Student Name (Block Capitals): ______

Cardiovascular Module

Cardiovascular Studies Semester 5.1

Student Number: ______

Photo: Cardiovascular Module

Cardiovascular Module Logbook

Confidentiality

Any breach of confidence in a clinical case is taken extremely seriously by the medical school and the persons involved may be liable for disciplinary action. The student is referred to the Code of Conduct as outlined in the 5.1 Handbook.

You must sign this prior to commencing the module

I have read and understood the University Code of Conduct and will abide by this.

______Signature Date Cardiovascular Module

CARDIOLOGY (TWO WEEKS)

INPATIENT AND EMERGENCY CARDIOLOGY (ONE WEEK)

CCU/Wards (Two days)

What do I need to do?

The purpose of the CCU/ward day is to give you an insight into the workings of the high dependency aspects of cardiology. The patients in the coronary care unit are generally post-MI, or have decompensated heart failure, or some other critical CVS illness, so the learning opportunities here are extensive. The patients on the ward are generally less unwell but still provide excellent learning opportunities. In order to get the most of the day, you are obliged to have done the following prior to the morning ward round:

1. Have taken three patient histories for presentation on the ward round 2. Have examined the same patients 3. Have looked up their recent clinical course, investigations, current medications, and plans for further management in the patient chart. This includes bloods, xray and CVS investigations such as ECG and echo

On the morning ward round you should present a succinct summary of the current patient status using the following format:

1. Brief summary of HPC, PMH and inpatient course 2. The patient's subjective symptoms over the last 24 hours 3. Your objective clinical findings 4. Results of recent investigations 5. Plans for further management

Time is limited on the ward round, so you need to deliver as much information as you can in as short a time as is possible- remember, the consultant or registrars will usually be aware of the patient's history, so your job is to update them as much as possible. The SHOs and nurses can help you to prepare.

Patients presented - CCU

Patient's initials and identifier Date Signature of Tutor

1 ______

2 ______

3 ______Cardiovascular Module

Patients presented - Wards

Patient's initials and identifier Diagnosis Signature of Tutor

1 ______

2 ______

3 ______

Cardiology Ward Rounds (CCU/Wards)

Date Signature of Tutor

1 ______

2 ______

3 ______

4 ______

Daily: Start 8.30, Cardiology Department Tutorial Room

Tutor assessment: in each case the student: (circle)

1. Knew the patient history YES NO

2. Had examined the patient YES NO

3. Knew the patient's recent investigations YES NO

4. Had a broad idea of the plan for further management YES NO

Tutor comments

Overall assessment Excellent Good Satisfactory Unsatisfactory

Signature of Tutor: ______Date: ______Cardiovascular Module

Patient Histories

Use this space to write a brief summary of each patient you saw in the CCU or on the wards. This is subject to evaluation at the end of your rotation.

Patient 1

Patient 2

Patient 3

Patient 4 Cardiovascular Module

ED/MAU (Two days)

What do I need to do?

The emergency department and medical assessment unit provide ample opportunity to interview, examine and evaluate patients under close supervision. There is an SHO on duty to the ED and MAU every day (pager number 182) who will have you to find patients and will listen to your case presentations. During each ED/MAU day, you should see at least three patients. At the end of one of the ED/MAU days, you go on call until 10pm. This is mandatory. If you do not go on call, you will not be signed off.

Cardiology Emergency Admissions Clerked and Presented

1 ______

2 ______

3 ______

4 ______

5 ______

6 ______

7 ______

8 ______

Tutor assessment: in each case the student: (circle)

1. Knew the patient history YES NO

3. Knew the patient's recent investigations YES NO

4. Outlined a general plan for further management YES NO

Tutor comments

Signature of Tutor: ______Date: ______

This Student has been on call for cardiology (Pass/Fail)

Inpatient and Emergency Cardiology: Procedures Performed

Supervised IV Cannulation

1 ______

2 ______

3 ______

4 ______

Daily, wards and angiography suite; liaise with intern

1 ______

2 ______

3 ______

Available every day on wards and in cardiac investigations unit. Liaise with interns and technicians. Cardiovascular Module

Patient histories

Use this space to write a brief summary of each patient you saw in the MAU or in the ED. This is subject to evaluation at the end of your rotation.

Patient 1

Patient 2

Patient 3

Patient 5

Patient 6

Patient 7

OUTPATIENT CARDIOLOGY AND INVESTIGATIONS (ONE WEEK)

Stress Tests Observed

1 ______

Daily, cardiac investigations unit

Holter Monitor Interpretation Observed

1 ______

Pacemaker/ICD Interrogation Observed

1 ______

Echo (TTE or TOE) Observed

1 ______

Daily, cardiac investigations unit Cardiovascular Module

CATH LAB DAY

What to do

The reason we ask you to attend the cath lab is not to stand on the darkness for hours- it is so you are exposed to the patients undergoing a cardiac procedure. If you attend at the cath lab, you will quickly begin to understand why patients have angiograms, why some of them get stents, what the indications for pacemaker insertion are, why we put in ICDs, and so on. Much of cardiology nowadays involves some form of intervention, with which you need to be familiar, no matter where your career might take you. It is also a near-certainty that you will be admitting/clerking/referring a patient for a cardiac intervention at some stage in the future, so now is the time to learn how to do it! You should arrive early, so as to start clerking patients and be ready to present to the registrar or consultant.

How to admit a patient for angiography

The decision to send the patient for angiography has already been made, so your don't need to dwell too long on the HPC; in general, the patient will have experienced chest pain or dyspnoea. When admitting a patient for any procedure, you need to establish a few things:

1. Why the procedure is being performed. 2. What the patient's past medical history is (with specific regard to renal function in cases of angiography) 3. What medications the patient is on 4. If they have any allergies 5. If there is any obvious contraindication to the procedure 6. If there are any examination findings which may preclude angiography (specifically, is there an easily palpable femoral pulse)

Is the patient on dual antiplatelet therapy?

This is the question the consultant is most likely to ask you- not being on dual antiplatelet therapy precludes stent insertion, so ask the patient this question specifically.

Admission care pathways are available from the cath lab staff. Liaise with the interns. Remember, each patient will also need an IV line!

Patients Clerked for Angiography / Pacemaker / ICD

1 ______

2 ______

3 ______

4 ______

Daily, Angiography Suite; patients arrive at 8am; start clerking then; liaise with the duty intern Cardiovascular Module

Diagnostic Angiography Observed

1 ______

Daily, angiography suite

Record the abnormalities below

Percutaneous Coronary Intervention Observed

1 ______

Record the abnormalities below

Pacemaker/ICD Insertion Observed

1 ______*

Tutor assessment: in each case, the student:

1. Knew the patient history and indication for procedure YES NO

3. Knew the indications for and complications of the procedure YES NO

Tutor comments

Patient Histories

Use this space to write a brief summary of each patient you saw during your cath lab day (procedure, indication, intervention, medications on discharge). This is subject to evaluation at the end of your rotation. Cardiovascular Module

Clinic Day

What to do There are two types of patient in clinic: the new patient and the review patient. With a new patient, you take a full history, perform a full examination, come up with a differential diagnosis and think of what investigations you want to perform. You then present the patient to the registrar or consultant, go see the patient together and come up with a plan.

With review patients, the diagnosis has already been made and the patient is presenting for routine evaluation of symptoms and their clinical condition. Here, a SOAP format is useful- ask the patient about relevant subjective symptoms, examine them for objective clinical findings, put these together to get an assessment of their condition and make a plan for further investigation or management.

Times and places The main cardiology clinics are on all day Wednesday (9.45 – 1pm and 2pm-5pm) and on Thursday morning (9.45 – 1pm), on the first floor of the outpatient department. There is also a heart failure clinic on Friday mornings after journal club.

Cardiology Clinic – Patients Clerked and Presented

1 ______

2 ______

3 ______

4 ______

5 ______

Wednesday 10am -5pm, Thursday 10am-1pm, First Floor, Outpatient Department Three Sessions, two to three students per session

Tutor comments

Patient histories

Use this space to write a brief summary of each patient you saw in clinic. This is subject to evaluation at the end of your rotation.

Patient 1

Patient 2

Patient 3

Patient 4

Consultations

What to do The cardiology department runs a busy inpatient consult service. In such cases, a medical or surgical team submits a formal consult, which is a request for a cardiology opinion on further management of the patient. For example, a routine blood test post-op may demonstrate an elevated troponin; the team may be unsure how to interpret the test result and ask for a formal consult. This usually involves a review of the patient's history, physical examination, a review of investigations and formulation of a set of recommendations. You should see at least two patients.

When you go to see a consult, you should link with the consult registrar before and after you have seen the patient; before so they can tell you what to look for, after so you can present your history. The consult registrar may be contacted on page 761. You should only take a copy of the consult- the original should stay with the SpR.

Cardiology Consults – Patients Clerked and Presented

1 ______

2 ______

3 ______

Tutor comments

# Cardiovascular Module

Patient histories

Use this space to write a brief summary of each patient you saw on consults. This is subject to evaluation at the end of your rotation.

Allied services

In addition to seeing patients in clinic, in the cath lab, and on consults, you should attend the cardiac rehabilitation services and the nurse-led heart failure clinic. These services provide excellent learning opportunities- you get a chance to see patients in the few weeks post-MI when they are coming to terms with their illness and in a good position to describe the effects it has had on their lives. Similarly, attending the heart failure clinic gives good insights into the realities of having a chronic long-term illness.

In addition, there is a journal club and case conference every Friday that the people on the cardiology part of the rotation should attend.

Cardiac Rehabilitation Session Attended (1 hour)

______

Daily, Cardiac Rehabilitation Unit, Link Corridor to Obs/Gynae

Nurse-Led Heart Failure Clinic Attended (1 hour per student)

______

Daily, HF Unit, Link Corridor to Obs/Gynae

Cardiology Journal Club Attended

1 ______

2 ______

Friday 8 am-9am, Cardiology Department Cardiovascular Module

VASCULAR SURGERY

How to clerk a patient for vascular surgery

When admitting a patient for surgery, the decision to operate has already been made, so the emphasis is placed more on ensuring the patient can safely go through with the operation. This involves:

1. Full history and examination 2. ECG 3. Chest Xray, and usually pulmonary function testing 4. Bloods, including renal function, FBC, coagulation studies, and grouping and crossmatching blood 5. Anaesthesia assessment

You should liaise with the vascular NCHDs in this regard- they will help you admit the patient and will supervise you in performing procedures such as IV cannulation

Tutor comments

Ward Patients clerked for Vascular Surgery

Patient's initials and board number Diagnosis Signature of Tutor

1 ______

2 ______

3 ______

4 ______

Inpatients admitted on the wards – liaise with surgical intern/SHO

Tutor comments

Emergency Vascular Surgery Admissions Clerked and Presented

1 ______

2 ______

Emergency Department. Liaise with duty SHO

Vascular Surgery Bedside Tutorial

______Cardiovascular Module

Tutorials

Note to tutors: for the bedside tutorials, the students should have identified and prepared at least two patients for this tutorial, and should have approached you in this regard a day in advance. If this has not been done, the tutorial should be deferred.

Note to students: the tutor must be alerted to the above before the tutorial.

Cardiology Bedside Tutorials

Week 1 ______Date ______

______Date ______

Week 2 ______Date ______

______Date ______

Times: Tuesday 2pm (I/E Group), Wednesday 9.30am (I/E Group), Thursday 3pm (O/I Group ), Friday 2pm (O/I Group)

Where: Cardiology Tutorial Room

Note: The Wednesday/Friday Tutorials are consultant provided, the Tuesday/Thursday tutorials NCHD provided; you should be exposed to the same number of both Cardiovascular Module

Cardiology- Core topics

Cardiovascular medications ______Date ______

Hypertension and hypotension ______Date ______

Atrial fibrillation ______Date ______

Murmurs ______Date ______

ECG interpretation ______Date ______

Acute Coronary Syndromes ______Date ______

Arrhythmias and antiarrhythmics ______Date ______

Emergencies, and when to ______Date ______get help

Vascular Surgery- Core Topics

PVD and ______Date ______Acute Limb Ischaemia

Carotid Disease ______Date ______

Venous/ Lymphatic ______Date ______

AAA+Mesenteric ______Date ______

Cardiothoracic Surgery- Core Topics

Thoracic Outlet ______Date ______Syndrome Cardiovascular Module

Appendix 1

General Organisation

With regard to cardiology, the two weeks are divided into Inpatient and Emergency Cardiology and Outpatient and Cardiology Investigations. During I+E, the student:

1. Spends two days on CCU and the wards 2. Spends two days in ED/MAU 3. Goes on call for at least one evening 4. Takes a day off

During O + I, the student:

1. Goes to available clinics on a rotating basis (i.e. students 1+2 Wednesday Morning, students 3+4 Wednesday afternoon etc) 2. Spends a day in cardiac investigations (Echo/ECG/Stress/Holter etc) 3. Spends a day in the cath lab (clerking patients and observing procedures) 4. Goes to the heart failure clinic and cardiac rehab for an hour or so

Who divides us into the 4 groups and decides on a rota for the cath lab, CCU, wards, clinic, etc?

You do. In your professional lives you will be organising rotas, splitting jobs and assigning tasks. You can start now.

How do I get the most out of my rotation?

Be proactive. The rotation is designed to expose you to aspects of clinical care which are not found in books- the real-world encounter, the decision making process of experienced clinicians, the realities of your future job as a doctor. It is not a tutorial series with some ward rounds thrown in. You are in the wards to see patients and to see how doctors work in the real world. Nothing you will read, and no tutorial you will receive is a substitute for direct interaction with patients, and the experiences you accumulate as a result. The books may tell you what someone looks like when they're having a heart attack but no amount of description will ever take the place of seeing the real thing- the panic, the expression on the patient's face, the ED nurse doing about five things all at once while you try to keep your thoughts straight and remember what drugs to give. Similarly, seeing a patient being counseled in clinic about their claudication, or being consented for cardiac surgery is infinitely more instructive than reading about it.

In essence:

1. Be around, and be on time 2. You get out what you put in 3. At all times, be professional and treat patients with the respect they deserve 4. Have respect and consideration for the doctors and the nursing staff, especially when they are tired or overworked. 5. Show some initiative. 6. Finally, have respect for each other; look out for the other people in your group; if they're struggling, help them out or let one of the tutors know Cardiovascular Module

Appendix 2

Tutorials in Cardiology

The tutorial timetable looks like this, but is subject to change depending in whether the tutor can make it or not:

Monday Tuesday Wednesday Thursday Friday Morning 9:30 am (Cardiology Bedside Department) Tutorial (Consultant) I+E

Afternoon Bedside Bedside Bedside 2pm Tutorial Tutorial Tutorial (Cardiology (Reg/SHO) (Tutor) (Consultant) Department) I+E O+I O+I Afternoon Core topic Core topic 5pm tutorial tutorial (CSI) (Cardiology (Cardiology Consultant) Registrar/ All Tutor) All

I+E: Inpatient and emergency group O+I: Outpatient and investigations group

Frequently Asked Questions

Do I really have to go on call?

Yes. Lots of acute presentations of CVS disease come in at night, or during the evening. This represents a unique opportunity to learn and is invaluable for handling on-call during your intern year.

The team seem really busy. Would it be better if I went to the library?

No! Help out instead. See patients, do jobs, put in lines, do bloods, and be proactive.

There wasn't a pacemaker insertion/PCI/ the day I was on for the cath lab. Can I go back again to try and see one? Cardiovascular Module

Yes, by all means, as long as the cath lab staff are okay with more than one student being there. Ask first.

How do I get in contact with the SHO or Registrar?

Page them. To use the pager system, dial 81, the number of the pager, and then the number of the extension you're at. If you need a number, call switch by dialling 9. Be polite when you call.

How do I know what's on in the Cath Lab in the morning?

There's a list in the office beside the cath lab with the patient's name, planned procedure, and location. Use it when you're trying to find patients to clerk for your cath lab day.

How do I know what surgery is going on tomorrow?

The team will get a list of patients the day before surgery, so ask them for a copy- the intern will certainly have one. You should aim to clerk these patients for their surgery and present them on the morning ward round.

What preparation do I have to do for the bedside tutorial?

You have to have taken a history from and performed a physical examination on two patients. The SHOs and registrars will help you find them. The task can be split between two students. You also need to contact the designated tutor and confirm that the time is convenient for them – they could be in the middle of an arrest. You should rotate the responsibility within the group. The registrar couldn't do the tutorial because they were running late in clinic. What do I do?

Page them and reschedule. It's easier for you to find them rather than the other way around.

I've arrived to clinic but none of the team are there yet. What should I do?

Grab a chart and a room and start seeing a patient. You'll be ready to go when the tutor gets there.

What do I do with patients in clinic?

There are two types of patient in clinic- reviews and new cases. With review cases, it is useful to apply a SOAP (subjective, objective, assessment, and plan) template to each patient you see. Think about what you would do in terms of management and compare this with what actually happens. For new patients, you take a full history and perform a full examination, formulate a differential diagnosis and decide on a plan of investigation and management.

How should I introduce myself to patients?

“Student doctor” is the clearest term; patients tend to understand it better than “medical student” (which, to be fair, could be anything). Be sure to identify your role, obtain informed consent, and reassure the patient that they will be seen by a senior doctor in due course.

Can I obtain consent for procedures?

No. This can only be obtained by qualified practitioners, but you are advised to sit in on the process Cardiovascular Module and observe how it's done.

When do I have to hand in this logbook?

On the last day of the rotation.

What safety precautions do I need to take in the cath lab and vascular theatre?

Both environments use flouroscopy (i.e. radiation), so you have to wear lead coats and thyroid shields as protection. Ask the nurses or doctors where you can find them.

What do I do if a patient suddenly becomes unstable while I'm interviewing them?

Call for help! If the patient becomes unresponsive, commence CPR and ask the nurses to call an arrest.

What preparation do I need to do for the core topic tutorials?

You should have read around the topic and made a list of things that don't make sense to you, and ask about them.

Is the logbook the be-all and end-all?

No. It helps us figure out how much you've been turning up, and what you've been seeing. It also guides you towards those things we want you to see.

Do I get pre-tutorial reading material?

No. You are referred to an appropriate textbook and are expected to have read up before the tutorial. Cardiovascular Module

Appendix 3

Feedback

This logbook is an ongoing project; we would appreciate your feedback on the layout and ease of use. We also welcome your comments on the overall structure of the rotation, what works, what doesn't and where you learned the most.

Comments

Appendix 6

For tutor use only

Logbook >70% complete  < 70% complete 

Tutorials >70% complete  < 70% complete 

Remedial action required Yes  No 

If yes, head of module informed 