Cardiology clinic

Today I went to the cardiology clinic -- in the brand new chronic disease building (photo below) -- and went to rounds in the CCU. This CCU is really, really nice compared to the general wards. The patients have their own beds, the nurses have a much, much smaller census, and they have a couple continuous EKG, heart rate, SpO2 monitors. There is also a pretty well established (though not always carried out) protocol for much of what goes on the in the CCU, including admission orders. For example, everyone is supposed to get an EKG upon arrival into the CCU. They have many of the drugs we have at home like dobutamine drips, norepinephrine drips, etc. The main thing they do not have is a cath lab. The other main difference is the pathophysiology you see her compared to the CCU at home. Almost everyone has rheumatic heart disease. With some really crazy pathology. There is this one boy I saw you is 17 years old and has really severe aortic and mitral regurgitation. His AR is so bad that he basically doesn't have an aortic valve -- he has no S2 on exam. His heart is so hyperdynamic that you easily see his chest heave with each beat and you can almost see the thrill from his mitral valve. It was both fascinating to see and also devastating.

The cardiology clinic was also interesting for much of the same reasons. It is very efficient compared to the wards here -- they see usually 80 patients in a morning between 4-5 providers. Patients don't have set times but instead queue up in the morning. Against most of the patients have rheumatic heart disease, while many also have hypertension and ischemic heart disease like what we see at home. I saw a couple patients with severe mitral stenosis and they had very good exams -- the classic diastolic rumble and palpable thrill. Most were my age or younger, but one was 60 or 65 which is unusual. He had a mitral valve area less than 0.5 which is very, very severe, plus very  severe pulmonary hypertension and a left atrial thrombus. It is crazy to see how well he looked given all those numbers. On the other hand, I saw a patient with dilated and ischemic cardiomyopathy and a low ejection fraction who had gone to the US last year to get an ICD placed! That blew my mind. Talk about disparity of resources around here. He was doing really well though, so good for him!

Overall, again it was great to see another outpatient clinic and to see how organized they are compared to inpatient here and also how well people are when they are outside of the hospital!