Rotation: Cardiology
Sites:
- Inpatient - Northwest Texas Hospital
Instructor:
- Walter Allison, M.D.
Makeup of team:
Cardiology attending, one upper level resident, one intern
Patient Characteristics for the Cardiology Service
- The team will admit up to three patients per weekday who present with a cardiac-specific complaint. These problems include, but are not limited to:
Chest pain
CHF symptoms that are not life threatening
Palpitations
Syncope
Hypertensive crises
Arrythmias, including atrial fibrillation/flutter and SVT
- The Cardiology Service can admit lesser intensity CCU patients. These patients will be followed by the Cardiology Service, even if they are transferred from the CCU to a floor bed.
- Under unusual circumstances, a floor patient may be considered for transfer to the Cardiology Service. This will count as one of the three admissions for that day to the Cardiology Service.
- Patients selected for the service must not have non-cardiac co-morbities that require initial diagnosis, further evaluation, or aggressive intervention. For example, stable diabetes or chronic kidney disease are acceptable.
- Patients with concomitant organ failure such as those requiring hemodialysis or ventilator management will be excluded from the service. Those who develop such conditions while on the service, even if in the CCU, will be transferred to the ICU service or an appropriate ward team.
- The Cardiology team may on occasion perform consults on cardiac patients on other services (e.g. surgery, Ob-Gyn), involving such conditions as perioperative chest pain, cardiac complications of pregnancy, rhythm disturbances, etc.
Cardiology Service Logistics
- The Cardiology intern or resident will admit any patients triaged to the service between 7:00 AM and 5:00 PM on weekdays. As is the case with the ward teams, the Consult Service resident will be instrumental in admitting patients during the morning hours while rounds are being conducted.
- The upper level resident on call (either the ward team resident, ICU resident, consult resident, or night float) will identify any admissions appropriate for the Cardiology service. This can be accomplished by that resident triaging the patient in the ER following a brief evaluation. If the patient is to be admitted to the Cardiology service, the full H&P will be performed by the Cardiology Service housestaff officer (or the night float if between 9:00 PM and 7:00 AM). The Cardiology Service must respond promptly to any request for admission in order to maintain efficient patient care throughout in the ER.
- The upper level resident on the Cardiology service should be notified of any admissions to the service up to 5 PM. The Cardiology resident can decline the admission to the service if the daily cap of three or total service census of 16 has been reached, or if the patient clearly is inappropriate for the service (i.e., a non-cardiac problem or co-morbidities that would complicate the hospital course). Collegiality will be required to make this work. If a decision on where to admit cannot be reached by the residents involved, the floor or ICU attending will be the final arbiter.
- It is important for the Cardiology resident to notify the ward team resident on call of the admissions status of the Cardiology service at the end of the day so that this can be transmitted to the Night Float resident.
- The Cardiology Service will round on all existing patients on the service each weekday morning with Dr. Allison. On weekends, either the intern or resident will round on the patients and be excused by noon. The weekend ward attending who is on call Saturday will attend on the Cardiology service over the weekend. Dr. Allison will conduct attending rounds approximately every fourth weekend.
- The Cardiology Service will not accept admissions on the weekends.
- New admissions to the Cardiology Service will be accepted Monday through Thursday from 7:00 AM to 5:00 PM and Friday 7:00 AM to 12:00 noon. The Night Float can admit to the service Sunday through Thursday night.
Educational goals/competencies
Patient care
Learning Objectives:
- Evaluation of chest pain (and other symptoms such as dyspnea, syncope, etc., which may or may not be cardiac in origin).
- Diagnosis and management of common cardiac arrhythmias.
- Appropriate utilization of diagnostic modalities for cardiac diseases and heart-related symptoms. Particular emphasis is to be placed on EKG interpretation and use of stress testing.
- Application of therapeutic strategies such as pharmacotherapy and minimally invasive procedures for common cardiac problems.
- Utilization of hospital resources for the efficient evaluation and discharge of patients with cardiac-specific complaints.
Medical knowledge
- A. Coronary artery disease. Residents will be expected to understand contemporary evaluation and management of ST segment elevation MI, acute coronary syndromes, and stable angina pectoris, including the indications for noninvasive evaluation and catheter based interventions. The complications of acute MI should be thoroughly understood.
- Congestive heart failure. Residents should be familiar with the causes, evaluation and management of patients with both systolic and diastolic dysfunction. Residents should understand the management of decompensated CHF, including acute pulmonary edema, as well as best-practice therapies to prevent long term deterioration and sudden cardiac death.
- Arrhythmias. Residents should become adept at the diagnosis of rhythm disturbances and should be familiar with the treatment of common dysrhythmias such as atrial fibrillation, atrial flutter, supraventricular tachycardia and symptomatic bradycardia. Residents should be familiar with the evaluation and acute treatment of wide complex tachycardia, should know when to refer to a cardiac electrophysiologist, and should have some knowledge of device based management of these patients.
- Valvular heart disease. Residents will be thoroughly familiar with the physical exam diagnosis of common valvular abnormalities (especially the characteristic murmurs associated with each) and should understand indications for intervention (both catheter based and surgical) in aortic stenosis, aortic regurgitation, mitral stenosis, and mitral regurgitation.
- Pericardial disease. Residents will be expected to understand the clinical presentation (including physical exam) and diagnosis of pericarditis, pericardial tamponade, and constrictive pericarditis. The use of the echocardiogram and indications for pericardiocentesis will be emphasized.
- Diagnostic methods. Residents will learn interpretation of the EKG through frequent discussion with the attending as well as outside reading. On a daily basis the indications and interpretation of echocardiograms (including transesophageal echocardiograms) will be reviewed. Residents will gain knowledge of the use of left and right heart catheterization, intravascular ultrasound, pacemaker and AICD.
- Miscellaneous. Residents will understand the contemporary management of hypertension, aortic disease (including dissection), peripheral vascular disease, the common presentations of congenital heart disease in the adult, and cardiac disease in pregnancy. The preoperative evaluation of patients with known or suspected cardiac disease (especially CAD and CHF) should be learned as well.
Interpersonal / communication skills
Residents will learn how to obtain a pertinent cardiac history and how to communicate often complicated anatomical and physiological information to the patient. Hospitalized patients with cardiac problems often face life threatening and life changing decisions. The resident will learn how to deal compassionately with patients and their family members in such situations. Residents will learn how to communicate effectively with referring physicians, CCU nurses, and others on the health care team.
Professionalism
Residents will treat all members of the health care team with respect. Since cardiology involves specialized knowledge and techniques that may not be universally understood, the resident will learn how to educate and inform patients and members of the health care team without making them feel belittled.
Residents will regularly see their patients before attending rounds and will make sure that pertinent data is available for rounds. Residents will be on time for rounds and clinics. If the resident has other obligations (i.e. conferences, continuity clinics, etc) he/she will inform the attending ahead of time. If patient care duties (including reading echocardiograms, attending heart caths, etc) entail returning to the hospital or clinic afterwards, the resident will do so.
Practice based learning
Cardiology is a rapidly changing discipline. Large multicenter cooperative studies are constantly being conducted and published, and diagnostic and treatment strategies are constantly being refined. Therefore, the resident must know how to keep up with the flood of new information in cardiology. The resident should have a solid working knowledge of the recent literature and should make use of computer based information systems to keep abreast of these changes. In addition to broader journals such as The New England Journal of Medicine and the Annals of Internal Medicine (which often publish important cardiology studies) residents should develop some familiarity with cardiology subspecialty journals such as Circulation and The American Journal of Cardiology All new information, however, should not be immediately incorporated into practice. The resident will learn how to critically assess such information; the importance of consensus statements and practice guidelines, so important in cardiology, will be emphasized.
Systems based practice
Many of the procedures, both diagnostic and therapeutic, in cardiology are expensive and may entail risk to the patient. Reimbursement systems (medicare, medicaid, managed care plans, etc) may impact on the proper delivery of cardiac care. In addition, cardiac disease can involve long recuperation or debility. The resident will learn about cardiac rehabilitation, subacute or long term care facilities, home health care (i.e. home oxygen, home physical therapy and the medical indications for each). Finally the terminally or irreversibly ill cardiac patient cannot be ignored. The resident will interact with hospice care facilities in providing the care for such patients.
At the Amarillo VAMC residents will operate within a somewhat regimented system but one with innovative features such as physician order entry and a comprehensive computer system that makes many previous studies immediately available. At Northwest Texas Hospital , our service takes care of many patients from the J.O. Wyatt clinic; so the resident will learn how to operate in a system with a restrictive formulary and controls on patient access to subspecialty care. We also see many patients from the Texas Department of Corrections, a system that obviously has several unique features. In particular, we will interact with prison based physicians, the infirmary facility, and case managers, especially when expensive (transplant) or invasive (cardiac surgery) procedures are necessary. Fortunately the hospital and prison based case managers are readily available to assist the resident in learning the intricacies of these systems.
Text/references to be consulted
The main texts for the course will be the cardiovascular section of Harrison 's Principles of Internal Medicine and The Complete Guide to ECGs by O'Keefe, Hammill and Freed. Residents are encouraged to read the Cardiovascular section of the latest MKSAP before starting the course. Major textbooks including Braunwald's can be consulted for in-depth information on specific subjects.
Methods of evaluation
Dr. Allison meets on a daily basis with residents and so has the opportunity to assess performance frequently. In addition to the above core competencies, residents will be assessed on their enthusiasm and attendance on rounds and at lectures and conferences. The standard department form will be utilized. No written exam is given.