Internal medicine and rheumatology specialist Siobhan Deshauer, MD, takes us through a day in her life as a hospital physician.
Following is a partial transcript of the video (note that errors are possible):
Deshauer: Hey, guys. I'm Siobhan, an internal medicine and rheumatology specialist. I just got to the hospital. I have got quite a few interesting patients that I'm rounding on and I'm excited to bring you with me today.
I have been getting a lot of requests from you guys to do more vlogs, and it's true it's been so long since I have done one. But I have got to say I'm really excited to be filming again today and telling you guys some updates about what's been keeping me so busy. I feel like we've just got to catch up.
Okay. My morning routine is basically head to the office and then make my tea, and print out a list of patients. That's the list of patients I'm going to be seeing today. Okay. We've got about 18-19 patients to see today, and there is one in particular that I'm really excited to tell you about with their permission and keeping it anonymous.
This is a woman in her 30s who presented to hospital with a seizure. She was at a food court, I think, waiting for food when she dropped and had a seizure. Someone called an ambulance, and she was rushed to the hospital. Then, again, when she was in the emergency department, she had another seizure and at that time the nurses checked her blood glucose and it was dangerously low.
They corrected her sugar, but it just kept dropping over and over again. They hooked her up to a D10W infusion, which is basically just an infusion of sugar water. Then she got admitted to hospital and I met her the next morning. When I went to see her, she looked fine. She was sitting up in bed and she was just sipping on ginger ale.
I asked her if this had ever happened before and she has never had a seizure, but she does get these episodes where she feels kind of shaky, anxious, and a bit sweaty. She has drank some soda at that time and feels better. She has been drinking more and more soda to make that feeling go away. And at this point she is drinking 24 cans of soda per day, even waking up in the middle of the night to drink some more as well. She actually doesn't go anywhere without a can of soda with her and she kind of looked at me like she felt guilty, saying, "I think I'm addicted to soda." I think she is probably having episodes of low blood sugar that she has just been self-medicating at home and, as you can tell, I'm excited. I'm intrigued and I really want to figure out what is going on so we can help her.
Diabetic medications are by far the most common cause of hypoglycemia that I see, but there are many other conditions that can lead to low glucose production or high insulin production. But from what the patients told me and from the initial investigations that have been done, we can cross out a number of these conditions already. The only way to actually figure this out is by getting a sample of her blood when her glucose levels are really low. So how are we going to do that? Well, she is going on a fast, no calories, no caffeine for up to 72 hours until we can get that sample. I honestly feel so badly for her. I would be incredibly cranky if I had to do this, but I just think it's so important for her to get these answers.
Okay. I'm heading upstairs now to see how the fasting is going. Now, the patient hasn't eaten since I think dinner last night and she hasn't gone low yet. The nurses are getting pretty nervous because they are worried she is going to go hypoglycemic and have a seizure, which is really understandable and it could happen. I'm just going to walk by frequently today, check in and make sure everyone is feeling comfortable.
By the way, did you notice something different, no mask walking around the hospital! This is still pretty new, so I still feel a little bit weird like I'm doing something wrong, but it's such a nice change. But we still do see patients with masks on. That hasn't changed yet.
Walking into the room, I check on the patient and she tells me she is hungry but okay. Her sugars are around 3.8 but haven't dropped low enough yet. At her bedside, I have got emergency medications available, an emergency glucagon kit and D50w, which is a concentrated sugar solution that can be directly injected into her veins if needed.
All right. Now it's basically a waiting game. For now, I'm going to go see my other patients. Mark has been waiting patiently to go get lunch. Okay, I'm finally ready and, of course, he now gets paged. This is always what happens. We try to make plans for lunch and then one of us is always getting busy. Okay, destination Tim Hortons.
Mark: It's our only option.
Deshauer: Only option today. It's not my favorite. We'll make do.
Mark: The bagel B.E.L.T. [bacon, egg, lettuce, tomato] is not bad.
Deshauer: It's okay.
Mark: What do you guys think?
Deshauer: This is not an advertisement.
Mark: You guys might be wondering where have we been? It's actually been a crazy month. We started up here 2 weeks straight on service, here in the Sault, lots of calls, a big and long patient list, and somehow we managed to squeak in a little bit of violin practicing every morning at 4:30.
Deshauer: And that's because we just got back from playing with the World Doctors Orchestra, seriously, a whole orchestra full of doctors that get together from all around the world to put on charity concerts. It was just so amazing to be able to meet so many different musician physicians.
Mark: Yeah. She is not the only Violin MD.
Deshauer: True.
Mark: We met probably another 20 violin MDs. There is a whole section of viola MDs, cello MDs, and...
Deshauer: Tuba MDs.
Mark: Yeah.
Deshauer: We got to meet some of you guys from the community who came to the concert. It was such a special experience, and we definitely want to do more of those.
After that, we spent a few days exploring Phoenix and hiking. I just couldn't get over the size and beauty of the cacti. We were so excited to ride in a self-driving car for the first time. It was absolutely incredible to watch this vehicle navigate turns and merge into other lanes. I honestly thought I'd be nervous, but it felt surprisingly safe. What do you think? Would you try riding in one of these cars?
Mark: You know what?
Deshauer: Bye. Oh, and the other reason it's been so busy is because I have been training for my first half marathon, which is in just 2 weeks, and Mark is running his first full marathon the same day.
Mark: That's right. It's been a lot of running and a lot of call too. Sometimes those two things intersect in a really funny way. I'll be out trying to hit my splits, completely out of breath. I get a call from the ward: "Hi, it's Dr. Weatherall speaking," and the nurse is like, "Are you running right now?" Speaking of running, we should probably get going and see the rest of our patients.
Deshauer: Sounds good. All right. Let's do it.
Okay. Now, I'm preparing to give a patient two shoulder injections with corticosteroid or, as most people call it, cortisone mixed with lidocaine. This patient has bursitis in both shoulders and it's really painful for her, so she is incredibly grateful to get the injections today.
It's actually really nice to use my rheumatology skills in the hospital. "Great. How low? Perfect, yep. You got the... yep. Okay. Perfect. Yep, give the glucagon and I'll be right upstairs. Thank you. Okay. Bye."
Okay. Her sugar dropped down to 2.8. They have got the bloodwork done. Now they are giving glucagon, which is the hormone that should raise up her sugars right away, but I want to go and see her now.
Walking into the room, I learned that the patient had become symptomatic, feeling sweaty, light-headed, and tremulous, all symptoms of hypoglycemia. After drawing blood work and giving an injection of glucagon, the fast is finally over and the patient was already ordering food to the hospital.
Okay. She is doing well now. She is sitting there having her ginger ale. It looks good. I think we're in the clear. We won't know what happens for about 3 to 5 days. I will update you at the end of the video.
So often I see comments from you guys saying things like "Your hospital is empty. Like where is everybody?" But I want to tell you that I'm usually strategic. For instance, today is a Sunday and that's why there is not a lot of people here, especially in this area of the hospital. But I promise the hospital does get busy, but again empty hallways. The other part of that is I do want to get consent for anyone who is in the video. If someone is in the background, I just don't film. For all of you wondering why the hospital...?
Okay. Hey, guys. The rest of the day was a total blur. It was impossible to film. Things just got so busy. Now I'm at home done with the the work week. You can tell behind me looks a little bit different. That's because we moved, another thing that's kept us really busy recently.
Now, let's chat about our hypoglycemia patient. I want to update you. The blood work took about 4 days to come back. And when it did it showed high levels of serum insulin, proinsulin, and C peptide. Now, any med students or residents watching are probably having flashbacks to exams, because this is getting pretty deep into some complex physiology. Basically, this tells us that her body is making too much insulin. And I'm most suspicious that there is either a tumor that's making that insulin or she is producing antibodies against insulin or the insulin receptor.
Now, both of these conditions are super rare. I have never actually seen them in real life. I have just read about them in textbooks. But it really goes to show you that if you don't look for those really rare things, you'll never diagnose them. I ordered some blood work and a CT scan, and then my weeks on service were up and I handed over to the next doctor. So I actually don't have the answer. I think it's one of those rare conditions, and I hope that satisfies your curiosity and knowing that there are some other really rare causes of hypoglycemia out there. It's one of the realities of doing acute hospital medicine is that you can really only do 1 or 2 weeks at a time. Otherwise, you would just burn out, because it's so intense while you're doing that work. But then you don't always get to follow your patients to figure out what happens in the end.
Siobhan Deshauer, MD, is an internal medicine and rheumatology specialist in Toronto. Before medicine, she was a violinist, which is why is called Violin MD.