Mount Sinai – Division of Pediatric Cardiology

“””RotationsInpatient Service“”””””””

The inpatient service involves all aspects of care of
newborns, infants, children, and adults hospitalized with congenital
heart or acquired heart disease, as well as adults with congenital
heart disease. These patients include individuals admitted for cardiac
surgery, convalescing patients returning from the Pediatric Cardiothoracic
Intensive Care Unit (PCICU) postoperatively, newborns with congenital
heart disease born at our institution or transferred from other institutions,
and patients admitted electively or in an emergency for the management
of cardiac problems such as congestive heart failure, cardiac allograft
rejection, or arrhythmia management.

The inpatient service team includes a pediatric cardiology attending,
a pediatric cardiology fellow, pediatric residents, and fourth-year
medical students rotating on the service for one month. The team is
responsible for pediatric patients with cardiac problems hospitalized
in the neonatal intensive care unit (NICU), the pediatric intensive
care unit (PICU), and the pediatric inpatient floors, and adults with
congenital heart disease on medical, surgical, or obstetrical floors.
The team is also responsible for consults in any of the aforementioned
areas as well as in the newborn nurseries and the pediatric emergency
room.

The inpatient service team makes daily teaching rounds during which
all patients are examined and all relevant laboratory data including
electrocardiograms and chest roentgenograms are reviewed. Typically,
these rounds require 2-3 hours/day. Each patient’s problems are
discussed, and the proposed diagnostic and/or therapeutic plans are
devised. As the pediatric cardiology fellows progress through their
training, they are given greater responsibility in leading the rounds
and making clinical decisions about the patients. Consultations are
carried out either by the fellow with subsequent bedside review by
the faculty member or jointly by the fellow and faculty member, depending
both on the nature of the consultation and the level of the fellow.
Clinical emergencies such as unstable newborns with congenital heart
disease or children with low cardiac output are managed jointly.

During this rotation, fellows have opportunities to perform certain
procedures such as cardioversion of tachyarrhythmias (both with adenosine
and direct current), placement of central lines, and emergent pericardiocenteses.
The fellow is also responsible for interpreting all pediatric electrocardiograms
performed on inpatients. These interpretations are all reviewed by the
faculty member and discussed further as warranted.

In addition to the impromptu discussions related to issues arising
on clinical rounds, more formal didactic sessions are held. The pediatric
cardiology fellows are assigned topics for brief discussions, often
triggered by interesting patients on the service. In addition, the faculty
member and fellows are expected to spend time instructing the more junior
members of the team in basic pediatric cardiology such as the physical
examination, physiology/pathophysiology of common congenital heart lesions,
and interpretation of the pediatric electrocardiogram. As before, the
fellow assumes increasing proportions of these teaching responsibilities
as s/he advances.

During the inservice rotation, the pediatric cardiology fellow learns
about interfacing with numerous other services, both medical and non-medical.
A nurse clinician, social worker, and child life specialist provide
input and require feedback from the inservice team in the care of patients,
as well as in discharge disposition. The fellow is responsible for regularly
discussing the patients with these integral members of the teams, thereby
learning about relevant important issues such as arranging home care,
certain technical aspects of both public and private health care coverage,
and the importance of the psychosocial issues in the care of children
undergoing traumatic procedures or suffering from chronic illness.

The fellows also interact with referring pediatricians, both pediatricians
and pediatric cardiologists. This interaction provides the fellow with
opportunities to understand his/her role as a consultant at a referral
center and to learn how to assist referring physicians in stabilizing
sick patients at distant locations.

The pediatric cardiology fellow interacts with physicians from numerous
other pediatric subspecialties. These interactions provide instruction
in the proper role of the pediatric cardiologist in the care of patients
with a variety of problems and also in the role of other specialists
in the care of children with congenital heart disease.

Finally, the pediatric cardiology fellow interacts with physicians
from adult medical services, including adult cardiologists and obstetricians.
The fellow and faculty member on the inpatient service provide consultation
on adults with congenital heart disease including newly presenting patients,
those with chronic problems (e.g., heart failure, arrhythmias), and
pregnant women with corrected or palliated congenital heart defects.
In addition, the fellow participates in the management of fetuses with
congenital heart disease, heart failure, and/or arrhythmias, in conjunction
with the high risk obstetrical service.

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