Week 4 at Rex

I've seen a couple of interesting cases this week, including:
- A stent placement in the left main coronary artery, a procedure known in the cath lab as "the widow-maker." I was just going to observe a cardiac cath, which they say usually take 30-45 min, but I walked into a complicate case that took over 3 hours. The 66 yo white male had a calcified plaque blocking ~75-80% of his left main. The lab techs said that they would usually send a pt like that for a CABG immediately. However, this pt already had multiple bypass grafts on smaller coronary arteries ~10 years ago, so he wasn't a good candidate for another surgery. So, they were just going to place a stent to open up the artery, but the plaque was so hard that the stent wasn't really widening the artery. The doctor tried the next size wider stent, but no sucess. He mentioned trying a rotoblator, a diamond-tipped blade that would cut away the plaque. The nurses and techs instantly became edgy. (I should say, the nurses and techs sitting with me in the observation room, not the nurses out with the pt, who was sedated but still very much awake.) I asked why the rotoblator was such a big deal. They replied frankly that it was a huge risk with such an important vessel; if the doctor accidentally cut the vessel, the pt would bleed out and die on the table, and if he accidentally dislodged a large piece of the plaque, it would probably cause a massive MI. Another cardiologist was consulted, and the doctor was persauded to just try the next size larger stent. The stent went in, but I never got the final report on how well the vessel was widened.
The techs were really nice and understanding of my role. One said that while it's really rewarding to help someone survive a MI, they're just treating the symptoms while I'm actually addressing the real problem.
- A 41 yo woman with end stage scleroderma, admitted after she aspirated during an endoscopy, which also revealed that she had undigested food in her stomach. She had been having trouble eating for a while - her BMI was down to 15. My recommendation was a j-tube d/t severe dysphagia and gastroparesis, but the doctor wouldn't perform the endoscopy necessary to place the tube d/t the complications with the last one. So, this woman is basically going to tolerate what food she can. I brought her different oral supplements to try, gave her and her husband handouts on a blenderized diet, and explained how she could meet her energy and PRO needs with thick liquids. It was just hard to see someone still so full of life essentially being trapped in her own body, with her skin thickening to what looked like hard plastic.
- A 99 yo woman with pancreatitis. We got a consult from the doctor to educate on a low-fat (50 gm fat) diet, but it turns out that the woman pretty much stretches the 3 meals that Meals on Wheels brings her to last the entire week. I wonder if she even gets 50 gm of fat per week. I hope for her sake she's just a little senile and really eats more frequently - she was the sweetest lady. My preceptor and I abandoned the instruction and just encouraged her to eat, and then we went to talk to the social worker. The social worker will follow up with whatever family she has, the assisted living neighborhood where she lives, and Meals on Wheels. Much like the HAICC conference, it made me appreciate social workers. I can't do my job unless people have food to eat.
- A 40-something man in for multiple CABG and then diagnosed with T2DM. However, based on his insulin therapy and lab values for the few days he's been in the hospital, it seems possible that he's not really diabetic - it's just the stress of the stress test and subsequent surgery that has made him appear diabetic. Of course, he's at risk anyway since he's morbidly obese, so we went ahead with the diabetes diet instruct. The instruct was made more complicated by his living arrangements - alone in an efficiency apartment with no kitchen. Again, social work is going to be really important in getting his needs met during his recovery. We tried to think creatively and really apply the info to what he'll be able to do. Fortunately, he was really smart and can count carbs on labels really easily.