Cardiology Endorsements
by Dominic Sia, M.D.
In the cardiology rotation, you spend part of your time in Lincoln and part of it in the Children's Hospital at Montefiore (CHAM). In Lincoln, you are responsible for answering, examining and writing consults from the different units (PICU, Floor, NICU, Nursery) and reporting to the attending to discuss the case, and also for the twice weekly Cardiolgy clinics for the hospital. For the days you spend in Montefiore, you are responsible for rounding with the PICU cardiac patients (10th floor - known as CHAM 10) and writing the progress notes on them as well as rounding on the current cases being followed up by the cardiology service on the floors (8th-9th floors - known as CHAM 8 & 9). The rest of the day is spent in the cardiology clinics (located at CHAM 4 - 4th floor) looking at patients. You are also expected to attend the weekly Cath Conference held on Mondays 4-6 pm at Montefiore (Benjamin Rosenthal Pavillon). Lastly, on Mondays and Thursdays, you are required to pick up the EKGs to be read, which will be found in the Pediatric Office which you are to bring to the clinic to be read by the attending (Dr. Shenoy and Dr. Sharma).
Getting registered with the House Staff office of Montefiore
Before the start of your rotation, see Rosa to fill up the Montefiore rotation form which she has to fax to Montefiore for you to get your ID and username and password for the EMR system. During the first couple of days of your rotations, during times when you are free, try to pass by the House Staff office. The office is located on 150 210th Avenue at the corner of Bainbridge and 210th street. The building looks like an old colonial building with the monicker "Mini-White House". The house staff office is on the 3rd floor of the building. Look for "Nilsa Sambula". She will confirm receipt of the fax from Rosa and give you another form. You will have to take this form and have it signed by Dr. Christine Tracy who is the rotation coordinator up on the cardiology clinic on the 4th floor. You can take this opportunity (if you still have not done so) to introduce yourself to Dr. Tracy. You need to bring this signed form back to Nilsa who will then give you an approval letter which you will now bring to the security office which is located at 3324 Rochambeau Avenue (next block parallel to Bainbridge avenue). At the security office, your picture will be taken and you will be given an ID. Later they will call you to give you your computer username and password for the EMR system of the hospital.
Dr. Tracy usually has a handout describing the rotation as well as a booklet on Pediatric Cardiology which she will provide you on your first days in Montefiore.
There are usually other residents rotating in Cardiology from other institutions - Bronx Lebanon, Jacobi and Montefiore residents. Each month, there can be as much as 1-2 residents from each institution or none at all depending on the timing.
SCHEDULE
Generally, your schedule for a given week will look like the following:
Schedule
Monday
9-12 Clinic at Lincoln with Dr. Shenoy
1-3 freetime
4PM Cardiac catheterization conference at Montefiore
Tuesday
8-9 PICU rounds
9-12 Clinic at Montefiore
1-5 Clinic at Montefiore
Wednesday
8-9 PICU rounds
9-12 Clinic at Montefiore
1-5 Clinic at Montefiore
Thursday
9-12 Clinic at Lincoln with Dr. Sharma
1-5 Fetal Echo
Friday
8-9 PICU
9-12 Clinic at Montefiore
1-5 Clinic at Montefiore
Modifications to this schedule will include:
1) Clinic days - you will be excused from the above schedule for the half day of your clinic day(s) for the week. Clinic days take priority.
2) Call and post-call days. For the days you spend in Montefiore when you go on call, inform the attending in charge early enough and leave early by 3 PM to go back to Lincoln. Inform them also that you will not be available the next day if you are expected to be at Montefiore. If you are on call during the days you spend in Lincoln, just finish the clinic before going to your call. You are free during your post-call day and are excused from the activities for that day.
Try to formulate your schedule for the month and inform Dr. Tracy of the days when you won't be going to Montefiore. She usually prepares a calendar for the month where you need to put the days when you won't be in Montefiore.
CLINICS in LINCOLN
During the days that you are to report to Lincoln for the Cardiology clinics (Mondays and Thursday), you are not required to do rounds on the PICU cardiac patients at Montefiore. The other resident's rotating in the service from other instutitions will be responsible for doing the rounds and the notes. During these days, you are not required to come early and can come around 8 for the morning conference. Don't forget to pick up the EKG's to be read from the Pediatric office and bring it to the clinic with you to be handed to the attending for reading. In the clinic, do not forget to order EKGs for the patient's who are going to undergo EKG's (most patient's require an EKG - some follow-ups don't), and to order echocardiography for those requiring echo. You can use the Cardiology Template to write the notes.
REFERRALS IN LINCOLN
During your rotation, you will get calls from the different units of the hospital for referrals. For referrals for EKG reading, you will simply have to pick up the EKGs and have your attending read it. If you are out of Lincoln, the resident referring will have to call the attending on call, fax the EKGs to them and wait for their response. For other referrals, you are responsible to see the patients and write cardiology notes on them. Remind resident's making referrals to order echocardiogram together with the Cardiology referral. Make sure to inform your attending of any referrals (although usually they have already been informed by the attending in charge of the patient).
PICU ROUNDS IN MONTEFIORE
The PICU at Montefiore is located on the 10th floor of Children's Hospital at Montefiore (CHAM). During the weekdays that you spend in Montefiore, you are expected to be at the CHAM early enough to make rounds on the cardiology patients there, examine the patients and do your notes in time for the official rounds that start at 8 am. It is better to get there by 7-7:30 to have this done. Determine the cardiac cases admitted to the PICU by asking the nurses and doctors or looking at the board for the heart symbol next to the names of the patients. Another way is to refer to the upper portion of the board in the cardiology clinics on the 4th floor where the referrals are usually listed. Divide the patients between yourself and the other cardiology redidents present for the day. Discuss the cases with the nurse in charge and the resident in charge to know if there were any changes overnight. Your notes must be in SOAP format and should include the pertinent labs and imaging done. When the rounds start, you do not have to join the formal rounds on the other patient's, you can wait until the cardiology attending on service arrives. When the cardiology attending arrives, make rounds on your patients and listen to any changes in the plan and update the notes you have made. Give them to the cardiology attending after the rounds, he/she will stick the sticker note he/she filled up during the rounds which represent their notes.
CLINICS IN MONTEFIORE
The Cardiology Clinic is located on the 4th floor of CHAM (Turn left once you exit the room for the elevators). Usually the clinic starts at 9 AM and lasts until around 4 in the afternoon with a short break in between for lunch. It can be light or busy depending on the amount of patients scheduled and on whether they show up.
There is a white board on the clinic which shows the important information. On the upper left portion of the board is listed all the cardiac patients in the PICU and al the referrals in the floors. On the center portion of the boards is listed all the echos being done in the clinic with their progress. There are small magnets that the nurses move around to determine the status of patients. There are 3 echo units in the clinic. On the peripheral portion of the board are listed the names of the patients to be seen for the day below the name of the attending and next to the name they stick the magnet that determines the status of the patient. The nurses usually put the charts of the patients who are ready to be seen on a tray on the wall. The attendings usually like to discuss the cases ahead of time with you before you go to see the patients. They use paper charts. There are two kinds of forms - new patients and follow-up patient's forms. It is just checking the applicable options and filling in some blank spaces.
CARDIAC CATHETERIZATION CONFERENCE
The cardiac cateterization conference is held at the Benjamin Rosenthal Pavillon located in the main hospital from 4:30 -6:00 of Mondays. From the 210th ave entrance (at the corner of Rochambeau), make a right at the 2nd corridor and go straight to the end. There is an elevator on the left side, take it to the 1st floor (You are on the M level) and you will reach the Pediatric's Department. Look for the conference room. Most of the items to be discussed during the conference will be above your head but try to keep awake and try to pay attention as these are the cases to be done in the OR and the cardiac cath lab during the week and also the cases you will be following up in the PICU and the floor.
OBSERVATION IN THE CARDIAC CATHETERIZATION LAB
Try to arrange to be able to observe at the cardiac catheterization lab. You have to ask Dr. Pass and Dr. Sutton for this. You can either ask them when you meet them in the cardiac cath conference or when you meet them in the hospital. Surgeries are done Tue-Thu. Usually they are able to do 3-5 cases a day. If you get permission, make sure to inform Dr. Tracy and the staff at the clinic and update the schedule.
KNOW YOUR ATTENDING STAFF
Try to get to know the attending and support staff of the Cardiology service as this can help you a lot as you move around. You can visit the following site that lists the people and their functions in the service.
http://www.montekids.org/services/cardiology/team/
Rajesh Shenoy, M.D. Jayendra Sharma, M.D.
LUNCH AT MONTEFIORE
You can have lunch at the different cafeteria's in the hospital or in an outside restaurant. You are allowed to bring lunch and eat it there. There is a cafeteria at the lower level of the CHAM. There is also a cafeteria just off the entrance to the main hospital.
OTHER TIPS
1) EKGs It is expected before you present the case and show the EKGs with the attendings that you have already read them and have a preliminary interpretatioon.
2) There is usually a cardiology attending on service for the week who takes care of rounding everyday on the patient's on the PICU and floors and who is responsible for answering referrals from Lincoln when CHAM is in service.
3) Growth charts are found in the drawer in the clinic - ask the nurses where you can find them. Growth charts are usually already part of the chart.
EKG Reading
Your reading should show the rate, rhythm, axis, intervals and interpretation of the R and L forces form the V leads.
Rate – Count the number of small squares and divide 1500 by number.
Rhythm - Determine first what kind of rhythm the EKG. If there is a P wave before every QRS and if at leads I, II and aVF the P is upright then this is a sinus rhythm. If any of the leads (I, II and AVF) have a downward deflecting P wave, then this is an ectopic atrial rhythm. Absence of P wave can either be due to an supraventricular or atrioventricular rhythm if the QRS is narrow, or due to a Premature Ventricular Contraction if the QRS is wide. If the QRS comes too early then it is termed a premature beat and if there is a long delay before the beat then it is called an escape beat.
Axis - Determine the axis by looking at the QRS in leads I and aVF. Compare the upward and downward forces of each lead and get the difference. Lead I goes from left to right - negative to positive and aVF goes from upwards to down - negative to positive. The intersection of the values on each lead determines the axis. Normal axis is the R lower quadrant, R axis is when the forces fall on L lower quadrant. L axis deviation if it falls on the R upper axis.
Intervals - Compute the PR interval, the QRS interval, the ST segment, the QT and QTc.
R&L forces - Look at the upward and downward deflections on leads V1 to V6. Generally there is more downward (right sided forces) deflection on V1 and more upward (left sided forces) deflections on V6. Criteria for R or L ventricular hypertrophy is dependent on age.