Location: Sulpizio CVC Park in either parking structure (the near one has green B parking and the one farthest from the building is all

green B parking).  Walk to the front entrance with all the glass where you can see the elevators.  Bring your badge because the doors are locked at night.  Walk to the elevators you can see from the outside, take them to the third floor, left off the elevator, first right, first

left, first right will get you to the work room.  You're in the correct spot if you see two flat screens on the wall and probably some origami.

 Basics

There are 2 teams, general cardiology (red names) and cardiomyopathy (black names) Gen cards rounds first 8-10am and then cardiomyopathy 10am-noon. The night intern just rounds on gen cards

patients so they can get out in time EPIC: domain/context is 'IP Cardiology' There are 3 Lists in Epic to be familiar with:

o ‘CVC Full’ - All patients are listed here

o ‘CVC Gen Beacher’ - Gen Cards patients

o 'CVC CM Beacher' - Cardiomyopathy patients

Gen cards common presentations: ACS, chest pain r/o, routine CHF exacerbations, EP patients, etc. Tend to be less sick than cardiomyopathy patient’s, but occasionally can crash quick too so be vigilant.

Cardiomyopathy common presentation: Cardiogenic shock, patients with LVADs, transplants, awaiting transplants, or balloon pumps, etc.

Important equations (See attached hemodynamics powerpoint)o FICK CO = 135 * BSA / (13 * Hgb * [Arterial sat from pulse ox in fraction minus MVO2 in fraction])

o SVR = 80 (MAP - CVP) / CO from Fick.

o PVR = 80 (wedge pressure - mean pulm art) / CO from Fick.

Team census: Typically 12 gen cards, 4 cardiomyopathy. We push old (nearing d/c or nothing active happening) patients to the fellows if we go over cap, which happens a lot. It’s possible to have more than 4 cardiomyopathy if there are less than 12 gen cards patients. This process is driven by the fellow.

There is a common intern pager (x2965) so you just forward and unforward from that Patients are in the following locations (have someone show you, it won’t make sense in words)

o Most patients are on 3rd/4th floor of CVC

o Thornton – 2nd floor in the TICU, PACU and Thornton hospital – rarely PTU

o 1st floor ED

Typical Day Flow DAY INTERNS

o 5am: Pre-rounding (see Tips for Pre-rounding separately). No conferences in the morning. Sometimes night

intern can give you an idea of who you’ll pre-round on but there can be a lot of turnover throughout the night. o 8am: gen cards rounds start.

o 10am: cardiomyopathy rounds start. A lot of time we are still seeing pt with gen cards so who ever has CM pts

to presents splits off.o 12pm: rounds usually done around noon. Run the list with the night resident and then GET FOOD

o 12-3pm (short) or 6pm (long): Consults, notes, new admits, anything that comes up on the floor, teaching

NIGHT INTERNo 9pm: Night intern gets in; gets signs out from night resident

o 9pm-10am: Wait for admits and start doing PM lab checks/trends, I/O checks, groin site checks etc. Prep

notes for the next morning so you can just update the plans and get out on time.

TIPS FOR PRE-ROUNDING/NOTESo We will share the templates for CVC H&P and Progress Notes with you or you can ask someone

Try to use the same template as your co-interns so that if you end up seeing each other’s patients (like on the weekend) it’s easy to follow the format and make updates

o Get sign out from night intern on your patients around 5amo We found it works best to prep notes as you preround and then print them off for roundso Call tele tech and ask for reads on your patients, numbers are on the wall (CVC 78466, Thorn 78464)o Always keep a running list of current cardiac meds and drips as well as a list of outpatient cardiac medso Often patient’s will have Swans so get all hemodynamic info + MVO2/SvO2 trends from central line VBGso Be thorough with your analysis of I/Os – what diuretic regimen are they on, did they require additional

overnight doses, when were drips started/turned off, what did their UOP do following those changes (calculate hourly rates)

o When it comes to physical exam you MUST have a JVP measurement and a comment on if the patient feels warm or cold

o Include ECHO reports, Cath reports, Stress test results in your notes as you’ll likely be asked about specific numbers/findings – focus on the MOST RECENT tests (maybe the last two ECHOs at most to compare findings)

o Bring physical EKGs to rounds for new patients or if a new EKG was warranted on an old patient. For some reason EKGs don’t get uploaded into Epic so you’ll have to make copies or bring the originals

o Pacemaker interrogations are often left in charts or can be found in an EP note available to downloado If a patient has a cath, it often isn't entered into EPIC by the next morning so there is a green cath report

in their physical chart.  Make a photocopy of the cath report and bring that to rounds.o The printer in the work room is pathetic so plan to print your notes/sign outs from nursing stations

GENERAL ADVICEo With the new schedule we found that if the short intern (5am-3pm) holds the floor pager it allows the long

intern (5am-6pm) to help with admissions until short leaves and then can take the pager. o Communication can be challenging i.e. fellows communicate with each other just by sending SMS and get

all the necessary information in seconds while you get it just occasionally and in hours; so ask for updates/run the list often

o Remember you get ~$100 added to your badge while on CVC and the cafeteria actually serves real food so take advantage

o There are nourishment rooms with water dispensers, graham crackers, and peanut butter [AND COZY SHACK PUDDING] next to the nursing stations.

THE ACADEMIC STUFFo It may be helpful to read up on cardiac pressures/normal values. The quick and dirty for pressures in RA

5, RV 25/5, PA 25/5, LA(wedge) 10(Dr. Adlers fav numbers are 8 for RA and 15 for wedge...he will definitely ask you this!)In our blue book an easy way to remember pressures is nickle for RA, dime for LA, quarter for RV and dollar for LV.

o RHC = Swans and are used for pressure monitoring; this helps determine if the patient has left sided failure(elevated wedge), right sided pressures(elevated PA/RV and RA w/o elevated wedge) and also gives you cardiac output.

o there are 2 ways to measure CO. One is a FICK calculation and one is by thermodilution(nurses actually measure this by mixing blood in the swan...I'm not quite sure how). Attendings will like both CO and the cardiac index reported.

o also important when reporting hemodynamics is the MVO2(off a VBG). Normal is about 60, high 50s are good for these cardiogenic shock patients but we trend them pretty frequently and base a lot of clinical decisions off it. Too high MVO2 can mean the patient is septic(higher CO)

o Swan numbers are under the ICU tab: CVP(central venous pressure, basically RA, correlates with your JVD), PAP(pulmonary arter pressures), PAM(pulmonary arter mean), PCWP(pulm cap wedge pressure), CO(cardiac output), CI(cardiac index), SVR(systemic vascular resistance), PVR(pulmonary vascular resistance)

o With swan patients they like MAPs (make sure cuff and art line correlate, if not just report the difference)o Main ggts we use are for ionotrophic support:

milrinone: ionodilator--> contractility and vasodilates (decreases SVR) dobutamine: mainly increases contractility, mild vasodilator (decreases SVR again) dopamine: low dose(increase renal blood flow, vasodilates), medium(ionotropic), high(alpha,

vasoconstricts) ----> only gtt that cannot be given through PIV due to vasocontrictive propertieso if you have time look up pictures of intraaortic balloon pumps and LVADS so you have a quick idea of

what they areo intraaortic balloon pump: assists in cardiogenic shock; balloon expands during diastole(raises diaslic

pressures) inorder to better perfuse the coronary arteries. Deflates during systole and has a 'vaccum' affect which decreases afterload and offloads the heart. (to listen to the heart sounds have the nurse stop the pump first)

o LVAD: used if patient is persistently in cardiogenic shock and awaiting transplant or can be used as desitnation now too i think if patient with just terrible cardiac output. Basically a motor that connects the left ventricle to the aorta so the LV doesn't have to work to get blood out and is continous pump. (importantly, if this is a nonpulsitile continuous LVAD they don't have bps, use MAPS when reporting vitals, not bps. Also on physical exam instead of heart sounds you'll hear 'the mechanical hum of the LVAD')