Transcription
They say "The Pitt" on HBO is the most accurate medical drama of all time. Let's see if that's true. Bee whoop.
Oh, and you got the med students and new interns starting today. So good luck with that.
Like you're legging me. Must be July. That's the season when new residents and interns start.
Come back here! No more needles! Oh, oh! Sir! No more needles!
It's the ER. So stuff like that does happen.
Dr. Robinavitch? Melissa King. I will be joining you today. I just came from two months in the VA.
Hey, welcome to The Pitt. This is Dr. Jack Abbot.
Nice to meet you. I can't tell you how excited I am to be here today, so.
I wonder if this is a resident or a med student because these types of introductions happen exactly like this. Sometimes it's even during a stressful moment where you're trying to not get in the way, but you wanna announce who you are, and you have to be there, so it can get pretty awkward pretty quickly.
As you can see, we have some new faces with us this morning. Good morning, good morning. Come on over. Starting with second-year resident Dr. Melissa King, fresh from the VA.
Everyone calls me Mel. I'm so happy to be here.
Trinity Santos, intern.
Victoria Javadi, MS3.
MS3 means med student year three. Means one more year to go.
Dennis Whitaker, MS4.
Usually when you're a fourth year and you're rotating in a hospital, you're choosing hospitals where you'd like to get a residency, and that's called a sub internship because ideally you'd get your internship there as a first-year resident, and it's a time where you show off your skills, your ability to learn, your curiosity. You create connections to people in the field, so whether it's other residents, other attendings, or even some of the staff.
Actually, this is the most important person that you're gonna meet today. This is Dana. She's our charge nurse. She is the ring leader of our circus. Do what she says when she says it, okay? Great. Senior residents, you got your sign-outs?
Yep. Sign-outs are basically when you're leaving your shift, you have to hand over to another teammate, the patients that you were taking care of. Basically, the patients that are waiting for rooms, patients that are in the middle of their evaluation, and what's interesting, and this comes up frequently when we talk about hours worked for residents during a hospital shift, the less hours a resident works, so, for example, if you're moving from a 24-hour shift to a 12-hour shift, you're gonna have more handoffs. And statistically speaking, with each handoff, there are more likely to be errors because when there's a handoff, mistakes happen. We've seen that actually working perhaps longer hours can decrease chance of medical error in some instances, simply because there's one less handoff.
Okay, let's do this.
Patients, they check in for registration here. A nurse eyeballs them, make sure they're not dying. If not, they're moved to one of two triage rooms for vitals and a quick chair exam where you can run your labs and your x-rays.
And then they come back to-
Waiting room till the bed opens up.
For how long?
Eight hours if they're lucky, a lot of times, 12.
Is it always this busy?
No. It gets a lot busier.
ERs and hospitals are absolutely, understaffed. These days, the smaller hospitals especially are facing situations where bigger hospitals eat them up, or they just close entirely, and the people in that area are left hanging.
This is Sherry.
Hi. Sherry, I'm Dr. McKay. I have some student doctors with me today. Do you mind if they observe?
Sure.
That's a good question to ask, and that's the exact way you're supposed to ask it. I just would rather the med students not hear that conversation 'cause then as a patient, you might feel some type of way of saying no when the pressure of the med students is already there.
What's going on, Sherry?
I, ah.
Ooh, that's a heavy burn. The hand is a really bad place to get burns because contractures form, and contractures essentially squeeze the skin together, close the skin together, and, as a result, you can lose functional mobility of the fingers, and obviously, fine motor movement is very important with the hands. A hand surgeon should ideally be involved as well as an occupational therapist who work really closely with patients in improving and fine tuning fine motor movement. Fine tuning fine motor movement.
Do you know how much longer this'll take?
Yeah, let's see. You taking anything for the pain?
Not yet.
1,000 of Tylenol, 400 ibuprofen, and saline dressing?
Yes.
That's pretty good. Pretty good dosing. I would just ask if the patient has any allergies maybe before doing that, but maybe it's already in the chart, so I'll give 'em benefit of the doubt. And you might be wondering why are they combining a non-steroidal anti-inflammatory with acetaminophen, which is Tylenol? You could do that in areas where you have very severe pain and there's nothing systemic going on and there's no reasons why they can't take those meds. That's because acetaminophen is processed by the liver while the non-steroidal anti-inflammatory is processed by the kidney. So they don't necessarily impact the same organs.
Hey, doc.
And we all know Louie Cloverfield. Blood alcohol of 420 at 11:00 PM.
I've been cutting back.
How is he still breathing?
That's a lethal dose for you and me. That's happy hour for Louis.
Sobered up, had two rounds of lorazepam.
Lorazepam is a benzodiazepine. It's similar type of medication to what most people know is Xanax, and the reason we give it is actually to prevent symptoms of delirium tremens, which is known as DTs, more commonly. It calms someone down. It prevents tremors. It prevents even seizures that are associated with DTs. Usually the medication we used during someone's alcohol withdrawal is called Librium.
Hold out your hands for me, Louie. Another two of lorazepam.
On it.
And a scrip for Librium.
42-year-old male, Sam Wallace, blunt head with agonal respirations. Dropped down on the T tracks. Couldn't tube him. LMA him, please.
He's a good Samaritan. Took a spill helping a woman who fell the track. She's right behind us.
Trauma 1. Go ahead. Come on.
Woman fell from T Platform. Good vitals and no head injuries. Degloving injury.
Oh, degloving injury's one of the worst injuries to visualize! I hope they don't show it. Basically, imagine just full skin removal. That's the only way I can put it.
With open fracture, dislocation.
Oh, they showed it.
How we doing? Ready? Okay, here we go, ready? One, two, three.
Good breath sounds bilaterally.
Good breath sounds bilaterally signal that there's good air entry, which means that there's lower likelihood for pneumothorax, which can happen after an injury or trauma like that where the lung essentially collapses internally, and when that happens, the person's not able to oxygenate.
Pupils four millimeters and reacting.
Okay, that's encouraging.
They're gonna be looking for bleeding internally.
That's a lot more London than expected.
The scalp does bleed a lot. There's a lot of very small capillaries there, so even a small gash inside the scalp can be bleeding a lot, but in a situation like this, you really wanna get a stat CT scan of the head and make sure that the bleeding is only external, not internal.
And he's probably anticoagulating for A-fib.
They suspect he's bleeding a lot more because he's taking a medication that will decrease his ability to form a clot because someone who has atrial fibrillation in their heart, the heart beats abnormally, meaning that it fibrillate. It almost like shakes like this. You'll see that on an EKG very clearly. You can in fact feel an irregular rhythm oftentimes when you check someone's pulse who has atrial fibrillation. When the heart beats irregularly like that, it can form a clot in one of the chambers of the heart and then shoot it up to the brain, leading to a stroke. Obviously a dangerous and deadly situation. So many of these patients are on anticoagulation, meaning they're getting medications to decrease the risk of forming a clot, but there's trade-offs to that, which means that you have an increased chance of bleeding and not just bleeding everyday life like GI bleeding losses or a minor cut, but during a major trauma, very, very dangerous.
50 of fen didn't touch it!
Did she faint or did she trip off the platform?
Nobody knows! The other guy jumped down, pulled her off the tracks just as the train was rolling in. Isolated injury to the foot. The train ran over her foot, got caught between the platform and the incoming train.
Ma'am? Ma'am, what's your name?
All right, can't see open fracture! Two grams cefazolin!
Do you speak any English?
I hear that they're screaming about antibiotics. Absolutely you need that when you have such an open wound on the leg.
Students,
Drop 20 ccs.
what might have made her faint on the platform?
It could be an arrhythmia,
TIA.
cardiac.
CVA.
TIA is like a mini stroke that lasts for certain seconds. A CVA is a full-on stroke. The list is so long in a situation like this with no information. It could be something as simple as a vasovagal where temperature, pressure, body didn't react as fast. It clamped down the arteries in the legs in order to return blood flow to the brain upon standing. Could be orthostatic hypotension. You could have more serious things like she just noted a stroke or a mini stroke, heart attack. I mean, the list really goes on and on. You need to first stabilize the patient and then start working your way forwards into diagnosing what could've led to the initial insult, which was her falling.
So she needs?
EKG.
EKG and a troponin.
Okay, good.
EKG and troponin is how you rule out the heart attack that we just talked about. EKG tells us the rhythm of the heart right now, which would signal to us that there's a heart attack right now or perhaps one recently if you had an EKG to compare to in the past. The troponin is an enzyme that's released by cardiac muscle tissue that essentially shows damage to the cardiac muscle. All these things, clinical picture, the labs of the troponins, the EKG all tell us a more complete picture as to whether or not someone is having a heart attack.
Subway train degloved her foot with an open fracture dislocation.
Ooh, and I thought my heels were painful.
Hemodynamically stable.
Hemodynamically stable is a good sign. That means blood pressure isn't falling. That means we're not having a significant amount of blood loss to lose blood pressure, and the fact that she's crying is actually a valuable sign. That means that she has enough awareness to protect her airway.
The cords are very anterior.
Yeah, that's 'cause we can't flex the neck. Keep the hockey stick straight up.
This is a very high level. When we had intubations back in my residency training, you didn't have a fancy video monitor to assist you, and you had to do it just manually.
Intubated for agonal respirations. GCS 5.
GCs 5 means you intubate 'cause below eight, you intubate.
We need to talk about your numbers.
People we've saved?
Our door to balloon time has beat federal standards.
Door to balloon time is like the PCI when someone has a heart attack, how quickly you get them into the door. It is important to be able to be quick in a few situations. So when a heart attack patient comes in, how quickly you get them in as well as someone who is a stroke patient, how quickly you get them through the whole system. And there are national standards for this, and if you don't comply with them, that means you need to improve your protocols.
Patient satisfaction.
If you're still alive, you should be satisfied.
Our goal is 36% very satisfied with their care. Your department is at eight. Do you know how likely patients are to recommend this hospital?
This is an emergency department, not a Taco Bell.
11%.
Well, if you want people to be happier, don't make 'em wait for 12 hours.
I never know when they have these conversations with doctors, and I've been in rooms where these unfortunate conversations have happened, what do they want the doctor to do? Put on a smiley face sticker? Like what can you do outside of be good at practicing medicine and be kind to patients?
Nice job.
Do you think he'll wake up?
Maybe. Maybe not.
With neurologic damage, it's really a touch and go process where you have to monitor clinical improvement. There's really nothing that you could look on lab tests to know if a patient will have neurologic deficits after an injury to the brain, and I'm talking about injury like a stroke or a trauma like this.
No good deed goes unpunished.
Oh, has anyone notified the family?
As a resident, that's usually your role.
I could try.
Calling family members, calling pharmacies to find out patients' medications, calling other hospitals to get prior medical records, that's what you do as a resident.
Pan-scan is negative. That means you can admit to orthopedics.
But there may have been a medical etiology if she fainted.
That's not surgical. Get an internal medicine consult or admit to medicine with ortho consulting.
I agree. That's completely right. So which service is the main service matters a lot in the hospital. For example, if you have a patient with a medical problem like diabetes, a heart issue, a stroke, and you admit them to ortho, that's a problem 'cause ortho's fixing and monitoring the surgical issue, but no one's monitoring the internal medicine side of things. So you either need to admit to ortho with an internal medicine consult or the other way around. Usually with ortho, at least in my experience, it's been they're on the ortho ward, and then the internal medicine team comes in and monitors the medications, does the diagnosing in addition to everything that the ortho team has done.
I was fine until about two weeks ago after the Rochester marathon.
Okay. Any falls or injuries?
Just tired, sore muscles.
Yeah, I'd be in bed for a month. Was this your first triathlon?
God no. No, I do one every few months.
He's gonna have rhabdomyolysis and kidney failure.
This goes under your tongue.
They're gonna say his temperature's 104.
Temp, 98.2.
Oh. Dammit.
Take a deep breath from me, Otis.
Little pin prick now, okay?
That was a quick IV. He didn't even palpate there. He just went bam, threw it right in there.
Otis?
See, that happens very frequently when someone gets blood drawn. So could be that, but you gotta be careful. Check for a pulse. Still take all the precautionary measures.
No pulse. Crash cart. Lay flat!
Let's check a rhythm.
Saline pads.
Okay, very good. Call for help right away. Code blue first, code blue first!
V-tach.
Oh my God. Why aren't they doing chest compressions? Oh no. They didn't even do chest compressions!
It's back to normal sinus.
Yeah, see like this is wonderful, but the crash cart isn't always available. Turning it on takes some time. All that time you could be on the chest perfusing.
Healthy 31 year old, V-tach arrest two weeks after triathlon, NSR with one shock. He's a little young for an MI, huh?
Exactly right. What's the differential, Dr. Collins?
Drug overdose, electrolytes, long QT?
Electrolytes is probably the leading one, especially post triathlon.
Ooh, Brugada syndrome, WPW.
Brugada syndrome, Wolff-Parkinson-White, what she's talking about, these are all abnormal rhythms of the heart that can predispose someone's heart to very quickly stopping, and very frequently, it happens in young people 'cause they weren't aware that they had this, and their heart is otherwise healthy, but the electrical rhythm is abnormal, so much so that it could trigger them to go into this V-tach situation.
Otis?
Oh, groaning's good. Five of nasal O2 CBC, CMP, troponin, and.
Is he pushing epinephrine or bicarb?
One gram calcium gluconate, IV push.
Oh, he's trying to stabilize the heart.
The monitor. Wider QRS and peaked T waves. Hyperkalemia.
How'd he get that?
Intense exercise, cause muscle breakdown, rhabdomyolysis.
Come on, props!
Not bad.
QRS is narrowed. Much better.
Potassium is 7.7, creatinine 5.6.
High potassium and renal failure. Just what you thought.
Must be my lucky day.
Ordering 10 units of regular insulin and 25 grams of glucose.
Insulin drives potassium into cells from the blood so we can help lower blood potassium levels.
Why insulin glucose?
Shift the potassium intercellularly.
Exactly.
And the reason why they give, by the way, insulin and glucose is because you're giving the insulin not to lower the person's glucose. Their glucose is normal. You're giving insulin to drive the potassium into the cells away from the blood, but that in turn also lowers the glucose. So you can make someone hypoglycemic or very low glucose, and that's dangerous, can lead to death. So you want to give them glucose at the same time.
Am I gonna be okay?
Yeah. You just need to take it easy on yourself. Muscle breakdown and myoglobin damaged your kidneys.
We knew that already from the very first second he came on screen, baby.
And you'll need dialysis to clear it all out.
And I'll be okay?
Yeah.
I'm surprised it's that intense that he needs dialysis. I wonder what the recommendation for rhabdo when you actually need dialysis.
89-year-old woman from a SNF, history of emphysema, CHF, MS, V-fib, unresponsive to three shocks.
For those who don't know, SNF is a senior nursing facility.
What is that?
LUCAS chest compression system.
Robotic CPR.
Whoa! I've only seen this on Instagram memes.
Was there an advanced directive?
No. Full code from the nursing home.
Seriously? So this is the qualm and situation we get into often where we know providing cardiopulmonary resuscitation is futile and actually harmful to the patient, but in many instances, we continue doing it because we don't have an advanced directive or we don't have a family member present to make decisions as a power of attorney. It's very unfortunate, and that's why actually, in a lot of my visits, especially what we call Medicare annual visits, we talk about what the patient would like to have happen if their heart were to stop. It's a conversation worth having in a non-emergent setting to make sure situations like this don't go and happen by the dozens.
Still V-fib.
LUCAS on. One round of epi, one more shock, and then we call it?
I wonder if that LUCAS is as good or perhaps even better than manual chest compressions. Remember, when someone has a non-shockable rhythm, there's very little you can do outside of continuing to give medications and performing chest compressions.
Stop. Call it. Nursing home just faxed us a DNR.
Are you kidding?
Power off the defibrillator and the LUCAS.
Complete waste of time and money.
It's not just time and money. It's just terrible for the patient that they had to go through that, and again, A DNR is a do not resuscitate form that the patient or the patient's family member sign off on, and there's multiple types of DNR. There's DNR A or B. Sometimes DNR A means like you get comfort care treatment. For a DNR B, it means you get full treatment, but you don't get resuscitation if your heart were to stop.
Who the hell works at that place?
A nurse taking care of 60 patients who couldn't find the form.
She called 911 so she could take care of the others.
That's how you approach charitable thinking.
Otis's BP is crashing, 70 over 50. Still waiting for dialysis.
So he's becoming hypertensive for some reason. I wonder what the rhythm is.
They're doing an ultrasound to monitor wall movement of the heart.
Diastolic collapse at the right atrium and right ventricle.
Tamponade from uremic effusion.
That's why his BP is low?
Yep.
He has too much fluid and pressure around the heart.
So basically, the heart sit in the sac, and sometimes there is a buildup of fluid surrounding that sac, and it exerts a pressure onto the heart, causing a tamponade effect where the heart is not able to relax. When a heart is not able to relax, it's not able to fill, so that when it does contract, it doesn't actually shoot any blood out.
Otis, you've got some fluid around your heart. We need to get it out.
So in a situation like this, you have to do a pericardiocentesis where you actually drain the fluid from around the heart. You do that generally under ultrasound guidance. If it's significant enough, you leave a chest tube in there to allow it to continue to drain.
Pressure down, 60 over 40.
So in a situation like that, the blood pressure is so low that it's not able to perfuse the vital organs, vital organs being the brain, the kidney, the heart.
You're going in right over the center of my probe, advancing very slowly, looking for the tip. Very, very slowly. Do not hit that heart. Dr. Santos, you see that sea of black? That's the effusion we're looking for, a little white dot.
And the white is the needle.
There it is.
Got it.
Drain.
Aspirating.
Three ccs should be enough.
Pulse ox is 99.
Pressure's up 124 over 78.
Looks like things are back to normal.
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