Life as a doctor is selfless and selfish at the same time
It was 5:45 in the morning on a Monday after a full weekend of call. Thoroughly exhausted, I shuffled into the elevator and was met by the stench of stale clothing mixed with cigarette smoke. A painfully thin teenager exited, looking lost. I allowed him to wander out, grateful to be spared his odor. I was apathetic, overtaken by a weariness I vowed as a medical student never to have.
Morning rounds passed without incident. All our CABG patients were more or less stable. I collected each patient’s overnight events, vital signs, laboratory values, daily chest X-ray, EKG, fluid balance and wound status. With my attending’...
Source: Kevin, M.D. - Medical Weblog - June 20, 2018 Category: General Medicine Authors: < a href="https://www.kevinmd.com/blog/post-author/farah-karipineni" rel="tag" > Farah Karipineni, MD < /a > Tags: Physician Cardiology Hospital-Based Medicine Surgery Source Type: blogs
Patient with Paced Rhythm in Severe Cardiomyopathy Presents with SOB due to Acute Decompensated Heart Failure
This is a middle-aged male with h/o with a history ofheart failure with severely reducedejection fraction due to dilated ischemic cardiomyopathy (EF 5-10%), probably with some component of non-ischemic cardiomyopathy, with h/o CABG, who is status post ICD placement (and previous appropriate shocks for VT) and biventricular pacer ( " cardiac resynchronization therapy " ), who is on amiodarone for VT suppression, and has h/o LV thrombus and is on chronicanticoagulation with warfarin.He presented forparoxysmal nocturnal dyspnea that didn ' t resolve with use of his home prn diuretics. He was hyp...
Source: Dr. Smith's ECG Blog - June 9, 2018 Category: Cardiology Authors: Steve Smith Source Type: blogs
Weakness, head trauma, and an abnormal ECG
Written by Pendell Meyers, with edits by Steve SmithA man in his 50s with history of CAD s/p CABG, CHF, and COPD presented after several falls attributed to acute generalized weakness. Several had reportedly resulted in head trauma. There was a normal neurologic exam.Here is his ECG:What do you think?Sinus rhythm at around 60 bpm. There is STD with " down-up " T-waves in V2-V6, or more accurately T-wave inversion followed by large U-waves. The morphology is classic for hypokalemia. The computerized QT interval and QTc were 676ms and 663ms, which is really a measure of the Q-U interval instead of the QT interval...
Source: Dr. Smith's ECG Blog - May 27, 2018 Category: Cardiology Authors: Pendell Source Type: blogs
Chest Pain, " Negative " Stress Tests, POCUS, & ECG Equations -- A Case from Salim Rezaie (R.E.B.E.L. EM)
This case is posted by Salim Rezaie (@srrezaie)Chest Pain, “Negative” Stress Tests, POCUS,& ECG EquationsIt has some peer review by me at the end, so we ' reco-posting!!Chest Pain, " Negative " Stress Tests, POCUS,& ECG Equationsby Salim RezaieI was working a busy shift in the ED, like many of us do, and the next patient I was going to see was a 57 year old male with no real medical problems complaining of chest pain. I remember thinking as I walked into the room this guy looks ashen and diaphoretic ….he doesn’t look well. He is a paramedic telling me how he has been having off and on chest pain...
Source: Dr. Smith's ECG Blog - April 30, 2018 Category: Cardiology Authors: Steve Smith Source Type: blogs
You have two hours to save this patient's life
Written by Pendell Meyers, edits by Steve SmithA female in her 60s with history of CAD s/p PCI and CABG, alcohol abuse, and recurrent pancreatitis presented at 14:55 complaining of sudden onset epigastric pain. Initial vital signs were heart rate 44 bpm, respiratory rate 16, BP 143/67, SpO2 96% on room air. On initial exam she was in mild distress and complaining of severe nausea.Here is her initial ECG:What do you think?There is decreased ECG quality due to baseline movement. Despite this, there are clearly hyperacute T-waves in lead III with reciprocal negative hyperacute T-waves in aVL (and lead I) with likely a small a...
Source: Dr. Smith's ECG Blog - March 24, 2018 Category: Cardiology Authors: Pendell Source Type: blogs
Instant Wave-Free Ratio for the Assessment of Coronaries: Interview with Andrew Tochterman of Philips
Philips offers a portfolio of advanced image-guided therapy devices, and has developed instant wave-free ratio (iFR), a method to assess if a coronary stenosis is causing myocardial ischemia.
If a coronary vessel is partially occluded, it is important to assess the extent to which it is reducing the blood supply to the myocardium, as this will affect treatment and prognosis. One way to do this is with a coronary pressure guide wire used to measure the pressure difference before and after the arterial blockage. Typically, clinicians will inject vasodilators to increase blood flow while performing these pressure measurements...
Source: Medgadget - March 23, 2018 Category: Medical Devices Authors: Conn Hastings Tags: Cardiology Exclusive Radiology Source Type: blogs
Prepping intern notes
I received a wonderful tweet based on my nouns need adjectives post.
I’m prepping materials for incoming interns inspired in part by this. Focus is on notes for our inpatient service. Got anything to add?
The idea is to list common chronic problems and specify information that an admission note should include. Here are my thoughts including his suggestions and my modifications
COPD – PFTs if done, current meds, home oxygen?, possibly Gold Stage
Heart failure – systolic function, define type of heart failure, any valvular disease, current meds, if EF < 35% does patient have AICD, EKG – does t...
Source: DB's Medical Rants - March 23, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Syncope, History of Coronary Disease, and ST Elevation: Should Medics Activate the Cath Lab?
A 60-something male had a syncopal episode. 911 was called. The patient had no complaint of chest pain or shortness of breath. A prehospital ECG was recorded:Limb leadsPrecordial LeadsThere is ST Elevation in V1-V3, and in aVL, with reciprocal ST depression in II, III, and aVF.There is also some ST depression in V5 and V6, and ST elevation in aVR.What do you think?The medics interpreted the ST elevation, with reciprocal ST depression, as STEMI, and activated the cath lab.Note that you cannot see the entire QRS on the prehospital ECG. The R-waves in leads II and III are cut off. The S-waves in V...
Source: Dr. Smith's ECG Blog - March 14, 2018 Category: Cardiology Authors: Steve Smith Source Type: blogs
ST-Elevation in aVR with diffuse ST-Depression: An ECG pattern that you must know and understand!
This case comes from Sam Ghali (@EM_RESUS). A 60-year-old man calls 911 after experiencing sudden onset chest pain, palpitations, and shortness of breath. Here are his vital signs:HR: 130-160, BP: 140/75, RR:22, Temp: 98.5 F, SaO2: 98%This is his 12-Lead ECG:He is in atrial fibrillation with a rapid ventricular response at a rate of around 140 bpm. There are several abberantly conducted beats. There is ST-Elevation in aVR of several millimeters and diffuse ST-Depression with the maximal depression vector towards Lead II in the limb leads and towards V5 in the precordial leads.ECG reading is all ab...
Source: Dr. Smith's ECG Blog - February 28, 2018 Category: Cardiology Authors: Steve Smith Source Type: blogs
Right Bundle Branch Block and ST Depression in V1-V3. Is that normal? And a complication.
A late middle-aged male with h/o 3 vessel bypass (CABG), type 2 diabetes, peripheral vascular disease, DVT, Chronic Kideny Disease, and chronic combined systolic and diastolic congestive heart failure presented with chest pain which started approximately 2 hours prior to arrival.Here was the initial ED ECG:Sinus RhythmThere is an rSR ' in V1, with wide S-waves in lateral leads (right bundle branch block, RBBB).Normally, RBBB has a bit of ST depression in V1-V3 that is discordant (in the opposite direction of) the R ' -wave.So that bit of ST Depression in V1 is normal.What about V2 and V3?Notice there is no R ' -wave in V2 ...
Source: Dr. Smith's ECG Blog - February 24, 2018 Category: Cardiology Authors: Steve Smith Source Type: blogs
Critical Issues in PCI : ” Left ” main cries foul . . . calls for “ Right ” thinkers ?
Conquering left main disease is considered as crowning glory for the Interventional cardiologists. For over three decades , CABG has remained the undisputed modality which is being challenged today. Fortunately, the Incidence of true isolated left main disease is low .(If Medina bifurcation subset is excluded)
With growing expertise , advanced hardware and Imaging ( like a 360 degree OCT fly through view ) one can virtually sit inside the left main and complete a PCI .
Still , coronary care is much . . . much . . . more than a technology in transit !
Most importantly, these complex PCIs require rigorous...
Source: Dr.S.Venkatesan MD - February 10, 2018 Category: Cardiology Authors: dr s venkatesan Tags: CABG Indications cardiac surgery Cardiology -Interventional -PCI cardiology -Therapeutics Cardiology -unresolved questions cardiology wisdom cath lab tips and tricks best option for left main disease left main pci or cabg precombat synta Source Type: blogs
Bilateral internal mammary artery grafting for CABG
– Representative image
Bilateral internal mammary artery grafting for CABG
Advantage of bilateral internal mammary artery grafting (BIMA grafting) for coronary artery bypass grafting over using a single arterial conduit (left internal mammary artery) is a better survival documented by a meta analysis of 9 observational studies involving over fifteen thousand patients with follow up over 9 years [1]. But there is a reluctance of some cardiac surgeons to use both internal mammary arteries for fear of deep sternal wound infections, often causing mediastinitis. Important risk factors for deep sternal wound infections ar...
Source: Cardiophile MD - January 9, 2018 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: General Cardiology Source Type: blogs
Off pump vs on pump CABG
On pump CABG is the conventional method in which heart is arrested using potassium rich cardioplegia solution and the heart lung machine takes over the circulatory and gas exchange functions of the body. In off pump CABG, heart is fixed using suction devices and it continues to beat while bypass grafting is done. But the procedure is technically more demanding for surgical skill and potential risk of incomplete revascularization may occur. The theoretical advantages of off pump CABG are the reduction of systemic inflammatory state related to cardiopulmonary bypass, microemboli, increased permeability of blood brain barrie...
Source: Cardiophile MD - January 8, 2018 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: Cardiac Surgery Source Type: blogs
Risk factors which can affect the outcome of CABG
(Coronary Artery Bypass Grafting)
Age and gender: advanced age and female gender have less favourable outcome.
Previous cardiovascular events: prior cardiovascular surgery, interventions, myocardial infarction, stroke or transient ischemic attacks.
Cardiovascular variables: left ventricular function, hypertension, cardiac arrhythmias.
Diabetes mellitus, chronic renal disease, chronic obstructive pulmonary disease.
Complexity of disease: number of vessels involved, severity of associated valvular stenosis or regurgitation and endocarditis if any.
Hemodynamic status and urgency of surgery.
Pulmonary hypertensi...
Source: Cardiophile MD - January 6, 2018 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: Cardiac Surgery Source Type: blogs
How value-based pay can worsen patient outcomes
Results of a study released JAMA Cardiology demonstrated that lower readmission rates among hospitalized heart failure patients, a key focus of recent Medicare value-based payment efforts, were associated with increased patient mortality. In other words, patients admitted to the hospital for heart failure are being re-admitted less frequently, but dying at higher numbers. Value-based pay, as it turns out, where monetary incentives and penalties are tied to the results of various quality metrics, may cause more harm than good. More troubling still is that Medicare has made such programs the centerpiece of its payment reform...
Source: Kevin, M.D. - Medical Weblog - December 28, 2017 Category: General Medicine Authors: < a href="https://www.kevinmd.com/blog/post-author/matthew-hahn" rel="tag" > Matthew Hahn, MD < /a > Tags: Policy Cardiology Public Health & Source Type: blogs
