna stay upstairs until the stat x-ray is done and to be making sure the blood pressure is improving with fluids.
And the results are in: it is a pneumonia.
So the blood pressure is improving, but we're still gonna watch this patient closely tonight.
Hey Siobhan. Do you have a minute to go over that consult?
Oh, yeah yeah. You're done already?! Wow.
-Yeah. So, um, I took a look at the OR notes. Seems like they got a lot of fluid while they were in the OR and that's been
kind of building up in their lungs and causing difficulty with breathing.
-Yeah. -So, we could try getting rid of that to see if that helps. The other thing to consider would be a PE.
-Yes. -And so if it doesn't improve with
reducing the volume, we could see if we should get a scan to look for a possible PE.
Okay. I'm so glad you thought about that, because we just don't want to miss the things that are gonna kill the patient.
-Yeah -But I totally agree with you, the chest x-ray looks like that. So yeah, okay, give some Lasix and then follow up in a couple hours.
-Yeah, that sounds good. -Okay. Good job. -Thanks. -Awesome.
I'm so lucky to have such a hard-working team on with me tonight, because the consults just keep on coming.
It's 3:00 in the morning.
I'm starting to get really tired and then I went into my bag, because I've brought a big mug of tea
and I forgot it in the kitchen at home! I'm so disappointed and we have no caffeine available at this time.
So I'm probably gonna find some sugar and eat that instead. It's not what I advise, but it's gonna get me through the night.
*Pager beeping*
*Automated voice* Code blue.
Alright, so the patient's now been transferred to the ICU, so now the ICU team takes over.
And now I have to get back to the emergency department and see where we're at in terms of consults and
see how the junior residents are doing.
Hey, this is Siobhan the SMR returning a page.
Oh.
Okay, so I just got a consult from the emergency department.
It's a man in his 50s who just recently came back from Africa and
he's been getting these fevers almost every single day.
And apparently he thought he just had a cold, but it's been going on for so long that he finally came into the emergency department,
because he was starting to feel so weak.
Blood work done in the emergency department shows an elevated white blood cell count and some elevated liver enzymes.
So doing my physical exam,
I paid special attention to the liver and I could actually feel it below the level of his ribs.
And by tapping on his belly and listening for these dull or
resonant sounds, I was able to estimate that his liver seems enlarged,
but the rest of his physical exam was pretty normal.
Okay, so at this point I'm most concerned about an infection,
especially with the recent travel history and now seeing this enlarged liver.
It still could be something like cancer, but I really want to do some blood cultures,
we'll do a swab like a smear for malaria
and an abdominal imaging as well and do some more blood work and then we'll get some more answers, hopefully.
So update, guys.
The blood work for that patient came back positive for malaria.
So he actually has malaria and I know some of you guys probably live in countries where people get malaria a lot:
that is not the case in Canada. So it's very rare for us to see this.
So it's a little bit exciting and now we actually know how to treat him.
So we'll give some medications and probably get infectious diseases involved tomorrow morning as well.
Oh no. 7:30. So close to the end of the shift!
And I'm getting a page!
False alarm. Not actually a consult.
Alright guys, so it's now 8:00 in the morning.
We've had a total of 15 consults tonight
and now it's time to go upstairs to go and meet the morning team and tell them about the patients that we admitted overnight
and the things that happened on the ward.
Finally done.
Um, I had the opportunity to go and chat with the different staff in the morning and you know they agreed with what I did medically,
but there's also the art to medicine and getting to chat with them means I get to learn their style, how they approach things
with their experience, which is so useful.
And now I'm done. I'm heading home and honestly, I'm so tired and I'm sooo hungry.
So I'm gonna go get some breakfast and then I'll be chatting with you guys next week.
So let me know if you've any questions,
if you have any comments, let me know in the comments cause I always love to hear from you guys.
Okay. Bye for now!