Join medical resident Siobhan Deshauer, MD, for a night shift in the intensive care unit. She’ll be caring for critically ill patients, solving medical mysteries, intubating a patient who cannot breathe, and reacting to a code blue emergency.

Following is a rough transcript (Note that errors are possible):

Siobhan Deshauer, MD: Code blue, Level 5, Room 537. Code blue, Level 5, Room 537.

Hey, guys. I’m Siobhan, a 5th-year medical resident. I just got to the hospital and I’m starting a night shift in the intensive care unit and I’m bringing you guys along.

OK. First things first, let’s go grab a call room and drop off my stuff. Oh, wow. I’m paged already. OK. Let’s see who it is.

Hi, this is Siobhan from ICU returning a page. I’ll be down shortly. Thanks very much.

OK, so that was the emergency room doctor. There was a patient who was found unconscious outside, was brought to the hospital, and was unresponsive, so they intubated him. At this point now, he is definitely going to get admitted to the ICU and the question is why was he unconscious. That’s what we have to figure out now.

Walking into the emergency department, I find a middle-aged man lying unconscious connected to life support. I do a really thorough physical exam, which is largely normal, so no clues as to why he was found unconscious. Then I go to the computer and check the lab results. The CT scan of his head is normal, but there are some abnormalities on his blood work.

The pH in his blood is too low, meaning it’s too acidic. This is really dangerous because the proteins and cells in our body stop working properly when it’s too acidic, and that includes the brain, which may explain why this patient was found unconscious. We are already checking for the most common causes like lactic acid buildup or kidney failure, but so far all these tests are normal.

He has got what we call a metabolic acidosis, so there is basically too much acid in his blood. But the question is where is that coming from? There are some calculations that we can do to help figure that out.

Using a calculation called the osmolar gap, I can determine if there is a substance in his blood that we aren’t testing for — something that might explain the high acid levels. According to my calculations, this patient has an osmolar gap, and that’s often caused by toxic alcohols — things like methanol that can be in homemade alcohol like moonshine or ethylene glycol from antifreeze.

They are actually not tests that we usually order, so I have to call the biochemist to get special approval to even test for it: Hi, can you please page the biochemist on call to this phone number? Great. Thank you.

Now we wait. This is kind of like the annoying part of a paging system, and now I’m stuck beside this phone, so might as well write my note while we are waiting.

Hi, this is Siobhan from ICU. Great. Thank you so much for getting back to me. Yes, so I’ve got a 56-year-old man here who was found unconscious with an unexplained osmolar gap, and I’m hoping to get approval to send off the toxic alcohol panel. Yeah, for sure. I’ll spell his name for you.

These toxic alcohols are really dangerous. Methanol can be found in moonshine, which is a homemade alcohol. It causes optic nerve damage and can lead to blindness. Then ethylene glycol, which is found in antifreeze, causes low calcium in the blood and that can cause fatal cardiac arrhythmias.

If the test comes back positive, if it is a toxic alcohol, and that’s like my most likely cause right now, then the next step is dialysis to filter out and clean the blood.

I’m actually going to give Nephrology a call to give them a heads-up to start that ball rolling. The best part is that I know the nephrology resident who was on call tonight, so I can just give him a call rather than waiting by the phone and paging, because I have got to start rounding on the other ICU patients soon.

OK. Now it’s time for evening rounds where we go around and follow up with each of the patients and assess them with the bedside nurse. We have just finished rounds and I’m really worried about one patient in particular. He has been here for about 24 hours with a pneumonia that’s not COVID, but he continues to require more and more oxygen. Now, he is on the highest level of oxygen.

Unfortunately, he is struggling to breathe. You can see his muscles are working so hard, and he is starting to get tired. The next step is that we have to intubate him and hook him up to life support. The respiratory therapist is just getting prepared right now, so let’s get going and do this.

The key to a successful intubation is preparation, making sure that you have all the equipment you need ready and in the room. In this case, that includes using a GlideScope, which is a tool for intubation with a built-in camera.

I put it into the patient’s mouth so I can see down their throat. Then when I see the vocal cords, I push the breathing tube through them and into the patient’s trachea. This way I’ve secured the airway.

That was smooth. I love using the GlideScope. You can see everything. You can visualize going down and see the vocal cords, see your tube going in so easily.

Anyway, now he is intubated, he is sedated, and I’m just going to call his family as an update.

No way. OK. Yeah, yeah. Thanks for giving me a call. Perfect. Yeah, yeah. I’m going to talk to Nephrology now: Great. Thanks. OK. Bye.

That was the ICU nurse. The core lab called and the methanol level came back positive and actually really high, so I’m going to text the nephrology resident now and hopefully they can do dialysis tonight. But I’m using my phone to film, so give me a second.

Wow! We have our diagnosis. Now, we know the extra acid in the patient’s blood was coming from methanol poisoning. Mystery solved. Now, the kidney specialists on call are coming into the hospital to start dialysis and filter out the methanol from his blood. At this point, only time will tell if he’s going to have a complete recovery or if he will have permanent damage to his eyesight or nerves.

All right, finally time for a late dinner. We actually got some leftover … well, actually not that leftover. It’s take-out Chinese from earlier, tofu stir fry. This seems perfect for tonight and guys, look at this massive jug. Because I never drink enough water, Mark sent me here with this huge container full of water and electrolytes, so I have to finish it before going home to make sure I don’t actually become dehydrated like every other time I’m on call.

This is my last year of residency and it’s hard to believe. Like it goes by slowly and quickly — I’m not really sure — and this is going to be a busy year. I’m going to be doing my rheumatology licensing exam, and I have got to figure out what I’m going to do next year and sort of more life planning. It’s exciting and a little bit daunting, actually.

OK. Guys, we need to get going right away. This is a patient with severe sepsis on the floor. It sounds like there may be pre-code right now and I probably might come down to the ICU. Let’s go.

When I get to the room, I see an elderly man with an oxygen mask on, struggling to breathe. The vital machine shows a low blood pressure.

His nurse fills me in on the important details: The patient had recently had surgery, spiked a fever earlier in the day, and has now decompensated very quickly. They have already sent off blood work stat, but it hasn’t come back yet.

This patient is critically ill. Based on the way he is breathing and his low oxygen saturations, he needs to be intubated immediately. There is no time to …

Woman: Code blue, Level 5, Room 537.

Deshauer: Within minutes, the room is flooded with people, and with them comes the code blue cart and all the equipment we need. The team jumps into action, starting IVs, giving blood pressure medications, and intubating the patient. Within about 20 minutes, he stabilized and we transport him down to the ICU, where we continue working.

I start by inserting a central line, a very large IV, into his neck, so we can safely give potent life-saving medications, and next an arterial line into his radial artery so we can get continuous blood pressure monitoring.

OK. Wow, so the patient is now in the ICU intubated, put a central line in, put an arterial line in, and he is looking a lot more stable, but still very tachycardic. We are still going to figure out exactly what’s going on and run some more tests now. Oh, wow, that was tight.

OK, let’s pick up where we left off. But you know what I think is going on with this patient is that I think he probably has a pulmonary embolism — or that’s my best guess anyways. He has got all the risk factors. His history of cancer, he just recently had surgery, all of those things can promote blood clots. Plus, he was so hypoxic. Like his oxygen levels were so low and yet his x-ray looked pretty normal — like it didn’t explain all the symptoms, and that can be a hallmark of a blood clot in the lungs as well.

He should be going down to get a CT scan shortly and I am expecting to get a page to let me know the results. In the meantime, finish up with dinner while we got a chance.

Oh, my gosh. Hi, this is Siobhan from ICU returning a page. OK. That was one of the ICU nurses. It sounds like there are two things that are going on. The first is the result of that CT scan for the patient. He actually does have blood clots in both lungs, so I have just asked her to start some blood thinners, and that’s how we’re going to treat that.

But then we also have a new patient that’s being transferred to the ICU right now — pneumonia, most likely COVID. Just if it gets … OK. There is no point complaining, but let’s go.

Oh, man. I got to say I just want to be in bed right now. But I guess if we’re down here anyway, I can check up on that methanol patient and see how he is doing after dialysis.

Oh boy. The rest of the night was just a total blur, one thing after the other. But luckily the patients are now relatively stable, considering they were in the ICU.

I managed to finish all my water — my other goal for the night. Now, I can’t wait to go home and finally get to sleep.

Thanks for joining me. If you want to see more videos like this, I’ve got a whole playlist of various ICU call shifts, so you check that out.

Otherwise, 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 her YouTube channel is called Violin MD.