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Heart Failure and EKGs

Posted Oct 09 2008 6:52pm
This is my last week on Cards. I should have had to be on call again this weekend, but since I'm switching to a general Internal Medicine (IM) team next week, I lucked out and will get the whole weekend off. I'm grateful for that, because it's been a hectic past couple of weeks.
Yesterday and the day before, we had two EKG sessions led by one of the chief residents. They gave us sample EKGs and helped us go through them and practice interpreting them. Since my cardiology attending is the CCF guru of EKG and has been doing impromptu teaching sessions with my team over the past two weeks, I came in already feeling pretty well prepared. Then last night, my intern was going over EKGs with me in the ER while we were on call. Like I've said before, this intern really likes to teach, and I've learned a lot from him over the past two weeks.

I am still following one of the patients we were consulted to see in the ER a while ago. He had come in short of breath with a 25 pound weight gain due to an exacerbation of his congestive heart failure (CHF). Because of retaining so much fluid, he had the most impressive pitting edema (swollen legs due to excess fluid) that I had ever seen. Saying that his edema was pitting means that when I pressed on the swollen ankle with one finger and then let go, the pit made by my finger would stay visible on his ankle for a few minutes afterward. It's almost like how a piece of clay will still have an indentation after you push your finger in and then take it out.

Anyway, he had so much excess fluid in his body when he showed up to the ER that he couldn't even lie down--if he did, his lungs would fill up with fluid, and he wouldn't be able to breathe. He also couldn't walk because it made him too short of breath. So he had to stay sitting in a chair all the time. In spite of that, he was cheerful and joked around with me. We spent an hour in the ER going through his history and physical until my team came down. Then my intern admitted him to the floor.

The obvious solution was to give him an IV diuretic (similar to a water pill) to try to get some of that fluid off, which is exactly what we did. However, it created a real catch-22: every time we tried to increase his dose of diuretic, his kidneys would start to fail. But if we decreased the dose of diuretic to improve his kidney function, he would gain back a few pounds of fluid, negating the progress we had made in diuresing him. After several days of this stalemate, the team decided to transfer him down to the heart failure ICU. He still had so much fluid on him that he had to stay sitting up in his chair all the time, and he couldn't walk, talk or lie down without becoming severely short of breath.

Now that he's in the ICU, he isn't my patient any more. But he and I get along pretty well, so I have still been stopping by the ICU to check on him when I have some time. Today, he introduced me to some of his friends who were visiting him, and I told him that I'd come by again on Monday when I get back. Unfortunately, so far, the ICU team isn't having any more luck with diuresing him than we did.
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