So this patient is having a heart attack right now as we speak.
The ambulance is just pulling up and we're gonna rush into the cath lab to try to open up one of his blood vessels.
Morning guys. I'm Siobhan, a 3rd-year medical resident.
I'm on my cardiology rotation and I'm just starting a 26-hour call shift in the middle of the COVID pandemic.
So, let's see how today goes.
Ok, so it's 6 p.m. now, like the day has flown by.
I planned to vlog and show you guys the day, but it's been so busy. So many things going on, it was impossible.
I'm really hoping I'll be able to film for the rest of the night.
Okay, back in the call room. I can actually take off my mask for a bit. Oh my goodness.
Haha okay.
So tonight I am
carrying the cardiology pager.
That means that I'm covering the
inpatient cardiology unit, the cardiac critical care unit. These are really sick patients who are often on life-support,
intubated.
Seeing any cardiac patient in the emergency department going to code blues, medical emergencies and of course managing heart attacks.
Hi, this is Siobhan from cardiology returning a page. Do you know how far away from the hospital they are right now?
Sounds good. Okay, I will meet you there. Thanks. Okay, bye.
Okay, so that was a call about a patient who is having a STEMI, one of the most serious types of heart attacks.
They're currently in an ambulance being shipped to the hospital.
They should be here in about 20 minutes,
which means we have a few minutes to talk about what a STEMI is before they get here.
So a STEMI is an ST elevation
Myocardial Infarction.
And if we break that down,
Myocardial Infarction is just the medical term for heart attack.
That basically just means that the heart is not getting enough blood and oxygen, so heart cells start to die and
the death of cells is what causes pain in a heart attack.
There are actually different types of heart attacks, so it's critical to be able to identify
the most serious ones, the ones that need immediate treatment.
So the best first test to do is an ECG,
which is a tracing of the heart that shows us the electrical conduction of the heart.
So part of the ECG tracing is called the ST segment.
Now if that ST segment is elevated, it's a sign that one of the major arteries in the heart is blocked.
So that's how we get ST Elevation
Myocardial Infarction (STEMI), this is a medical emergency. If a blood vessel is blocked,
it means that every minute that it's blocked more heart cells are dying.
And that's why we rush patients to the hospital and try to open up that blockage as fast as possible.
So there is so much to learn in medicine, in cardiology, internal medicine in general.
So if you're looking for a good resource, you might want to check out the McMaster textbook of Internal Medicine.
They've got a free website, app,
an actual book and it's concise information, to the point. Stuff that you actually need to know,
so I find it super helpful.
It's not a sponsored video or anything. I just think that it's good to have more reliable resources out there.
Anyway, let's get going because our patient is probably gonna get here soon.
So I've just texted Zeeshan, he's one of the interventional cardiology fellows.
So we're gonna meet him now and look at the patient's ECG, his heart tracing. This gentleman
looks like he's having a heart attack when you look at the ECG here.
It looks like he's got big ST elevations in the inferior leads, so leads 2, 3 and aVF.
And there's kind of corresponding ST depressions in the lateral leads, like 1 and aVL.
So all of those things point towards someone having an acute heart attack.
And we're gonna be taking the settlement to the lab right now to see if there's anything we can fix.
All right, they have started.
So the patient is lying on the table and they're inserting a wire into the radial artery of the wrist.
The wire gets pushed all the way up to the heart and into the coronary arteries.
These are the arteries that run along the outside of the heart and supply blood to the heart muscle.
Then they shoot dye into the artery to see where the blockage is.
On this image you can see the patient's spine on the right and if you look carefully you can see some movement and that's the heart
beating and right there... There it is! Can you see how the artery just stops there?!
It should be a lot longer.
So there's a total occlusion of the artery.
After the wires advance through the blockage, a balloon is inflated, which pushes open a metal stent and opens up the blockage.
So now you can see a lot more blood flow down the artery, but it's still not completely open.
There's actually a large blood clot further down the artery.
So as you can see after we did the ballooning the stent, there's a fair amount of clot here.
And so we took a catheter that you can see here with that radial pig tip and sucked out lots of
clot and after we did that this is the final vessel and you can see
that we restored flow, the stent is widely open.
And effectively the issue that was causing the heart attack has now been treated.
That's it. A blockage like this forms over years and it's made of fat, cholesterol and calcium.
Some risk factors are smoking and unhealthy diet, lack of exercise, high blood pressure and diabetes.
So keeping up with an active healthy lifestyle is extremely
important in preventing heart disease.
Although even if we do our best to control everything,
unfortunately there are still genetic factors that are beyond our control.
Okay, so the procedure went well. The patient is being transferred back to the cardiac care unit. And the funny thing is,
because we try to get patients in and treat them so quickly,
I actually haven't had a chance to speak to the patient yet.
So I'm gonna go meet him now, learn about his past and what happened to him.
When I walk into the room, the patient is lying in bed. He's awake,
he's alert
and when I ask him what happened,
he tells me that he was sitting and watching TV and then all of a sudden
he developed chest pain. It felt like someone was sitting on his chest,
he started sweating profusely and it became hard to breathe. So his wife immediately called 911.
He's never had a heart attack before,
but his main risk factor is that he's been smoking for the last 35 years.
So we talked about the importance of quitting and he's extremely motivated now that he's had this heart attack. Oh, hey Emily.
I heard there's a patient that's being transferred into the unit for cardioversion. Yeah, that's right. They're actually on their way.
What kind of meds did you want me to get for them? Oh, that'd be great.
Let's do propofol, fentanyl and some phenylephrine. Perfect. I'll get them ready, we'll see you in 5. Awesome. Great, thank you.
So the patient who's being transferred here to the CCU is a healthy fit man who never had any past medical history.
Yesterday he felt like his heart was racing and he started to get a bit short of breath and a little bit dizzy,
so he came to the hospital. In the emergency department they found that he had an abnormal heart rhythm called atrial fibrillation.
Basically the heart sort of twitches and you get this irregular heartbeat that's not really squeezing properly.
They tried some medications down the emergency department, but it didn't break that abnormal rhythm.
So today we're bringing him to the CCU where we're gonna sedate him and give him a shock to the heart and that should bring
him back to a normal rhythm.
So we're giving propofol and fentanyl as sedation and then we actually place pads on his chest and that's how we deliver the shock.
So as soon as he's fallen asleep, we charge the defibrillator and after making sure no one else is touching the bed, we shock him.
And then everyone's all clear from the bed. Okay, so I'll be hitting shock.
Here you can see his abnormal rhythm before the shock and then after the shock you can see he's back in a normal rhythm.
Oh and update on Coronavirus in the hospital.
Our numbers have actually tripled.
Recently there was an outbreak in a long-term care facility and
so many patients have come to the hospital now.
So it still feels very real in the hospitals, even though it feels like when I walk around outside,
there's so many people out and about now. I guess because of the nice weather, but
it's still happening guys.
All right,
things have finally slowed down a little bit, so we can start evening rounds where we go around and
see all the patients here on the CCU.
Patience in the cardiac care unit are critically ill and that's why we systematically review patients at the bedside at least twice a day.
Evening rounds are a time when we can check on bloodwork, review heart rhythm strips
and then address any issues that have come up from the nursing perspective.
So that's really important for patient care and
plus it also helps to reduce the number of pages that I'm going to get later on tonight. So it's a win-win for everyone.
Rushing into the room I immediately see a dangerous rhythm on the monitor.
The patient is in a ventricular tachycardia and he's not responsive. The treatment is shocking the heart.
Wow! Okay, I've got to say this process of going and shocking the patient was so efficient.
It was fantastic! The patient already had pads on their chest.
So I literally walked in, was able to see the rhythm, charge it up and just shock the patient.
And he just woke up immediately and just looked at me and was talking right away. Like it's amazing.
Effectively his heart was not pumping. If we left him like that, he would have died. So anyway, cardiac care unit: very cool place.
Saving lives. After all that excitement, I think I want to try to actually get some sleep now. I'm starting to fade.
Hi, it's Siobhan from cardiology returning the page.
Okay, ehm... What's the patient's heart rate right now? Yeah, no problem. I'll be down soon.
Okay, thanks.
Bye.
Okay...
So the emergency physician is calling. There is a patient down the emergency department who
has a really low, like a...
Slow heart rate. Sorry to say low heart rate, a slow heart rate. So bradycardia and
they're wondering if we can see the patient.
So, okay... Gonna wake myself up for a second. Let's go!
Walking into the room, I meet a small elderly woman with a big bruise on her head.
She tells me that she fainted suddenly and without warning and she just remembers waking up on the ground.
Her daughter called 911 and when EMS arrived, they did an ECG and found that she was bradycardic.
It's very helpful that we have that rhythm strip now and can see that she went into a 3rd degree heartblock.
This means that something was blocking the electrical signal in the heart, leading to a slow heart rate and that's what caused her to faint.
Now in the emergency department her heart rhythm has gone back to normal,
but it could flip back into that dangerous heartblock at any time.
We're gonna have to admit the patient and they're probably gonna need to get a pacemaker when they're in the hospital.
So just in case their heart stops firing
on its own,
then the pacemaker will fire for it
and they won't faint like they did today.
Freedom! Haha. All right. Well, you know what?! That was... It was a good night.
Really busy day, lots of learning and I hope that you guys learned something new about STEMIs. So if you have any questions,
things you're curious about, just let me know in the comments below!
And otherwise, I'll be seeing you next video. So bye for now!