Join Siobhan Deshauer, MD, for a night shift in the intensive care unit (ICU). In this video, she discusses a man in his 40s who had a cardiac arrest at home. What caused this cardiac arrest? And why do we cool patients' body temperature after they arrive in the ICU?
Watch the video above to find out.
Following is a rough transcript (note errors are possible):
Siobhan Deshauer, MD: Hey, guys! I'm Siobhan, a fourth-year medical resident. Tonight I'm starting an ICU shift here in the hospital and will be looking after patients with COVID and who are in the ICU for other reasons. It's never predictable, so let's head downstairs. We'll see what's going on in the ICU, get some handover from the doctors who've been here during the day, and then go from there.
"Oh, hi. This is Siobhan from ICU returning a page. How do you spell that? And currently he is intubated, but he is hemodynamically stable. Great. Yeah, I'll come right down and see him."
There is a man in his early 40s who had a cardiac arrest at home. Apparently, his wife started CPR quickly and they got ROSC in the emergency department, so return of spontaneous circulation. Basically they got his heart beating again. They got him back.
Now, we have to try to figure out what made him have the cardiac arrest to begin with, and then continue to support his care and monitor him closely in the ICU. Let's go down and see him.
I walk into the room and see a man in his early 40s who is intubated and connected to life support. I examined him looking for any clues to explain what caused his heart to stop, but his physical exam is actually quite normal aside from the fact that he is unconscious and in a coma.
Looking at the blood work, I'm trying to see if there are any clues to really explain why this otherwise healthy guy had a cardiac arrest. Everything on the blood work just shows that for a period of time he wasn't getting enough blood and oxygen circulating to his organs, which happens to everybody whose heart stops beating. It doesn't give us a clue for what's causing it.
I can see that his liver didn't get enough oxygen for a while and so the enzymes are elevated. His kidney markers are up. His heart, he has got troponin level that's elevated, but that's because he had CPR for about 15 minutes. None of it is really giving us a clear idea for what caused the arrest. We need to keep searching for the cause.
"I have to say I think you did a fantastic job thinking quickly, starting CPR right away, and getting him to the hospital, really. I'm looking to get a bit more information about your husband and to know exactly what happened tonight. Can you tell me? Can you tell me a bit about his past medical history? Has he ever spent time in the hospital or been diagnosed with anything? Well, thank you so much for the information. I'm so sorry that you're going through this. I can't even imagine how stressful it must be."
I can't even imagine what she's going through right now.
What I learned is that he is a completely healthy guy until now -- works as an accountant, works out three to four times a week, and they have a home gym because of COVID. He was working out this afternoon and his wife heard a thud. When he didn't answer, she rushed into the room and found that he wasn't breathing. She couldn't feel a pulse, and so she started CPR right away, and I'm so impressed. That is absolutely the best and most important thing to do, CPR, CPR, CPR. That's the first and most important thing.
I also asked her if there are any unexplained or strange accidents or deaths in the family. Interestingly, she tells me that the patient's uncle drowned in his 30s and apparently he was actually a strong swimmer. The whole family was devastated and really confused about this. Now seeing him coming in with a cardiac arrest, you wonder if the same thing has happened. Could there be a genetic heart problem or an arrhythmia that's running in the family? That's kind of the most likely thing that comes to mind right now.
Let's take a closer look at his ECG and see if we can see any abnormalities. We may not be able to figure it out tonight, but I think it's at least a lead.
Now, this is interesting. His ECG shows a long QT interval, which means his heart takes longer to depolarize or recharge before it can beat. This can be caused by genetic conditions, certain medications, or even electrolyte imbalances like low potassium or low magnesium. In this case, he isn't taking any medications and his electrolytes are normal, so I'm even more suspicious of a genetic cause now.
OK. We're transferring him to the ICU now. We are going to keep him on telemetry so we'll be monitoring his heart rate continuously and we'll do some more investigations. We'll also start cooling his body temperature, and that's actually to prevent brain damage after cardiac arrest, but I'll tell you more about that later. For now, we should get going to do our evening rounds in the ICU and see how the rest of the patients are doing.
During evening rounds, we walk from patient room to patient room, checking on blood work, discussing any active issues with the bedside nurse, and trying to anticipate problems that might come up overnight.
The ICU was still very full, with two patients in rooms that used to be private rooms, but the good news is that the number of new COVID patients has dropped dramatically, and we're starting to see other issues again, like surgical complications or aggressive cancers.
Our new patient is now here in the ICU as well and the team started cooling his body temperature. We'll check back in on him a little bit later.
Deshauer: That's a weird thing to get used to.
Male Doctor: Yeah. Yeah.
Deshauer: You know what? I think all of it, for being natural, is just fine.
I am so ready to have some food. OK. Check this out. It may not look delicious, but it is. Beans and rice with curry, oh my gosh. This is a really weird angle. But, yeah, Mark and I have become obsessed with the instant pot and this is our most, sort of, favorite go-to at this point. It just is warm and delicious and so nutritious. You can make huge batches at once, so this is like my go-to food right now.
Let's go check in on that cardiac arrest patient and see how he is doing. He should be cooling down now. When a patient has a cardiac arrest, blood is no longer circulating and their organs are starved of oxygen. The brain is highly sensitive to this change, and even if we get the heart pumping again, the brain can be irreversibly damaged. Research shows that if we cool a person's body temperature after restarting their heart, we can reduce or even prevent brain damage and improve a person's overall chance of survival.
Deshauer: Hello!
Lauren (ICU Nurse): Oh, hey.
Deshauer: How is our guy doing?
Lauren: Well, when he came down post-arrest, we had determined that we weren't getting any neurological response -- so anything to pain, not opening his eyes, or moving his limbs, or anything like that, to touch, voice, painful stimuli. We made the decision with the ICU team that we needed to do a therapeutic hypothermia, so a cooling protocol.
Deshauer: What are we at now?
Lauren: We're at around 35°C, which is pretty decent...
Deshauer: Not bad.
Lauren: ... after about an hour of starting it where our target temperature is 34°C to 36°C for the next 24 hours or so. We're well on our way to maintaining.
Deshauer: For everyone here, tell us a little bit about, how do you actually cool a patient off?
Lauren: Sure. We have our Gaymar machines, so essentially our cooling machine, and we put sterile water in the machine and it comes through these hoses, two blankets underneath and on top of them. It creates sort of like that icy temperature we need.
Deshauer: I have just heard about a patient on the COVID ward who is requiring more and more oxygen. It sounds like up to about 70% oxygen, so I'm going to go take a look. I wonder if this patient needs to come downstairs just to be monitored a bit more closely. It doesn't sound like they need to get rushed to intubation, so we'll see.
Walking into the room, I still find myself surprised to see such young patients. This is a woman in her 20s who swabbed positive for COVID about 1 week ago and has been in the hospital for 2 days. She is self-proning, so she is lying on her stomach to breathe better.
Actually, in my last video, I talk about why COVID patients often breathe better lying on their stomach. .
While assessing the patient, I can see how anxious she is, and I do my best to reassure her that we're going to take good care of her downstairs in the ICU. She nods, but I can see how scared she is still.
OK. I am definitely convinced this patient needs to come to the ICU, but I'm hoping we won't have to actually intubate this patient. I'm hoping we can use something called BiPAP [bilevel positive airway pressure], where we force more air to open up the lungs and try to avoid intubation because we know that patients are staying on ventilators so much longer than a regular pneumonia when they have the COVID pneumonia. Sometimes we have patients on the ventilator for 4 to 6 weeks, which is a shockingly long time. I'm hoping this doesn't happen to that patient.
Also, did you notice this might be the first time that I'm talking about COVID patients tonight? It's really dark in this hallway, but anyway that's got to be a first. It is so dark here. What is happening? Anyway, it's nice not to be talking about COVID patients the whole time and actually remember there is more to medicine than just COVID.
We just got another consult from the emergency department. It sounds like a patient in septic shock, and I have been told that he has diabetes for many years. It looks like the infections probably stemming from a diabetic foot infection. We'll go take a look and see what we can do to help. I have a feeling that he's going to need to be admitted to the ICU. We're filling up really quickly. We actually don't have very many beds left right now.
I walk into the room and meet a middle-aged man with a history of poorly controlled diabetes affecting his eyesight, kidneys, and nerves. The nerve damage in his feet is so bad that he couldn't feel when he stepped on a metal staple last week. The staple buried deep into his foot and he only noticed it when he was changing his sock and discovered that one of them was wet with pus. It wasn't until he developed a fever and felt so weak that he could hardly walk that he decided to call an ambulance and come to the hospital. What a bad infection. Poor guy.
He definitely has cellulitis, so an infection of the skin, but I suspect he also probably has osteomyelitis, which is an infection going down into the bone. Partly that's because when I take a Q-tip I can actually probe down and touch his bone, so you know the bacteria can just get into there.
I have drawn a line around that infection on his skin to make sure it's not growing rapidly. Because if it grows really rapidly, you worry about things like necrotizing fasciitis, an aggressive flesh-eating disease, and that's a surgical emergency, we have to take him to the OR.
We'll go back and check in and make sure that that infection isn't spreading really quickly. I don't think that's what's going on. For now, we'll get some imaging of his foot. We'll give him antibiotics, keep giving him blood pressure support, and then admit him to the ICU.
You guys know I don't often take elevators. I do take the stairs. It's faster, you get a couple more steps in. But it's that time of night. It's the time of the elevator night.
It's that time of night when things are not too crazy, and I'm sort of wondering if we can actually get a little sleep. It would be so nice.
Good morning! I have been up taking a look at some of those patients from last night, so I've got updates. The patient who had the cardiac arrest, he has been stable overnight. At one point, he actually had gotten a little bit too cold, so I had to back off on cooling. But he has been stable. We don't expect him to wake up this soon. It's still a matter of time to watch and wait, and see how he is going to do in terms of his recovery.
Oh, yeah, and that patient, the septic patient with the diabetic foot infection, I drew that line and the infection didn't spread beyond the lines. I feel pretty comfortable saying that this is not something more extreme like flesh-eating disease. It's a pretty straightforward, but really bad, infection. The imaging that we did, even just a plain x-ray, does show that he has got signs of infection of the bone. He is going to be a long road in terms of recovery and antibiotics. He will be on at least 6 weeks of antibiotics to really treat that bone infection.
But I am just so happy to be talking to you guys about something other than COVID. It's like, oh, finally things are really turning around, they're looking better, and I just feel so hopeful after this call shift. I just feel so different than it did even a month ago.
OK. Well, thanks so much for watching. If you want to see more videos like this, then be sure to subscribe and that way I'll see you in the next video. Bye for now.
Siobhan Deshauer, MD, is an internal medicine resident in Toronto. Before medicine, she was a violinist, which is why is called Violin MD.