 Hey friends, I'm officially one month into my three year cardiology fellowship. Let me take you on a call day where I'll be in the hospital for 28 hours and share exactly what I do all day, the cold procedures, and cases that I get to do. Let's get started. Now as a cardiology fellow, I'm on call once a week. This means I cover the ICU at night time in the hospital, in house, even case that I'm needed. During these days, I tend to wake up around 4.30 to 5am to have a little time to myself plus take care of my one month old daughter. Once I've finally managed to put her up for another nap, I'll enjoy my morning coffee, do a little workout, and stretching routine, and then try to get into studying a little bit of cardiology. Today I'm taking some time of adding some of those pearls that I wrote down in my notebook that I learned the day before from my attending and my patients into a digital database. I always try my best to make sure the things that I've learned actually stick and have a place that I can refer back to them easily. Then I use that remaining time to do some quick flashcards of what I've learned over the past month and review some new cardiac studies that I've come out. By this time, it's about 7am and my daughter's up and ready for another meal. And once I get her fed and back to bed, it's time to get ready for work. Now let's talk about how the call day is going to work out. Now although I'm on the ICU at night time during my call days as a cardiology fellow, I will rotate across various areas of cardiology during the daytime. This month I'm on the heart failure rotation. And usually I get in around 8am, but since today's a call day, I push it back just a bit to 8.30. My commute is right around 30 minutes, which is when I usually have my second cup of coffee as well as try to listen to podcasts related to cardiology or anything just to get my head straight. And once I'm ready for the day, I also need to make sure that I pack enough snacks, drinks, and my toiletries to keep me through and clean for the overnight shift. And out the door we go. Now my commute currently from our new house is about 30 minutes, time that I usually use listening to podcasts about cardiology or something else just to get my head straight before I go into the shift. Now that I've made it to the hospital as a fellow, my job is to see the new consults for the heart failure service, plus see any primary patients we may have on the cardiology main floor. Most of these patients are here for volume overload, plant procedures, or arrhythmias. But sometimes we will also have patients we see in clinic who are here for non-cardiac reasons, but for these patients we usually just follow along to make sure they continue to do well from a cardiac perspective. Once I get to my office and my computer, I begin reviewing the charts of all of our patients, writing down their labs, EKG findings, et cetera, and begin to do my rounds. Now my attending for today likes to round in the afternoon, so this gives me ample time to see everyone. And by around 8.50 I'm already out and about seeing our patients. Now since I was a full-time internal medicine hospitals for a year, I'm used to seeing a lot more patients that I'm currently doing, and thus I know how to be efficient, thankfully, as a fellow. So not only am I able to see all of our patients quickly, thankfully most of our patients are doing well, so I go ahead and get back to the office to begin drafting my notes, updating orders and medications, as well as getting ready for rounds. Now comparatively to most rotations that I'll do as a fellow, being on the CHF or heart failure rotation is pretty light. And since I'm early in my fellowship, I want to make sure that I'm learning as much as possible. So whenever I have some free time like I am right now, between the hours of 10 to 12, I try to hang out in ICU learning more cardiology and helping with procedures. Sure enough, as soon as I get to the ICU, the attending asks me if I can help take a balloon pump out. Now let's pause there, a balloon pump. What in the world is that? Let's break that down. And when someone's heart isn't doing well, for example the setting of cardiogenic shock, which can happen due to a heart attack or a variety of reasons, their heart, aka their pump, needs help. A balloon pump is a device that's put through the groin via the femoral artery and sits in that patient's descending a order. One of the major blood vessels. And it essentially works by helping offload some of the workload of the weak heart by participating as a mini vacuum, pulling blood away from the left ventricle of the heart when the muscle itself can't do it all by itself. It also helps increase blood flow to the coronary vessels of the heart to make sure that our weak heart is still getting profusion. Pretty cool stuff. And thankfully for this patient, they're doing much better and they likely can have this pump taken out. So my job as a fellow is to remove it, turn off the machine, and hold pressure to avoid bleeding or a hematoma in their groin. In 30 minutes of pressure later, we're all done and no signs of bleeding. And as soon as I leave this patient's room, we're already ready for our next procedure. This time a pa catheter or a swan. Now in cardiology, we're obsessed with volume status. The heart is basically a pump and we want to know how your pump is working and how much fluid you're working with and against. And we can obtain this information through something called a swan gans catheter or swan for short. Now the patient who needs this swan is one who's recently admitted to the ICU here for cardiogenic shock. We know he has a lot of fluid on him and we know he has a weak heart or a weak pump. We're just not sure how bad they are. Thus the swan will help us monitor these factors 24 seven. Now this is a bedside procedure which you can do with just a little bit of local lidocaine and ultrasound and the kit to actually do the procedure. The first part of the procedure is simply to get central access. Now whenever you're doing a central line just to get medications to somebody's heart in the setting of any kind of shock, you'll go ahead and usually use their large internal jugular vein in their neck. Just think about it as an IV that you normally have in your hand being able to deliver more medications quickly to the heart and all of this is done under ultrasound. Now once I have central access through a catheter I can then begin to feed my swan through it. Now once the initial needle and catheter are in you can then feed the swan line which has multiple ports. Some for meds, fluids, and some to detect both pressure and temperature. Now as I'm putting in the swan I'm looking at the monitor to see the pressure and waveforms it creates. Cool thing about the heart is that different parts of the heart are known to have characteristics in the waveforms plus the pressures that they normally would have. Thus I can tell exactly where my catheter is without even needing an x-ray. Ultimately I want the catheter to go inside the pulmonary artery so I can get all the information I need for this patient. For this procedure using just the waveforms alone I'm confident of where my catheter is but I order an x-ray just to confirm the position just to be safe. And when you get it right it'll look something like this. By the time I'm done with this procedure it's already noon it's time for me to step away to go to our daily noon conferences where we learn as fellows about a new topic in cardiology taught by our faculty and our colleagues. Once conference is over then it's time to round up my attending. Thankfully since everyone is stable rounds are more about learning today and don't take too long. Just like the day before I make sure to jot down any pearls in my attending teaches me about cardiology or our patients which I plan on transferring to my digital database tomorrow. By the time that I'm done rounding with my attending updating my notes with our updated plans and discussing them with our primary team I'm already beginning to prepare for my overnight shift. And tonight is unique because I already know of two new patients coming to our service at some point during the night. The first is a middle-aged male who's visiting the state and is found to have worsening shortness of breath. He's in the emergency room right now so I go to see him. Sure enough this poor guy looks miserable. Turns out he was recently diagnosed with heart failure and hasn't felt the same in quite some time. But over the past week his shortness of breath has worsened and he has some swelling in his legs and likely fluid in his lungs. This is pretty classic heart failure. What wasn't classic however were some of the meds that he was put on for his supposed heart failure. It was clear that this guy needed a cardiologist when he returned home. In the meantime our job was to admit him, make him pee out that excess fluid, and optimize his medications so his heart could remodel and get stronger. Easy enough admit and super nice guy. And by the time that I leave the emergency room the daytime ICU fellow is ready to sign out their patients to me. During this process they will usually tell me about the patients and discuss any overnight activities or things that they would like me to do or watch out for. Thankfully everyone seems stable. Let's hope that that's the case the entire night. And by the time that we finish our sign out usually around 5-6pm the second patient I knew was coming has already arrived via ambulance. Time to go see them. I quickly pull up their chart to just understand their basic history and what they're here for and this patient seems sick on paper so I know I needed to lay eyes on them pretty quickly. Here we have a middle-aged female with a history of cancer who comes in with acute chest pain. She's coming from another hospital so they've already done most of her work up. Turns out she has a large pulmonary embolism, a saddle PE, in other words a nasty blood clot in her lungs that can quickly cause someone to compensate. I pull up her CT images and her cardiac ultrasound and it's clear that her clot burden is large and her heart is already showing signs of being stressed out. When this happens we're concerned that somebody could easily develop low blood pressure and decompensate quickly. So I rush over to see this lady and thankfully when I saw her aside from fatigue she and her blood pressure were just fine. I discussed a plan for her pulmonary embolism with the interventional cardiologist who's on call overnight. The plan is for her to go to the cath lab first thing in the morning to aspirate some of those clots out. Now that I've seen these two new patients for the evening I go ahead and make sure I knock out both the orders and notes and time to lay eyes on everyone else in the ICU. Now for most of these patients I can tell by just looking at their chart that they'll be fine overnight. Their blood pressure looks great, they have a plan and nothing dramatically has changed or any big events during the daytime. But some based on just their history require a little bit of checking in even if they look okay on paper. For instance tonight we have a patient who's on ECMO waiting a heart transplant. So let's pause again. ECMO, what is that? Let's break it down once more. Think of it as a bypass machine that can be in the room with the patient. This patient in particular has a bad heart and they need a transplant but in the meantime they need the big guns. The ECMO machine to deliver oxygenated blood to their body. How does it work? This patient has one catheter in one of their major veins pulling out deoxygenated blood outside their body that's going to go through their ECMO circuit. It's going to oxygenate it and then it's going to go back into the patient's artery through another catheter to feed the body with oxygen that it needs. Now normally this is the job of the heart and the lungs but because this patient doesn't have a great heart we can't count on it to go ahead and actually function the way it needs to. My job tonight as a fellow is to make sure that his heart looks good under ultrasound. So I go ahead and grab the ultrasound machine from the ICU and put the probe on him quickly. I can tell he looks a little bit dehydrated so I decided to give him some fluids to make sure that he, his heart, and the ECMO machine are as optimized as possible. Now so far today has been an eventful and fun call day but now I'm going to go ahead and transition in grabbing some food and snacks and heading to my call room. Now since I'm in the hospital or in a house overnight get my own call room with a bed, computer, bathroom, and a shower. I'm also close enough to the ICU in case I need to rush over but the plan today is to get some sleep and as soon as I try to lay down I get a text from one of the cardiothoracic surgeons. Apparently at some point in the night we're expecting to have a transfer come in for an aortic dissection and aortic regurgitation. Now for many reasons and rare instances patients can have a tear in one of the layers of their major artery of the body, theorta. This can cause compression of flow of blood through their troop pipe or lumen which can be catastrophic. Think of it like gradually pushing down on a garden hose restricting the blood flow that goes to all of your major organs of your body. And if that wasn't bad enough this patient not only had a huge dissection but also had an aortic valve which was wide open. Now normally your aortic valve is the gateway between the left ventricle of your heart and the rest of your body. And if this valve is wide open you have a lot of back flow of blood which is normally meant to go forward to supply oxygen to the body. Now combine a bad aortic valve and a severe dissection equals bad news. This patient needed a surgery to fix both his valve and his dissection and my job was to go ahead and optimize him until they can get him into the OR. Now because he was a transfer he could arrive at any point of the night so I make sure I look over his chart understand what medications he's already going to be on and go ahead and try to grab some sleep until I get that text message that he's arrived. And around three to four a.m. I'm told that the patient has arrived into his room so I go ahead and rush down there to make sure that he's stable. Now thankfully just like our last patient this patient looks much better than their chart would indicate and so I make sure that I get onto that optimization as quickly as possible. For this patient in particular I go ahead and quickly place an arterial line at bedside think of it like an IV but instead of your vein it's in your artery. The arterial line is an easy way for me to track his blood pressure 24-7 and I can use this to titrate IV meds to bring down his blood pressure and optimize that stress on his heart from both the valve and the dissection. Thankfully he tolerates the procedure well and I finished the arterial line within minutes and it's now time to get an evening snack. Usually this involves going to the doctor lounge to grab some ice cream. And with the use of the sugar crash from the ice cream I managed to get a few hours of sleep before the daytime fellow and team come. When they do I make sure I sign out any overnight events, talk about the new patients I admitted, and do a quick round with attending on the old patients. And by the time that we're done it's around 9 30 to 10 and I'm officially relieved from call and began to go home for the day. And even though I had a busy and eventful call day I thankfully got enough sleep so now it's time to go hang out with my wife and my daughter. But friends thanks for following me in the day of life as a fellow if you want more videos like this make sure you hit that like and subscribe to get more content like this in the future. Let me know in the comments what questions you have or if you want more episodes like this and I'll be inclined to make them more frequently for you guys. And if you enjoyed this video make sure you watch these two videos right here on why I chose the field of cardiology in the first place and how I'm studying for my cardiology fellowship on a day-to-day basis. As always my friends thank you so much for joining me on my journey hopefully I was a little help to you guys on yours and we'll catch you guys in the next one. Peace.