Join internal medicine and rheumatology specialist Siobhan Deshauer, MD, as she spends a week working at a hospital with her husband, Mark, an emergency medicine physician and hospitalist.
Following is a transcript (note that errors are possible):
Deshauer: Hey, guys. I’m Siobhan, an internal medicine and rheumatology specialist.
Mark: I’m Mark, an emergency physician and hospitalist.
Deshauer: This is the very first time that we’re working in the same hospital since residency. We’re here in Sault Ste. Marie, also known as “The Soo,” a city in northern Ontario, Canada, about an hour flight from Toronto. There is a lack of permanent doctors living here, so we’ve come for a week to help provide coverage at the hospital. It’s our first time in the city, so we arrived a day early to bike around and check out the area.
In Canada, we have to share the road with our feathery friends, Canadian geese.
What are you doing, Mark?
Mark: Just getting some good vibes. I think it’s going to be a good day.
Deshauer: Now, it’s time to get down to work and start morning rounds. Most of our patients are on the same floor, so we are usually able to meet up throughout the day. I always like to start the day by seeing the sickest patients first. In this case, it’s an elderly man with a COVID-19 infection and he is on 6 L of oxygen right now.
Walking into the room, I see a man sitting up in a chair, breathing faster than normal, but still smiling as I introduce myself. He is currently treated with oxygen, dexamethasone, and remdesivir for his COVID-19 infection. I’m relieved that he is feeling better than yesterday, but I’ll be more reassured when his heart rate comes down and he is requiring less oxygen. If that doesn’t happen soon, I’m going to get a CT scan of his chest to look for a blood clot. But I don’t think we are quite there yet.
Here, I actually get called. I don’t have a pager. Hello, and how are his vitals? All right. You know what, I’ll just come and meet you now. Perfect. Thanks.
One of the patients is having a new headache that’s very severe and the nurse is really worried about it, so I’m going to go meet her now. This patient was admitted to hospital after falling off a ladder and hitting his head. The CT in the emergency department showed a small brain bleed called a subdural hematoma and he was admitted for monitoring. What makes things more complicated is that his platelet counts are low and we’re currently running tests to figure out why.
Platelets are blood cells that help form clots and stop bleeding, so you can imagine he is at higher risk of that brain bleed getting bigger.
I’m getting a stat CT head now to see if the bleed has gotten any bigger. This feels just like a call shift ahead about a month ago. I can’t believe this is happening again.
Mark: So how is your day going?
Deshauer: Well, right now I’m waiting for a patient to come back from an urgent CT head because I’m worried they might be bleeding, so I feel a little bit on edge to get the results back. What about you? How is it going?
Mark: Well, I just actually have a lumbar puncture I’m planning to do this afternoon.
Deshauer: Oh, that’s awesome.
Mark: A suspected meningitis.
Deshauer: Wow. We’ve got like the neuro day happening.
Mark: It’s true. It’s true. There is always a theme, it feels like.
Deshauer: I totally agree, yeah.
Mark: When I saw the patient this morning, he was complaining of a new headache, fever, and neck stiffness. I am concerned this could be meningitis, inflammation in the membrane surrounding the brain. I have already started the antibiotics, got a CT scan of his head, and now it’s time to collect a sample of his spinal fluid.
I’m taking a sample of the fluids surrounding the spinal cord to confirm the diagnosis of meningitis. I insert a long needle between the bones of the spine, pushing until I feel a pop when I pass through the last layer of tissue. Then I remove the stylet and the spinal fluid comes dripping out. Quickly I attach the pressure sensor before collecting samples for the lab.
When I first insert the spinal needle, the first thing I do once I’m getting spinal fluid coming out is I check the opening pressure. To do that, I attach this manometer. The spinal fluid comes into this tube and rises all the way up. For our patient, it actually went all the way up to 34, which is really high and definitely suggest meningitis.
Oh, great. We finally got the results back for the lumbar puncture that we did earlier. More evidence of meningitis here. We have elevated protein, elevated lactate, and an elevated white count. Now we’re just waiting on the cultures and PCR.
Deshauer: I just got a call back from the radiologist. The CT scan shows the bleed is much bigger and there is actually something called midline shift, meaning the blood is actually compressing the brain. This is a really bad sign. He needs to be seen by neurosurgery, but we don’t have neurosurgery in this hospital.
Subdural hematomas are treated by removing the blood that’s compressing the brain. Neurosurgeons can either do a craniotomy, which is where they remove part of the skull temporarily, or they can drill a small hole in the skull called a burr hole and insert a tube to drain the blood.
Hi, can you please connect me to CritiCall, please? Yes, I’m calling from Sault Ste. Marie. I’m looking to speak with a neurosurgeon.
Now the tough part, just waiting until they call me back. It’s usually pretty quick when it’s life or limb, but in this moment every minute feels like a really long time. We’ll see.
I wish there was more I could do right now. But while we’re waiting, all I can do is control his blood pressure — because high blood pressure will make him bleed faster — and give him multiple platelet transfusions to help slow down and stop the bleeding.
It’s CritiCall. Hello. Okay. I have got good and bad news. The good news is that there is a flight ambulance that can land and pick up our patient in the next hour. The bad news is that there is no nurse available to actually go in the ambulance and transport the patient to the airport — seriously. So I have just decided I’m going to take the patient. I’ll go with him because otherwise he is going to have to wait for another 3 to 4 hours and we do not have that kind of time.
Okay. Here we go. This is definitely not something I do often. It’s actually only the second time I have ever had to accompany a patient by ambulance. My job here is primarily monitoring to see if the patient decompensates and loses consciousness, in which case we probably have to intubate him.
But the 20-minute ride to the airport goes really smoothly. Then I give handover to the flight paramedics, the patient gets loaded into the plane and my job here is done. Luckily, the ambulance didn’t get another call, so they were able to drop me back at the hospital.
Mark: Ah, time to put my feet up. Aw. Oh, no. It’s not plugged in. Oh, well. I guess I can just lay on the couch this way.
Deshauer: All right, guys. Thanks for joining us. Well, hopefully we can bring you guys along soon. Otherwise, we’ll see you in the next video. So…
Mark: Bye for now.
Deshauer: Bye for now!
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.