Author: Emma Hughes

Overall, I am so thankful that I was able to connect with Dr. Lewis and her staff in the Lillington clinic. I had a really great experience and I was able to learn more about the cardiovascular system as well as the healthcare system and clinical patient care. The experience was enlightening and I was able to explore the field and arrive at conclusions that I would not have been able to in an all-virtual, hands-off type of learning experience format.

Some patients who come to visit the cardiology center have typical cardiac symptoms, and yet their hearts are completely normal. Typical ‘cardiac’ symptoms- symptoms that are indicative of a multitude of cardiac issues- include symptoms such as tightening of the chest, tightening between the shoulder blades, swelling of the legs, and more. We can, however, often times identify the source of the issue through questioning and testing. By analyzing EKG charts as well as echocardiograms, we are sometimes able to rule out the cardiovascular system as the source of an issue, however we are then left to question the true source of the discomfort. Sometimes, it is nothing more than our surroundings or even our mental health that can be the cause. A patient with high levels of stress and anxiety in their life surrounding a stressful personal situation seemed to have conjured up symptoms in the body that mirrored those of cardiac symptoms. Furthermore, a different patient suffering from mental health issues, namely sustained major depressive disorder, seemed to have very persistent and exacerbated symptoms. This concept was interesting to me, because it showed that those who are already suffering from diseases, especially mental ones, are even more vulnerable to truly developing cardiac issues, or even having ghost symptoms.

Today I spent most of my day in clinic with Dr. Lewis meeting with patients, as I did in the mornings of each of my first two days. Several patients today showed evidence of sleep apnea, and as a result, I decided to make that the focal point of my post for today. Sleep apnea is a sleep disorder that presents itself during sleep. When a patient has this disorder, they will wake up in the middle of the night, sometimes multiple times, gasping for air. This occurs because airways can become blocked, and simply put: you stop breathing. The body corrects for this, however, as when blood oxygen levels are abnormally low, the brain senses it and wakes you up. Unfortunately, a lot of people with sleep apnea don’t even know that they have it, so doctors must evaluate and monitor their symptoms if they believe they may have the disease. Symptoms present themselves as snoring, gasping for air, dry mouth upon waking up, headaches, insomnia, hypersomnia (sleepiness during the day), difficulty with attention during the day, and more. But what does this have to do with the heart and cardiovascular system? Having sleep apnea can lead to a multitude of cardiovascular issues. The disease can cause weakening of the heart due to the decreased oxygenation, and stress that it places on the cardiovascular system as a whole. As a result, the heart can sustain arrhythmias (irregular/abnormal heartbeats and rhythm), uncontrolled high blood pressure, heart failure, and pulmonary hypertension.

In the afternoon of my second day at UNC’s Heart and Vascular center, I sat in on more stress tests, however this time around, they were nuclear stress tests. Nuclear stress tests have the same general goals and functions as the aforementioned exercise stress test, however are administered in a different way. Nuclear stress tests are geared towards patients who are physically unable to get on the treadmill and complete the exercise portion necessary for the other type of stress test. This could be due to physical limitations such as weak joints, those who are wheelchair bound, or any other limitations that make it impossible to reach their target heart rates by exercising on the treadmill. Instead, two sets of images are taken of the heart, the first of the heart at rest, and the second of the heart under ‘stress’.

First, a radiotracer in injected into the bloodstream through an IV in the wrist. After this is given time to thoroughly circulate through the bloodstream, the first image is taken. The ‘camera’ used collects input from the previously administered radiotracer, these signals creating an image displayed on a computer screen. Once the initial, resting photos have been taken, the patient is given a medication (again, through the radial IV) that essentially tricks the body into believing that it is stressed. This experience can be incredibly uncomfortable for about 3-5 minutes until the effects wear off. The nurse in-house also taught me an additional trick- the medication binds to certain receptors in the body and a diet coke happens to bind to those same receptors. As a result, giving a patient a diet coke will make them feel better, because it will help ease the effects and strength of the medication quicker. Finally, the second set of images are taken once the heart is sufficiently active, or ‘stressed’ by the medication, and the patient is done with their testing. Based on the results and interpretations of the images presented, doctors are able to identify blockages, diagnose coronary artery disease, understand what course of treatment to pursue, and even how treatment may be working. The image below represents what doctors see when they receive results back from nuclear stress testing:

 

The morning of my second day at UNC’s heart and vascular center very much mirrored the happenings of the first day. Dr. Lewis and I met with several patients (about 10-12) over the duration of the morning, looking over their patient files beforehand, and debriefing afterwards. Dr. Lewis shared with me that under normal circumstances, over the course of a year, she would typically write 5 death notes for patients. This, however, differed this year, as she wrote upwards of 30. She explained that not only COVID19, but several other diseases seemed to be rampant in our communities, and the communities all around the world. It was overwhelming to hear the stories from patients who had lost loved ones- sisters, brothers, parents, children, and friends- and how it affected their attitude and approach to healthcare today. Unfortunately, I am unable to share these stories because of HIPAA.

The afternoon of my first day at North Carolina Heart & Vascular, I sat in for a few stress tests and cardiovascular ultrasounds, all of which were performed by the in-house cardiac sonographer.

Stress tests are tests used by cardiologists to determine how the heart responds to stress by inducing controlled exercise and measuring the heart’s response. Each patient has 11 electrodes attached to their chests, placed to measure and track the electrical signals the heart generates to beat. This representation of the signals is called an EKG or electrocardiogram. Patients are put on a treadmill that has in incline. It begins slow and flat, and in 3 minute intervals, the treadmill both speeds up and the incline is increased. After the patient meets and exceeds their target heart rate (determined by their age and weight), they quickly transition from the treadmill to the table, lying on their sides. This transition is important, because a hardworking heart that is ‘exercising’ may reveal to the doctor any blockages in the arteries, dependent on how the heart is moving.

Cardiac ultrasounds are done the same way whether they are after a stress test or done singularly. These tests can be called ECHOS or echocardiograms. A transducer is used to transmit sound waves into the body and then record the waves the are echoed or returned back to it. These return waves allow the heart to be interpreted, and create an image of the structure on a screen. These tests allow doctors to assess how the heart chambers and valves are working, and thus can allow for condition diagnosis. One patient we saw was an old gentlemen, aged 89, whose heart valves, both the bicuspid and tricuspid,  regurgitated. This meant that the blood which should be pumping in one direction instead flowed backwards to previous chambers in between beats, because his valves were separated, and thus did not block and regulate blood flow in between beats. Several other heart conditions and abnormalities can be discovered through the ultrasound.

Today was my first day working at the North Carolina Heart & Vascular center with Dr. Ashley Lewis and her team. I was fortunate to already have a connection to Dr. Lewis (her being my next door neighbor), and was able to set up my apprenticeship on my own terms. I was able to join Dr. Lewis for clinical outreach, which she does in Lillington, a little town shy of an hour from our homes. During the drive, I was able to bond with her, and ask her my pressing questions about her backstory as a doctor and my own potential pathway towards becoming an MD. She gave me plenty of great recommendations and had lots of great insights.

In the morning, we met with 10 patients, many of which were patients who Dr. Lewis already knew, and had treated before. These were follow up appointments to check in on their vascular health. A rare few of the patients were new, and Dr. Lewis and I were able to meet them for the first time. Before we went into each patient’s room, we went over their patient history, medications, EKG charts, and the patient’s heart rate taken by the nurse upon their arrival. We visited patients with an array of cardiovascular issues, including irregular blood pressures, valve diseases, heart murmurs of aortic stenosis. After each patient we regrouped by debriefing, updating the patient’s charts, sending in prescriptions to pharmacies, and getting ready for the next patient.