When a premed student comes to shadow me, they are wide-eyed, enthusiastic, and giddy. When I place a stethoscope in their ears, there is always a brief moment of silence, then a broad smile upon hearing the heartbeat of a stranger for the first time. This older seasoned cardiologist seeks to impart the knowledge that can come only from experience. It set me to thinking: what tricks of the trade would I teach my younger less experienced self? How many lives could I have saved or improved over the course of my 26 years of private practice if I had known then what I know now?
The following tidbits have saved countless disasters from befalling my patients. I invite you readers to add some of your own.
Telemetry: Check It Every Single Day
Every day we discharge thousands of vulnerable humans with runs of atrial fibrillation, asystoles, atrial tachycardia, and Vtach in the name of “monitor fatigue.” Our decision to review these telemetry strips (or not) will influence whether some of our patients die prematurely, fall down or stand up, or continue to move their body parts symmetrically for their lifetime. Every nurse should check the telemetry of each of their patients when they first come on duty and again before they leave, but they don’t.
They don’t have time, and many don’t receive training to sort artifact from arrhythmia. We cannot count on the monitor tech to bring our attention to abnormal rhythm strips, either. Many of our patients have a lot going on in the rhythm world that is recorded but never acknowledged, and I’ll bet this affects 30-day admit rates. (I’m sure some smart lawyer can find those strips even if we can’t.)
Orthostatic Testing—Don’t Seat Them
One of my pet peeves is the manner in which orthostasis is often tested. The patient is instructed to assume the supine position for 5 minutes while the baseline heart rate and blood pressure are recorded. They are then usually told to sit for a minute and the vitals are again recorded. Then we ask them to stand for 1 minute and vitals are recorded yet again.
Do you sit for 1 minute before you stand when you get out of bed in the morning? No. You will get more bang for your buck if you test supine, standing at 1 minute, and check again after 3 minutes standing.
Check a Dog’s Nose and a Human’s Tongue
I recall once being paged stat for hypotension. When I ran to the ICU, neosynephrine was dripping and the monitor was flashing 80 mm Hg systolic. The patient was awake but weak. I called for the echocardiogram machine to be brought to the bedside.
Meanwhile, I asked the patient to “stick out” their tongue. It was so dry that if I’d flicked it, it would have become dust. A quick echo confirmed a left ventricular ejection fraction of 70% and no significant abnormality. Two liters of saline later, the neo was off and the patient was mentating normally. We have to remember that BUNs lie about hydration, especially in older patients, but tongues are sometimes a pretty good measure.
Syncopal/Presyncopal: Get Their Feet Up
I’ve held up legs in the church balcony (and pew), on an airplane, and in hospital bathrooms multiple times. Vagal folks and even folks with supraventricular tachycardia (SVT) will often respond to a leg raise. No medical experience is required and it gives panicking family members and bystanders something to do that’s actually helpful. While the syncopal or presyncopal person’s legs undergo the ole heave-ho from bystanders, we doctors have more time to attend to, well . . . doctor stuff that might also be impactful on the outcome.
How to Ascertain If It’s a STEMI or Repol?
ST-segment elevation MI (STEMI) or repolarization? It’s usually a crazy question regarding a patient with no chest pain but a funky-looking ECG. Sometimes, even more confusing is the case with funky chest pain and a funky ECG. You hate to haul them into the cath lab for nothing.
Since we don’t have seamless EHRs in this country, we often have no previous ECG for comparison. If echo is handy, it’s helpful because lack of a wall-motion abnormality is a good vote that it’s not a STEMI. A negative troponin despite 3 days’ worth of chest pain also makes STEMI a low-probability diagnosis, but if you can’t sort it, or if your gut keeps nagging you, then to the cath lab you must go.
Respect the RV
I once saw a gentleman with a hip fracture and a 2-year-old coronary angiogram demonstrating patent stents (for CAD without angina). He proceeded to do a “mini-crash” in the OR. He complained of chest pain as he awoke on the operating table, became hypotensive, and required 2 units of blood. Although it didn’t make much sense, the STs were depressed across the precordium and the troponin elevated to 1.4 ng/mL the next morning.
Thank God I repeated the echo. The right ventricle (RV) had stretched to about one-third greater than the presurgery size and had become pretty darned lazy. The RV systolic pressure increased by 20 mm Hg. The LVEF was still pristine. A CTA demonstrated a logjam in the left main pulmonary artery and right-sided emboli as well.
I never knew if he had parts of his hip in his lung or just a clot, but no matter, he rocked out great with some anticoagulation. If you have even a slight suspicion of pulmonary embolism, you’d better work it up. If your gut feeling is to repeat an echo in a very sick patient, just do it. Furthermore, if your patient’s RV isn’t functioning on echo, you’d better ask why with a D-dimer, a sleep screen, a COPD screen, or another look for an interatrial communication.
Not All Arrhythmias Need to Be Treated
The young Dr Walton-Shirley would have added a beta-blocker or calcium-channel blocker for any eight-beat run of SVT on a Holter. I’ve learned since that the adage “True, true, and unrelated” often applies to Holter readings. If symptoms are ongoing, marry them to an arrhythmia with a 30-day event monitor.
On the other hand, if the patient has a ton of runs and palpitations, it’s usually time to pull the trigger and prescribe a rate-slowing med.
Trust and Touch the Patient
Believe the patient, not the record. It sounds trite, but it’s a rule that has served my patients well. I saw a patient recently for “angina” who was nearly obtunded. His temperature had just been recorded at 98.7°F.
His back was so hot when I rolled him over that I could have fried an egg on it. I called for the nurse to recheck his temp and it was 103.7°F. He’s a mouth breather, so his temp had likely been elevated for hours. Furthermore, rolling him over produced severe pain, revealing that the cause of his “angina” was noncardiac. Further testing revealed an epidural abscess of unclear etiology
As practitioners, we must touch people. It’s easy thing to ask for a repeat temp. Take the time to do it, and it will pay off in spades.
Remove Shoes and Socks
A rather plump 70-year-old lady with diabetes was referred to me because of her hypertension. She sat on the exam table with her shoes and socks still in place. When I took off her shoe, I smelled a peculiar odor and when I removed the sock, the right great toe was a red, oozy ball of pus. “How long has your toe looked like that?” I asked. “About a year,” she answered, which meant my exam table wasn’t the only one she sat on with her shoes and socks in place.
She got an immediate referral to wound care and a later discussion to make certain she had undergone an arterial Doppler.
Look Under Their Feet
I took excellent care of a patient’s heart for 15 years. We went through angioplasties, bypass surgery, and an electrophysiology evaluation for frequent PVCs. I kept her just above the ICD waterline with tons of heart-failure meds (avoiding a defibrillator to this day).
A while back, she came in for a preop risk assessment for melanoma excision. “Where is your melanoma?” I asked, assuming it was on some body part that no cardiologist would be faulted for not examining. “Right there,” she said, pointing to the sole of her foot.
My heart sank. I had taken off her shoes and socks a million times, but I’d never looked under her foot. I made sure she had 2+ dorsalis pedis and posterior pulses and no pitting edema but I never craned my head a few degrees southward to check the soles of her feet, and so she’s now fighting for her life.
After shadowing me, a premed student leaves knowing what it is to be invited into the private lives of strangers every day. They will long for the opportunity to enjoy the exhilaration of saving a life and simultaneously fear the agony of every missed diagnosis. I cast pearls of knowledge before them in the hope that this helps them be a better physician, and my ultimate goal is for them to be better than the younger me.
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