To 'Trop-T' With Love

Sometimes the realm of 'situational wisdom' is rather difficult to apprehend. Apprehension is one aspect... then again, failure to realise the mishandling of one even after being prompted and told otherwise is indeed a gross mistake that is totally unacceptable..

As I was browsing through my blogs at 0330H on my on-call day 2 days ago, I was approached by my house officer for an ECG that was totally hazardous! It was a complete LBBB with wide QRS, almost mimicking a VT. I attended to the patient immediately.

Mr. S had presented himself with symptoms of heart failure of acute onset, however he denied having any chest pain, and he had no ECG done before for comparison at this admission. Having reviewed the ED notes, I was rather displeased by the fact that no ECG was done at ED. Well, I could accept this, owing to the fact that I had worked in ED before and hence I know the plight of my ED colleagues quite well - short-handed and overwhelmed, being yelled at frequently by patients and relatives, both with solicited and unsolicited reasons. My patience was further 'tested', as I later found out that iv furosemide was not on board, given that my ED colleague diagnosis was congestive cardiac failure and that patient was panting away profusely!

I reckoned that probably Trop-T would be a helpful tool in deciding the significance of complete LBBB. Hence I called up the same ED colleague who had managed the patient initially, and courteously asked for a lift of helping hand on supplying me a Trop-T test kit. (Trop-T test kit is only available in ED in my hospital)

Then, I was rather irritated when she kept on insisting that in order to use Trop-T by other departments, the head of emergency department must be informed and give consent first. My god, it was 4 in the morning! And the best part was that this case was obviously mishandled by the ED colleague, who's supposed to be able to prescribe Trop-T anyway!

I told her that if she would have managed this case properly (did an ECG), she would have called me to ED to review and hence I would have ordered a Trop-T anyway (which in that case, she'd be obliged to comply!). I could easily swallow the mistake of not doing an ECG initially...and probably also the failure of prescribing furosemide. But why not lift me a helping hand and spare me a Trop-T test kit for rapid diagnosis and hence I could carry on to my appropriate treatment?

This is what I call 'situational wisdom' - To be sticky to the bureaucratic formality as far as possible, but at the same time, to use our wisdom to do away the sometimes unnecessary red-tape that could hinder optimal performance.

Verdict:
Mr S was later intubated and ventilated for acute pulmonary oedema secondary to an acute coronary event. The LBBB was most probably new onset and represent an acute ischaemic event.

Enigmatic CardioDetect(R)

I had my best call so far on the 12 March 2006, doing cardio posting on call.

Weekends were usually relatively quite (without much of the perioperative assessment referrals). And this was by far one of the most quite call I have ever had.

At 0435, my colleague in ED actually called me to review a case. A gentleman with history of end-stage renal failure on regular haemodialysis had presented with acute onset of dyspnoea but no chest pain. Coupled with the history of non-compliance to fluid restriction, and the antecedent history of inadequate dialysis, I was almost certain that it was a fluid overload case warranting urgent nephrology consultation.

I was called in for assistance as he was tested positive for CardioDetect(R) - a relatively new biomarker of myocardial injury with higher sensitivity but lower specificity compared to our good old Troponins. It was a falsely positive result as CardioDetect(R) - a human fatty-acid binding protein (h-FABP) can be elevated in renal failure and other muscular injuries as well. In other words, it is a good tool to rule out ACS, albeit an inadequate test to confirm one.

I printed out the article bearing the indications and limitations, together with the summary of the sensitivity and specificity of the test to my fellow colleagues in ED for their reference.

We learnt together by doing calls, seeing patients, albeit in a rather tiring way ;)

Back To Square One!?

I'll be posted back to cardio starting tomorrow. I gather that there will be plenty of learning opportunities for me, albeit it would be my 2nd round of doing cardio.

One of my colleagues had uttered: "You'd be better off doing something else rather than repeating the same posting. It's just like back to square one!”

I couldn't have disagreed more.

Cardio harbours the bulk of general internal medicine. Not knowing cardiology well, one would be a mediocre physician at best!

Though I must admit that most seniors in my department are relentlessly against the idea of doing cardio, the exact reason behind is way beyond my knowledge. And it has been sort of a taboo to bring the topic into discussion.

Instead of going back to square one, I foresee great opportunities ahead of me ;)