Unilateral Diaphragmatic Palsy After CABG

It had been a hefty day. I had kept myself busy for a presentation. Had not written anything for my blog. Was looking for an interesting case to kick my inner sense.

Just to engage myself in activities, I took my iPhone in my hand. Opened Facebook followed by WhatsApp as it peeped new messages. Our all-india CTVS thread..

 

Somebody has sent an X -ray image and an adding question below it. I clicked the image, but it started downloading. How X ray can be in video, i thought to myself. It was still downloading. Reliance Jio was doing its job. I was eager to answer, but already two doctors has answered back. I knew i was late, as always. It took 30 seconds to be downloaded but no time to open.

It was not an X Ray. Wow, flouroscopy? I was sure! But was querying myself, can X Ray images be taken in video format. It took me some minutes to clear it out… Flouroscopy is a version of X Ray in succession.

I have never seen something like that. It has been a long time we used to do X Ray and diagnose it to be collapse or effusion or eventuation. But what flouroscopy showed was lively. I uploaded the video to my youtube site to show it here in my blog.

Long time had passed to my training as a cardiac surgeon but it was a new eye opener.

Somebody had answered, “Right diaphragmatic palsy following phrenic nerve palsy while harvesting RIMA.”

I had no other answer to give. The fluoroscopy was clear, Sternum was shown as \ wrapped in stainless steel wires. Before I wrote something the doctor with the question replied a big thumbs up to the previous answer.

I queried, “How did you manage the case?” There was much expectation of response from the other

Got a reply a bit late but loved it the way he has answered with use of triball exercises.

“Triball Exercises” – wow, what a better way to present the simple look marvellous. Triball exercise is the spirometer with three balls we give to all cardiac surgery patients for breathing exercises.

After adequate visuals, I played the video once again and felt pleased.

 

Some Cardiologists May Not Know; ECGs Never Hide A Problem!

There had always been a cold war between the cardiologists and cardiac surgeons all the time. Its not limited to the consultant, even it shows its effect at resident level. I was not exception to the rule. Still, I do have many ethical issues. Never queried anything unless urgent or necessary from cardiologists or their residents.

Fig: Though the ECG looks normal, if you will give a closer look you will find whole cardiology hidden inside.

It was tough time for me, when my eyes were paining and i was on steroid and immunesuppressant for my eye problem, I had been told by my professor to do case presentation in the board room. He proceeded with the best case, the recent one we had done a couple of days back- “combined left pneumonectomy with aortocoronary bypass grafting.”

Before I could give any hint of eye problem to my professor, he went on adding what to write and how to preset.

“It will be a nice case, Sibashankar.” ” You have enough time, 3 days.” “Prepare yourself and show me the presentation tomorrow”

“Yes, Sir.” I expressed my solitude as he handed over the departmental letter from academics.

God to save my eyes, i have no other expectation beyond his desire. I made  up my mind to write it at last. There was no other way out. I have to stay in the department till the completion of the course, two more lousy year.

I collected all the photographs that is to be shown in the slide show.  Collected the ECG and tried to read it as I had to read the ECG at the time of presentation.

Surgeons impression on a difficult ECG, you can better imagine! I found nothing. But could not make up my mind ,”How ECG can be normal in a patient with chest pain and having triple vessel disease with complete occlusion of LCx-OM and RCA. LAD was also significantly diseased and there were not enough collaterals as can be seen in coronary angiography.

I tried to assure myself but could not. I was in deep thought regarding the presentation with all possible options that I can take to make my presentation better.

A cardiology resident came into the duty room. He was one year senior to me and I used to call him sir. He relaxed himself in the bed. I have never ever asked any question to him as he never ever had answered any correctly or with decency.

But this time it was different. I was desperate that someone should read the ECG so that I can present to the audience. Asked to myself, “Should I show the ECG to him?” All my life I had been lived on ego. It has been the only thing that has kept me alive and going. Ego is the only thing to keep me reading and the only thing that has made me a doctor. Never ever in my life have I ever left it aside. I don’t know, but its the truth. You can say I am possessed with ego; oh yes, a bucketful of it.

I could not make me satisfied with the ECG and asked to the cardiology resident to read this as I handed over my iPhone to him. He took the phone and kept it inside his chest as he was lying down supine with his own mobile in his hand. As he was seeing his own mobile and i looked towards the television and forgot my mobile to collect. More than minutes had been passed, an other cardiology resident remind him to be careful for the iPhone on belly which i have handed over. I got into sense and looked towards him. A trench of anger penetrated my cerebrum as he took the mobile in his hand and carelessly told, “Its nothing.” “Normal ECG.”

Normal ECG!! Wow, say me anything other than this. Told him about the coronary angiography report with total occlusion of the two major vessels of he heart with scarred posterior wall. He casually answered, “Patient can have with normal ECG with blockages in coronaries.”

Another cardiology resident joined him in the race. I have not expected much from them. Its not compulsory that doctor has to know all his speciality or a cardiology has to read all ECGs. But i cannot soothe myself if they don’t agree to understand the same. Here come my ego and i am best in that.

That day passed. Could not search enough on ECG findings that is to be found on coronary artery diseases. Holi celebration was in full fledge, getting holi messages in my WhatsApp. I was replying colour images to all the well-wishers. There i noticed the message of one of the cardiac resident, very close, near dear and someone i really respect from the bottom of my heart. I send him holi wishes. All of a sudden i realised, its worth showing him the ECG.

I directly called him. He picked up the phone. After initial formal wishing over phone I asked about the ECG. He listened and replied, “ECG could not be normal with two coronaries hundred percent blocked and with any scar area in heart.”



Thats what i have been looking for. A little patience and thinking it to deep using the basic knowledge which he had shown. I told him “I am sending you the ECG through WhatsApp, you check and say.”

 

 

 




He took his time and called back. I was eager to listen to him. “I could not actually find the problems this ECG show, but definitely its not a normal one.”

Again that what is what i had needed to hear. Simplicity at its best.  He added, “This ECG had fragmented QRS complexes and it indicate something, maybe scarred area in the heart.” He confirmed it by searching it in the internet.

I was happy as I got one finding. He did not stop there and in a thoughtful voice replied, “There is also non-specific ST-T changes in the lateral leads.”

His points were clear, I looked though the ECG again and felt the same. A cardiologist can make an ECG talk. But definitely a good cardiologist.

He asked me again about the echo and coronary angiography findings and added, ” I also see slow R wave progression in precordial leads.”

Oh my God! When I was getting nothing, now i had three findings to explain my ECG. He kept himself sticked to the topic and started churning the topic. His last word before keeping the phone was, “I will let you know if i find anything else.” He did not forgot to wish me good luck for the presentation.

Next day was my presentation. It went well, cool and convictive. I had not forgotten to thank him, for his clear suggestions, in the next meet.