In the heart of things.
This week was full-on cardiology, involving rotations with residents through various departments of the stand-alone cardiology hospital here in Santo Domingo, the Instituto Dominicana de Cardiologia, IDC for short.
As if to get your mind on the subject, the hill leading up to the IDC is steep, and many patients with a consult appointment end up walking directly to the emergency department complaining of shortness of breath, fatigue and sometimes even chest pain. Adding insult to injury, small pump-carafes filled with sugary Dominican coffee. litany of public health signs. Salt is liberally added to almost all foods in the DR, likely contributing to high rates of hypertension.
This week was split into main areas of observation for me: the emergency department, the catheterization/angiogram center, and the exercise stress test center.
First up: the ED. Although the ED is intended to handle only cardiac emergencies, there is a consistent stream of patients with non-cardiac complaints. Many are family members of patients who had a scheduled appointment elsewhere in the hospital. Many of the non-cardiologic or respiratory complaints are quickly triaged, but those that involve either organ system are generally investigated further. Needless to say, a significant number of atrial fibrillation exacerbations and potential pneumonia cases arrive here.
Several features of the ED stood out to me. Though each patient bed is equipped with a monitor, the physicians prefer to rely on manual sphygmomanometer technique to monitor patients’ blood pressure. Additionally, ECGs are produced without any electronic analysis, so physicians must be efficient in reviewing ECG printouts. ED doctors must also be proficient in reading chest x-rays, and at drawing blood. The blood draws are often handed to patients’ family members to take to the laboratory for processing. While these practices are different than those in the United States, there is one definite commonality: the amount of paperwork required per patient. There is no electronic health records system here, so notes/referrals/scripts are handwritten and copies are produced using carbon paper.
Second up: the “Cath lab.” There was a multitude of patients with severe heart disease. I saw an 89-year-old with clean vessels, but also a 45-year-old patient with history of aortic stenosis, significant and surgical history of two previous stents. Upon angiogram, it was decided that further stent placement was insufficient, and the patient would need to undergo surgery for both aortic valve replacement and triple bypass. means of determining the degree of valve obstruction/calcification/stenosis is to compare the gradient between aortic and ventricular pressures; the larger the gradient, the more severe the valve disease. It was interesting to see the differences in approach for angiogram, predominantly either femoral or brachial. Each physician had an explanation for the superiority of their preferred method. Considering the nature of the procedure, it is amazing how relatively bloodless it actually is.
Finally, the cardiac exercise stress test. It disheartening to see several stress tests end abruptly due to exercise-induced angina. Seeing ECG changes in real-time as the patient exerts themselves is mesmerizing.
A few final notes: I spent Thursday on “service,” meaning I rounded with the residents overnight on the admitted patients, checking vitals and documenting patients’ ongoing courses in the hospital. I saw the gradations in admission rooms rooms are shared rooms with no partitions, older beds and minimally working fans. The semi-private rooms each house two patients, separated by a divider and equipped with televisions. The VIP section is white-walled and sparkling clean, with keycard security to enter the hall and individual rooms with private bathroom, air conditioner and a waiting room. However, despite these differences, I was happy that the level of care was approximately equal for all rooms.
I am thankful for my time in the IDC, and I hope to glean more information from residents and attendings in my remaining time here.