I woke up this morning hoping that I could leave the Cardiology department with a good understanding and perspective on the specialty, and hopefully narrow down what I found appealing about it. I started things off in the Cardiology ICU unit following Dr. Wu as he checked on the patients on the floor. Just by looking at the patients through the windows into their separate rooms, I could already feel the severity of their conditions. So many tubes, wires, IV bags, and machinery surrounded these patients that it was obvious of their struggle to overcome their conditions. Most patients were unconscious, and on a few of them I could really see the fight to improve in their faces.
The beauty of the specialty, and of medicine in general, came to me when I found out one of the patients had originally arrived without a heart rate. She was resuscitated, but unfortunately she remained in a comatose state. Not much was else was available for her except for transferring her into the Ward for care until further improvement. Still, imagining that a person who has basically given their last breath with an arrested heart can be given life again is intense.
Something interesting about the Chinese culture was revealed to me by Dr. Wu when explaining the history of a patient that had acute MI and acute pulmonary edema. Apparently the patient had herpes zoster and in his immunocompromised state, the disease flared up presenting as rashes all around the midsection accordingly along specific dermatomes. Many Chinese refer to this sign as a "skin snake" and believe it is a sign of death. Dr. Wu assured me that this had no truth in it, but it was interesting to hear about such an extreme view of a disease.
After spending the morning in the ICU, I decided to head to the Ward one last time to go on rounds with my original preceptor Dr. Chou. I saw several patients, some who were the same patients from before. After brushing up on my pharmacology earlier in the week, more of the drugs the patients were taking and the physicians were listing made sense to me. (One thing is for sure, diuretics are important!) One of the patients had a coronary artery bypass graft, and I learned the importance of statins in secondary prevention in these cases. One of the attending physicians, Dr. Kuo, gave me his take on the evolution of statin use in the future. Apparently, statins will basically become like daily vitamins, in his opinion. It makes sense considering the current health trends in our lives. But that is an entirely different discussion.
I was able to go to the ECHO room one last time as well. In the ultrasound images, I had the opportunity to see a ruptured chordae tendinae that was flapping around whenever the mitral valve opened and closed. Dr. Wang, the attending there, surprised me a with a little quiz question:
Dr. Wang -- "What would this cause?"
Me -- "Incomplete valve closure...so...regurgitation."
He didn't say anything after that, so I assumed I was right.
All in all, the week spent in Cardiology has been eye-opening. The specialty ranges from an internal medicine setting to a surgical/procedural setting, so in a sense you get a little of both worlds. It definitely has many complexities to it, so there is a high demand for logic and physiologic understanding. Basically, Cardiology = Lots of Studying! I had a lot of fun in the Cardiology department, and I was able to solidify a good amount of what I learned in the CV portion of our CVRR curriculum. Hopefully, Emergency Medicine next week will do the same.
Showing posts with label cardiology. Show all posts
Showing posts with label cardiology. Show all posts
Friday, June 12, 2009
Thursday, June 11, 2009
Day 4 of Cardiology - Sean
The morning began in the Catheterization Lab once again. A patient suffering from angina pectoris was found to have stenosis in the Left Anterior Descending Artery of the heart. I was able to watch the cardiologists place a drug eluting stent into the collapsed lesion. The technique used the inflation of an angioplasty balloon to secure the stent into place by hooking into the blood vessel's walls. I learned that even though a stent was put into place, there is still a 5% chance that re-stenosis may occur due to the body's physiological repair mechanisms. Although, drug eluting stents try to prevent this from occuring through the slow release of specific drugs.
In the afternoon, I was able to head to the Cardiology Ward again for rounds. I was looking forward to this because of how much I felt I learned from my first experience. My preceptor joined me as I followed along with attending physician Dr. Chang who lead a group of residents and interns to see patients. It was pretty much the same routine as it was on Monday. They presented the patient (in English for my sake) and discussed the reasons for their choices of treatment. The types of cases I saw were: CHF, mitral valve replacement with a mechanical valve, myocarditis, pericarditis, pericardial effusion, acute myocardial infarction, and chronic DVT.
My preceptor let me auscultate the patient with the mechanical replacement valve and I could clearly hear the obvious clicking sound it made. Interestingly enough, Dr. Chou said that the patient can often hear it when they sleep or when they are somewhere quiet. In some cases, the sound may even annoy the patient, but Dr. Chou said that it's something they just have to deal with.
An interesting case was a 21 year old patient with chronic chest pain, but the etiology of the pain was unknown. My preceptor told me that there is a list of common diseases they usually rule out first before exploring other causes for chest pain. The 6 possible common disease were:
1) acute myocardial infarction (assessed by EKG, CXR, cardiac enzymes)
2) aortic dissection
3) pulmonary embolism
4) tension pneumothorax
5) esophageal rupture
6) perforitic peptic ulcer.
I really enjoyed the ward again. It's just a lot more fun when you know what's going on. Unfortunately, there's only one more day of Cardiology left. I hope tomorrow is another good day because Cardiology has been great so far.
In the afternoon, I was able to head to the Cardiology Ward again for rounds. I was looking forward to this because of how much I felt I learned from my first experience. My preceptor joined me as I followed along with attending physician Dr. Chang who lead a group of residents and interns to see patients. It was pretty much the same routine as it was on Monday. They presented the patient (in English for my sake) and discussed the reasons for their choices of treatment. The types of cases I saw were: CHF, mitral valve replacement with a mechanical valve, myocarditis, pericarditis, pericardial effusion, acute myocardial infarction, and chronic DVT.
My preceptor let me auscultate the patient with the mechanical replacement valve and I could clearly hear the obvious clicking sound it made. Interestingly enough, Dr. Chou said that the patient can often hear it when they sleep or when they are somewhere quiet. In some cases, the sound may even annoy the patient, but Dr. Chou said that it's something they just have to deal with.
An interesting case was a 21 year old patient with chronic chest pain, but the etiology of the pain was unknown. My preceptor told me that there is a list of common diseases they usually rule out first before exploring other causes for chest pain. The 6 possible common disease were:
1) acute myocardial infarction (assessed by EKG, CXR, cardiac enzymes)
2) aortic dissection
3) pulmonary embolism
4) tension pneumothorax
5) esophageal rupture
6) perforitic peptic ulcer.
I really enjoyed the ward again. It's just a lot more fun when you know what's going on. Unfortunately, there's only one more day of Cardiology left. I hope tomorrow is another good day because Cardiology has been great so far.
Wednesday, June 10, 2009
Day 3 of Cardiology - Sean
This morning in the Cath Lab, there was a patient that required Cardiac Resynchronization Therapy (CRT). According to Dr. Hsu, this was one of the more complex procedures in the Cardiology specialty. The patient currently had a pacemaker implanted but the rate of contraction it was programmed for before no longer was effective in orchestrating a synchronized contraction for efficient blood output. 0.08 seconds was the interval that the patient's current pacemaker was off. Thus, the CRT would serve as an upgrade replacement for the current pacemaker.
The heart beating with the patients old pacemaker, under flouroscopy.
During the procedure when the old pacemaker was removed, an external pacemaker was used while the new electrodes were put into place. The cardiologists decided it was better to leave the old electrodes in place since they were so embedded into the heart's tissue. It would do more harm than good to surgically remove them.
The new pacemaker required the placement of 3 new electrodes: one that leads into the right atrium, one that leads to the lateral wall of the left ventricle through the coronary sinus, and one that leads to the right ventricle near the interventricular septum. Each target was carefully selected by the cardiologists for maximal desired effect.
Here the 3 new electrodes are visible; the 2 old electrodes are present as well.
The new pacemaker by Medtronic; it was implanted in the left subclavicular region.
An interesting thing I learned was that whenever a pacemaker procedure is performed, the manufacturing company of the pacemaker sends representatives to bring the device to the operation and also assist during. I was told that Medtronic is the largest pacemaker company, so their representatives were in the flouroscopy room during the entire procedure. One good thing about this was that after the 5 hour procedure, the representatives treated us all out for lunch.
In the afternoon, I went to the echocardiography room where Dr. Wang explained all the tricks about reading the ultrasound images. The premise is similar to venous ultrasound, except you're looking at the heart. Doppler is again useful here to detect blood flow, so anytime you see both colors crossing at the valve regions, that is indication of regurgitation. The velocity of the blood flow could also indicate stenosis if it was higher than normal. I was surprised when Dr. Wang performed transesophageal echocariography because I did not realize that the probe would be so long. Lidocaine spray was used to numb the gag reflex somewhat, and it looked very uncomfortable for the patient, but the back view of the heart seemed very useful for locating any problems in that region.
I was sort of pimped once today, but I guessed right:
Dr. Wang -- "Is this a thrombus?"
Me -- "Where?"
Dr. Wang -- "Right here." (points at screen).
Me -- "Oh. That looks like its the left auricle."
Dr. Wang -- "Good. So what do you think?"
Me -- "Umm...it doesn't look like a thrombus to me, but I've never really seen a thrombus before."
Dr. Wang -- "Sometimes you need to have some guts and confidence in your answer."
Me -- "Hmm. No, that is NOT a thrombus."
Dr. Wang -- "Very nice!" (chuckles a bit)
The heart beating with the patients old pacemaker, under flouroscopy.
During the procedure when the old pacemaker was removed, an external pacemaker was used while the new electrodes were put into place. The cardiologists decided it was better to leave the old electrodes in place since they were so embedded into the heart's tissue. It would do more harm than good to surgically remove them.
The new pacemaker required the placement of 3 new electrodes: one that leads into the right atrium, one that leads to the lateral wall of the left ventricle through the coronary sinus, and one that leads to the right ventricle near the interventricular septum. Each target was carefully selected by the cardiologists for maximal desired effect.
Here the 3 new electrodes are visible; the 2 old electrodes are present as well.
The new pacemaker by Medtronic; it was implanted in the left subclavicular region.
An interesting thing I learned was that whenever a pacemaker procedure is performed, the manufacturing company of the pacemaker sends representatives to bring the device to the operation and also assist during. I was told that Medtronic is the largest pacemaker company, so their representatives were in the flouroscopy room during the entire procedure. One good thing about this was that after the 5 hour procedure, the representatives treated us all out for lunch.
In the afternoon, I went to the echocardiography room where Dr. Wang explained all the tricks about reading the ultrasound images. The premise is similar to venous ultrasound, except you're looking at the heart. Doppler is again useful here to detect blood flow, so anytime you see both colors crossing at the valve regions, that is indication of regurgitation. The velocity of the blood flow could also indicate stenosis if it was higher than normal. I was surprised when Dr. Wang performed transesophageal echocariography because I did not realize that the probe would be so long. Lidocaine spray was used to numb the gag reflex somewhat, and it looked very uncomfortable for the patient, but the back view of the heart seemed very useful for locating any problems in that region.
I was sort of pimped once today, but I guessed right:
Dr. Wang -- "Is this a thrombus?"
Me -- "Where?"
Dr. Wang -- "Right here." (points at screen).
Me -- "Oh. That looks like its the left auricle."
Dr. Wang -- "Good. So what do you think?"
Me -- "Umm...it doesn't look like a thrombus to me, but I've never really seen a thrombus before."
Dr. Wang -- "Sometimes you need to have some guts and confidence in your answer."
Me -- "Hmm. No, that is NOT a thrombus."
Dr. Wang -- "Very nice!" (chuckles a bit)
Tuesday, June 9, 2009
Day 2 of Cardiology - Sean
In the morning, I was scheduled to be in the "BVG room" with Dr. Chiang, one of the cardiology attendings. When I first got there, Dr. Chou was there to greet me and made sure everything was going well so far. He soon left me to observe Dr. Chiang, and later Dr. Wu (another attending), use Venous Ultrasound imaging to screen the lower extremeties of their patients for any instances of deep vein thrombi (DVT).
As he saw his patients, he took time to describe the basics of reading the images that appeared on the machine's screen. In simple terms, the ultrasound probe is best kept at around a 60 degree angle to the blood vessels for the best detection of blood velocity. The flow direction is also detected by the flow using Doppler effects. If the color showed RED, the flow direction was toward the probe; if it was BLUE, the flow was away from the probe. Using the velocity and direction, Dr. Chiang seemed to find his way around the lower vasculature towards the hidden clots that existed. I noticed while he moved the probe that there were areas where both colors were prominent in the lumen of the vessels. He told me that it was indicative of plaque buildup, which causes turbulence of the blood. Using these cues, he was able to make a rough guess of where a possible clot may reside. I was having trouble in the beginning just trying to orient myself between the vessels and its surroundings, so I was amazed at how he knew where exactly he was in the vasculature.
One technique of identifying the presence of DVT that I thought was interesting involved manually applying pressure to the distal portions of the veins to alter the blood flow. If there was a DVT, the flow would not be affected by the external occlusion. This technique, termed "augmentation", was used on all of the patients that came in that morning. The types of cases that came in included patients with varicose veins, intermittent claudication, pitting edema, and confirmed DVT in the femoral artery. In the patient with a confirmed DVT, it turned out that the major arterial vessels below one of her knees were not functional, but the venous vasculature was fine. The patient, fortunately, showed no signs of gangrene because of collateral vasculature and recanulization that was perfusing a sufficient supply of blood to the area. By lunch time I had seen enough patients to finally get the hang of what I was seeing on the imaging screen.
The afternoon schedule was again in the "BVG room" except this time the attending physician I followed was Dr. Hsu. The patients he examined next all had artificial blood vessels grafted into one of their upper extremities. Dr. Hsu performed follow-up exams on the condition of their grafts and also tried to figure out what was wrong if they experienced problems with the grafts. One of the patients, unfortunately, was experiencing more than 50% stenosis at the graft-venous junction. The placement of a graft involved creating a fistula between an artery and vein. In this case, the graft connected the basilica vein to the brachial artery. The stenosis was affecting the blood flow more than Dr. Hsu would have like, so he decided the patient should go in for an immediate angioplasty.
The angioplasty took place in the Catheterization Lab, where they used flouroscopy to guide the procedure. It was amazing watching them insert a guide wire through the radial artery, through the graft, all the way to the site of the stenosis. Then a catheter with a balloon at the end was inserted over the wire and inflated to expand the collapsed junction. After a few minutes of having the balloon in place, the catheter and wire were removed. I noticed a significant enlargement of the vessel after that. Just a side note, the patient was conscious the entire time! That was probably the most surprising thing because I had no idea that a procedure like that did not require patient sedation. The Cath Lab turned out to be an exciting part of Cardiology, and I am looking forward to spending more time there the rest of the week.
As he saw his patients, he took time to describe the basics of reading the images that appeared on the machine's screen. In simple terms, the ultrasound probe is best kept at around a 60 degree angle to the blood vessels for the best detection of blood velocity. The flow direction is also detected by the flow using Doppler effects. If the color showed RED, the flow direction was toward the probe; if it was BLUE, the flow was away from the probe. Using the velocity and direction, Dr. Chiang seemed to find his way around the lower vasculature towards the hidden clots that existed. I noticed while he moved the probe that there were areas where both colors were prominent in the lumen of the vessels. He told me that it was indicative of plaque buildup, which causes turbulence of the blood. Using these cues, he was able to make a rough guess of where a possible clot may reside. I was having trouble in the beginning just trying to orient myself between the vessels and its surroundings, so I was amazed at how he knew where exactly he was in the vasculature.
One technique of identifying the presence of DVT that I thought was interesting involved manually applying pressure to the distal portions of the veins to alter the blood flow. If there was a DVT, the flow would not be affected by the external occlusion. This technique, termed "augmentation", was used on all of the patients that came in that morning. The types of cases that came in included patients with varicose veins, intermittent claudication, pitting edema, and confirmed DVT in the femoral artery. In the patient with a confirmed DVT, it turned out that the major arterial vessels below one of her knees were not functional, but the venous vasculature was fine. The patient, fortunately, showed no signs of gangrene because of collateral vasculature and recanulization that was perfusing a sufficient supply of blood to the area. By lunch time I had seen enough patients to finally get the hang of what I was seeing on the imaging screen.
The afternoon schedule was again in the "BVG room" except this time the attending physician I followed was Dr. Hsu. The patients he examined next all had artificial blood vessels grafted into one of their upper extremities. Dr. Hsu performed follow-up exams on the condition of their grafts and also tried to figure out what was wrong if they experienced problems with the grafts. One of the patients, unfortunately, was experiencing more than 50% stenosis at the graft-venous junction. The placement of a graft involved creating a fistula between an artery and vein. In this case, the graft connected the basilica vein to the brachial artery. The stenosis was affecting the blood flow more than Dr. Hsu would have like, so he decided the patient should go in for an immediate angioplasty.
The angioplasty took place in the Catheterization Lab, where they used flouroscopy to guide the procedure. It was amazing watching them insert a guide wire through the radial artery, through the graft, all the way to the site of the stenosis. Then a catheter with a balloon at the end was inserted over the wire and inflated to expand the collapsed junction. After a few minutes of having the balloon in place, the catheter and wire were removed. I noticed a significant enlargement of the vessel after that. Just a side note, the patient was conscious the entire time! That was probably the most surprising thing because I had no idea that a procedure like that did not require patient sedation. The Cath Lab turned out to be an exciting part of Cardiology, and I am looking forward to spending more time there the rest of the week.
Monday, June 8, 2009
Day 1 of Cardiology - Sean
I didn't know what to expect starting the week in Cardiology. I was very excited though because of having finished the cardiovascular unit this past semester. I felt like this was my opportunity to see how much of that knowledge I could apply in the clinical setting. Of course, that's assuming I retained enough of it.
Area C of the 6th floor housed one of the Cardiology Wards, and that was where I met my preceptor, Dr. Chou. To my surprise, he was expecting me and actually had a printed schedule for the rest of the week. Dr. Chou was the chief Cardiology resident and based on his experiences, he felt I would benefit most from spending time with different attending physicians throughout the week. He brought me to the different areas of the hospital to meet the attendings I would be learning from. Each day was separated into morning and afternoon, and I was to shadow one of those attendings during those times while they performed some specific component of their specialty. For this first day, I was in the ward with my preceptor for rounds.
The first patient we saw was in line to go in for an electrophysiology study tomorrow. His heart rate was irregularly irregular, and I was actually able to palpate this by his radial pulse. There was a problem, however, because the nurses and junior residents could not seem to get a Foley catheter inserted. If you do not know what a Foley catheter is, wikipedia explains it here pretty nicely. So my preceptor went ahead and gave it a try. Since the patient did not have a history of benign prostatic hyperplasia, he felt like it shouldn't be a problem. After 3 long attempts (one including a technique that used a syringe full of lubricating jelly--use your imagination), Dr. Chou decided to stop. He suspected that one of the patient's drugs might have been an anticholinergic agent that caused the urinary sphincter to contract, making the opening to the bladder very small. Observing this from the sidelines was awkward, but it was interesting to see the various techniques used.
Many of the other patients in the ward, as one would expect, were sufferring from heart disease. I was surprised by how familiar I was with the cases I encountered. Distended jugular veins indicating increased JVP, pitting edema, EKGs with ST elevation indicating MIs, syncope, hypertension, right heart failure, unstable & stable angina -- I recognized all of these signs and was able to keep up with the attending and his residents. Although my understanding was not as in depth as theirs, I feel like I impressed them with what I already knew. And when I did not know what something was, I made sure to ask for clarifications and explanations. I was having a lot of fun doing rounds here. The pharmacology was easy to pick up on as well. Drugs like loop diuretics (furosemide, bumetanide), ACE inhibitors, ARBs, and carvedilol were some of the many drugs that I heard thrown into the air during patient presentations by the residents and intern. I've studied these enough times to know what each one was responsible for treating.
Another big moment for me during rounds occured when I was allowed to ausculate a patient suffering from myocarditis and pericarditis. My preceptor told me to listen and tell him what I heard. What I heard was a crumpling sound between heart sounds, and he told me that it was a pericardial friction rub. Apparently it is not something you hear too often in patients. I was very excited after hearing my very first "real" heart sound in a "real" patient. It turns out that tests and imaging scans showed the patient had tamponade and so pericardiocentesis was recommended for the patient.
It was a great feeling to realize that I had knew more than I thought I did. But, the conditions of some of these patients were really serious and made me feel disappointed that I didn't know more so I could help them. The attendings and residents had it covered, but I felt like I wanted to know what to do or what the patients needed. I guess we'll see how much I can learn in the days ahead.
Area C of the 6th floor housed one of the Cardiology Wards, and that was where I met my preceptor, Dr. Chou. To my surprise, he was expecting me and actually had a printed schedule for the rest of the week. Dr. Chou was the chief Cardiology resident and based on his experiences, he felt I would benefit most from spending time with different attending physicians throughout the week. He brought me to the different areas of the hospital to meet the attendings I would be learning from. Each day was separated into morning and afternoon, and I was to shadow one of those attendings during those times while they performed some specific component of their specialty. For this first day, I was in the ward with my preceptor for rounds.
The first patient we saw was in line to go in for an electrophysiology study tomorrow. His heart rate was irregularly irregular, and I was actually able to palpate this by his radial pulse. There was a problem, however, because the nurses and junior residents could not seem to get a Foley catheter inserted. If you do not know what a Foley catheter is, wikipedia explains it here pretty nicely. So my preceptor went ahead and gave it a try. Since the patient did not have a history of benign prostatic hyperplasia, he felt like it shouldn't be a problem. After 3 long attempts (one including a technique that used a syringe full of lubricating jelly--use your imagination), Dr. Chou decided to stop. He suspected that one of the patient's drugs might have been an anticholinergic agent that caused the urinary sphincter to contract, making the opening to the bladder very small. Observing this from the sidelines was awkward, but it was interesting to see the various techniques used.
Many of the other patients in the ward, as one would expect, were sufferring from heart disease. I was surprised by how familiar I was with the cases I encountered. Distended jugular veins indicating increased JVP, pitting edema, EKGs with ST elevation indicating MIs, syncope, hypertension, right heart failure, unstable & stable angina -- I recognized all of these signs and was able to keep up with the attending and his residents. Although my understanding was not as in depth as theirs, I feel like I impressed them with what I already knew. And when I did not know what something was, I made sure to ask for clarifications and explanations. I was having a lot of fun doing rounds here. The pharmacology was easy to pick up on as well. Drugs like loop diuretics (furosemide, bumetanide), ACE inhibitors, ARBs, and carvedilol were some of the many drugs that I heard thrown into the air during patient presentations by the residents and intern. I've studied these enough times to know what each one was responsible for treating.
Another big moment for me during rounds occured when I was allowed to ausculate a patient suffering from myocarditis and pericarditis. My preceptor told me to listen and tell him what I heard. What I heard was a crumpling sound between heart sounds, and he told me that it was a pericardial friction rub. Apparently it is not something you hear too often in patients. I was very excited after hearing my very first "real" heart sound in a "real" patient. It turns out that tests and imaging scans showed the patient had tamponade and so pericardiocentesis was recommended for the patient.
It was a great feeling to realize that I had knew more than I thought I did. But, the conditions of some of these patients were really serious and made me feel disappointed that I didn't know more so I could help them. The attendings and residents had it covered, but I felt like I wanted to know what to do or what the patients needed. I guess we'll see how much I can learn in the days ahead.
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