PGY-1 Cardiology

PLACES TO SEE AND BE SEEN:

1. Be at the alcove on the CARE floor at 7:30 am every morning, including
weekends. Unless it is your day off. The weekly schedule telling you what
day you have off is above the printer in the alcove.
2. Call Room is back by the cardiac rehab doors, when you get off the
elevators on the 6th floor facing the CARE unit, take a left down the hall
and the G1 call room is a few doors down on the left. It is
the handlettered sign something to the effect "Call room, for heart
lovers only." The G3 call room is next door.
3. Morning report is at 8:15 on the 5th floor, go past the first hallway of
the cardiology clinic and take a right at the second hallway by the desk
and follow it to the end.
4. Rounds usually start at 9 am. If a team is post call, rounds start in
the CCU Conference Room. If a team is on call, rounds start in the CARE
conference room.
5. On your post post call days, your team is the consult team. This means
in addition to seeing your patients you are seeing new consults from the
rest of the hospital. Generally you staff these in the afternoon on
cardiology rounds unless there is something urgent in which case you should
tell the fellow/cardiology staff immediately.
6. Consult rounds start in the afternoon, usually at 2 pm and meet in the
alcove.

Most of your patients will be on CARE, CCU (behind CARE), or short stay
(down the hall from CARE near dialysis)

HOW THINGS WORK:

1. You are on the Cardiology C team. The sister team is A. This means both
teams have the same internal medicine attending and the C senior covers day
float for A when A is post call, and vice versa. Generally, you should know
the A patients in addition to your own.
2. The A/C teams and B/D teams have 2 different internal medicine
attendings. There is one cardiology staff and one fellow for all of the
teams. Fellow is a good resource. You staff everyone through the internal
medicine attending, usually first. The attending will decide which patients
need to be seen by the staff cardiologist (unless it is pretty
straightforward, such as STEMI, then usually the on call
cardiologist/interventionalist is on board from the stab room). For
example, usually people who are getting caths, CHF exacerbations are seen
by thecardiologist.
3. Usually the interns and day float from the other teams will sign out to
you. Make sure your senior knows about sick people.
4. Technically G1s are not supposed to do discharge summaries. Ask about
this for details.
5. If you see a consult, it is your responsibility to follow that person
daily and update the staff cardiologist until the team signs off. Remember
this, it has been an issue recently.
6. Have EKGs ready for rounds. Be on the lookout for good conference EKGs.


COMMON ISSUES

1. During every call night you will likely be getting a few ACS rule outs.
Make sure everyone has serial EKGS (at least 2) and 4 troponins- one on
admission and then 3 more 4 hours apart. If those are unchanged and normal,
then someone is "ruled out." Not everyone gets a stress test. If you think
someone needs a stress test or echo, then go ahead and order one for the
morning (This is definitely okay with Dr. Walsh, others I am not
sure.)Usually you should get fasting lipid panels for the next morning
also. Classify people as chest pain, typical, chest pain atypical, chest
pain, non cardiac.
2. If you are called for chest pain, evaluate the patient, get an EKG to
look for a change, give nitro/morphine. Order trops if you think they need
them. Indications for cath (at least calling the fellow) are 1. hemodynamic
instability 2. EKG change 3. Persistent chest pain not controlled by
adequate nitro/morphine (don't snow them!).
3. If you are called by CCU for something scary such as cp and sob with
desats, get RT and BiPAP, EKG, CXR, give fluid boluses if they are not in
pulmonary edema. This is at least a good place to start. Oh yes, and call
your senior!
4. If you are called for arrhythmia, get stat K, Mg at very least, EKG with
rhythm strip, see if patient is symptomatic and look at their drugs for a
culprit. Esmolol drips are good for afib with RVR but they don't do them on
the CARE floor. Diltiazem drips are ok on CARE floor. I wouldn't start one
of these without consulting with your senior.
5. CHF exacerbations: if really bad, BiPAP and nitro drip in addition to
the following. If stable resp-wise, diurese them, get a foley in if you
can, write for strict I/O and daily weights, and figure out what set them
off.
6. Conditions to think about with bad hypertension: renal artery stenosis
(consider renal ultrasound), hyperaldosteronism (consider serum renin/aldo
levels), pheochromocytoma (VMA assay)
7. Generally: all patients with CAD or s/p acute MI get beta blocker
(metoprolol or carvedilol if in HF), ace inhibitor (lisinopril), asa,
statin (simvastatin is generic), and plavix if they get a stent. Be careful
of starting beta blockers in acute decompensated HF.
8. If you are on call, you are part of the code team.

STRESS TESTS:

No stress tests on the weekend. Sorry.
If you think a patient needs one in the am...
1. Ask if they can walk/run on treadmill for 6-12 minutes. They need to get
to 80% of their max heart rate (220-age then x 0.80). This is an exercise
echocardiogram.
2. If no, then adenosine sestamibi is your best bet. Patients need to be
npo at least 2 hours before
3. If they have some sort of contraindication to adenosine sestamibi (bad
bad asthma, for example) you can order a dobutamine stress echo.

Look and see what kind of stress tests people have had in the past and try
to order the same test, because then you can order the same kind of test
and compare past results.

Echos: Many people will end up getting transthoracic echocardiograms (TTE)
to look for things like systolic function, EF, wall motion abnormalities,
volume status. Most people with CHF exacerbations will get that. Again,
feel free to order in the middle of the night if you are confident your
patient will require. Techs must get called in on the weekends for echos.

Discharges: do not d/c people with follow up in medicine clinic. Have
people follow up with specific internal medicine doctors, or put in
referral to medicine clinic.