Day 2
This morning we observed Dr. Chen as he performed echocardiography (also known as echo) on 7 patients. Echocardiography is a test that uses sounds waves to create moving pictures of the heart. These images can be used to identify abnormalities of the heart muscle or heart valves, as well as the size and shape of the heart. A type of echocardiography, known as Doppler ultrasound depicts blood flow through the heart's chambers and valves.
Some of the patients were within normal limits of heart function, even if they had some mitral valve prolapse, or mild tricuspid valve regurgitation, mitral valve regurgitation, or pulmonic valve regurgitation. This was the case for the 2 male patients who needed to be cleared for military training. Taiwan law provides for compulsory military service for men between the ages of 18-36, so these patients needed to get an echo to begin their service. Left ventricle contractility and ejection fraction were also checked (EF <50% is considered to be reduced EF), as was the presence of pulmonary hypertension. Echo can also be used to distinguish between chamber dilation and chamber hypertrophy, which look similar on chest x-ray. A female patient with a mechanical valve replacement came to have an echo as part of her regular follow-up, although apparently, mechanical valves are a bit difficult to see and interpret by echo. The valve that was replaced was the aortic valve and the echo revealed some valve degeneration, but it was still acceptable. In addition she had mild aortic regurgitation, mild aortic stenosis, good left ventricle contractility, and mild pulmonary hypertension. Dr. Chen explained that the destruction of the replaced valve cannot be stopped because it is a autoimmune reaction, so heart function can only be supported, but since the disease progress is slow, we can adapt to it.
Echocardiography is a powerful tool that is used in medicine. It can reveal so much about the condition of the heart and the equipment performs all the necessary calculations. However, the findings depend heavily upon the amount of experience of the user. Thus it is important to note that however advanced medical technologies become, there is no technology that can replace the a physician's experience. Computers may use algorithms to help reach a diagnosis, but a doctor's experience in the field will guide the diagnosis and treatment of a disease, even if the patient presents with an abnormal presentation.
This afternoon we went back to the catheterization lab and observed 2 procedures. The second procedure was a venography. The patient had significant lower extremity swelling the and purpose of the procedure was to determine if there was deep vein thrombosis. The catheter was advanced from the right side to the left side (right femoral vein to the right common iliac vein to the left common iliac vein to the left femoral vein). The results of the venography showed that there was no obstruction in the femoral or common iliac vein, thereby excluding a diagnosis of deep vein thrombosis. The problem is most likely in the lymphatic drainage.
Patients are not sedated during catheter lab procedures, so they are awake and conscious. While observing the procedures, I could not help wondering about what the patients were thinking and feeling as they lay on the table, knowing that a long wire was being inserted into one of their blood vessels, while possibly fearing what the results of the test might be. I would like to think that being cognizant of the patient's perspective will help my future practice, because I can frame my discussions with the patient in a manner that best suits them and their health goals and treatments.
Day 3
Today we observed both Dr. Wang (morning, 5 patients) and Dr. Huang (afternoon, 12 patients) perform echocardiography. Dr. Huang explained the standard positions he used, which were:
-Parasternal long axis
-Right ventricular inflow view
-Parasternal short axis
-Four chamber view (RA, RV, LA, LV, mitral valve, tricuspid valve can be seen)
-Simpson method to determine ejection fraction for accurate measurement
-3 chamber view (LA, LV, and aortic bulb can be seen)
We also saw other views, including the 5 chamber view and subcostal view.
Today reinforced how important echocardiography is as a diagnostic tool in cardiovascular disease and I really would like to improve my skills in interpreting echocardiograms.
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