Week 2 - The Adventure Continues

Week 2 (Written June 29, 2009)
The second week of summer immersion I was stationed in Trans-Esophageal Echocardiogram (TEE). Essentially an ultrasound probe is put down the patient’s throat to image the heart without the attenuation by the chest wall seen in trans-thoracic ultrasound. Both pulsed wave and continuous Doppler is being used. I was shadowing a doctor, Dave, a third year cardiology fellow who was actually finishing his fellowship and leaving to a private practice at the end of the week. Donald was the nurse in TEE, and he was very good at keeping the patients calm and comfortable. The attending physicians, fellows, and nurses are an interesting kaleidoscope of personalities. Some are friendly upfront, they say good morning and they go out of their way to meet the unfamiliar person in the room; others are much more curt or reserved until they see me everyday; and a few look through me pretty consistently. Normally for a TEE there would be a nurse, a fellow, and an attending cardiologist.
First the nurse brings the patient in on a gurney (a rolling bed with rails that can also prop the patient into a sitting position). Next the fellow explains the procedure and risks of the test to the patient, reviews the patient’s medical history, and has them sign a consent form. The worst part of a TEE is actually when the patient must gargle two viscous anesthetics (one is swallowed the other spit out), and the fellow or the nurse sprays a topical anesthetic into the back of the patient’s throat. This is to numb the esophagus and prevent a gag reflex later during the test, but unfortunately it tastes terrible and everyone coughs, a few gag, and some even throw up. It was at this point that I found out I have a sympathetic gag reflex. Then the nurse has the patient roll onto their side, the lights are turned off, and then a medicine that makes the patient sleepy is delivered through an IV. The patient is still able to respond during the test (to swallow, cough, or tighten their stomach muscles), but the drug also makes it so that they remember nothing or very little of the test. A bite block is put in to prevent damage to the patient’s teeth, the probe, or the doctor’s fingers (some unconscious people are remarkably feisty). Then everyone waits for the attending cardiologist to arrive.
Once the attending cardiologist arrives, the fellow inserts the probe (which is about 3 feet long and has a diameter a little less than a quarter), passes the probe over the patient’s tongue, the patient is told to gulp, and the probe is pushed down the esophagus. The week I was in TEE was also the last week for many of the 3rd year fellows and also the week that the second year fellows are getting training for moving into new rotations. So, there were a lot more people in TEE than normal for some of the tests, and I probably learned a lot more since they were taking time to train and explain techniques to the new fellows. Although the fellow is controlling the probe, flexing and rotating it to direct the ultrasonic cone at different parts of the heart, the attending is like a navigator combination backseat driver directing the fellow in which valves and chambers to look at. The very first TEE I saw the new fellow and the patient had a bad time of it (the worst TEE in history according to the 3rd year fellow and the attending cardiologist) – the patient had particularly strong reaction to the flavor of the anesthetic, an unusual shaped palate, and a hyaline hernia. After 4 or 5 tries to get the probe into the patient’s esophagus they found that the stomach had pushed through the diaphragm and was blocking the view of the heart. When they woke the patient up and told them that no pictures could be obtained, he looked so sad that I wanted to cry.
During the week, since I was in TEE for five days, I saw a lot of different TEEs (okay I guess that was somewhat redundant sentence). The coolest part of the TEE imaging modality is that you can see the leaflets of the valves and the walls of the heart moving in real time, a color map of the fluid velocity profile can be used to identify plumes of regurgitation through the valves, and then there’s the bubble test. The bubble test is where agitated saline solution is injected into the blood stream through an IV, the blood enters the right atrium and then the right ventricle. This is used to look for holes in the wall between the right and the left sides of the heart, or a septal defect. Having a hole in this wall is apparently fairly common – almost 25% of the population according to one of the cardiologists – but the size determines how critical it is. The bubbles are obliterated in the pulmonary system so no bubbles should be visible on the left side of the heart, unless there is a septal defect.
People come for a TEE for different reasons. Several patients had arrhythmias but before they could undergo cardioversion a TEE is done to make sure that no clots are present in their heart. The cardiologist checks for clots or thrombi and areas of slow flow (which appears as “smoke” on the screen) if a clot is present, cardioversion is very risky because the clot could be dislodged and cause a stroke. Some people come in with heart symptoms and the TEE is used to try and determine what could be causing the symptoms. One person had a fungal infection in her blood and the TEE was used to check for endocarditis. To avoid giving a laundry list of all the cases – I’ll just mention that the valve replacements were the most interesting to see. Mechanical valves and bioprosthetic valves are checked for regurgitation, if the suture ring is properly seated in the tissue, and if the flow through the valve is appropriate.
The patients have mixed reactions to having the tests explained and signing a consent form. One woman was quite irritated by the process “I don’t know why you are telling me all these things, I have to have the test, so I don’t really care”.
Note: Germ phobia makes sense in a hospital setting. The risk of infection and the potential for fast transmission is immense. There is hand sanitizer everywhere in the hospital (unfortunately now I am completely paranoid when I leave the hospital and subway railings freak me out). One of the things that makes New York City so different from other places I’ve lived is the continuous noise of millions of people all living in the same place all at once. There is constant activity. It is like pure sensory overload 24 hrs a day – monitors beeping in the hospital and sound echoing through the subway, into your windows, and down the street. Perhaps that’s why in elevators most people don’t talk, because other than the ding and the well enunciating voice announcing the floor its somewhat sound insulated, and so they step into an elevator and that is their quiet time for the day.
I really enjoyed the second week of immersion, and I feel like I am getting better at reading new situations and learning to time my questions. If I catch a doctor at the right moment they are willing to let me tag along to something new, such as the “Cath. Lab” or cardiac catherization I got to see. A catheter is inserted into a person’s groin and snaked up to the person’s heart and dye can be released for contrast or a stent can be inserted along the same route and deployed in the coronary arteries. Also the very best part of the clinical week was when I got to help the nurse during one of the TEEs. One of the patients was a restless sleeper (chewing on the probe, thrashing, and fighting the IV tubes and EKG cables). So they needed and extra pair of hands to keep the patient from ripping out the IV. (Really all I did was hold the patient’s hand, but I was thrilled.)