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Veterans Affairs San Diego Healthcare System Rotation

The Cardiology Fellow on the VA Cardiology rotation plays a crucial role in patient care and teaching in the CCU and Cardiology Consult services at the VA. The fellow is supervised by both CCU and Cardiology Consult attendings, and interacts daily with attendings and fellows in the Cardiac Catheterization/Interventional Laboratory and Electrophysiology Services. The Cardiology Fellow offices are located on 4 North near the Cardiac Catheterization Laboratory.

The major responsibilities during this rotation include:

  • Evaluation and management of patients admitted to the CCU-Cardiology service with the ICU housestaff and CCU attending
  • Management of inpatient Cardiology consults with the Cardiology Consult Attending and Cardiology Consult team (medical residents and students rotating on the VA Cardiology Consult service)
  • Interpretation of inpatient ECGs, Holters, and Event monitors with the CCU Attending
  • Performance of transesophageal echocardiography (TEE) with the echocardiography attending
  • Performance of inpatient cardioversions with attending supervision

Educational goals

The goals of this rotation are to become thoroughly familiar with the management of critically ill and hospitalized patients and to serve as a sub-specialty consultant. The Cardiology Fellow will manage patients with cardiovascular diseases including acute myocardial infarction, acute coronary syndrome, congestive heart failure, arrhythmias, valvular and pericardial diseases.

The fellow will be trained to perform procedures, such as pulmonary arterial catheterization, placement of temporary pacemakers and transesophageal echocardiograms. The fellow will learn how to interpret the results from these procedures and tests including the ECG, echocardiogram, Holter and event recorders, permanent pacemaker and defibrillator interrogation and the essentials of electrophysiologic testing.

Intensive Care Unit (ICU)

The ICU on 5 South is a combined coronary care (CCU), medical (MICU) and surgical (SICU) intensive care units. The CCU and MICU services are combined, with care delivered by a single medical team of housestaff and students, supervised by two attendings: the Cardiology CCU Attending and Pulmonary Critical Care Attending (each with their own fellow).

Each patient is designated for admission to either the CCU or MICU team. The Cardiology Fellow is responsible only for CCU patients, and will follow them until they are discharged from the hospital, including after transfer to the medicine service. The fellow may be asked to consult on MICU or SICU patients, which are discussed with the CCU attending. In addition to the ICU, patients may be admitted to the CCU-Cardiology service in the Direct Observation Unit (DOU), a step down unit with beds shared between Medicine and Surgery services on 5 South adjacent to the ICU, and to the Telemetry wards on 5 East and 3 North.

CCU admissions

Patients are admitted to the CCU service from the Emergency Department (ED) or Urgent Care Centers (UCC), hospital wards, Cardiac Catheterization Laboratory, Electrophysiology Service, or transferred from outside medical centers. The ED or ward will call the ICU resident for a “unit evaluation.” The ICU resident assesses whether the patient requires CCU level care, then calls the Cardiology Fellow to discuss whether or not to admit the patient to the CCU (or MICU).

It is important for the Fellow to ensure that patients in the ED receive timely consultations and appropriate recommendations. If the ED or ward attending disagree with the recommendations of the MICU resident and/or CCU fellow, the fellow should discuss the case with the CCU attending in a timely manner before making a final decision on the disposition. Fellows should inform the CCU Attending of all admissions, particularly over the weekend.

CCU work-ups

The Cardiology Fellow is required to write a note on all patients who have been admitted to the CCU. The CCU attending will write an admission note, which may be an addendum to the ICU Resident admission note. Cardiology fellow notes should document major decisions and treatment plans, even when deciding not to admit or transfer the patient to the CCU. It is not sufficient to have a resident’s note state “case discussed with fellow” without a separate note documenting the decisions by the Cardiology Fellow.

Prior to discharge or transfer, it is often helpful for the Cardiology Fellow to summarize the events in the CCU and document the plans to ensure appropriate follow-up and management discussed daily with the CCU Attending and team. Many patients are scheduled for post-discharge visits with the Cardiology fellow in the Fellows’ Tuesday afternoon clinic. The fellows should be aware of how far out they are booked in their own Fellows’ clinics to make commitments for follow-up realistic.

Morning work rounds

Work rounds primarily focus on management decisions. The housestaff must be allowed sufficient time to complete their notes, arrange transfers or discharges, and go home post-call.

  • CCU rounds: 7:30 – 9:00 a.m.
  • Pulmonary-Critical Care team rounds: 9:30 – 11:00 a.m.

All rounds by the CCU and Pulmonary- Critical Care teams should end by 11:00 a.m.

Weekend coverage

Fellows cross-cover the VA and Sulpizio Cardiovascular Center (CVC) over the weekends. Arrive promptly at 7:30 a.m. on Saturday and Sunday in order to become familiar with the patients and management plans.

After fellows complete VA CCU rounds, they go to the Sulpizio CVC for rounds. The Cardiology Fellow should always discuss any new admissions with the CCU Attending, as well as the status of each patient on the service. The CCU Attending should see all new patients within 24 hours after admission and have this documented in the Computerized Patient Record System (CPRS).

Cardiology consult responsibilities

The Cardiology fellow addresses inpatient and outpatient consults. Formal (rather than curbside) consults are encouraged with all consults entered into paperless electronic chart Computerized Patient Record System (CPRS). Fellows must appropriately link their note with the consult in CPRS or the note will be “misfiled” and the consult considered unanswered.

Emergency and urgent inpatient/Urgent Care Center consults

The Cardiology Fellow handles emergency or urgent consults Monday - Friday during the daytime from the MICU, SICU, post-operative room, Urgent Care Center or DOU. This may involve patients experiencing acute hemodynamic compromise, signs or symptoms of ischemia, serious bradycardias or tachyarrhythmias (including AF, SVT or VT/VF), or issues arising from their anti-arrhythmic medications.

Cases from the MICU, SICU, and post cardiac surgery patients are presented to the CCU Attending. The others are presented to the Cardiology Consult Attending.

Routine inpatient Cardiology Consults

Fellows manage all inpatient consults and are responsible for reviewing their daily progress with the Cardiology Consult Attending. Routine, non-urgent consults can be assigned to the Medicine Residents or medical students on the Cardiology Consult service for presentation to the Cardiology Consult Attending.

When the resident is unavailable (e.g., at clinic or off post-call), or when there are no residents or students on the VA Cardiology Consult rotation, fellows are responsible for completing the consult and presenting it to the Cardiology Consult Attending.

VA Cardiology Fellow's Clinic

Fellows have a continuity clinic at the VA on Tuesdays (1-4 p.m., 3 West Access Area) every other week, alternating with a Wednesday afternoon clinic at UCSD.

The attendings for the VA clinic are Drs. Denise Barnard and Alan Maisel, who concurrently hold their own clinic in the same area, or the Cardiology Consult Attending.

Fellows see new and continuity patients at each clinic session. Every patient who is new to the facility must be seen by or discussed with an attending. This can be documented by an independent attending note, an attending addendum to the fellow’s note, and/or by a description of attending involvement in the fellow’s note.

Patients who are seen on return visits should be seen by or discussed with an attending at a frequency to ensure effective and appropriate treatment.

Fellows are assigned patients to follow throughout their three-year fellowship. This may include new patients referred to Cardiology for a consult, patients discharged from the hospital, and patients who underwent procedures. New patients may be seen only once (e.g. as a post-PCI follow-up).

If the patient’s cardiovascular disease is relatively stable, they should be discharged from this clinic and followed by their Primary Care provider and referred back to Cardiology as needed. This frees up the number of openings to see new patients. As a rough guide, fellows are allotted one hour for new patients, and are scheduled to see returning patient every half hour.