Heartfelt with Dr Melissa Walton-Shirley

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TIMACS-another reason to be on time to the office.

Nov 11, 2008 00:54 EST


  A typical scenario in the day in the life of a busy cardiologist:

 You arrive to the hospital with plenty of time to see everyone on your rounding list.  You are fairly refreshed because you weren't on  call last night.  You rush at first, but then seeing you have about thirty minutes before you have to be at the office, you take a little extra time to talk to Mrs. Jones about her husband because you just didn't have the time yesterday.  She really appreciates it, gives you a hug and just as you are about to turn the handle on the exit door to dash over to the office, a pesky  nurse says  (sorry Becky), "don't forget to see Mrs. Peters, she was admitted to you  at 3 am this morning  with ST's down, troponin I of 0.7.   "No one called me " I say, trying to explain why Elvis is about to leave the building. "   The nurse never misses a beat and says "She's OK now,....ST's back to baseline on a heparin drip, beta blocker and aspirin. Here's her chart", and pulls me into her room where her family has been anxiously awaiting my arrival.   

"GREAT",  I think to myself.  I took extra time to try and do a good thing for one patient  only to realize I've done a bad thing for another by not allowing myself enough time to take this patient to the cath lab. The ER called my partner who is already doing a case in the lab and either forgot to call me just hasn't had time.   None the less, I check the cath lab and we are booked until late evening.  My office doesn't wind down until after the first open time slot.  The patient doesn't want to be NPO all day and quite frankly, no one looks forward to doing a cath late in the evening. 

Now, with TIMACS, we have good news for our  patients   with ST''s down since there is no advantage or disadvantage of going to the cath lab late or early (EXCEPT in those with GRACE scores > 140) and good news for our office patients that we can actually plan on being to the office on time, well at least sometimes.  However, early invasive strategy had a large impact on reducing the rate of refractory ischemia by 70% which prompted the "take me early" direction given by Dr Bhat.  

Though Dr. Bhat, the commentator said  if he were the patient, he would want us to "take him early" to the lab, it's not always practical and in those circumstances patients can safely wait. I fear the only losers in the "waiting" strategy are the  insurance companies who expect us to serve 24/7, even though a quick phone call to their office on the weekend will certainly verify that they do not. 

 Melissa





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Your comments
TIMACS-another reason to be on time to the office.
# 1 of 6
November 11, 2008 11:39 (EST)
Melissa

Steve Stiles, described as "shockingly organized" last evening, when he received a prestigious  and well deserved award for his expertise in medical journalism, placed a direct link to the GRACE risk score last evening along with his coverage on the topic. (thus confirming his thorough approach to everything!)  Since I'm inherently lazy about memorizing such stuff, I thought I'd just do a little cursory review in case any of you share the same lazy-at-memorization gene.

The GRACE risk score has been shown to be superior to the TIMI risk calculator and studies utilizing it demonstrate prognostic power up to 4 years post index admission.  GRACE risk includes parameters of age, HR, SBP, Creatinine, CHF, cardiac arrest at admission, ST segment deviation, elevated cardiac enzymes and in one trial included a history of CAD and whether or not the patient underwent PCI. 

I was thinking however, that with increasing score pushing us into  going to the lab sooner than later there is now one exception where the risk benefit ratio of going earlier has now increased:  elevated Creatinine.  Now that we have TIMACS, it would be nice to actually adjust the GRACE risk to address the need for adequate hydration prior to contrast exposure, since hurrying these patients to the lab could spell big trouble for no significant benefit early in the hospitalization,

Melissa
# 2 of 6
November 12, 2008 12:11 (EST)
Becky

No need for apologies!  I heard 'no one called me" lots when I worked nights and early am's.  Unfortunately, most of the time the doc was correct!  I'm thankful for all this "new" risk scoring and testing to help prevent those missed calls or at least give some breathing room to being called.

BTW-great post on the 'CHF" diagnosis.  I would LOVE to go back (sometimes) to the good old days of just looking at your patient and not all the danged monitors!  God gave us brains to use, and use them we should.  Many a time in the middle of the night my co-workers and I were credited for a "save" when all we did was really look at our patient who was going down the tube and report what we saw and what we were doing, giving suggestions/recommendations to the resident/intern/attending, and then following up.  I guess that is now called the rapid response team and is a 'novel" approach to care.

Vapidly reading your posts and sending on info to my docs.....

Becky
# 3 of 6
November 13, 2008 11:18 (EST)
Ghassan-S Kiwan

May I say this ?? :what a "SAFE"relief for the patient and the carddiologist.....

one should however always keep in mind to maximize treatment during this waiting period and never take things for granted..
# 4 of 6
November 13, 2008 08:58 (EST)
Melissa

Well put Ghassan-S

Safe relief is better than worried relief anyday!

Melissa
# 5 of 6
April 24, 2009 07:15 (EDT)
Pirsey
The style of writing is quite familiar to me. Did you write guest posts for other blogs?
# 6 of 6
April 28, 2009 06:55 (EDT)
melissa

Pirsey,

I've written for local newspapers since age 16 (as the high school class reporter!!), provided commentary for other outlets occasionally, comment on other bloggs and I've been with theheart.org for over 5 years.  I hope you find our website helpful.

Melissa

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About Dr Melissa Walton-Shirley
Dr Walton-Shirley performs invasive cardiology, nuclear cardiology, and stress echocardiography in a private practice in Glasgow, KY.

Her chief medical interests are CHF/hypertrophic obstructive cardiomyopathy and the promotion of primary PCI for acute MI. Recently she played a significant role in helping to launch an ambitious pilot study of primary PCI in Kentucky, the Kentucky Primary Angioplasty Pilot Project. She has also participated in the TIMI 19, Duke-HF, NRMI, and CRUSADE trials and is proud to have been an advocate of the first smoke-free initiative in Kentucky (2011). She champions a smoke-free America.

Dr Walton-Shirley received her undergraduate degree at the University of Kentucky and went to medical school and did her residency and fellowship at the University of Louisville. She is married with two daughters. Her interests include singing, writing poetry and songs, fitness, and, of course, theheart.org.