P031: "WHAT A COOL CASE!! AN EXAMPLE OF THE ENORMOUS VALUE IN INTERDISCIPLINARY COLLABORATION"
Keya Locke, MD, Zachary Deutch, MD; University of Florida-Jacksonville
Background: The benefit of interdisciplinary training is exemplified in this report of the urgent treatment of a massive pulmonary embolus. Upon finishing medical training and a clinically-based PGY-1 year, anesthesiology trainees rotate almost exclusively through core-type anesthesia-related clinical experiences, with only intermittent exposure to other disciplines. Direct involvement in this case only came about through educational interaction with the cardiology department. At University of Florida Health-Jacksonville, anesthesiology residents have the opportunity to take part in a month-long cardiac ultrasound (TTE/TTE) rotation, during which they spend a large portion of the time with cardiologists and cardiology fellows.
Case Report: Patient is a 66 year old female with medical history significant for hypertension and morbid obesity who presented to the emergency room complaining of shortness of breath (SOB). Cardiology was consulted, and found that the patient's history and physical exam were not consistent with fluid overload (i.e. no crackles on lung exam, trace pitting edema, no JVD, no murmurs on auscultation). On this basis, cardiology recommended workup of other causes of SOB and transthoracic echocardiography (TTE) the following day.
The following day the TTE was reviewed in the cardiology reading room, where an anesthesiology trainee (Dr. Locke—lead author) was present as part of her collaborative cardiac ultrasound rotation. The images were impressive, showing freely mobile thrombus in the right atrium (RA), which intermittently traversed the tricuspid valve and extended into the IVC. Dr. Locke suggested cardiothoracic (CT) surgery be consulted immediately. This was done, and the echo was reviewed, confirming a large, mobile atrial thrombus flowing back and forth through the tricuspid valve. In concert with interventional radiology (IR), the treatment plan was formulated: emergency CT-angiography, followed by AngioVac procedure to suction out the RA thrombus, with IR cleaning out any residual pulmonary artery emboli. CT-A showed that the clot was no longer in the heart, likely due to distal migration. Treatment plan then changed to placement of infusion catheters in both main pulmonary arteries for overnight thrombolysis. A left lower extremity DVT was also noted on ultrasound during treatment, and an IVC filter was placed.
Pt tolerated procedure well and without complications. Patient was transferred to the medical ICU on heparin infusion, with stable vitals and no respiratory problems. AOx4. She was discharged to Skilled Nursing Facility10 days later, at her baseline state of health.
Discussion: This case, though interesting in and of itself (as the above images attest to) has its greatest teaching value in the inter-professional experience, not the medical/clinical implications. An anesthesiology trainee was afforded the unusual and invaluable opportunity to follow a critically-ill patient through the continuum of treatment, from the moment of diagnosis to stable transfer of care to the ICU team. Along the way, the trainee interacted as a valued member of a rapidly-convened multidisciplinary team, including cardiology (her primary assignment), radiology, and cardiac surgery. The untapped potential of interdisciplinary rotations and cross-collaboration among specialties is clearly vast, and is demonstrated first-hand by this case.