STEMI – the role of the fellow.

You are rounding on a weekend, STEMI in the ED, more than likely you will be the first one on the scene to see the patient as most of the staff and interventionalist are at least ½ hour away. You should keep a few things in mind as your role:

1. Make sure the cath lab team is activated, call the operator just to see if all the calls went out.
2. Get a pertinent history from the patient about the event, when it started, quality, etc.
3. Make sure you get history about any bleeding problems in the past or planned surgeries in the future (if something big coming up soon, you may need to place a bare metal stent).
4. NEVER EVER EVER EVER hold up transport to the lab for any reason. Do not waste time getting right sided leads if the patient is about to go up, if you have some time, it would be a nice academic exercise.
5. Try to help the team to set the patient up on the table and get ready with your lead to get started. You do not want to be the last person in the room with your lead on, as everyone will be doing things and will not have time to help you get ready.
6. In the lab, try you best to stay out of the way and help when asked. More often than not, it is high stress environment and the artery has to be opened up ASAP, so the adrenaline is flowing.
7. Never ever let go of the wire, if you are asked to hold it in place. Just stare at it once it is between your hand and the table, glance at the monitor as well to make sure it is not moving, but do not let go.
8. After the case, always keep an eye on the groin and document it in the chart, with date and time.

A STEMI is a time to observe and take in everything happening around you, do not get too discouraged if you do not get to do a lot, you will in due time...

HR 150-ish – Flutter or VT (narrow or wide complex)?

You will see this problem quite a bit. With a HR around 150, always make sure you are not missing flutter with wide complex tachycardia (could have baseline BBB). Even if you do not see the flutter wave, look for them with your calipers. Measure the R-R interval with the calipers; place them on the ECG grid lines; take half of that measurement and start looking for bumps along the T-wave for the flutter wave. If you see a clear P-wave, try to march out the flutter waves with the calipers from above measurement. Hope this makes sense, can catch it more than a few times if you look for Flutter whenever you see a HR of 150.

1st Year Cardiology Fellowship: What to read?

There is a lot of material out there to read. Question is what to read your first year as a good foundation. I suggest Braunwald’s Heart Disease. It is by far the most complete text out there for anyone to read. There are also specialty texts out there for each sub-specialty (echo, nuclear, cath) but you can get into those texts later on in your training. There is no need to try and read everything out there on a particular rotation, just make sure you read something basic to get an understanding of things.

More importantly in the 1^st year, make sure you are exceptional with your clinical decision-making. At the end of the day, no matter what or how much you read, if you cannot be a sound clinician then everything else does not really matter much.

How do you tell who is a 1st year fellow?

Check to see who has a bruise on his/her left shin! (oooo the pain of the camera smacking me in the shin)

Always keep one eye on the camera as its in motion most of the time and if you lose track of where it is headed next, you will take it on the left shin. Very painful at times...no worries, it happens.