6/18/18 8-4 This was my first day and it was pretty much an introduction in Dr. McKechnie’s work life. He was at Chesapeake Regional Medical Center today. His day my start out scheduled where he has plans to make rounds, check up on his office, make patient notes, and conduct procedures, but at any second he may have to throw that all away when techs and nurses call for an emergency. McKechnie is one of the best at triaging. He prefers to do everything he has to do all at one time when he can. His office is full of patients that need his help and text him. As soon as he hears his phone go off he answers. Today I watched many procedures that took between 50-90 minutes long. It varies based off of the difficulty of guiding the wire into the heart, looking for blockages, and if needed fixing them. Most of the time if Dr. McKechnie is conducting a cardiac catheterization (which is just using dye and medications to prevent clotting around the wire and to make the vessel expand to look for blockages around the heart in vital arteries) and he sees a blockage, he tries to do the stent and balloon all in that same time so the patient doesn’t have to come back in for a separate procedure. In between procedures he types up notes on patients based off of what he sees, he visits patients and describes what he did and what they should do next, and prescribes medicines such plavix and aspirin. His main way of fixing blockages in the heart is balloon and stent angioplasty. If he can’t based off of various issues, he recommends bypass surgery where a vessel from the leg is used to create an alternative for blood to flow if the blockage is too large. Today was a good day where only 1 patient needed a stent put in. The rest were able to leave that day and the stent patient left the next morning. Dr. McKechnie stents and only treats a blockage if there is 70% or greater narrowing in an artery. If it is below that medications are prescribed to lower blood pressure and prevent clotting but since a good amount of blood can flow further action wouldn’t be necessary.

6/20/18 8-4:30Today was my first day at Sentara Heart Hospital in Norfolk. Even though it is at a different location, the same type of procedures and work-life is conducted. There is a little bit more running around of McKechnie as patients are located all across the hospital. The rooms are pretty much the same as they would be at Chesapeake even though Sentara is a newer hospital. Procedures still take a long time and the patients aren’t completely sedated because they don’t feel much pain during the procedure. It was not until recently where cardiologists entered into the wrist rather the the femoral artery. The reason for starting with the wrist is because of patient satisfaction. Since both of these locations of entry are through critical arteries, there are tools that help prevent too much bleeding after the procedure. If these compression tools weren’t used then the patient will suffer with blood loss. This could be life ending and horrible to the patient. Clotting of the leg takes longer since he femoral artery is much bigger. Also going through the leg means that the patients can’t move/walk for 2 days extending the hospital visit taking up time, money and resources. Going through the leg also hurts more to the patient. Even though it is easier for the doctor and takes less time to navigate, the patient comes first. The legs are

chosen last behind the wrists (radial artery); if they are unpassable. Reasons why patients may come to the hospital would be symptoms of shortness of breath, chest pain, heart attack, failed stress tests, abnormal heart beats, high blood pressure, etc. Today few procedures were conducted but more stents were placed.

8/21/18 8-4:30Today was my second day at the heart hospital and my third day shadowing. Before procedures McKechnie visits patients telling them what he plans on doing, asks them how they were doing, and tries to develop a relationship. Before he meets the patients, he reads their notes to be well informed before meeting them. This takes a large part of his day as he believes that patient interaction is a crucial part of his day. This helps ease the minds of his patients. Today I was taught how to determine what a normal heart beat looks like. You don’t compare other peoples heart beat, but you actually watch for irregularities within a pattern of someone's heartbeat. There are various types of waves such as p-waves within a normal heart rhythm. Today I also got to see scars and wounds from patients that had went under open heart surgery. I got to see a newly developed technology that is used to minimize infection risks and time of recovery. Today I got to listen to an irregular heartbeat through a stethoscope Later on that day, I got to listen and see a heartbeat that had a pacemaker. A pacemaker is used to assist the heart in keeping it beating at a safe and normal rhythm. There were only two procedures that day but the second was a long and the highest risk procedure I had seen so far. The patient had a weak heart, so during the procedure, a special piece of medical equipment was used to pump blood for the heart, so the patient could get necessary blood flow. Due to the complexity and the carefulness of Dr. McKechnie, the procedure ended after almost 2 and a half hours. Everything went well and the necessary stents were placed. This procedure was different because there was a large number of blockages, and bypass surgery/open-heart surgery would have been easily preferred, but since the patient had a weak heart it would not have been safe to do so. Dr. McKechnie had to place several stents rather than a typical one to fully fix this patient. Through all of his procedures, there are typically 2 technologist helping the doctor and then either a tech or a nurse the logs in what exactly the doctor does. Other techs and nurses are there if necessary. The day was also partially spent reviewing EKG’s and stress tests.

6/27/18 8-5Today was my first day at Virginia Beach Sentara. Dr. McKechnie and I walked into today thinking that we would only have 1 case. Within a 30 minute span we found out that there would be 4 more cases that day. The classic day of a cardiologist is that you know going into your day, you can’t have anything planned. The first patient came in from the ER with a mitral valve cord that had ruptured. Normally the cord acts like a parachute to keep the mitral valve in plan; however, when the cord tore the valve acted like a two way door between the left atrium and left ventricle. The valve closer improperly. This is called mitral valve prolapse. This allowed the to

blood to be able to leak backwards into the left atrium also known as mitral valve regurgitation. The cause of this was most likely a birth defect and not due to poor diet and exercise. Since this patient was visiting from out of town and stable, he was able to make it home. Dr. McKechnie had to communicate with other cardiologists from the patient's area to coordinate a proper procedure. This is another big part of a cardiologist’s job, having to communicate with other professions across in far places. There were 3 regular heart caths one of which the patient already had 7 stents and a tech told me that the most she has ever seen was 21. That is a large number especially for how small the heart is. I was also taught the four different heart valves. The tricuspid valve is located between the right atrium and the right ventricle, the pulmonary valve is located between the right ventricle and the pulmonary artery, the mitral valve is located between the left atrium and left ventricle, and finally, the aortic valve is between the left ventricle and the aorta. The valve is where blood passes through. That act like flaps that are located on each end of the 2 ventricles. The valves purpose is to prevent backward blood flow. As the heart muscle contracts and relaxes, the valves open and shut. Blood enters the heart through two large veins, emptying oxygen-poor blood from the body into the right atrium. As the ventricle contracts, blood leaves the heart through the pulmonary valve, into the pulmonary artery and to the lungs for it to get oxygenated. Also I learned that capillaries are thin blood vessels that connect the arteries and the veins Their thin walls allow oxygen, nutrients, carbon dioxide, and various waste products to pass to and from our organ’s cells.

6/29/18 8:30-12:30 Today was my first day at CVAL’s office which is McKechnie’s medical group. His group is a fairly large group consisting of 26 partners and various other employees. There were a lot technologists, nurses, front desk receptionists, physician’s assistants etc. This is my first time being at a doctor’s office and it was very interesting. I didn’t realize how many people Dr. McKechnie works with. Unlike radiology, cardiologists have their own offices where the meet with previous patients annually for check-ups, patients with heart-related symptoms, or for some people who just have questions. There were a large number of non-medical workers that helped make McKechnie’s day run smoothly. I was also informed that he also has 3 other offices around hampton roads. The day started at 8:40 when the first scheduled appointment should have started; however, this wasn’t the case. Often, patients are supposed to come in about 20 minutes earlier than scheduled so then tests and paperwork can be completed if necessary. Since the very first patient was late, Dr. McKechnie’s day was drastically thrown off because that means all future patients have to wait an additional 20 minutes and that's if that were the only patient that was late. He runs a tight schedule, so if something goes wrong, he is stuck dealing with frustrated people as workers and patients may have to even spend time after closing to help out. He plans on seeing patients every 20 minutes. In those 20 minutes, he asks the patients if that have had any symptoms or discomfort. He tells them how to improve their situation whether it be taking certain medications, exercise advice, diet advice, or telling them to try to quit smoking. He asks them how their normal days are and creates a personable, friendly relationship with the patients

he sees. He is concise and efficient and rarely does Dr. McKechnie go past time. Also, he checks with patients to make sure their stents are healing well just like their heart. If needed he schedules various tests such as stress tests, echos, etc. An EKG tells the electrical pattern of the heart, if there is an arthermia, or if there is a blockage. Also the size of the chambers of the heart can be found out with this data. Vascular ultrasounds use sound waves to evaluate the body’s circulatory system and helps identify blockages. Stress tests are used for monitoring someone's heart rate during a period of strenuous activity such as running on a treadmill. An EKG aka an electrocardiogram measures your heart’s electrical activity. It determines how fast the heart beats, how well its chambers conduct electrical energy, etc. Dr. McKechnie orders these based off of the patient’s symptoms or based off his expert opinion. Patients, during these 20 minutes, describe concerns and ask questions. If Dr. McKechnie has time in between seeing patients he reads echos, EKGs, and stress tests. Basically he did whatever he could that was productive, only taking breaks for the restroom. With each patient, Dr. McKechnie had me determine if the person was sinus (had a normal heart beat) or not. I was given EKGs and asked if the patient had a normal beat or not. If in between the QRS wave, there is a constant pattern and distance then the beat is normal. If it isn’t then the patient is in atrial fibrillation. There are different waves in a normal EKG. The most noticeable and biggest wave is the QRS wave. It is the tallest and/or shortest wave. Before it there is a small dip in the wave called the T wave and the small hump after the wave is the p wave. A normal heart beat has all three of these waves.

6/29/18 8-2:30Today was my second day at Chesapeake regional medical center. This was also the first day I got be up close and personal during a procedure. Most days I spend behind the glass watching afar with a nurse or technologist that logs what is being done. Today I got to put on scrubs and LED (to protect myself from radiation since this is a fluoroscopic procedure) since in order to see where the catheter and wire should be placed, x-rays have to be used. Also, radiation helps Dr.

McKechnie navigate across the body and see where blockages are with dye. This procedure, an ultrasound was also used to try to find the vein and artery used to navigate the sheath into the different areas of the heart. McKechnie took pressures of the lung to determine the efficiency of the heart with blood flow as well. When I was up close I got to see all of the various wires, catheters, etc. being put in and out of the body. Different types of wires and needles are used based off of the patient’s specific size and shape of the vessels. These wires are all specific in width and size and each one that gets used gets documented. In this procedure, the patient had already received a stent 6 weeks prior but there was an area right outside of the stent that had clotting. Dr. McKechnie ballooned is rather than adding another stent because it gets too dangerous to the patient. Before this procedure there was a heart catheterization that turned out being normal as hoped. Besides that Dr. McKechnie made his rounds and talked to other people in need. He was supposed to have 2 more procedures but one of the patients had too much anxiety and the other one got out of defib by themselves. This patient was supposed to get shocked back into a normal rhythm, but overnight the patient’s body recovered enough to get into a normal heart beat. Today has been the slowest day and less action since no more procedures are planned so I will head home early. Meanwhile, Dr. McKechnie will catch up on office work.

7/2/18 & 7/3/18 8-12:30These two days were spent with Dr. McKechnie at his chesapeake office. During these two days all we did was meet patients who were in need of Dr. McKechnie’s assistance. The majority of his clients are older, healthy to overweight people. Many of these people are nice and cooperative and are here just for common follow ups. Dr. Mckechnie meets with patients annually with patients who have gone under and type of stenting procedure or open heart surgery. He also meets with patients who have concerns as they may have had symptoms related to heart disease. From there Dr. McKechnie decides what should happen next whether it be have them meet with a different doctor, prescribe medications, set up a heart cath, or have various tests run. He is often rushed meeting with patients all day and trying to do other grueling work in between.

7/10/18 9-2:30Today I had to privilege to shadow Dr. Chakrabarti, one of McKechnie’s partners. He is also an interventional cardiologist, so many of his procedures are the same. Today there was a total of 3 procedures. The first one was a normal heart catheterization with a patient who came in with symptoms and elected to have this surgery done. This patient previously had a CABG where viens from the leg are taken from the leg and put into the heart to act as arteries when the primary artery has to much plaque buildup and stents wouldn’t be effective. The saphenous veins are the common veins used as a bypass graft. 3 out of the 4 grafts were open, but the last one

had been narrowed. As usual, a balloon and stent was used to expand the vessel. The next procedure was a unique procedure were man had a 100% blockage in one of his arteries. The whole artery was blocked so there was literally no blood flow through the artery. When there is no blood flow, all places after the blockage will die; however, the heart created its own bypass by naturally creating collaterals from neighboring vessels. They are small but provided just enough blood flow around the blockage to keep the remaining muscle alive. Dr. Chakrabarti used a wire to poke through the new blockage. This was easy because the blockage was soft because it was new. If it was hard then it would have been harder to get through as it calcified over time. The blockage was broken and will dissolve into the bloodstream. This procedure was urgent and was needed to save the heart's function. After this, a heart cath was conducted on a patient who showed heart-related symptoms of pain. He had undergone a bypass surgery 25 years ago and had a pacemaker put in. He had a weak heart but was doing all the right things. He became vegan and exercised more which kept his heart in tip top shape. It was obvious this patient did all the right things to keep his heart healthy. The only blockage he had was at the end at a small artery, so it was to difficult and unecessary to put a stent in. Dr. Chakrabarti just prescribed new medications to help with his symptoms. Also a tech described to me that there are two main types of heart attacks. One is called a STEMI and the other is called a NSTEMI. A STEMI is acute and is caused by a rise in an EKG after a QRS wave. An NSTEMI is defined by a rise in the enzyme troponin in the body. Chakrabarti was different than Dr. McKechnie in the way he met with the patient's family right after the operation, but both McKechnie and Chakrabarti typed their notes in the same format as soon as their part of the procedure was finished. He was quick and efficient in his work.

https://drive.google.com/open?id=16WRVhAKSxBfMLt1L4yJOhAGz-xHlp8GF(LINK TO A BEFORE AND AFTER OF A PROCEDURE)

7/12/18 9:30-2:30Today I got so see a variety of different procedures. I saw a patient who had the IVAS used on

him. This was used because there was a suspected blockage in the very important coronary artery. This was used as a camera put on the top of a vein to give the full 360 degree view of the heart it was used to make sure that there was a blockage because it was at a high risk place where heart surgery may be done if the patient's lungs were strong enough. This was used with the IVAS tool which is an abbreviation for intravascular ultrasound. This doesn’t get used often but in this case it was crucial. Another patient I saw was part of an international study help

supported by Dr. C. This was a great day because I got to meet two exceptional nurses who were there to support the study. The study was used for patients who would have had to been on three blood thinners to due AFIB and the routine plavix and aspirin. This study was already accepted in Europe but the USA is slower to accept things with stricter regulation. The study was to get the patient off of plavix as soon as possible as blood thinners are very dangerous where slight cuts could cause a person to bleed out. In this case half of the patients use regular drug-eluting stents and 3 blood thinners as the control while the other half gets uncoated stents only on the plavix for 14 days. Today was the first day where the computer randomized the choices where it ended up supporting the 14 day variable. It was an exciting day for Dr. C and for the nurses. There was also a routine heart cath. The patients did well during the surgery.

7/13/18 9-11Today was a very short day because there wasn’t any presceduled cases. It was crazy to see all sorts of different patients at various steps in their recovery for various reasons. There were patients with “wet” chests due to a stiff hearts. Fluid would get into the lungs and they heart couldn’t pump it out so a special medication which I forgot the name of was used to assist it. There were sadly dying patients who had a bad stroke and someone who had a complication during their procedure. Dr. C was very informative and respectful when explaining what happened to each of the patients. On a nicer note, I got to see a patient who was seconds from death 2 days ago make a great recovery after a pump was put in. Today was nothing but rounds that were different and exciting.

7/10/18 9-3Originally, todays plans were to go the ACC at EVMS whichs is a free clinic. Dr. Chakrabarti was planning on meeting with 6 patients in which 5 of them were already ready to meet with

him; however plans changed quickly. He got a paige from the emergency room informing him of a heart attack. Dr. C had to quickly run downstairs as the patient was inches from death. If Dr. C hadn’t met him within the hour he would have most likely not have made it. They rushed the patient from the ER to a Cath Lab where within minutes Dr. C found a complete blockage of the LVAD which is nicknamed the “widow-maker” for obvious reasons. This patient was a young patient that had a strong family history, smoked recreational drugs, and had a very poor diet. He actually had a stent put in recently but claimed that the $17 life-saving drugs were “too expensive.” This patient had a whole future for him but due to the lack of taking care of himself he could have died and now has permanent heart damage. Also since his friend took him into the ER and not an ambulance, some of the preventable issues are now life-long. Due to the lack of taking care of himself this uninsured patient will no long be able to live a full, healthy life, will have to have follow up visits, take stronger doses of drugs, will have to go to rehab, and may not be able to work again due to this critical mistake. The sad thing is that he was a lucky one. He survived and still has the opportunity to fix some of the mistakes and make sure it doesn’t get worse. Typically, patients of this character rarely listen and end up dying early to an easily preventable disease. Later in the day Dr. C and I would make rounds and visit with patient families as he explain each patient's condition and treatment in great detail. We also had a patient that had three difficult blockages to treat with stents because they were either placed deep in the artery, in a critical artery, or at a branch off of an artery. Dr. Chakrabarti made the decision to refer the patient to have a bypass surgery. Also I was taught today that before many cardiac procedures the patients have to go to the dentist to get teeth pulled and cleaned because the human mouth is one of the most bacteria filled places in the human body. If this bacteria gets into the bloodstream of an injured heart then endocarditis may occur which could lead to death. After these two procedures the last day turned into small talk about possibles colleges and other professions. I now got to meet and know Dr. Chakrabarti on a deep and personal level.