 Today, or tonight I should say, I'm gonna take you on a call shift which included a code STEMI, procedures that became way too dangerous to do, and more fun adventures as a cardiology fellow. Now as a first year fellow, I'm on call once a week. My calls are also in-house which means that I stay overnight in the hospital. During these call shifts my primary responsibility as on-call fellow is being the point of contact for any cardiology related questions for ICU patients and sick patients around the hospital. So let's go ahead and get started with our shift for today. Now every one of my call shifts starts around 4.30pm which means that I finish my day responsibilities today that meant a combination of reading stress tests in clinic and heading back to the hospital. And today I managed to get into the hospital right before 4pm. Now the first thing that I do in the evening is to review the list of patients in the ICU so I can be familiar with who the patients are, what they're there for, and who the sickest ones are out of the group. I then keep mental note of patients on the list who may have interesting findings on their echoes or imagings and then pull those up to read myself. This patient right here has really bad aortic stenosis aka a very tight valve. This patient on the other end here has a very weak heart which is barely squeezing when I look at their echo. After going through each patient's chart and images I then grab some quick caffeine and snack before the daytime fellow signs out the patients and any updates for the day. Once I have the sign out for all the patients I'll grab the list of my notes and walk the unit to make sure everyone is doing okay at the start of my shift. And just as luck would have it on my way walking over to the unit I hear the word Code Stemmy called overhead. Now Code Stemmy means somebody is suspected to have a heart attack based on both their symptoms and their EKG findings. Now obviously as the on-call cardiology fellow I'm responsible to go to all of these so as I'm walking over to the patients room I quickly pull up the EKG to know what I'm walking into. So I just got back from this Code Stemmy. They actually canceled it on my way up so a little bit of description. A Code Stemmy is basically where we're concerned somebody's having an active heart attack. My role overnight is usually laying eyes on them while all the interventionalists and their team is driving in to plan on taking a look and putting a stent in possibly. Since I'm on site it's to figure out are you having a heart attack or not. This patient however already had a catheterization somebody had already looked to see if their cornea arteries had some blockages and they actually do but they are being worked up for a possible bypass. And so the question was are they having something new and based off of the EKG that somebody called a possible heart attack on it didn't look much different than the last one and the patient's chest pain wasn't very different compared to what had been the past few days. So going back to do I need to have our interventionalist team come in and fix that and I think the discussion amongst everybody was that it wasn't. And so looking at the EKG we'll keep an eye on this patient overnight but not anything extra to do and then during the day team comes in or the day time we'll let them know and they can make any adjustments if they want to act quicker. Now after getting back to the office I spend whatever quiet time I get to finish some personal work. The first thing on my to-do list for the night is finishing some modules that I need to actually be able to do research as a fellow. Probably the most boring as modules I've ever done in my life but still gotta get done. Part of being a good fellow is always being on top of your learning and moving down the rabbit hole of learning new stuff in cardiology. There is so much in the field of cardiology that I didn't even know exist and so thus there is so much I need to learn. And when you have a decent evening like I've had so far it is a great time to learn. So here is what we're learning today. So I'm going to be starting ICU in just a few weeks which is going to be a little nerve wracking being a first year fellow and running the ICU. But one of the things that you have to really get comfortable with is what we call mechanical support. If somebody's heart is not pumping well then we can put devices into their hearts and essentially allow them to pump a little bit better or give the time for the heart to heal and allow these devices to kind of do the function of the heart for at least a short term. And so one thing that I feel or need to get more comfortable with is like knowing do I go up on the support? Do I go down? And what type of lab values, clinical signs do I use? Contextually, I think I know what to do but I want to make sure that I know all the nitty gritties in terms of what to look for on an echo or what to look for on their labs on a daily basis so I can better make decisions for these patients in just a few weeks. Because again it's going to be me especially if my tendings are making decisions on going down on things like an impella or a balloon pump or ECMO. I want to be able to know how fast do you do it or how often will you do it or what type of things are you looking at every time you're making some changes? So by no means does this have make sense to you guys but this is a great time so right now it is about 8.26 pm. I'm definitely getting tired and sleepy and I could be heading to bed right now but I think it's better use of my time to feel like my knowledge is getting a little bit better. And so what I'm going to do is I'm going to go ahead and actually pull this up and on the other monitor I will start to take some notes on RemNote so let me show you what that looks like. So this is RemNote, this is a tool that I am going to likely be making a video about in some point in the future but essentially what I have is an inbox for my cardiology learning all together. So whenever I have topics like I do today of things that I want to learn more about or make sure that I'm on top of I will add those in here and it's a growing pile so as you can see in cardiology we're really big on studies and so there is literally a collection of studies that I need to read and when I'm down on this list and I want to read a study I can just go there. In addition if I'm learning something and my attendings tell me something I'll just put it in this Pearl section and then every time I feel like I've mastered something so for example this right here this is a section that I actually learned about earlier today that may have already shown in the video but this is me learning about what to do with different types of blood thinners that we give for patients in the setting of heart attacks or ACS and I've already taken a lot of notes this probably took me 10-15 minutes but I want to make sure that I store this effectively so what I don't do is I then go ahead and just add some tags so let me do that so as you can see now I've added two tags to this and again I can make a video on Rome note if it's not already alive but these are two topics I'll pertain so if I ever want to learn anything about dual anti-platelet therapy or ACS I can just look up those tags and I will pull up all of these notes that I put into this section but now that this is done this is my system I just literally just throw it in the archive page and it is out of sight out of mind and there it is in addition to everything else that I've been doing with this although the lectures and studies will go in here so these are some of the studies that I've looked at with their notes but it's a quick easy way that I can search this if I wanted I could actually do flashcards from this entire page but this is my system and now I'm going to go ahead and do some notes on MCSD escalation using this this is how many pages is this okay it looks like a lot I don't know how many but we will get through this I will probably do a good amount of skimming and I usually always copy the link of the paper so that way I can refer to this in the future if I need to which I likely will have to do when I'm on my C rotation so with this free time I begin to spend the next 20 to 30 minutes of going through the article and taking down my notes so just managed to finish reading the article it is now 850 I think I've been reading for what 20ish minutes and this article is absolutely gold you guys can kind of see the quick notes I was able to write and not all of this is new to me but having it in one place kind of like a second brain so that way if I need to look up when to go down on somebody's support like their ECMO these are advanced things that you wouldn't be doing in residency typically but as a fellow I get to and so just making sure that I make the right moves by my patients have this article linked in case I ever want to refer to it and now if I just go back up to my home page this is the nice part of this entire system is I have all these notes I've already tagged it with what it needs to be so I can look it up later and I'm just put it in my archive and put it in my archive there you go so now it is in my archive and my inbox just looks like this in terms of what type of things I need to look up or are my lists next and that's pretty much how my studying goes now again it is 850 so I will look at the next thing on my to-do list and likely get ready for bed now before trying to get to bed I'll do a combination of things which includes having my dinner which today is chili that my wonderful wife prepared helping my clinic notes for the upcoming week and chart checking some of the sicker patients and ICU to just make sure that they're still stable while having my dinner I'll also catch up on some youtube currently I'm on a huge marathon video binge and once these last bits of tasks are done I'm going to go ahead and get ready to head to bed and I feel like as soon as the universe knows that I'm going to bed I usually get a text recall which right now is a call for a request to put an essential line on a patient now a central line is essentially an IV that we place commonly in someone's internal jugular vein in their neck it allows for quick medication administration blood draws and allows a nurse to have three ports versus the standard one that comes with a normal IV it's a procedure that any medicine doctor is trained to do during residency and stand out bedside using both ultrasound and sterile technique now this particular patient was having some issues with the nurses having reliable IVs and ultimately needed some critical IV medications so the request was made for me to put one in so around 9 p.m. I grab all of the supplies and the ultrasound machine that I need for the procedure hoping that it'll be a quick one and then we can head to bed soon but unfortunately it did not go that way so just got back from that line which did not go as planned patient continue to move for any procedure you want your patient to be as safe as possible while you're having a needle especially at their neck so this is one of the scenarios where you try everything to calm the patient control their pain and their anxiety and if you can't then you just kind of abort and you come up with a plan B because it's just too risky to have a sharp object while patients are just moving their neck which happens sometimes and so you just have to be aware of it and be able to audible we tried for an hour unsuccessful so came up with a plan B on how to help with that patient main is just pain and anxiety control overnight and if they really need another line hopefully we can put it in successfully or do it from a different place sometimes we can do it the groin it's usually not recommended it's not as clean as you can imagine something you have to do if it's needed so for this patient we'll see if we can get them by oral medications when they don't have an IV and yeah if they need me they'll call me if not I will try to head to bed it's 10 30 right now I feel like we've done enough this evening in terms of studying and keeping up with everybody so let's see how much sleep we can get if any see you guys later now while we wait to see how this patient will do with the oral medications that I prescribe for better pain control and ideally better urine output I'm headed to the call room to get some sleep and about three hours into my nap I get another call seems like our friend with the failed line attempt is not doing so hot nurse is concerned about his breathing and he needs an IV quick our friends um back in the room after being called for that one patient who ultimately needed that line so we went with plan B this time the patient was much more comfortable much more compliant with my instructions and able to get that line in smoothly just got back to the room and they're doing well so that's always a nice thing to hear and usually in these nights when you get called by one nurse or one doctor usually everyone else's messages somehow just happen to come together which is fine people need your help you help them and so after putting that line in I got messages of persons hemoglobin or their blood counts being low somebody's blood pressure was kind of low another doctor wanted me to lay eyes on somebody they're admitting from the emergency room because their blood pressure was low and so kind of saw all these patients or at least looked at their chart and now I'm just going to quickly write some notes in terms of just updating everything that done documenting that procedure documenting my decision making for that patient plus other patients that I saw overnight and it is 440 so hopefully hopefully I can get maybe an extra hour plus of sleep though usually the way these nights work for me is that if I can get five to six hours I can usually make the rest of the day because tomorrow I get to go home around seven or nine depending on certain scenarios and that means I'll have the rest of the day off until I come back to work the following day so this is Tuesday of Tuesday morning so I'll have the rest of Tuesday and I'll come back to work on a Wednesday so if you do it right and you get enough sleep during your night which we've got three four hours so far if I get an extra hour plus a nap this afternoon I can enjoy time with my wife and my daughter and actually have a full day off so I'm gonna write these notes I'll catch you guys soon so I quickly pull up his chart on the computer in the call room just to know what I'm walking into again and go ahead to see this patient now while typing up these quick notes for the night I'm starting to get messages from the nurse before their shifts in there's another description of what I'll get called overnight is about almost five o'clock and usually in the mornings there will be new x-rays on certain patients in the ICU and sometimes the nurses are not sure if something is normal or not depending on what they see so this is a patient this is yesterday this is today this is a patient that has a device that we call an LVAD basically is like a pump sitting in the muscle of the left side of their heart which is normally supposed to be able to squeeze blood out to everywhere else but for this patient that muscle is weak and so this pump essentially is bypassing part of that function of that heart or that side of the heart and so not only do they have this device if you can kind of see if something coming in here that like loops around in cardiology this is like a big thing that we use a lot this is called a swan gans catheter or a pa catheter it's basically a fancy IV that goes in the neck and has a catheter with a balloon at the very end that you can put into their right side of their heart and then essentially take it up in the initial part of their lungs and you use it to measure pressures and this is something that you get 24-7 monitoring of the patient in terms of how much pressure especially when you have a weak heart you want to make sure there's not a backup of fluid and so if all the numbers go up that means volume is going up and this catheter can pick it up but every day you want to make sure that that catheter is in the right place you can see this nurse is concerned because it looks different here it kind of looks like this catheter stops like here and then here it looks like it's going much much further the reason i'm not too concerned is she sent me the waveform of what it looks like on the monitor and it looks like a normal waveform there's no changes in numbers and then two you can see the orientation of this patient is different here at the pump is facing this way and here i'm kind of faced in more and so i think it's more or less going to be the same positioning but just returning the patient more and so the line is moving that way again not everyone will feel comfortable calling that so sometimes you have to look at x-rays but cool finding and uh just keep an eye on it and then you go from there on to the next one now once i've finished all my notes and messages i try to get another one hour of sleep before my shift ends and as soon as i lay down as we've seen multiple times tonight the universe will conspire against my sleep and suddenly i hear the words code blue called overhead now code blue means that somebody has lost their pulse and is a need for resuscitation now as the icu fellow i go to all of them in case the reason for their arrest is ultimately cardiac so it's about 5 20 a.m and i'm headed to the code while quickly looking up the patient on my phone now in this case this was ultimately a false code as the staff quickly realized that the patient was dnr or do not resuscitate so the hospital staff respected their wishes and allowed them to pass peacefully without pushing on their chest or giving them drastic medications which can be a lot for the body especially for our elderly all right good morning guys it is and now it's 6 32 i managed to sleep about an hour after that code that was supposed to be a code i have somebody that hasn't been training the right way overnight in the icu so what i'm about to do is just brush my teeth so it's about to be then my shift go see them i'm on the way out and then prepare to just let the fellow for the day kind of know about all of our fun adventures um and then that's pretty much the day i feel like i've got enough sleep so i'm gonna try to enjoy the rest of the day with my wife and my daughter so good call shift um felt like there's a lot learning in there for you guys for me um hopefully you guys enjoyed following me on today's um episode if you did hit that like subscribe whatever i'm putting down below hit your comments um with questions you guys have and then i'll catch you guys the next one take care peace