IER Placement: Cardiology

As part of the McMaster Physician Assistant Education Program curriculum, each student shadows a professional in the field relevant to the unit being studied that month. These are called IER placements and students are assigned a half-day shift at a hospital in Hamilton. IER stands for Interviewing, Examining and Reasoning. For this IER Placement:

  • Medical Foundation Unit: Cardiology
  • Professional Shadowed: Registered Nurse
  • Date of Placement: Thurs. Nov 6, 2014
  • Where: Hamilton General Hospital – Heart Investigation Unit

Read more about what I observed in my placement!

Disclaimer: All the images in the post are taken from a google search. It was inappropriate for me to take photos in the hospital where there are patients, doctors, and nurses, in which I would need their consent.

Upon arriving at the Heart Investigation Unit (HIU), I was assigned to follow a Registered Nurse. Despite having two other PA students shadow her before but she was still skeptical about the role of Physician Assistants. However, putting that aside, she allowed me to participate in the care of three patients that day (instead of strictly observing what she is doing).

Same day patient beds

The nurse gave me a tour around the the Heart Investigation Unit. There are 32 beds split between day patients who can leave within the day and those who will need to stay overnight. There are four cardiac catherterization laboratories. I have never seen on before so I thought it was super cool. Procedures performed in the HIU includes cardiac catheterizations, angioplasties, valvuloplasties and percutaneous aortic valve implantations. According to Hamilton Health Sciences, Hamilton is one of the few centres in Canada recognized as a leader in Primary Percutaneous Coronary Intervention (PCI).

Small Education of the Day

  • The heart has coronary arteries that supply oxygenated blood to the heart
  • Coronary Artery Disease (CAD) is also known as atherosclerosis, a build up of plaque in coronary arteries that can cause partial or complete blockage of blood flow
  • When the heart does not receive enough oxygen, the patient will experience chest pain (angina).
  • A heart attack (myocardial infarction) is when blood stops flowing to a part of the heart, causing heart tissue death from lack of oxygenated blood.
  • Cardiac Catheterization – a general term for a group of procedures that are performed by inserting a catheter into the chamber/vessel of the heart
    • Cardiac angiography – a catheter (thin flexible tube) is used inserted through either the radial, brachial or femoral artery until it reaches the heart. A special dye that can be picked up by the X-Ray machine is released from the catheter. Using the X-Ray machine, the physician can see where the blockages are in the coronary arteries.
    • Results may be normal or reveal that the symptoms can be controlled with medication. Sometimes the results will suggest the patient to go through coronary angioplasty, a procedure that will open up the partially/completely occluded coronary artery.

Prepping the Patient for Cardiac Catheterization

The patients I saw with the nurse are here for a cardiac catheterization because their referring doctor think that some of their coronary arteries are occluded. Before going into the cath lab, the patients were:

  • Undressed completely into a hospital gown
  • IV access line was started by the nurse (really cool to see how she did it!)
  • Hair removed at access site – radial or femoral (the nurse had to shave patient’s groin area)

The nurse explained to me the importance of checking three things before any patient goes into surgery:

  1. Baseline – What were their vitals before the surgery? ECG baseline? We need this to compare to findings after surgery.
  2. Medication – What medications is the patient on? We have to review all the medications the patient is currently taking, watching out for anticoagulants. I had the opportunity to help the nurse with this part of the procedure.
  3. Blood work – CBC, INR, Creatinine and Urea Nitrogen – the dye used in the catheterization is secreted by the kidneys so we want to make sure the patient’s kidneys are working! If patients have a low INR or are already taking anticoagulants, they may have severe bleeding during the surgery. Low INR and anticoagulants suggests that blood is less likely to clot in face of tissue injury.

The most memorable patient

One of the most memorable patient during my placement was a 64 year old man who came in with 5/10 (level of pain) chest pain. I guess the physician read his ECG and decided that this was an emergency. The nurse and I was called over to help. In a matter of minutes, the following were done:

  • The patient was undressed into a gown – the nurses and I did all that undressing while the patient was laying on the bed
  • Supplemental oxygen was administered via nasal prongs
  • Baby aspirin was given – to prevent platelets from further aggregating on the clot that is narrowing the artery
  • An IV access line was started – so that any medication or fluids can be easily administered into the patient

While all of this is happening, the doctor, in the most compassionate and reassuring voice, said to the patient that he is in an emergency situation and that he will be taken to the cath lab right away to see if his coronary arteries were blocked and if it is, they will do their best to clear it. I was standing in the corner at this point, trying to not get in the way but I was thinking that I want to be able to speak to MY patients in the future with that compassion and confidence. A consent form was then given to the patient to sign on the spot. I went into the cath lab and observed the entire procedure, which took an hour and apparently this is the fastest procedure! A procedure for a Total Coronary Occlusion is 3 hours. I watched the coronary arteries show up on the X-Ray screen when they injected the dye – which you can see where the occlusions are! This patient had pretty bad arteries. In the end, they decided to do an angioplasty without a stent on one of the arteries and that the patient needed a bypass surgery later that day.

Coronary angioplasty without a stent; inflating a balloon to force open the narrowed artery
Coronary angioplasty with stent; inflating a stent that will stay there in the artery

This is a coronary angiogram. T.O. stands for Total Occlusion. See how the angioplasty (Right) allowed blood to flow normally compared to the before angioplasty (Left)

Cool, huh?

Overall Experience

My overall experience was great, maybe because there was an emergency patient during my time there. If PAs do work in the HIU, they will most likely be in the cath lab assisting the physician with the procedures since nurses do all the pre and post surgical care. The nurse I was following was really helpful. The only thing she was unsure about regarding PAs were our training (only two years) and why we didn’t chose to become a physician instead (“You make more money as a doctor, especially when you end up doing the same thing they are”). Thank you for reading! Let me know in the comments below if anything I wrote down confused you or if there is anything I should add to my next IER placement experience post!


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