AHA FIT

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The Robotic Technology in Interventional Cardiology

Lina Ya'qoub, MD

The past few years have witnessed amazing advances in the robotic technology leading to its widespread utilization in both research and clinical aspects across multiple fields, including the cardiovascular field! I have recently attended a few conferences and the footprint of the robotic technology has been remarkable in each of them, emphasizing the great interest in the progress and utility of technology in our field. I decided to talk about robotic technology in interventional cardiology, the advantages and limitations of its use, and how I see it impacting the future of interventional cardiology.

  • How long have we used robotic technology in the cath lab?

Robotic technology has been used in surgical specialties and radiation therapy since the mid-1990s. Then, robotics systems for endovascular interventions were developed and have been utilized for different percutaneous interventions, including simple and complex coronary and peripheral interventions, as well as other structural heart disease procedures, including atrial septal defect closure.

  • Do we have scientific evidence-based trials assessing the robotic technology in interventional cardiology?

There are many prospective trials looking at robotic technology in both coronary and peripheral interventions. The two major studies are:

  1. PRECISE (Percutaneous Robotically Enhanced Coronary Interventions) trial: 164 patients with relatively simple lesions (>87% ACC/AHA type A/B; lesion length 12.2 6 4.8 mm), the investigators reported clinical success of 97.6%, technical success of 98.8% and > 95% median operator radiation reduction. Based on the results of this study, in 2012, the FDA approved the CorPath 200 System as the first robotic system for PCI.
  2. The RAPID (Robotic-Assisted Peripheral Interventions for Peripheral Artery Disease) trial, a prospective single-center, safety and feasibility study demonstrated the utility of the CorPath 200 system for robotic peripheral interventions. The study demonstrated 100% device technical and clinical success. No significant adverse events related to the device were reported, and based on this study, the CorPath 200 system received FDA approval for peripheral interventions.
  • Advantages
  • One of the main advantages of the robotic system in the cath lab is the reduction of radiation exposure for both the operators. The hazards of radiation are well-known and studies have demonstrated that the use of robots led to a reduction in radiation exposure [1]. Operators using the robotic system can either be in the cath lab several feet away from the radiation source or even in a separate room, where they can control the joystick and use the control pad to adjust the robot movements to control wires, the guide catheters and other devices (balloon, stents, etc..).
  • Robots also help avoid wearing heavy lead aprons and thus decrease the orthopedic problems that many operators suffer from in the long run, including back pain and arthritis.
  • Moreover, studies have also shown that robotic system use is associated with good precision and outcomes [1].
  • Robots have been increasingly utilized with around 100 hospitals in the US currently using robots in the cath lab. This quick and widespread utilization of this new technology demonstrates not only how safe and successful the robotic system is, but also how easy and user-friendly it is.

 

  • Limitations

In my opinion, this tool was developed to help operators, but not to replace them. Like any tool, the machine can potentially stop working, for a technical reason or other reasons, and at the end of the day, it is the physician’s responsibility to deal with the situation and solve the problem. In addition, the use of robotic system is limited in the following:

  • The use of robotics in STEMI or bifurcation lesions has not been well-established yet, although reports and smaller studies have shown it can be performed safely.
  • There are technical limitations of the robotic system, and if a lesion could not be treated, manual conversion is recommended.
  • Limited devices used by the current generation of robotic technology: use of over-the-wire balloons, intra-vascular imaging catheter, or mechanical circulatory support is not available with the current generation of robotics.
  • How will robots change the future of interventional cardiology?

The robotic technology has been increasingly utilized in multiple hospitals across the world. With more experience with robotic technology utilization, more knowledge and future upgrade of robotic systems, I think this tool will be increasingly utilized and updated to conform to the needs of patients, operators and different kinds of procedures and interventions; in fact, the robotic system is being studied in the utility of transcatheter aortic valve replacement (TAVR) procedures! Moreover, the utility of the robotic technology could potentially enable experienced operators to remotely perform complex interventional procedures in patients in different hospitals in rural or urban areas, different states, different countries or even different continents!

With the rapid progress in technology in all fields of our life, I think it is very important to establish and encourage more collaborations between technology and medical sciences, especially in procedural specialties, where precision and safety can be provided by these advanced robotics systems for optimal outcomes. I look forward to seeing how these technologies will evolve and transform our practice in the future!!

 

I would like to thank my colleague and friend, Dr. Jeff Hsu, for his help on this blog and for being an awesome senior buddy!!

References

  • Mahmud et al: Robotic technology in interventional cardiology: Current status and future perspectives. Catheter Cardiovasc Interv.2017 Nov 15;90(6):956-962.

https://onlinelibrary.wiley.com/doi/abs/10.1002/ccd.27209

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”
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Why Should We Care About Sex Differences in Do Not Attempt Resuscitation Orders After In-Hospital Cardiac Arrest?

Sasha Prisco, MD, PhD

As an AHA Early Career Blogger and member of the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation (3CPR), I am pleased to have the opportunity to summarize the recently published paper in the Journal of the American Heart Association (JAHA), “Do Sex Differences Exist in the Establishment of ‘Do Not Attempt Resuscitation’ Orders and Survival in Patients Successfully Resuscitated From In-Hospital Cardiac Arrest?”1 This paper was published in February during American Heart Month in the JAHA Spotlight: Go Red for Women 2020 series in conjunction with AHA’s Go Red for Women initiative.

In summary, Perman et al.1 used the Get With The Guidelines®-Resuscitation registry to determine whether there are sex differences in the establishment of “do not attempt resuscitation” (DNAR) orders after resuscitation from in-hospital cardiac arrest and whether the differences in DNAR use lead to differences in survival. They examined 71820 patients across 571 hospitals who had return of spontaneous circulation (ROSC) after in-hospital cardiac arrest and examined the association between de novo DNAR orders (any time after ROSC, within 12 hours of ROSC, or within 72 hours of ROSC) and sex and the association between sex, DNAR orders, and survival. The 72-hour time point was selected since after this time is when patients who are comatose after cardiac arrest begin to have neurologic findings that indicate poor prognosis and AHA guidelines recommend that the determination of neurologic prognosis should be delayed until at least 72 hours after ROSC (or 72 hours after reaching normothermia if targeted temperature management is used).

Of the 71820 patients, 42.4% of the cohort were women and women were on average older (mean±SD: 65.5±15.8 vs. 64.6±15.1 years; P<0.0001), less frequently of non-Hispanic white race (61.7% vs. 67.5%, P<0.0001), more likely to have a non-shockable cardiac arrest rhythm such as pulseless electrical activity (PEA) or asystole (81.6% vs. 78.0%, P<0.0001), and more likely to have a noncardiac illness at the time of admission (47.2% vs. 41.1%, P<0.0001) while men had a higher incidence of cardiac premorbid conditions.

Of the total cohort, 44.1% had a de novo DNAR order placed after ROSC. Of the entire cohort, 45.0% of women and 43.5% of men had a DNAR order after ROSC (unadjusted RR: 1.16; 95% CI, 1.12-1.21; adjusted RR [ARR]: 1.15; 95% CI, 1.10-1.20). Women had a higher rate of DNAR status early after resuscitation. Of those who had any DNAR order during the hospitalization, 51.8% of women compared to 46.5% of men had a DNAR order placed <12 hours after ROSC and 75.9% of women compared to 70.9% of men had a DNAR order placed <72 hours after ROSC. When adjusting for the patients’ demographics and cardiac arrest characteristics, female sex was associated with a higher likelihood of early DNAR <12 hours after ROSC (ARR: 1.40; 95% CI, 1.30-1.52) and DNAR <72 hours after ROSC (ARR: 1.35; 95% CI, 1.26-1.45) among those who had a DNAR order any time after ROSC.

Interestingly, after adjusting for patient and arrest characteristics, female sex was mildly associated with lower rates of survival to hospital discharge (ARR: 0.98; 95% CI, 0.96-1.00; P=0.04) and there were no differences in survival rate between men and women after adjusting for DNAR status within 72 hours. However, early DNAR status made within 72 hours of ROSC (combining data from men and women) was associated with decreased survival rate compared to those without a DNAR order or a DNAR order placed ≥72 hours after arrest (RR: 0.15; 95% CI, 0.14-0.17; P<0.0001).

This study by Perman et al.1 is not the first study to note differences in rates of do not resuscitate (DNR)/DNAR orders between men and women. Nakagawa et al.2 showed that women with acute intracranial hemorrhage were more likely to receive early (<24 hours from presentation) DNR orders than men. In a study of patients who received emergency surgery, women were more likely to receive a DNR order but morbidity and mortality rates were similar between men and women3.

Unfortunately, the reasons for women to more likely receive earlier DNR/DNAR orders are unknown at this time. Perhaps these differences could be due to patient preferences (e.g. women having earlier end of life discussions with family/surrogate decision-makers), implicit provider biases (e.g. female cancer patients were found to be more likely to receive early DNR orders from female physicians4), surrogate decision-maker biases, sociocultural factors, religious factors, situational influences, etc. Although DNR/DNAR orders are not requests for withdrawal of life-sustaining therapy, the presence of DNR/DNAR orders has previously been associated with decreased aggressive interventions and decreased survival to discharge for patients with out-of-hospital cardiac arrest5. This suggests that health care providers should be vigilant of the tendency to be less aggressive with care for patients with DNR/DNAR orders and ensure that their management plans align with the expectations of surrogate decision-makers. More robust qualitative data are needed in order to understand these differences.

References:

  1. Perman SM, Beaty BL, Daugherty SL, Havranek EP, Haukoos JS, Juarez-Colunga E, Bradley SM, Fendler TJ, Chan PS, † AHAGWTGRI. Do sex differences exist in the establishment of “Do not attempt resuscitation” Orders and survival in patients successfully resuscitated from in-hospital cardiac arrest? J Am Heart Assoc. 2020;9:e014200
  2. Nakagawa K, Vento MA, Seto TB, Koenig MA, Asai SM, Chang CW, Hemphill JC. Sex differences in the use of early do-not-resuscitate orders after intracerebral hemorrhage. Stroke. 2013;44:3229-3231
  3. Eachempati SR, Hydo L, Shou J, Barie PS. Sex differences in creation of do-not-resuscitate orders for critically ill elderly patients following emergency surgery. J Trauma. 2006;60:193-197; discussion 197-198
  4. Crosby MA, Cheng L, DeJesus AY, Travis EL, Rodriguez MA. Provider and patient gender influence on timing of do-not-resuscitate orders in hospitalized patients with cancer. J Palliat Med. 2016;19:728-733
  5. Richardson DK, Zive D, Daya M, Newgard CD. The impact of early do not resuscitate (dnr) orders on patient care and outcomes following resuscitation from out of hospital cardiac arrest. Resuscitation. 2013;84:483-487

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”
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How to Shine the Light on Hidden Figures in Science and Medicine

Christa Trexler, PhD

March is Women’s History month and like last year, I wanted to find a way to use this blog as a way to highlight some amazing women scientists and cardiologists. When writing my piece last year, I had a really hard time finding enough information about trailblazing women in cardiology — which was incredibly frustrating since we all know women are a driving force in our field.

I then came to realize, although I wasn’t surprised, that this isn’t specific to our field. One of the main reasons it was hard to make a list of notable women in cardiology is that less than 20% of Wikipedia articles are about women. Even Marie Curie shared her Wikipedia biography with her husband until recently. If winning a Nobel Prize doesn’t make you worthy of your own Wikipedia page, I’m not sure what does. This bias has become an issue in part because most of Wikipedia editors are men.

So, how do we fix this? What can you do?

It turns out, the answer to these questions is actually really easy! Since anyone can become an editor on Wikipedia, you yourself can edit or write pages for notable women and other under-represented scientists/physicians. This practice has actually become a popular grassroots movement, with Women in STEM Wikipedia-edit-a-thons sprouting up all over the country — I’ve been to three in the last year!

One of the main drivers of this movement is a physicist at Imperial College London, Dr. Jess Wade, has written over 900 biographies on Wikipedia in just the last couple of years. While writing almost a thousand articles seems a bit overwhelming, you can easily edit a page you think deserves to be beefed up or create one of your own by following this beginner’s guide, which also includes information about how to run your own edit-a-thon if you know of others who are interested. Writing with friends is always more fun. The last edit-a-thon focused on creating pages for under-represented scientists that I attended was this past weekend on International Women’s Day and had a wonderful keynote address from Dr.Maryam Zaringhalam, who has been another driver of making Wikipedia a more inclusive space. In just a couple of hours at this edit-a-thon we added 5 new biographies, made over 200 edits and added over 12,000 words to Wikipedia! This was just our group — on this day, there were actually more than 12 other groups working with us virtually and collectively we added over 60,000 words to Wikipedia. You can actually catch the livestream of this event, including Dr. Zaringhalam’s phenomenal keynote here.

So this Women’s History Month, take action to make our community more inclusive by starting with the internet — it’s easy, rewarding and fun, I promise!

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”
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The Health Costs of Hunger Part 2: What we can do about it

Allison Webel, PhD

If you read my February blog, you know that food insecurity is a complex and overwhelming issue in the United States. In 2018, 37.2 million Americans were food insecure and of that, 6 million were children. The health consequences of food insecurity are significant and contribute to growing rates of chronic disease American’s have experienced in the past few decades. With recent changes to programs such as the supplemental nutritional assistance program (or SNAP), more Americans are at risk for becoming food insecure.

The lack of stable access to adequate safe food affects a persons’ health and well-being in profound ways. And as health care providers used to acting, we want to do something about food insecurity in our communities.  But what can be done and where to start?  To answer these critical questions, I spoke with Alissa Glenn, consultant of food as medicine program at the Greater Cleveland Food Bank, who offered this advice.

  1. Acknowledge that food insecurity is pervasive and talk about it. Hunger affects people of every gender, age, race and ethnicity throughout the United States. Yet, an important reason people often do not pursue supportive programs such as SNAP, is the longstanding stigma around assistance. One of the best ways to break this stigma is by talking openly and compassionately about food insecurity in your community.
  2. Educate yourself and your colleagues. My February blog, had a lot of scientific resources on food insecurity hyperlinked. Last year, the AHA published a science advisory on innovative strategies to create a healthy and sustainable food system that can provide useful context. In addition, lay resources such as the Feeding America website and books like Stuffed and Starved can help explain this complex issue. Finally, consider inviting your local food bank to conduct a continuing education or a Grand Rounds session on addressing food insecurity in clinical settings. They can describe local resources in your own community and practice poverty simulations to help healthcare providers feel more comfortable discussing food insecurity with patients.
  3. Ask your patients about it. Screening for food insecurity is recommended by groups such as the American Association of Pediatrics which suggests incorporating such a screening at every patient visit. I know, we have to fit so much into each patient encounter that trying to fit in one more thing seems impossible. But a quick, simple strategy is to administer the Hunger Vital Sign™ (Left Insert).

It can be hard for patients to acknowledge they are food insecure so helping them feel comfortable can result in more honest answers. Best practices include asking screening questions after the patient has been with the provider for a while, having a team member with a longstanding relationship ask screening questions, and if possible, to ask them via tablet or computer to reduce awkwardness.

  1. Refer patients and family members who are food insecure and may need immediate help to local resources. This can include local food pantries, produce distribution sites, hot meals, and perhaps, onsite therapeutic food clinics. If your clinical setting is lucky enough to have to have a registered dietitian, involve them in developing a list of local resources to be distributed to patients. Case managers and outreach workers can also provide patients resources about short and long-term support for food insecurity. To find a food bank near you, please check out the Feeding America
  2. Advocate for anti-hunger programs. SNAP is the first line of defense against food insecurity. For every meal that a food bank provides, SNAP provides 9 meals. As the largest effort to address hunger in the U.S., changes to this program that reduce eligibility or benefits will increase the number of hungry Americans. Working with your community and engaging with your elected officials about how hunger influences the health care you provide are powerful ways to advocate for their continued support. To find out more about advocating for SNAP and the Child Nutrition Reauthorization Act, please review the Advocating for a Hunger-Free America
  3. Use your professional associations. As healthcare professionals, we have a powerful voice. Every day we talk with dozens of patients and family members about how to improve their health and well-being. As you get more comfortable talking with your patients talking about food insecurity, you will likely hear stories about how hunger affects their health. Work with your professional associations to collect those stories and with one voice advocate for changes in practice, education, and policy.

 Last month, the AHA released its 2030 Impact Goal. This ambitious statement recognized the importance of structural changes to achieve a world of more equitable, longer, healthier lives. It creates a framework from which professional organizations can harness the energy and experience of its members to initiate conversations about food insecurity, incorporate food insecurity education into the training of providers, increase food insecurity screening in clinical settings, and use the collective voice of 40 million volunteers and members to effectively advocate for anti-hunger programs.

There are many ways you can work with the AHA to reduce food insecurity in America. Consider working with your scientific council to propose a scientific statement on the effects of food insecurity on cardiovascular health, propose a workshop on clinical food insecurity protocols at a Scientific Sessions meeting, or write an editorial on your experiences helping a patient with food insecurity. The enormity of hunger in America, and its deleterious effects on the health of our patients, can be overwhelming. But even small steps such as reading a book on food insecurity, screening patients in your clinic, or advocating for structural change, can be powerful ways to help to reduce food insecurity.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”
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Science Communication Is The Bridge We Need

Mo Al-Khalaf, PhD

Nowadays it’s typical and obvious that conversations create and maintain their existence within “bubbles” or “echo chambers”. The examples are plenty and diverse, across all topics and around the whole world. This is partly a result of the expanding space that allows for more conversations to happen, namely the interconnected world of online web. Never before has it been easier to have a conversation between individuals that reside in different continents, and have the conversation be as fluent and dynamic, in real-time, as if the individuals are all sitting around the same table. And not only is it a matter of technology that facilitates these conversations, it is also the ability to have a large, common, and easily accessible wealth of information to fuel the talks. These factors combine to create a type of communication ecosystem so rich and diverse, that it has inevitably been utilized to support wide-ranging types of microenvironments and subject matters.

New ways facilitate the ability to communicate between individuals interested in ideas, regardless of the actual quality, reason or purpose of these ideas and conversations. It is however not my goal here to debate or argue against some of the prevailing conversations that exist now on the internet. That feels like an issue that requires a different format and a different type of communication than a blogpost in a health and science geared online platform! Instead, my goal today is to spotlight and encourage more of the type of rich communication possible, especially by directing my message towards… and you probably guessed this, scientists (and physicians and all other types of academics. Scientists get the headline in this blogpost because… well I’m a scientist myself!).

I believe that in this rich ecosystem of communication possibilities, there needs to be an increased effort by scientists to engage in open discussions with as many individuals as possible. This is counter to what has been the case for the past century, where scientists placed the highest priority into communicating their knowledge, investigative findings and even their questions (with no present answers) to other scientists, in platforms that are extremely inaccessible to the vast majority of the general public. Scientists (and academics in general) almost intentionally sidelined themselves from active participation in what the world was preoccupied with and talking about at any point in time.

To that extent, it is highly encouraging and exciting, to see that in the past few years, attention and valuable effort has been put into the wide-ranging field of Science Communication (#SciComm), by a growing number of young and established scientists, that answered the call of science beyond the walls of the lab, or the research group, university or hospital that houses them.  #SciComm can have many forms, and all of them are totally appropriate, depending on how it is performed, and by whom, and for what purpose. #SciComm can be an addition to the portfolio of an active scientist (student, early-career or even a fully tenured senior investigator). #SciComm can also be an entry-level job by a recent science graduate that has an interest in media and public outreach. #SciComm can also be a lengthy career all on its own, spanning decades (you know who’s basically a #SciCommer: Bill Nye! Also, David Suzuki, and Sir David Attenborough!).

Science communication to the public takes a completely different form, of course, compared to science communication between peers. Academic and medical publications read by their intended communities are perfect examples of “conversation bubbles” and echo chambers. There is no doubt a benefit in having conversations between subject-matter experts. The increased potential of collaboration and the advancement of ideas and innovations has greatly benefited from the ability to communicate within these well-structured communication bubbles. So I would not want this type of discussion to end or be discouraged at all. However, it is increasingly evident that scientists also need to utilize, and take advantage of, the widening communication avenues. Otherwise, the role scientists play in the expanding world will inevitably shrink and become marginalized.

(Collage assembled from pixabay.com images)

New avenues for scientists (and everyone else) exist in all relevant communication styles: If writing is preferred, many blogs/online magazines and newsletters are accessible (or easily created), which can be utilized to “translate” knowledge that exists in academic and medical publications, and allow far easier accessibility for the public. A word of caution here is warranted though: it is important to learn about the content provider (publisher), and vet the content on that platform, to know for sure the value and accuracy that is present there. As scientists, we must value our own output, and make sure it gets sorted into a worthwhile content provider/publisher, and never in a “predatory” or compromised communication form. We should not lend credibility to something that fosters false or biased or unproductive content.

Moving on, when audio style communication is desirable, then podcasts are the modern-day addition to the “radio” format of science communication. And finally, if video is the go-to communication medium, then YouTube is there for everyone. And just like with my words of caution regarding writing and content disseminating new avenues, one must be careful about Podcast and YouTube channels that one is thinking of contributing to; great options exist and are highly recommended, but there also exists a large number of channels and content distributors that would do more harm than benefit to the overall science and general public. Today I’m not going to tackle the world of Social Media here (Twitter, Instagram, TikTok, etc), but know that these also count towards #SciComm (and probably could be the most dominant force of communication moving forward). That’s a future topic to write about!

So, as a scientist, an early career professional, and an enthusiastic communicator of knowledge, to as a wide an audience as I can reach, I’ll continue to encourage, support and amplify the desire for more science communication, and utilization of the expanding avenues available for everyone. Because when science is available for all, the world can tackle more challenges, and everyone can benefit.

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”
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March Madness – Dealing with the Stressing of Training

Barinder Hansra, MD

March is synonymous with college basketball, winning brackets (or losing in my case), and general merriment. For those of us in medicine, it may have a different meaning – stresses of matching, winter blues, and a general feeling of being burnt out. For me, March was one of the hardest months to get through in training, despite it being my birthday month.

Living in Massachusetts means long winters and I notice the general spirit of trainees tends to drop during this time. The novelty of winter has grown old, as the holidays have passed and we all seem to anxiously await the spring. The grueling winter days make it challenging to be outdoors, inhibiting us from enjoying our hobbies, and in short, tired of being cold. My friends who have trained or are working in cold climates (i.e Minnesota, Michigan, Wisconsin, Vermont to mention a few) have echoed the same sentiment. My personal interactions with interns and residents are often highlighted by fatigue, decreased empathy towards patients, and a desperate need for “the year to be over.” So, what are the tools we can use to help get through our own March Madness?

Here are a few tips and tricks that have helped me improve my wellbeing.

  • Stress to Strength: Growing up, I played soccer, basketball, tennis, tried picking up running (but limited by jumpers’ knee), and occasionally surfing. Clearly, none of these are great activities if it’s cold outside which caused me to feel claustrophobic in the winters. I instead work out in the hospital gym much more to try to stay active and have a positive outlet for when I am stressed. I often get asked, “what’s a good strategy for me to make it to the gym with our crazy schedule?” I’ve realized not everyone wants to go to the gym before work (which is my routine) but having small, achievable goals is the way to go. For example, try going one day before work, one day after work, and once during the weekend. You don’t need to go every single day to be healthy or stress-free. Having a few days per week in dedicated time slots will help create structure and not make going to work out feel like a chore.
  • Mindfulness: Mindfulness is becoming more popular in the west and for valid reasons. It is the ability to pay attention to the present moment with curiosity, openness, and acceptance. We can exacerbate stress if we ruminate about the past, worry about the future, or even engage in self-criticism; and I have been guilty of all 3. I discovered a great app called “Headspace” that helped me with guided mediation and mindfulness. The app has evolved to help fit nearly everyone’s needs and I have recommended it to several friends/colleagues.
  • Making my list, checking it twice: Trainees have so many tasks they need to complete: pre-rounding, rounding, Epic tasks, notes, discharge summaries, more Epic tasks, case reports, quality improvement projects, and if they have time – grocery shopping. I always keep a list of tasks I need to complete – partly because it helps me stay organized, but also my obsessive-compulsive personality LOVES to cross tasks off the list. If you get overwhelmed with the countless tasks you have to do, start keeping a list. This will help create structure, organization, and improve productivity.

 

  • Reach Out: We all need to have friends, family, and colleagues to turn to when we are feeling burnt out. Fortunately, many training programs have resources available from their GME office, which are often underutilized. My clinic preceptor (and friend) Dr. Brigid Carlson has invited me out for coffee, dinner with her family, and always welcomes me to speak to her if I am feeling overwhelmed. Knowing I have someone to turn to has helped me not “bottle things up.”

Although March Madness is traditionally stressful with college basketball, it should not be the same for the workplace. With spring on the horizon, many of us feel the stresses of training but there are resources to help us to continue to be successful.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

 
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How Coronavirus (COVID-19) can affect your heart health?

Noora Alhajri, MD, MPH

The rapid spread of the coronavirus (now known as COVID-19) has sparked a global alarm. The World Health Organization (WHO) has declared a state of public health emergency of international concern (PHEIC), as many countries are grappling with a rise in the number of confirmed cases. As of March 5th 2020, data from WHO have shown that more than 95,499 confirmed cases have been identified in 84 countries/territories with more than > 99% of the cases emerging from China1. In the United States, the Centers for Disease Control and Prevention (CDC) have increased the risk from Coronavirus spread to level 3 and advised against non-essential travels to China, Iran, Italy, and South Korea. “It is not so much a questions of if this will happen anymore, but rather more a question of exactly when this will happen and how many people in this country will have severe illness” said Dr. Nancy Messonier, director of the National Center for Immunization and Respiratory Disease at the Center for Disease Control and Prevention in the United States.

What is coronavirus?

Coronavirus (CoV) are a large family of viruses that causes illness ranging from the common cold to more severe diseases such as the Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-Cov). A novel coronavirus (nCov) is a new strain that has not been previously identified in humans. Coronavirus are zoonotic, meaning they can transmit between animals (such as bats, cats, camel, and cattle) and human.

What is the clinical profile of COVID-19 infection?

 Coronavirus infection is spread from human-to-human via droplets or direct contact. The infection is estimated to have a mean incubation period of 6.4 days (0-27 days), and a basic reproduction number of 2.24-3.58. Fever was the most common clinical feature followed by cough, shortness of breath, body ache, headache, and sore throat. There have been reports of gastrointestinal symptoms (nausea, vomiting, or diarrhea) before respiratory symptoms occur, but this is largely a respiratory virus. Those who have the virus may not have obvious symptoms (asymptomatic), or may have symptoms ranging from mild to severe. In some cases, the virus could be life-threatening. Older adults are less likely to present with fever, thus close assessment of these group of patients with other symptoms such as cough and shortness of breath is critical.

What are the cardiac Implications of COVID-19?

Early reports show that 50% of hospitalized COVID-19 patients had an underlying chronic medical illness, 80% of which are cardiovascular and cerebrovascular disease. The American College of Cardiology (ACC) issued a bulletin recently to warn patients with heart disease about their potential risk for complications if they contracted the disease. This does not mean that patients with cardiovascular disease or with cerebrovascular disease are at increased risk of getting coronavirus. However, they should practice additional precautions, since they are at great risk for complications. Nearly 20% of people developed Acute Respiratory Distress Syndrome (ARDS) according to a case report of Wuhan hospitalized patients. In addition, 7.2% of patients developed acute cardiac injury, 8.7% shock, 3.6% developed acute kidney injury, and 16.7% developed arrhythmia. Several unpublished first-hand reports suggest at least some patients develop myocarditis. Therefore, it would be reasonable to triage patients with COVID-19 infection according to the presence of underlying cardiovascular disease, renal disease, respiratory and other chronic diseases for prioritized treatment.

Several experts suggested rigorous use of guideline-directed plaque stabilizers (such as ACE-inhibitors, Statin, Beta-blockers, Aspirin) as it could protect cardiovascular patients during wide-spread outbreak of the virus. Furthermore, it is important for patients with cardiovascular disease to remain up to date with vaccination, including pneumococcal vaccine given the risk of secondary bacterial infection. It would be also crucial to receive the influenza vaccine to prevent any other sources of fever which could be initially confused with coronavirus infection.

The outbreak of COVID-19 has become a global clinical and public health threat. Knowledge about this novel virus remains limited. What we can do now is aggressively implement infection control measures to prevent the spread of COVID-19 via human- to- human transmission.

References:

  1. World Health Organization declares Global Emergency: A review of the 2019 Novel Coronavirus (COVID-19), International Journal of Surgery, (March 2020)
  2. Travel Health Notices: https://wwwnc.cdc.gov/travel/notices#travel-notice-definitions
  3. Chen H, Zhou M, Dong X, et al. Epidemiological and Clinical Characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; published online January 29. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930211-7
  4. Wang D, Hu B, Hu C, et al.Clinical Characteristics of 138 Hospitalized Patients with2019 Novel Coronavirus- Infected Pneumonia in Wuhan, China. JAMA. Published online February 07, 2020. doi:10.1001/jama.2020.1585
  5. Cardiac Implications of Novel Coronavirus (COVID-19): https://www.acc.org/~/media/665AFA1E710B4B3293138D14BE8D1213.pdf

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”
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Writing is Hard— And Here’s Why You Should Do it

Elizabeth Knight, PhD, DNP

If you are in academia, you are likely familiar with the “publish or perish” mantra. Publishing in peer-reviewed journals is absolutely valuable, both for researchers and for clinicians. It’s a robust way to develop and share knowledge. It can help you get promoted. It can raise your profile in your field. But for people with competing demands (teaching, clinical practice, the rest of your life), it’s not always accessible.

Don’t worry— there are other reasons to write and other ways to publish. In navigating what kind of writing and publishing is valuable, it’s crucial to understand your goals. One size does not fit all. The best approach for you depends on your professional trajectory. If you have an academic appointment and you are pursuing tenure and promotion, then yes, data-based and peer-reviewed publications are your priority. But perhaps your role is different, or broader— maybe you see yourself as a public educator or advocate, a clinical expert, or a mentor. Writing is hugely valuable in these roles as well, but it doesn’t necessarily look the same. Or, to put it in other terms, writing is like medication admiration. You need to check the “5 rights”: What’s the right drug (topic), dose (length), route (venue), time (frequency), and patient (author)?

If you are not (or not solely) pursuing an academic career in the sciences, think outside the box, and consider:

  • Writing about science and medicine for a popular audience— think of influential physician and nurse authors like Theresa Brown, Atul Gawande, Lisa Sanders, or Jerome Groopman.
  • Write for a clinical audience— in my field, Journal for Nurse Practitioners or American Family Physician, for example, publish articles on clinical topics.
  • Writing creatively, in health humanities publications (or some medical journals publish poetry on occasion). Or write to nourish your life outside of science and medicine (the poet William Carlos Williams was a physician).
  • Writing for a blog. Blogging is a great way to share ideas and influence rapidly and less formally.
  • Writing as a personal practice. Many highly successful people practice some form of journaling as a way of working out ideas and thoughts that later serve as the basis of important work. A writing routine– even if it’s ten minutes a day– can be a catalyst for creative and productive work.

If you want to write more, no matter what the content and context, consider:

  • Never “just” give a talk— can it also be a paper? A poster? Explore it fully, and expand the potential audience for your work by considering different venues and angles. Get more mileage from each project you take on.
  • Say yes. . . and say no. Take on projects and accept invitations that allow you to develop an idea— but only ones that align with your goals and interests. Don’t say yes if you truly don’t have the bandwidth, or if the offer doesn’t advance your progress in some way. But DO say yes to things that are outside of your comfort zone. You might expand your expertise and influence in valuable ways.
  • Join (or start) writing groups: accountability & feedback are invaluable. Colleagues who will read your work and give you mock reviews are precious. Develop these relationships early in your career and they will serve you well.
  • Look at author guidelines for publications you read (whether these are high-impact journals or tiny blogs). Could you make a contribution?
  • Think about your unique skills and experiences. What is it that you have that no one else does? What do you have to say that you haven’t heard said before? You have a unique voice and you should use it. I have heard many writers say they created work they wanted to read but couldn’t find. The novelist Barbara Kingsolver says, “don’t try to figure out what other people want to hear from you; figure out what you have to say.”This is great advice to produce writing with a strong point of view.

 How will you include more writing in your professional life?

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”
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On teaching Professionalism

Adham Karim, MD

Professionalism is a multi-faceted concept that carries different meanings to different people; it ranges from a physician’s bedside manner and acknowledging mistakes, to how one interacts with their peers and if they show up on time. Not only that, but this all-encompassing term is cited as a core competency by the American Association of Medical Colleges. It is also a part of the American Medical Association’s code of ethics and explicitly mentioned in the syllabi of most medical schools and training programs across the U.S. Despite the broad acceptance of professionalism as a key character component of a well-rounded clinician, there is a significant difficulty experienced in trying to teach this to trainees. This may seem a little long-winded, but this is a subject that really resonated with me, and with JAMA instituting a professionalism section a few years ago, there have been more and more pieces published on the topic; I’m happy to see that this is gaining more traction. Everybody will tell you that administrative burdens and needing to deal with insurance providers for prior auths and the like definitely contribute to burnout, but having unprofessional colleagues can be just as burdensome and unsafe for patients!

I recently came across an excellent piece in the New England Journal of Medicine titled “Responding to Unprofessional Behavior by Trainees – A “Just Culture” Framework” wherein Dr. Wasserman, Redinger, and Gibb attempted to tackle the difficult yet important concept of professionalism in medical training. The article made a strong case for treating lapses in professionalism as if they were medical errors of varying severity, and they included an infographic, as well as gave several examples to go with this framework. In my opinion, professionalism is one of those behaviors that is nearly impossible to teach in a classroom and is often developed through a mix of modeling behaviors from more senior physicians, as well as a little bit of one’s own personality/temperament mixed in.

There was an example cited by the authors that centers around a medical student who has begun a collaboration with a mentor on some database analysis. The mentor states this is an IRB-exempt study and urges the student to begin analysis immediately, but the student’s research office instructs her not to download the data until getting an official exemption was issued by the IRB. The mentor pressures the student into downloading it anyways, and the student gets reprimanded for this. Wasserman et al suggest this is a lapse in professionalism at the lowest level – “no-fault suboptimality” resulting from the student’s faulty understanding that the supervisor (mentor) is right. They focus on teaching the student “strategies for diplomatically addressing her mentor” and acknowledge it is a difficult situation. What they don’t do, however, is acknowledge the context of this lapse of professionalism; they make no mention of addressing the mentor’s behavior or holding them accountable.

By all means, I agree that the student’s incorrect logic needs to be addressed. But, by not addressing the lapse in the professionalism of the mentor, I think the authors missed an opportunity to strengthen the analogy of professionalism and medical errors. In the “Just Culture” movement, physicians were just as accountable as nurses, who were as accountable as medical students for speaking up against unsafe practices. In this scenario, I would argue that the mentor is more liable, and should be held even more accountable than the medical student. As the authors have already made clear, trainees are still developing their understanding of professionalism, but this mentor is arguably an individual who has completed their training and should have a stronger grasp of professionalism than a mere medical student.

I concede that their article was aimed moreso at addressing lapses in professionalism of trainees, but this circles back to my personal view of how professionalism is developed. As others have stated, ensuring an individual trainee’s “competence in the area of professionalism requires the concerted efforts of many.” However, what about non-trainees? You could assume that a hospital board or professional society will self-govern to ensure professional behaviors, but with a term that is so loosely defined, and with financial incentives on the line, how much would someone be able to move the needle? I think most of us can remember at least one time (or many), when a senior physician tore into a helpless colleague, or became frustrated and lost their temper. How often do you think these individuals get a time-out or get part of their wages withheld as a punishment?

This brings me to my point: if the system is flawed, how does putting additional pressure on trainees fix that? The “do as I say, not as I do” approach has never been tested in a randomized trial, but conventional teaching theory (and common sense) will tell you that this is not effective. I myself am a trainee still (you’re reading the Fellows In Training blog, duh), so I certainly do not have all the answers.

From my time spent in developing medical school curricula, and sitting on academic disciplinary committees, I’ve come away with a few insights that I think might help. When the issue is a systems issue – such as “well everyone in my class skips grand rounds, I thought it was ok” the individual who got caught usually got caught due to chance, and reprimanding them would be unfair. Wasserman et al mentioned that the system needs to be changed, but didn’t talk about how. I’m gonna piggyback on that, because systems changes are difficult, and can be nuanced depending on the problem.

I think that lapses in professionalism should be addressed, but a better approach would be one that relies on positive feedback rather than only mentioning professionalism when it is missing. For example, in my medical school, and most training programs, at the middle and end points of a rotation, mentors would take the medical students for some formative “feedback”. Sometimes they were going off a form issued by the medical school, other times they would go off what they felt should be emphasized. If throughout a trainee’s career, different levels of professional behavior are emphasized by instructors, this could go a long way.

One example of this would be that mentors are instructed to focus on the aspect of timeliness and respectfulness with first-year students, making sure to comment on these in each student’s feedback; but when they give feedback to third years, they emphasize other aspects of professionalism, such as truthfulness, admitting to mistakes, knowledge gaps, etc.

Many theories have been put forth as to why professionalism can be such a difficult concept to teach and practice, but I think a critical shortcoming we have to acknowledge is the disconnect between the two worlds that trainees must straddle: the world in which we teach professionalism, and the world in which they practice.

 

References:

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”
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Vaper Vapor

Anika Hines, PhD, MPH

January 2020 has come and gone. Resolutions were set (and some broken). I suspect—given what we know about the effects of smoking—that somewhere among the estimated 34.2 million smokers in the US 1,2  lie a few who resolved to shake the habit. Cigarette smoking is the leading cause of preventable disease and death in the United States accounting for more than 480,000 deaths every year (about 1 in 5 deaths).1

But, What About Vaping?

In November 2019, the AHA launched its #quitlying campaign to address the youth vaping crisis. As an AHA Early Career blogger, I began to tweet (@DrAnikaLHines) what I was learning about vaping (a topic that I’ve otherwise not broached) from the 2019 Scientific Sessions:

  • From 2017 to 2019, e-cigarette use among high school students increased by 135%3 (about 25% of high school students have “vaped” in the past 30 days).3 E-cigarette use tripled among middle school students—from 3.3% to 10.5%.3
  • E-cigarette use drove a 59% increase in use of any tobacco product among high school students (from 19.6% in 2017 to 31.2% in 2018).3
  • While more research is needed, the Surgeon General has concluded that several studies show E-cigarette use is “strongly associated” with the use of other tobacco products among youth and young adults, including conventional cigarettes.3
  • Many questions remain about the long-term health effects of these products and their effectiveness in helping smokers quit.4
  • The evidence is already clear that it is unsafe for young people to use e-cigarettes or any other product containing nicotine.4
  • Some of the flavorings found in e-cigarettes have been shown to cause serious lung disease when inhaled.5

Well, fellow bloggers and I were met with backlash and cries of “vaping saved my life” and “vaping is harm reduction” and “vaping is promoted as a cessation technique in Europe” and my favorite—‘big heart, quit crying” by individual (adult) users and small retailers. As I mentioned before, I don’t research vaping, so I had no retort. I do, however, live in a department that happens to be seated in the hotbed of the tobacco discourse (Virginia) and jam-packed with researchers who have devoted their careers to cancer prevention and tobacco products. Literally! VCU has a Center for the Study of Tobacco Products. Here’s what I’ve learned about alternative tobacco products being used in Virginia (and nationally):

  1. Not every vape is created the same. The two products at the core of discussion are e-cigarette and tobacco-heated products.10 E-cigarettes are battery-powered and heat liquid usually containing nicotine in order to produce an aerosol. There’s a wide variety of designs, electrical power, levels of nicotine delivery, and flavors.10 Devices include cig-a-like, refillable tank systems, and pod mod innovations. On the other hand, heated tobacco products (also electronic), heat tobacco to produce an aerosol containing nicotine.11 (This is where tobacco giants like Phillip Morris have become involved, including their “I quit ordinary smoking” (IQOS) product approved for sale by the FDA in April 2019).10
  2. Adult and youth reasons for use differ; so, there are separate sets of issues. Adults cite quitting/reducing smoking and health reasons for using e-cigarettes. Youth attribute their vaping to their social networks (friends and family who use them) and/or the availability of flavors.6 Data from 2013 indicated that 13.1% of high school e-cigarette users had never used another tobacco product.3 E-cigarette use is strongly associated with the use of other tobacco products among youth and young adults, including conventional cigarettes.3,7,8
  3. The long-term effects of alternative tobacco products in adult smokers, including e-cigarettes and heated tobacco products, remain unclear; however, preventing nicotine addiction among youth is a priority. Studies of the effectiveness of products as smoking cessation approaches are inconclusive. The Centers for Disease Control and Prevention says that e-cigarettes are not safe for youth, young adults, pregnant women, or adults who do not currently use tobacco products.4 Heated tobacco products, such as the IQOS device, have been linked to pulmonary disease and cancer, but not to the same extent as combustible products.9

Summary

We don’t know everything, but we know enough to say that vaping is not a “harmless” habit. It is not recommended for youth, young adults, pregnant women or adult non-smokers.4 Smokers who opt into e-cigarettes should know that there’s no guarantee that it will help them quit and that e-cigarettes bear their own risks of injury and mortality. E-cigarettes are not recommended as a smoking cessation aid. Further, a recent CDC study found that most adult e-cigarette users don’t stop using combustible products, but become “dual users”.11

My Take

As I see it, the biggest issue is framing vaping as harmless. More alarming, is the interplay between peer influence and attractive flavoring that draws youth into a nicotine addiction long before their brains have the capacity to make an informed decision.

Vaper vapor, indeed.

 

References

1. Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults in the United States, 2019.

2. Creamer MR, Wang TW, Babb S, et al. Tobacco Product Use and Cessation Indicators Among Adults – United States, 2018. Morbidity and Mortality Weekly Report 2019, 68(45);1013-1019.

3. Campaign for Tobacco-Free Kids, “Electronic Cigarettes and Youth”, November 8, 2019 / Laura Bach. Accessed at: https://www.tobaccofreekids.org/assets/factsheets/0382.pdf

4. CDC, “Electronic Cigarettes.” https://www.cdc.gov/tobacco/basic_information/e-cigarettes/.

5. HHS, E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016, p 184.

6. Tsai J, Walton K, Coleman BN, et al. Reasons for electronic cigarette use among middle and high school students – National youth tobacco survey, United States, 2016. Morb Mortal Wkly Rep. 2018;67(6):196-200. doi:10.15585/mmwr.mm6706a5

7. Barrington-Trimis, JL, et al., “E-Cigarettes and Future Cigarette Use,” Pediatrics, 138(1), published online July 2016. Wills, TA, et al., “Ecigarette use is differentially related to smoking onset among lower risk adolescents,” Tobacco Control, published online August 19, 2016.

8. Berry, KM, et al., “Association of Electronic Cigarette Use with Subsequent Initiation of Tobacco Cigarettes in US Youths,” JAMA Network Open, 2(2), published online February 1, 2019.

 9. Salman R, Talih S, El-Hage R, et al. Free-Base and Total Nicotine, Reactive Oxygen Species, and Carbonyl Emissions From IQOS, a Heated Tobacco Product. Nicotine Tob Res. 2019;21(9):1285-1288. doi:10.1093/ntr/nty23

10. Barnes AJ and Snell LM. Alternative Tobacco Products Use in Virginia. https://hbp.vcu.edu/media/hbp/policybriefs/pdfs/VCU_eCig_10-19_F2.pdf

11. CDC, Electronic Cigarettes, What’s the Bottom Line? https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/Electronic-Cigarettes-Infographic-p.pdf

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”