As a part of our Anatomy and Physiology course this Jan Plan, we worked in small groups to research and present a case study to our peers and a few health care professionals during a mock Grand Rounds presentation. Grand Rounds is a tradition in the medical field in which physicians present case studies to their peers, other medical professionals and medical students on a medical topic to share things that they learned in particular cases, so that others can learn from these cases. The Grand Rounds presentations were a highlight for me this JanPlan. Not only was it interesting to explore a case study of our choosing and get to learn about a particular medical condition, but it also exposed me to the format of Grand Rounds presentation and gave me the opportunity to practice my public speaking skills (which is something that is very anxiety provoking for me).
My group used the New England Journal of Medicine’s database to find a case study that we all found interesting. After reading through various case studies, we settled on the case of a 32 year old female, who three weeks post partum presented to the emergency department with substernal chest pain that radiated to her jaw. Substernal chest pain can be a result of many different complications including: cardiovascular complications, respiratory problems, gastrointestinal complications and musculoskeletal problems. Although cardiovascular complications are the most common cause of chest pain, it is not typically a complication that is expected in an otherwise healthy 32-year-old female. However, the fact that this patient was postpartum increases the index of suspicion for myocardial infarction, pulmonary embolism and coronary artery dissection because of the hormones present during pregnancy. An angiogram in the emergency department revealed a left anterior descending coronary artery dissection with a 35mm segment of narrowing and 90% stenosis.
Coronary artery dissections occur when the inner and outer layer of the coronary artery separate and blood pools in the area between the layers, causing decreased blood flow to the heart. There are two major types of coronary artery dissections, those that are spontaneous and those that are mechanically precipitated. Given this patient’s postpartum status and the events that precipitated her dissection, her coronary artery dissection would be classified as spontaneous. Within spontaneous coronary artery dissections, there are four sub-classifications, however only two of those are relevant to this case: postpartum coronary artery dissections and idiopathic spontaneous coronary artery dissections, which are dissections that are result of increased hemodynamic pressure caused by shear stress. Based upon test results, the patient’s postpartum status and the lack of disease in her other arteries, the patient was diagnosed with a spontaneous postpartum coronary artery dissection. Since postpartum spontaneous coronary artery dissections are relatively rare, there is not a universal treatment protocol. Conservative treatment is preferred, however sometime more invasive measures are required. In this case, conservative treatment was the most appropriate plan since the patient was stable, was experiencing very little pain and only had slight cardiac ischemia. The patient was treated with an intra-aortic balloon pump for two days to make her coronary artery more patent and was also given β-blockers, aspirin (an antiplatelet agent) and heparin (an anticoagulation agent). After two days, the patient was showing significant signs of improvement and was discharged from the hospital after eight days. The patient was able to return to life as normal and at the time that the case was presented had no further complications.
Since we had used the New England Journal of Medicine database to find our case study, we were actually able to get our hands on the PowerPoint that was used in the original Grand Rounds presentation given at Massachusetts General Hospital. The PowerPoint contained videos from the angiograms done in the hospital as well as other helpful pictures and background details of the case that we would not have had access to if we had not been able to obtain this PowerPoint. Having the actual angiogram videos from this patient enhanced our presentation immensely and made the case study feel more real.
I found this topic to be especially intriguing because it combined two of my clinical interests: women’s health and cardiology. I have always been drawn to women’s health issues particularly pregnancy and birth and for a while now have considered becoming an OBGYN or midwife. Spontaneous coronary artery dissections (SCAD) are a rare complication of pregnancy, so it was really valuable to learn about the presentation and treatment options for SCAD and this knowledge could potentially be useful in my future career, which made the information feel very relevant. This JanPlan I discovered a new interest in the heart and cardiology. I had never considered cardiology to be a field I was particularly interested in, but the cardiovascular unit in this class really opened my eyes to the wonders and intricacies of the heart and has left me wanting to learn more. This topic fit my interests perfectly and I thought it was really cool that we got the opportunity to study a case and explore our personal interests in an incredibly relevant way. Postpartum SCADs are very rare and are often overlooked, but now I know what to look out for which will hopefully help me provide the best care possible to my future patients. I also felt that I learned a lot of important and relevant information from my peers presentations. It was really fun to get to watch my classmates present topics that they were passionate about. Grand Rounds was a very rewarding and interesting endeavor and was definitely a highlight of my month.
https://www.youtube.com/watch?feature=player_embedded&v=bODWv-x-eDc