Cardiology Rotation Day 5 The finale 24-June-2011

Bor-Han and I had another day in the ultrasound room to see move echocardiograms. In the morning we followed Dr. Huang Chieh-Yuan (Dr. 黃建元). Of all the cases in the morning the most interesting was that of a patient that is a heart transplant candidate. From the echo that Dr. Huang performed it was estimated that his ejection faction was to be around 20% from multiple views. The patient also had a mitral valve anulus dilation, a tricuspid valve lesion, and a part of the left ventricle that was not contracting much at all. As the patient is also suffering from Diabetes Mellitus and is on hemodialysis, Dr. Huang suspects that the heart condition could be due to ischemic heart disease with multi-vessel involvement. He also commented that it could also be dilated cardiomyopathy, but every other cause had to excluded before that conclusion. In the afternoon we followed Dr. Fung. The highlight was a patient suffering from peripheral arterial occlusive disease (PAOD) and ischemic ulcers. Her Ankle Brachial Pressure index (ABI) was in the 0.2 - 0.3 range much under 0.5 which is a sign of severe arterial disease. After looking through her medications Dr. Fung also commented that is was not a good choice to use beta-blockers to control her hypertension as it might result in vessel spasm further worsening her PAOD. All in all it was a good week in cardiology and I learned quite a bit from the different experiences with all the preceptors.

Cardiology Rotation Day 4 Learning how to do Echocardiography and more Ultrasounds 23-June-2011

Apparently there was only one patient scheduled for echocardiography in the morning with Dr. Chou and as the patient had not arrived yet Dr. Chou told us to check out the sonography of the carotid artery in the room next door. The whole process seemed a little easier than the echocardiogram process but it was still hard to make out some of the small narrowing and beginning build of plaque that the doctor operating the machine was able to see. Afterwards we returned to follow Dr. Chou as he completed his only morning echo. As the morning was so free Dr. Chou let us perform echocardiography on each other as long as no patients showed up. I started as the operator with Bor-Han as the patient. Dr. Chou walked me through how to position the probe in the second or third intercostal space and orient it so that the probe’s marker line was toward the right shoulder to get the parasternal long axis view. After some analysis we proceeded to go through the short-axis, four and five chamber views. It was really difficult to get the five chamber view and it really made me appreciate the amount of practice and experience it takes to get a real feel of echocardiography. Next up Bor-Han and I switched places and he got to got to go through all the views I did from before and went on to position the probe to visualize my inferior vena cava. Apparently in Taiwan they often check the inferior vena cava (IVC) for blockages, there is a different etiology for ICV blockage in Taiwan compared to the United States with hepatic masses being more common in Taiwan (Hep B and Hep C) compared to renal adenocarcinoma in the United States. I am very happy that I was able to get an opportunity to operate the machine and to have such a good preceptor to learn from in Dr. Chou. Oh and no pictures of us operating the machine this time as all our hands were busy.

Cardiology Rotation Day 3 Cath Lab and more Echoes 22-June-2011

Bor-Han and I started the day in the cath lab at 9:30 where a patient was scheduled to have his pacemaker procedure performed by Dr. Tu. After the patient arrived we watched as Dr. Tu and company got ready by putting on lead protection armor. It seems like it takes quite a bit of endurance and stamina with all the gear on, of course all the staff used back support. As Dr. Tu was doing the procedure Bor-Han and I watched from behind the glass, the angle of watch Dr. Tu was not too good as we could not completely see what he was doing all the time. None the less Dr. Fung and the employee of the pacemaker company (Medtronic) were there to provide explanations of what was going on during the procedure. The total procedure took about three hours, Dr. Tu had a little trouble getting the leads where he wanted a few times and had it dislodge a few other times. I can only imagine how much patience and concentration it takes to be able go through the entire procedure. Overall the procedure itself was interesting; I was able to see how much effort goes into pacemaker implantation and learn a bit about the details.

In the afternoon we visited the ultrasound room again to see and learn more about echoes from Dr. Chou Po-Han (Dr. 周伯翰). We went over many topics including how much the echocardiogram is operator dependant. In fact Dr. Chou said usually in a fellowship of two years you would have to do about 1000 echoes before you could be confident that they were correct. The first 250 are incorrect, the next 500 are maybe correct, and it takes awhile from there to get a good clear image. The whole process is through practice and getting familiar with the different possible results. We also got to see a few new things including the Tissue Doppler that is useful for assessing diastolic dysfunction and a review of why it is important to see the heart chambers from multiple views (non-ideal heart is not as spherical so equations to calculate the ejection fraction are less accurate if only one view is used).

Cariology Rotation Day 2 Echocardiograms, EKGs, running around the ward 21-June-2011

Following Dr. Chen Kuei-Feng (Dr. 陳桂峰), Bor-Han and I were very lucky today to see very different echocardiograms (echo) right after another. The first echo was a patient with regurgitation of all four valves (mitral, tricuspid, aortic and pulmonic). Dr. Chen used the opportunity to show us different views including the five chamber view (all four heart chambers, plus the aorta), how to use the doppler to get quantitative measurements of the heart and also how to use the color mode to assess turbulence (it shows up as a mosaic of red and blue, and usually indicates abnormal flow). For completeness Dr. Chen also showed us the chest x-ray depicting cardiomegaly and the EKG with Atrial fibrillation (A-fib).
The next echo was that of a normal heart with a mitral valve prolapse. Apparently mitral valve prolapse is fairly common and usually part of normal variation, in fact all of the hearts we saw today at least had mitral valve prolapse. Dr. Chen also commented the echo sensitivity attributes the common finding of mitral valve prolapse.

The third echo was from a patient with a prosthetic heart valve (metallic mechanical disc valve) from an operation more than ten years ago. It was interesting to see the distortion in the echo from the interference of the metal valve. One of the most fascinating things that Dr. Chen showed us was the chest x-ray (CXR) where we were able to see the valve when it was closed (showed up as a dark line) but not when it was open; he explained that disc valves are usually not very radiolucent, compared to the old ball and age valves where you were able to see the cage on the CXR. Dr. Chen also explained that the acceptable mitral area for prosthetic heart valves can be smaller, in this case the mitral area was calculated to be 2.8 cm² compared to the 4-6 cm² found in normal valves.

The forth echo with a patient with Tetralogy of Fallot, a congenital heart disease. This was the most interesting heart as everything was atypical. Dr. Chen also commented it was a very advanced case and that the echo will not be able to tell everything, such which surgical repair was perform (primary repair or two-stage repair). This also sparked a conversation about how long charts are kept as it would be interesting to know which operation was done, but apparently there were not records as charts are kept for about 11 years in Taiwan.

In addition to all the echoes in the morning Dr. Chen also outlined the thought process around how to use various physical exam signs, clinical presentations and the main diagnostic tools for cardiology (CXR, EKG and echo). CXR is usually used to check for cardiomegaly, EKG is a good way to assess arrhythmia, MI, and ischemia, while echo is good for valve assessment.

After lunch we were able to see a few more interesting echoes including another case where the patient had a congenital heart disease (ventricular septal defect) and other patient with rheumatic heart disease where Dr. Chen pointed out vegetative growth and the bend knee sign of mitral valve. Before Bor-Han and I went over the EKG room to observe how to place the EKG leads, before taking each other’s EKGs.

Me hooked up to the EKG leads below:

We concluded the day following Dr. Chen through the ward as he checked on several patients. The most fascinating case was a patient that he had been following for over 12 years. Dr. Chen went over the patient’s chart that was currently in the hospital awaiting pacemaker placement due to sick sinus syndrome. Originally the patient was on a beta-blocker to manage his hypertension which was withdrawn in favor of a mixed alpha and beta-blocker in hope to improve his bradycardia. Later the mixed blocker was removed and aminophylline was added to try and increase heart rate before the diagnosis of sick sinus syndrome and pacemaker placement was recommended. One interesting note is that this is the same patient we will be seeing Dr. Tu place a pacemaker in tomorrow morning. In any case today was filled with many exciting topics and I ended up learning a wealth about what cardiologists do.

Cardiology Rotation Day 1 Outpatient clinic and Ultrasound Room 20-June-2011

9:00 am started the day off in the outpatient clinic with Dr. Chen Kuei-Feng (Dr. 陳桂峰). The clinic was very busy; it almost felt like the pace I saw in the TCM department every patient was seen for about 2-3 minutes. Dr. Chen commented that it was possible as most of the patients he has followed for a long time and are in for chronic disease management (hypertension, diabetes mellitus, and hyperlipidemia most common). During the clinic Dr. Chen took time to familiarize Bor-Han and I with the ICD-9-CM International Classification of Disease method of coding and with the drug coding used by the hospital. We also got a review on calcium channel blocker side effects as a few of his patients came in with peripheral edema from Amilo (amlodipine besylate), a long acting calcium channel blocker. There was also a case involving the long term use of NSAIDs to manage joint pain that has resulted in gastric ulcers; Dr. Chen mentioned he had recently switch the patient over to a COX2 NSAID but it has not done much to stop the gastric ulcers. Other interesting things included a discussion about the importance of having patients with high blood pressure keep a daily long of blood pressures as it is more reliable compared to office blood pressure readings due to possible White Coat and other factors.

Later on we end up following Dr. Feng Wen-Kai (Dr. 馮文楷) and later Dr. Tu Chung-Chih (Dr. 涂崇誠) in the ultrasound room as they performed echocardiograms. We ended up learning about some of the basics of echocardiograms including the visualization of the different heart valves and the assessment of ventricular and atrial size. We also got a good introduction about how to correlate chest x-rays, EKGs and echo results to physical exam findings to get a good grasp of a patient’s condition. At the end of the day Dr. Tu, mentioned that he will be doing a pacemaker placement on Wednesday and invited us to observe.