TEE or TTE? I'll go for the overestimated EF thank you

Posted by Tom Vassas at Sunday, September 02, 2012

My cardiology rotation has ended to my dismay. Since starting rounds 3 weeks ago, each day has been a tremendous blur.

Generally getting to the hospital by 7, I had an hour or so to work up patients and identify any issues with med therapy I wanted to bring up on rounds. Our team (the Johnston cardiology service) had one attending, one fellow, two interns, two med students, one PGY1 and one pharmacy student. Due to how our rotations are structured it wont always be like that but this month was jam-packed, and it was a hoot every morning.

Rounds started around 815 and each day our attending wanted to go over new patients and had either the med students or interns present them, then interspersed the PGY1 and me would give our recommendations based on home meds, upcoming therapy, better options etc. For the most part, our attending Dr. Labounty, was pretty versed in the most up to date med options for patients and most of the research behind them. In that respect we didn't need to do much, but some issues they just didn't know too much about and deferred to us. Here's a brief list of topics that came up we got to make a difference on:

• Aspirin dosing has changed in the latest recommendations and it was interesting to get the attendings to go lower more often...none of this 162 or 243mg garbage.
• Spironolactone is great for heart failure but I never got Dr. Labounty to start someone on it after an MI, something about borderline EFs not being accurate...surrre
• For the rare patient with contraction alkalosis or simple metabolic alkalosis, he was all too eager to try acetazolamide when he's never used it once before and had no idea what to monitor for it
• Identified possible amiodarone induced pulmonary fibrosis - win
• Pentoxifylline is a great thing to D/C...especially when the patient is going into GI bleeds and needing blood every few days
• Dr. Labounty does not like pradaxa, never heard of xarelto, and will implicitly trust us to dose coumadin...even if someones INR only budges 0.1 with 15mg
• Diuretic conversions are apparently born hither unto all pharmacists and we are presumed to reproduce them as we could our ABCs
• Despite the eagerness of the fellow to load up vitamin K AND FFP, got the attending to think "hmm couldn't I just hold coumadin and not make his INR sub therapeutic for a week?"

These were just highlights and there were a lot more times when it was just a matter of him saying "I wanna do X, is that right?" But being on rounds gives a new appreciation for exactly what your recommendations do to the patient. Not only that side but you learn so much more about that field as far as what actually gets practiced. 

Of all the things I loved about the cardio rotation, two things come to my mind; I have seen many an angiogram and many a TEE/TTE that I will never forget the bright blue colored mitral regurgitation (in fact some guys terrible angiogram with total LAD occlusion made me ok sticking with ASA 325!). The other is on the second to last day when Dr. Labounty asked us if every cardio team gets a pharmacist and we said it isn't always likely. The look of disappointment and the soft spoken "Oh, ok. That's unfortunate" from him really made my month.

Next week is peds general medicine! Stay tuned. And by the way, TTE = trans-throacic echocardiogram and TEE = tran-esophogeal echocardiogram. And TEE is way better.

-TV