4. To foster scholarly activity that is both clinically oriented and research based in order to provide the resident with a meaningful understanding of and participation in clinical research, and to provide an opportunity for the resident to develop a personal science research project through meaningful supervised research with appropriate protected time and personnel.
5. Development of a clinical educator. The residents will be assigned teaching roles vis-à-vis their junior colleagues in the Department of Internal Medicine and Primary Care.
Objective: The cardiology resident will be conducting basic introduction to the interpretation of electrocardiograms and during the CCU rotation, will actively teach basic principles of hemodynamic monitoring and care of patients with acute coronary syndromes. To this end, the resident will use the published guidelines by the American College of Cardiology in conjunction with the American Heart Association.
6. Diagnosis and treatment of serious, acute disease in intensive and non-intensive patient care settings.
Objective: The resident will be trained to recognize and manage acute emergencies both in the Intensive and Cardiac Care Units as well as on the general floor including:
- Cardiac arrhythmias
- Hypotension
- Hypertensive crisis
- Pulmonary embolism
- Shock
- Cardiac Tamponade
- Acute arterial occlusions
7. Recognize and evaluate all manifestations of arteriosclerotic heart disease including:
- Acute coronary syndromes
- Hypertensive heart disease
- Cardiac arrhythmias
- Valvular heart disease
- Cardiomyopathy
- Pericardial disease
- Pulmonary heart disease
- Peripheral vascular disease
- Cerebral vascular disease
- Heart disease in pregnancy
- Adult congenital heart disease
Evaluate risk factors and educate patients in reducing risk factors:
a. Dyslipidemias
- Smoking
- Blood pressure control
- Obesity
- Diabetes mellitus
The resident is to have an experience in continuity of care in the cardiology clinic setting.
8. Provide the opportunity to achieve proficiency in technical skills required in cardiovascular
care.
a. Basic and advanced cardiac life support
b. Elective cardioversion
- Swan-Ganz right heart catheterization
- Insertion and management of temporary pacemakers including transvenous and external
- Right and left heart catheterization including coronary angiography as outlined below
- Exercise stress testing
- Echocardiography
- Pericardiocentesis
- Programming and follow-up surveillance of permanent pacemakers
- Cardiovascular rehabilitation
9. The resident will acquire basic clinical skills that are necessary to adequately plan the more sophisticated diagnostic interventions as well as therapeutic procedures.
Objective:
a. Detailed and pertinent history and physical examination including review of systems, family history, social history and occupational history.
b. Careful physical examination and attention to physical findings suggesting congenital heart disease, ausculation with attention to signs of valvular heart disease as well as attention to clinical findings of heart failure.
The ultimate goal of training in cardiovascular diseases is excellence that is uncompromising unqualified. The objective of the program is to provide an excellent foundation for cardiovascular residents in pursuit of a clinical career in cardiology and to prepare for certification in the subspecialty of cardiovascular diseases by the American Board of Internal medicine.
OBJECTIVES
- Extensive training in cardiac consultation skills, expertise in technical procedures and interpretation of radiological and pathological information.
- During the rotation in the cardiology clinic, the resident will have exposure to patients who present with ongoing cardiac problems including coronary artery disease, valvular heart disease, cardiomyopathy, hypertensive heart disease, pulmonary heart disease, and cardiomyopathies. The cardiology resident will follow assigned patients under the close supervision of the key faculty in the clinic. During the rotation, topics for review are assigned and reviewed with all the residents on a weekly basis. Diagnostic and therapeutic plans are formulated and discussed with the attending faculty.
- The resident will actively participate in research and is required to produce at least one research paper suitable for publication in a peer-reviewed journal.
- Throughout the entire curriculum, weekly conferences are held as outlined below:
Interventional Catheterization Conference
b. Cardiac Catheterization Conference
c. EKG Conference
d. Electrophysiology Conference
e. Clinical Cardiology Conference with core topics
f. Nuclear Cardiology Conference
g. Echocardiography Conference
h. Basic Science Conference
i. Monthly Cardiology Journal Review
The cardiology resident will actively participate in the conference and will be required to prepare case presentations, discuss hemodynamic and clinical findings as well specialized diagnostic procedures. Monthly Journal Reviews are attended by both the cardiology residents as well as key faculty. Current literature is reviewed and discussed with the attending faculty. This is core accredited. A monthly Research Conference is held where ongoing research projects are discussed and the residents are assigned to ongoing multicenter clinical research projects.
Nuclear cardiology rotations are provided at the University of Michigan Medical Center and Wayne State University, Harper Hospital. During these rotations, the cardiology resident will be instructed in imaging techniques in association with stress testing as well as cardiac function analysis (MUGA scan).
During the third year the cardiology resident has the unique opportunity to gain exposure to congenital heart disease during a rotation at Wayne State University’s Children’s Hospital.
During the third year the program will combine research and advanced training in the following tracts: invasive, non-invasive cardiology, and cardiac pacing.
STRUCTURE
All physicians accepted into the cardiovascular training program at Providence Hospital are either certified in Internal Medicine or expected to be certified during the first year of their cardiology residency. The cardiology residency training is divided into a core curriculum of basic training in cardiovascular diseases, which is required of all trainees in order to achieve competence as a consulting cardiologist. Additional training in one or more specialized areas during the third year of the fellowship is available and includes additional time spent in a non-invasive or invasive laboratory, such as echocardiography, electrophysiology or cardiac catheterization with intensive instruction in interventional percutaneous transluminal coronary angioplasty, cardiac pacing, and other interventional procedures.
Providence Hospital is the primary institution responsible for training of the cardiovascular resident. It is a 459 bed, not-for-profit tertiary care hospital, affiliated with the Ascension Health System. The average daily census for medicine is 80 patients, of which 34 patients are on the cardiology service, 29 on the oncology service and the remainder on general medicine and other subspecialty services. Providence Hospital sponsors ACGME approved training programs in internal medicine with subspecialty residencies in cardiology, gastroenterology and oncology, as well as training programs in general surgery, obstetrics and gynecology, family practice, radiology, plastic surgery and sports medicine. There is a transitional-year residency and a residency in neuro-otology and craniofacial reconstructive surgery. Providence Hospital has a major affiliation with Wayne State University. There is a limited affiliation with the University of Michigan. A cardiology resident spends the majority of his rotations at Providence Hospital with elective rotations at Children’s Hospital of Michigan, at Wayne State University affiliated hospitals and at the University of Michigan.
First Year Cardiology Residency
During the first year the cardiology resident spends a 12-month rotation in one-month blocks on one of the clinical services:
-two months Cardiac Care Unit
-three months Consultation Service
-three months Non-Invasive Service *
-three months Cardiac Catheterization Laboratory.
-one month of Cardiac Surgical Unit Services
(*One month with major emphasis on ECG, ECG stress testing, and ambulatory holter monitoring.)
During this time the resident is expected to develop basic cognitive and procedural skills including:
-left and right heart catheterization
-temporary transvenous pacemaker insertion
-intra-aortic balloon pump placement
-exercise and chemical stress testing with or without imaging studies
-transthoracic and transesophageal echocardiogram performance.
This is accomplished through the supervised performance of consultations, daily hospital rounds and active participation in procedures under the supervision of attending faculty. Clinical decision making and a cost-effective scholarly approach to cardiology problems are emphasized through teaching rounds, clinical rounds and clinical conferences. The first year cardiology resident is expected to present cases at the clinical conferences. A first year resident will be assigned or will participate in one or more research projects which should be completed, if possible, during the second or third year.
Second Year Cardiovascular Residency
The second year resident in cardiovascular diseases will spend nine months assigned to the clinical services with responsibility for decision making under the supervision of an attending faculty member. During the second year he or she will complete the required time for the first two years which include:
- Two months of Consult Service
- Three months of Noninvasive Imaging Service
- Two months of nuclear cardiology
- Three months in the cardiac catheterization laboratory
- Two months in electrophysiology
The inpatient experience during the first two years will comprise nine months of non-laboratory clinical practice activities, i.e. consultations, cardiac care unit and post operative care of cardiac surgery patients. Two months will be devoted to the electrophysiology rotation and pacemaker follow-up as well as ICD follow-up. In addition to further developing clinical and echocardiographic skills, the resident will develop more complex procedural skills as outlined below (cardiac catheterization, interventional procedures, transesophageal echocardiograms and electrophysiology studies) and will develop an appreciation for the indications, contraindications and technical limitations of these procedures. He/she will serve as a primary teaching resource for medical students, residents and first year cardiology residents.
Up to three months may be spent in outside rotations in pediatric cardiology and nuclear cardiology.
During the nuclear cardiology rotation the resident will be instructed in the basic properties of nuclear material and the handling and performance of nuclear testing both at rest and during exercise. He or she will interpret nuclear scans with the attending faculty.
The research component of the program requires the resident to complete one or more research projects under the supervision of key faculty.
Third Year Residency
The third year resident in cardiovascular diseases can follow two of three tracks: 1). invasive and non-interventional; or 2). non-invasive with nuclear training ; or 3). cardiac pacing.
1. During the invasive track the goals are perfection of procedural as well as clinical and cognitive skills.
Objective: The resident will participate actively in the performance of diagnostic cardiac catheterization as well as interventional procedures and will be involved in the training of junior residents assigned to the catheterization laboratory. All of this will be under the close supervision of the attending faculty.
In the intensive care and cardiac care setting, the senior cardiology resident will supervise and assist in the performance of emergency procedures such as right heart catheterization, temporary pacemaker insertion, pericardiocentesis, and elective and emergency cardioversions.
2. In the non-invasive track the senior cardiovascular resident will spend more time in the echocardiography laboratory where he will be responsible for supervising exercise and chemical stress tests as well as improving his skills in echocardiography with particular emphasis on transesophageal echocardiography and intravascular ultrasound.
3. In the cardiac pacing and electrophysiology laboratory the senior resident will be participating in diagnostic electrophysiology procedures, insertion of permanent pacemakers and insertion of implantable cardioverter defibrillators. One of the goals is for the resident to be a primary operator or assistant in at least 50 pacemakers and spend at least 100 hours in pacemaker follow-up.
During the third year the cardiology trainee can emphasize those rotations in which he or she seeks to obtain additional qualifications by choosing to spend a fourth year in:
- interventional cardiology
- echocardiography
- nuclear cardiology
The trainees will maintain records of participation in the form of a logbook documenting their participation in procedures such as cardiac catheterization, interventional procedures, echocardiograms, transesophageal echocardiograms, cardioversions, pacemaker implantations, and electrophysiologic procedures such as ablations.
Effective July 2002, there are two required rotation during this year and that is pediatric cardiology and CCU service. . During the rotation in pediatric cardiology the resident will acquire diagnostic skills in the diagnosis of congenital heart disease including ventricular septal defects, atrial septal defects, patent ductus arteriosus, transposition of the great vessels as well as more complex congenital abnormalities. During the senior CCU rotation the resident will function as the junior CCU teaching attending, with direct supervision from Dr. Delano Small. This will offer an opportunity for the resident to display the acquired knowledge and skills and demonstrate his or her scholarly attitudes for final polishing.
This third year permits the trainee to obtain greater experience and supervised training as well as the opportunity to demonstrate his or her acquired knowledge of cardiovascular disease.
IMPORTANT REMINDERS
1. Resident Duty Hours:
§ Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities.
§ Duty hours are defined as all clinical and academic activities related to the residency program. This includes patient care, related administrative tasks, transfer of patient care; time spent in-house during call activities, and scheduled academic activities.
§ Residents must be provided with one day out of seven free from all educational, administrative and clinical responsibilities, averaged over a four-week period, inclusive of call time. One day is defined as one continuous 24-hour period.
§ A minimum of ten hours for rest must be provided between all daily duty periods and after in-house call.
On-Call Activities
§ In-house call can only occur every third night, average over a four week time period.
§ Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for an additional six hours to handle educational, administrative, or transfer of care tasks. New patients cannot be accepted during this six-hour period.
§ At home call is not subject to the to the every third night limitation. Residents must still be provided with one day in seven off.
Summary
Duty hour regulations described above are mandated by both the ACGME and the AOA. These duty hour guidelines are important for several reasons, which include:
- the resident’s ability to function in an uninhibited, alert manner without compromise to patient care and/or patient safety
- the resident’s well being
Any resident presented with obstacles from an attending, making it difficult to adhere to the above described policy, is asked to speak with Dr. Christian Machado, Program Director, Cardiovascular Medicine or John D. Marler, Director of Medical Education, to remedy this situation. Residents who do not comply with these policies, not only place in jeopardy all programs here at Providence Hospital and Medical Centers, but also their individual well-being. Therefore, noncompliance will not be tolerated. Offending residents will have their contracts terminated.
2. Curriculum: Each resident is required to review the curriculum prior to the rotation and report any deviation from the curriculum to the program director. Each resident has signed an affidavit indicating that he has read the curriculum.
3. Absenteeism: Each resident must notify the attending physician of that rotation and the program director of any absences from the rotation. Absenteeism without notification will be a direct violation of the resident’s contract and subject to termination.
Created for Cardiology Program 05/05
CURRICULUM
Cardiac Care Unit (CCU) Rotation
Daily Schedule for CCU
Mon-Fri
7:00am - 8:00am: Management and teaching rounds with the cardiology attending. Reviewing with the residents and fellows the new patients admitted to the CCU thru the night, as well as other patients care issues.
Morning conference with teaching rounds Monday-Friday.
8:00am - 12:00 noon: Patient Care
12:00 pm - 1:00pm: Noon Conference (Internal medicine)
1:00pm - 2:00pm: Review of CXR, Echos, and Cath films with cardiology fellow.
2:00pm - 5:00pm: Patient Care.
5:00 pm - 5:30pm: Rounds for the review of the days events and sign-out with fellow/PGYIII.
5:00pm - 8:00 am: Resident On-Call for Cardiac Care Unit
PGYII IM resident on call for CCU
Cardiology Fellow on call for CCU
Sat - Sun
8:00am - 9:00am: Management rounds with the cardiology fellow.
9:00am - 11:30am: Patient care.
11:30 am - 12:00am: Sign out round with the cardiology fellow and night resident.
12:00pm - 8:00am: PGY II/III IM resident on call for CCU on Saturday.
8:00am - 7:00am: PGY II/III IM resident on call for CCU on Sunday.
CONFERENCE
- Medical Grand Rounds every Thursday 7:00am to 8:00am
- ECG Conference with Dr. Frank Hull, first Thursday of the month.
- EP and Arrhythmia Conference with Dr. Machado, every other Thursday of the month.
CORONARY CARE UNIT ROTATION FOR THE HOUSE OFFICERS AT PROVIDENCE HOSPITAL HOSPTIAL AND MEDICAL CENTER
1. Description
This is a one month rotation provided by the Division of Cardiology in the Providence Hospital Cardiac Care Unit, and 15 bed unit dedicated to the diagnoses and management of tertiary levels of life threatening acute cardiac illness.
2. Goals of the rotation
Identification of patients with life threatening acute cardiovascular disease.
Learning systematic approach to the diagnosis of acute life threatening cardiovascular disease incorporating elements of history taking, physical examination, ordering and interpreting various tests and sharpening skills of same.
Learn appropriate management of cardiac care patients, including those with acute coronary syndrome, arrhythmias, valvular heart diseases, CHF, aortic dissection, hypertensive emergencies.
Learn appropriate use of cardiovascular tests-their benefits, risks and limitations.
Achieve better understanding of CCU pharmacology- benefits, side effects and adverse reactions.
Improve technical skills in arterial line/central lines/ Swan-Ganz catheter/transvenous pacers under direct supervision of cardiology fellow/staff attending.
Learn indications for cardiac catheterization, revascularization, EPS, pacemakers and ICDs.
3. OBJECTIVES
1. The resident will obtain extensive experience with the management of intensive care patients with acute cardiovascular disorders and acute coronary syndromes.
2. The resident will understand the indications, risks and benefits of
a. Cardiac surgery
b. coronary angioplasty
c. various paces of cardiac rehabilitation
3. The resident will learn the necessary procedures in the management of cardiac care unit and intensive care unit patients, which includes:
a. pulmonary artery catheterization
b. insertion of temporary pacemakers
c. insertion of intra-aortic balloon pumps
d. elective and emergent cardioversions for both atrial as well as
ventricular arrhythmias
4. The resident will read, understand and apply the latest ACC/AHA guidelines for the treatment of acute myocardial infarction and acute syndromes in general.
REFERENCE
Website: www.acc.org/clinical/guidelines
4. Management team- The CCU will be managed by a team of physicians as follows:
Attending Physicians: BC/BE Cardiologist on staff
Cardiology Fellow: HO IV through HO VII
Resident: HO II or HO III in Internal medicine
Intern: HO I Internal Medicine or ER resident
Medical Student: Clinical rotators in the 4th year
Medical Students engaging in clinical rotation in year 4 may rotate through the CCU primarily as subinterns, performing guided history and physical examination and management under close supervision of the HOII/III
Interns HO I residents will function as primary providers to the patients. Their duty will include performing all initial history and examination and daily notes, order, and coordination of care of the patients with the team.
Residents HOII/HOII role in the CCU is that of a supervisor and guide to their respective interns in addition to serving as primary providers to the patients. They will confirm or correct the interns impressions during the initial history and physical examination and provide guidance in the diagnostic and therapeutic management. Residents will be expected to develop proficiency in basic CCU skills for procedures. Attendance is required at rounds and conferences and active participation is expected.
Attending Physician is responsible for the teaching rounds of the house staff. They will also be responsible for any specific problem that arises in the CCU. He or she will be directly responsible and oversee the CCU fellows rotation. If any invasive procedure needs to be done in the CCU and the personal cardiologist of the patient is not available, he or she will supervise the procedure. He or she will also be the final arbiter of who is to be admitted to or discharged from the CCU in the event of a dispute.
Admissions and transfers to the CCU: Attending Physicians must verbally communicate with the HO III/fellow rounding in the CCU during the day, or the HO III fellow on call after 5pm weekday, and on the weekends, regarding new admissions and transfers of patients to the CCU.
The HO/III fellow is responsible for notifying the admitting resident.
Responsibilities of the CCU Night Resident. He or she will receive sign out from the senior resident for the days at 5:00pm Monday through Friday, 11:30am on Saturday and 7:00am on Sunday. Night residents responsibilities includes admitting all new patients to the CCU, evaluating patients for potential admission in the ER or any floor in the hospital as required. As soon as they evaluate a patient for admission or otherwise they should call the fellow on call for the CCU regarding that patient. They will also take care of any problem in the CCU on any patient. They are expected to respond promptly to any summons from the CCU and should personally evaluate the patient they are called for rather than, dealing with the problem over the phone. Any problem on any patient should be called to the CCU fellow on call. All problems encounter through the night should be documented in the patient’s chart appropriately including the measures taken. The night resident will round in the morning and present new admissions and problems encounter on other patients.
Responsibilities of the Cardiology Fellows. He or she will be responsible for the daily running of the CCU under the direction of the rounder. He or she will be responsible for the daily teaching of the house staff on their patients. The fellow will assist in coordination of beds in the event of full unit. He or she will be available for the insertion or removal of all invasive lines including intra-aortic balloon pump. They will supervise the procedures of the house staff after acquiring adequate skills. Fellow assist in making decisions regarding CCU admits from the ER and transfers from floor.
Pharmacists and nutritional support will intermittently rotate in the CCU and provide daily input with respect to their particular specialties in the work rounds. Orientation lecture on common CCU medications, dosages will be given at the beginning of each month by CCU pharmacist.
Registered Nurses are responsible for various independent and interdependent patient care processes. They assess, plan, implement and educate nursing and collaborative health care needs through out a patient’s CCU stay. The CCU is staffed with an advanced practice nurse in addition to regular staff who is available for consultations as needed. Nurses collaborate daily with the medical staff through work rounds, education sessions, morbidity and mortality conferences, research activities etc.
5. ROUNDS AND CONFERENCES
Morning Teaching Rounds will be done with the Director of CCU and the rest of the CCU team from 7:00am to 8:00am Mon through Fri., on Sat from 8:00am to 9:00am. On Sun. the rounds will be from 7:00am to 8:00am with the CCU fellow leading the rounds. The night resident on call will present all new patients admitted through the night in the unit and management issues regarding all other patient will be discussed.
All residents and fellow shall go to their respective conferences at 8:00am & 12 noon except in cases of emergencies regarding patient care.
Morning work rounds will start at 8:00am with interns/residents taking care of their assigned patients. Any problems or questions regarding patient care should be addressed to the CCU fellow, and residents/fellow will work as a team in a congenial atmosphere.
The fellow will lead the group to review echo’s, cath films at 1:00pm
Every Thursday between 8:00am to 9:00am Medical Grand Rounds will be conducted in the Fisher Auditorium. Cardiology Grand Round will be on the first Thursday of every month. The staff attending, fellow and the residents in consultation will pick case for the week. Case will be prepared by the HO/fellow with the help of the residents and may be presented by primary care provider for that particular patient. Current literature including practice guidelines relevant to the case will be reviewed and discussed during the conference by the presenting team. All case discussions are conducted with absolute confidentiality as required by peer review and quality assurance standards.
Sign-out Rounds will start at 5:00pm with the CCU fellow or cardiology fellow on call, leading the group.
Quality Assurance and Quality Improvement
The senior fellow rotation I the Cath Lab, Coronary Care Unit and Non Invasive lab will participate in the QA/QI meetings.
6. ADMISSION, MANAGEMENT QUESTIONS
If the attending cardiologist is unavailable, every attempt should be made to reach his/her partner or covering cardiologist.
If partners are also unavailable, the management rounder (Medical Director) designee) should be contacted.
If the rounder is not available, Medical Director of CCU, Delano R. Small, MD, should be contacted. If Medical Director not available, Chief of Cardiology, Shukri David, MD should be contacted.
7. CARDIOLOGY FELLOWS TRAINING AND EVALUATION WITH THE CCU
The medical director will directly supervise the training of the fellows in the CCU. Specific goals will be defined at the beginning of each rotation and discussed with the fellow. The goals identified will follow the core competencies as outlined by the ACGME.
At the end of each month the medical director will complete an evaluation of the rounding fellow with regards to achievement of identified goals.
The medical director will meet with the fellow to discuss this evaluation.
CORE SYLLABUS
ACC/AHA Guidelines for the management of patients with acute myocardial infarction, Executive Summary, 1999 Update Circulation August, 1999; 100: pp 1016-1030
Platelet Glycoprotein IIb/IIIa receptor blockade in coronary artery disease.
A. Michael Lincoff, MD, FACC, Robert M. Califf, MD, FACC, Eric J. Topol, MD, FACC. JACC Vol.35, NO. 5, 000; April 2000: 1103-1115.
Cardiac arrhythmias diagnosis and management. Review article Downloaded from AHA website at WWW,americanheart.org
SAVE: Survival and VentrCCUlar Enlargement Study: Effect of captopril on mortality and morbidity in patients with left ventrCCUlar dysfunction after myocardial infarction. Results of the Survival and VentCCUlar Enlargement Trail; MEJM 327; 669-677, 1992.
ACC/AHA Guidelines of management of valvular heart disease, Bo now et al., ACC/AHA TASK FORCE REPORT
JACC Vol.32, No 5, November 1998: 1486-1588.
Aortic Dissection. Chapter from Braunwald, Text of Cardiovascular Medicine, Fifth edition, Chapter 45, PP 1554-1569.
Intra Oatic Balloon Pump, Chapter from Braunwald, Textbook of Cardiovascular Medidcine, Fifth edition, Chapter 19, PP 535-536.
Mechanical of Acute Myocardial Infarction.
CCU CONFERENCE
The topics of discussion for the conference will include but are not limited to:
1. Acute coronary syndromes
i) Recognition
ii) Management
iii) Complications
- Mechanical
- Arrhythmia
- Post intervention follow-up
2. Aortic dissection
3. Congestive heart failure and pulmonary edema
4. Acute valvular complications
5. Acute pulmonary embolism
6. Pericardial diseases
7. Primary arrhythmia
8. Bedside procedural complications
CCU, M & M : Guidelines for Presentations
Structure of Conference IN ADVANCE, determine how much time you wish to devote to each portion
Case Presentation Minutes Differential dx/discussion: For example, you may wish to
have the audience develop a differential Diagnosis at
various times (identified by X)
History
Physical 10-20 X
EKG
CXR
Labs
Audience Discussion 10-20 X
ECHO
Cath X
Case Summary 1-5
Presentation, including 10
Review of literature
Questions/Comments 5
_______________________________________________________
Preparation of Conference
- Select Case
- Determine 1-3 main teaching points (what are they? Why?)
- Make overheads as well as power point slides
§ Words, phrases, not sentences
§ Diagrams
§ Your summaries, NOT copy of echo, cath report, etc.
§ Problem list
§ Differential diagnosis
§ Articles(s)
§ References
________________________________________________________
Audiovisual Set up power-point unit: (with overhead as backup)
Set up echo; review with attending Review in advance attending or 3rd yr.
CURRICULUM
CARDIAC CATHETERIZATION LABORTORY
Cardiac Catheterization Laboratory Rotations in the Providence Hospital Cardiovascular Training Program.
INTRODUCTION
Providence Hospital has a fully computerized cardiac catheterization laboratory consisting of three digital laboratories with an annual census of over 3,000 cases including over 1000 coronary and peripheral interventional procedures consisting of percutaneous transluminal balloon angioplasties, rotational atherectomies rheolytic thrombectomy, stents, and intravascular brachytherapy. A full complement of percutaneous peripheral vascular diagnostic and interventional procedures is performed. The faculty consists of more than 15 active full time board certified physicians. All trainees will gain a substantive understanding of the indications, limitations, complications and medical and surgical implications of cardiac catheterization, and coronary and peripheral angiography and percutaneous coronary and peripheral interventions.
GOALS
The trainees will be instructed in normal and pathological hemodynamics and angiographic data and will acquire an understanding of the pathology of cardiovascular disease.
- The trainees will learn to integrate and analyze data in order to select cases for diagnostic catheterization as well as percutaneous therapeutic procedures and surgical interventions. Also they will learn which cases are best suited for stand -alone medical therapy.
OBJECTIVES
- The trainees will acquire skills to perform:
§ Right heart catheterizations and pulmonary artery catheterizations with balloon-tipped, flow-guided catheters and will be trained to interpret the acquired hemodynamic data.
§ Insertion of temporary right ventricular pacemakers as well as atrial pacemakers.
§ Pulmonary angiography and left heart catheterization including ventriculography and coronary and graft angiography.
§ Foreign body removal from the right-sided cardiac structure and pulmonary arterial tree.
§ Percardiocentesis for diagnostic or therapeutic purposes.
§ Active participation in the performance of all PCI’s and peri-procedural management.
§ Active participation in peripheral diagnostic and interventional procedures including assessment of renovascular hypertension and PVOD.
§ Learn the indications and safe performance of femoral closure devices and recognize and manage their potential complications.
- The trainees will become familiar with catheterization laboratory equipment including:
§ physiologic recorders
§ transducers
§ blood gas and activated clotting time (ACT) analyzers
§ image intensifiers and other x-ray equipment
§ digital imaging
§ report generation (in-line)
- The trainees are instructed in the principles of shunt detection, cardiac output, determination and wave-form pressure recording and analysis. They are also instructed in the technique of endomyocardial biopsy, as well as the insertion of intra-aortic balloon counterpulsation equipment and management thereof.
Familiarity with adult congenital heart disease is obtained during a one-month rotation on the pediatric cardiology service at Children’s Hospital.
During the rotation in the catheterization laboratory the trainee gains experience in the hemodynamics and anatomy of coronary artery disease, valvular heart disease including aortic stenosis , aortic insufficiency, mitral stenosis and mitral insufficiency, mitral valve prolapse, ventricular septal defects, atrial defects, ischemic and dilated cardiomyopathy, diseases of the aorta, pulmonary embolism and pulmonary hypertension, renovascular hypertension and peripheral vascular occlusive disease.
Coronary angiograms are performed using either a femoral approach or brachial approach. The cardiology trainee participates in each case and is guided by Board certified cardiologists including more than seven interventional cardiologists.
The cardiac catheterization program provides a minimum of four months in the catheterization laboratory and the resident participates in a minimum of 100 catheterizations usually exceeding that number significantly. During the first year three months are spent in the catheterization laboratory with another month in the second year. In the third year up to eight additional months in the catheterization laboratory are optional.
THE RESPONSIBILITIES OF THE TRAINEE
1. Brief work-up of the patients prior to catheterization. This includes documentation in the chart of non-invasive tests that have been performed, obtaining reports of previous cardiac catheterizations, cardiac surgery and other pertinent angiograms. After the pre-cath work-up is completed the trainee discusses the case with the attending cardiologist who will be supervising the procedure.
2. The trainees ensure that the appropriate pre-cath blood work-up has been obtained and is normal. Usual blood work includes CBC, platelet count, PT, PTT, electrolytes, BUN and creatinine and glucose. Clotting studies are particularly important in patients on oral anticoagulants.
3. The trainees review the patient’s medications and history of allergies. Patients with a history of iodine dye allergy, even an equivocal history, should receive dye allergy prophylaxis prior to catheterization. Patients undergoing a PTCA must get aspirin and clopidrogel prior to the procedure unless clear-cut allergies are documented. Patients on long-action Insulin should have a reduction in their dose the morning of catheterization. Potassium should be in the normal range. Patients on Glucophage will have their drug held for 48-72 hours post procedure.
4. The cardiovascular resident helps explain the indications and risks for the catheterization and the procedure to the patient and their family, and obtain an informed consent.
5. The trainees are expected to participate in the follow-up of the patient after the procedure. This may include performance of closure devices and removal of any sheaths that were left in after the procedure, often with continuation of IV GP II BIIIA inhibitor drips. Laboratory, nursing and technical staff may assist in sheath removal.
6. Catheterization reports will be completed on the day of the procedure.
RESPONSIBILITIES OF THE ATTENDING
1. Supervision of all technical aspects of cardiac angiography
2. Explain rationale for procedure including indications
3. Discuss and analyze all hemodynamics and angiographic data with fellows
4. Discuss and explain clinical decision on the basis of evidence based medical knowledge
5. Assist in recognizing and managing complications that arise from invasive procedures
6. Provide ongoing evaluation and feedback to resident
EDUCATION CURRICULUM AND CONFERENCES
Catheterization data is discussed in the bi-weekly Catheterization Conference as well as in the weekly Interventional Conference. The trainees, in addition, prepare didactic lectures to medical residents pertaining a variety of topics pertinent to their cath lab rotation. Dedicated conferences for the presentation and discussion of diagnostic and interventional cases are mandatory for all trainees.
RESEARCH
The residents are expected to participate actively in ongoing research protocols, including developing their own research projects, recruitment of patients, patient follow-up, abstract writing and oral presentation as well as preparation of manuscripts. Research is considered an integral part of the cath lab rotation.
Providence Hospital has a full compliment of cardiac surgeons and an immediate cardiac surgical consultation is available should complication arise in the laboratory. Likewise, vascular surgeons are readily available to assist in management of vascular complications. Over the course of the cardiovascular training program a trainee will have the opportunity to spend a total of 12 months in the catheterization laboratory. During this time he or she will perform over 300 procedures including at least 200 with primary hands-on responsibility. The trainee will also have the opportunity to participate in coronary and peripheral interventional procedures; however, if they plan to perform coronary or other cardiovascular therapeutic interventions, a fourth year of training will be required.
Invasive and interventional training at Providence Hospital has produced well-rounded cardiologists with the tools to pass the subspecialty Boards and become competent attending physicians.
EVALUATIONS
Fellows will meet cath lab director prior to start of rotation and monthly thereafter.
I. Trainees evaluation:
Trainee should be evaluated in such areas as:
a. Case selection and procedural judgment as well as interpretation and technical skills.
b. Quality of clinical follow-up
c. Reliability and work ethic
d. Complications
e. Interaction with other physicians, patients, laboratory support staff, nursing and ancillary staff
f. Initiative and ability to make independent and appropriate decisions are to be considered
g. The competency of all cardiology trainees in cardiac catheterization should be documented by both the program director and the director of the cardiac cath lab
II. Attending evaluation:
All trainees will evaluate attend cardiologist while rotating in the cath lab. Areas of evaluation should include:
a. Level of supervision
b. Feedback about performance and progress during cath lab rotation
c. Level of participation in teaching of the cardiac fellow
d. Availability for answering questions
e. Overall evaluation of the rotation
f. Comments
CURRICULUM
Level I: At least 4 months of training, and at least participating of catheterization of 100 patients.
Level II: A minimum of 12 months of training and at least 300 cath.
REFERENCE
1. Grier, D., Hartnell, G. Percutaneous Femoral Artery Puncture: Practice and Anatomy. The
British Journal of Radiology 1990: 63. 602-604
2. Grossman, Cardiac Catheterization, angiography, and Intervention. (Sixth Edition, 2000).
3. Pepine, Diagnostic and Therapeutic Cardiac Catheterization. (3rd Edition, 1998).
4. ACC/AHA Guidelines for Coronary Angiography (J Am Coll Cardiol 1999; 33:1756-827).
5. Gensini GG, Editor. Coronary Angiography, Mount Kisco, NY: Futura Publishing 1996.
6. Hanley PC, Vliester RE, Fisher LD, Smith HC. Indication for Coronary Angiography:
Changes in Laboratory Practice Over A Decade. Mayo Clinic Proceeding 1986: 61: 248-53
7. Greenberger PA, Patterson R. Adverse Reactions to Radiocotrast Media. Prog.
Cardiovascular Dis 1988: 31: 239-48
8. Textbook of Interventional Cardiology by Eric Topol
9. Cath SAP
CURRICULUM
CARDIOLOGY CONSULT/CLINIC ROTATIONS
Academic Cardiology Service - Outpatient Continuity Clinic/Inpatient Consultation Services
INTRODUCTION
The Academic Cardiology Services (ACS) represents the core of the cardiology resident’s training, through which the trainee is provided with the opportunity to integrate skills and experience she/he has acquired within the specialty rotations of the Cardiac Catheterization Laboratory (CCL), the Coronary Care Unit (CCU), Non-invasive laboratory (NIL), and the Electrophysiology Services (EPS)
From the first day of cardiology training, residents are expected to function as practicing cardiologists, with patient care activity supervised by appropriate faculty. The six trainees function together as a group practice, and will have the opportunity to provide cardiovascular care for patients derived from several sources, including referrals from the clinics of various cardiologist at PHMC, such as General Internal Medicine, Family Practice, General Surgery and surgical subspecialties. In addition, patients who are admitted to the hospital under the designation of “staff” patients are encouraged to refer to the ACS.
The outpatient experience of the ACS consists of the Cardiology Continuity Clinic, located in the Internal Medicine and Specialty Center. This clinic convenes weekly on Wednesday mornings at 09:00 & Friday afternoons. From 0900 hrs to 1200 hrs each cardiology trainee is expected to see between 1-2 new patients and 3-4 follow up patients, supervised by one preceptor assigned to the clinic. Patients consist of referrals from other clinics cited above as well as patients seen in follow-up from recent hospital encounters on the inpatient ACS.
The inpatient experience of the ACS consists of monthly rotation through which each trainee rotates. Each month one trainee is assigned to provide primary cardiovascular care for inpatients of the above patient population. The trainee works closely with the assigned faculty member. In addition to the faculty and cardiology trainee, the ACS inpatient team may consist of one or more medical residents, and one or more medical students. In these instances the cardiology trainee will be expected to function in a formal teaching role. Finally, close communication is required not only among members of the rounding team but between the cardiology trainee rounding on the service and the primary cardiologist for each given patient.
PERSONNEL ON ROTATION
Core of the rotation include one fellow and faculty member. Intern, resident and student may rotate with the service.
LEARNING OBJECTIVES
The curriculum for the ACS is broad, by necessity. During his/her exposure to the inpatient and outpatient ACS, the trainee will have the opportunity to acquire knowledge in:
Prevention of Cardiovascular Disease
Epidemiology and Biostatistics
Risk Factors
Lipid Disorders
Evaluation and Management of patients with:
Coronary artery Disease and its manifestation and complications
Arrhythmias
Hypertension
Cardiomyopathy
Valvular Heart Disease
Pericardial Disease
Pulmonary Heart Disease
Peripheral Vascular Disease
Cerebrovascular Disease
Heart Disease in pregnancy
Adult Congenital Heart Disease
The fellow doing non invasive rotation will also attend the Cardiovascular Rehabilitation Program in which his/her own patient will participate.
GOALS
The goal is for the cardiology resident to function as practicing cardiologist with patient care activity supervised directly by faculty attending physicians.
The cardiology resident will function together as a group practice and will have the opportunity to provide cardiovascular care to patients seen in consultation in the hospital, with continuity of care provided in the fellow's cardiology clinic.
The resident will be skilled in obtaining a history and performing a complete cardiovascular physical examination.
The resident will learn the role of aging and psychogenic factors in the production of symptoms.
The resident will acquire considerable experience to act as a consultant to other physicians and the level of direct supervision and responsibilities will slowly progress in proportion to his or her experiences and qualifications.
OBJECTIVES
The resident will become educated in:
a. Pathogenesis
b. Risk factors
c. Natural history
d. Diagnosis by history
e. Physical examination
f. Laboratory methods
g. Medical and surgical management
h. Complications
i. Prevention of cardiovascular conditions
j. Management of valvular heart disease
k. Management of cardiac arrthymia
l. Management of heart failure
m. Management of infective endocarditis
n. Interaction of pregnancy and cardiovascular disease
o. Cardiovascular complications of chronic renal failure
All of the above issues being common findings in pathology in the inpatient population as well as our outpatient population.
The resident will read, understand and utilize the expert consensus documents on assessment of cardiovascular risks by use of multiple risk factors, assessment equations, published in:
1. The Journal American College of Cardiology 1999, volume 34.
2. Ethical Coding and Billing Practices for Cardiovascular Medicine Specialist
3. Thirty Operative Cardiovascular Evaluations for Non-Cardiac Surgery. ACC/AHA Practice Guidelines Update available on the web at www.acc.org/clinical/guidelines.
ROLES AND RESPONSIBILITIES
CONSULTATION
ROLE OF FELLOW
Fellow is required to do four months of consult with faculty
Fellow responsibilities include:
- Seeing consultations requested of the academic cardiology services, which include patients who are in ER, Units and on the floor.
- For history, physical and daily progress notes
- For all communication with patient, family of patient and primary care physician if any
- Fellow during round should priority to the sick patients
- For sign in and sign out rounds.
- For any dictation to be done on his patient.
ROLE OF ATTENDING
Attending responsibilities include:
a). Bed side rounds are done by the attending physician on every patient every day assigned for that month.
b). During bed side rounds emphasis is given on skills to take history, physical examination and interpersonal relationship with the patient. After rounds patient problem is discussed in detail with emphasis on differential diagnosis and the mostly likely diagnosis. In the last, treatment options are discussed in detail, which are supported by evidence-based knowledge.
c). Availability round the clock if fellow need to ask any questions or need any help regarding supervision of any procedure.
d). Feedback in terms of fellow performance in the beginning, middle and at the end of the rotation.
CLINIC
ROLE OF A FELLOW:
a). Cardiovascular fellows sees patient in outpatient clinic from 9am to 12 noon every Wednesday and Fridays 1pm to 4pm except holidays.
b). In the Cardiovascular Disease Clinic, fellow is responsible for follow up patients whom they have seen in hospital, as well as new patients referred to the clinic by residents or outside physician.
c). Fellow sees the patient and does a complete history and physical first, followed by discussion with the attending cardiologist.
d). Fellow is responsible for following that patient in the clinic as well as in hospital. He is responsible for all test to be done, including scheduling and performing procedures and their result.
e). Fellow is responsible for communication with referring physician/residents.
f). Fellow is required to maintain a log of his/her patients
ROLE OF AN ATTENDING:
a). The fellows are supervised by at least two faculty persons.
b). Attending sees the patient with the fellow after he (fellow) has done complete history and physical/consult.
c). Discuss complete differential diagnosis and discuss various treatment modalities available.
d). Assist fellow in all respect regarding that patient and give complete feedback at the end of the rotation, including discussing evaluation with him one to one.
CONFERENCES
The outpatient clinic experience commences each Wednesday morning with a one hour Clinical Cardiology Conference at 08:00 hrs. the conference format generally allows for the presentation by a trainee of a previously assigned case encountered in the clinic. The presentation is then followed by a brief review of a relevant topic by the presenting trainee, and finally by open discussion among the trainees and attendant staff.
Relevant topics for the conference include a broad range of primarily outpatient issues particular emphasis is placed on primary and secondary prevention topics, including:
Hypertension ( Management of complex cases)
Diabetes Mellitus (special issues affecting diabetic patients)
Dyslipidemia (diagnosis and management)
Peripheral Vascular Disease (diagnosis and management)
Pre- and Post- Operative assessment and management of patients undergoing non-cardiac surgery
Throughout the year intra-mural and extra mural visiting faculty with recognized expertise in the above areas are invited to participate in the Clinical Cardiology Conference.
EVALUATIONS
On a monthly basis evaluation forms are forwarded to each cardiology trainee, to evaluate the faculty precepting in the clinic that month, as well as specifically the trainee rotating on the inpatient service for that month. Assigned faculty will evaluate each trainee monthly based on the outpatient experience, and again specifically the trainee assigned to the out patient service.
Evaluations used are identical to the standard forms used for each of the other rotations. Faculty are expected to assess each trainee’s comprehensive and specialized medical knowledge and provision of medical care, including advanced skills in history-taking, physical examination, clinical judgment, management, and consultation, and their ability to critically analyze clinical situation and make medical decisions. Faculty will also evaluate trainee’s technical proficiency, communications, humanistic qualities, professional attitudes and behavior, and commitment to scholarship.
Evaluation forms will be made available to the Program Director for preparation of the summative evaluation prepared annually.
REFERENCES
1. Diagnosis and Treatment of Chronic Arterial Insufficiency of The Lower Extremities: A Critical Review. Jeffrey I. Weitz, MD, Chair; John Byrne, MD; G. Patrick Clagett, MD;Michael E. Farkouth, MD; Et, Al.; Circ.1996;94:3026-3049.
2. Guidelines For Perioperative Cardiovascular Evaluation For Noncardiac c Surgery Report of The American College of Cardiology Of American Heart Association Task Force on Practice Guidelines (Committee On Perioperative Cardiovascular Evaluation For Noncar
