Tuesday, September 25, 2012

A Nurse Manager



I was sitting next to my gastroenterology clinic nurse reviewing a couple of patient phone calls and what they needed, so my assigned nurse could take care of them.  As we were finishing up the last patient contact, when in walked the clinic nurse manager, Kate. 
Kate leaned up against a desk close-by and waited for my clinic nurse and myself to finish our conversation over the last patient contact. Then she asked, “Sharon, what causes leg pain when I’m out walking my dog?”
I had a quizzical look on my face as I turned to face Kate.  “What do you mean by leg pain, Kate?”
Kate replied, “Well when I’m out walking my dog every morning and after I get home at night I’m able to walk about 3-4 blocks before I have to sit down somewhere and rest my legs, they become heavy and my lower legs just hurt.  I rub them which helps, and after a few minutes I’m able to stand back up and walk home at which time my legs hurt again.”
“Kate, that sounds like you could have some peripheral vascular disease.  What’s your family history, is there any cardiovascular disease in your family members?”
“Yeah, my younger brother is 53 and he’s had a heart attack, a subsequent surgery to have a quadruple bypass.  My dad died from a heart attack when he was 60.  My mom is in her 80’s and has congestive heart failure due to long standing hypertension (high blood pressure).”
“Okay, that’s a rather positive family history for cardiac disease.  When was the last time you had your lipids checked?”
“I haven’t had them checked.”
“Well, then I would make an appointment with your primary care provider pronto, let him know what your symptoms are, make sure to get your lipid levels drawn and ask him to send you to an interventional cardiologist who can assess your vascular structures in your legs, you’ll probably end up with having either stents placed or the cardiologist will do a balloon angioplasty based on how extensive your disease is.  The cardiologist will also send you to a cardiac rehab program so you can be involved in a supervised exercise program.”
“You think my problem with my legs is due to a lack of blood flow?”
“That’s what it sounds like.  I seem to also recall that you used to be a smoker and quit about 10 years ago, right?”
“Yeah, that’s right.”
“Well, that’s another risk factor for peripheral vascular disease.  So if I were you, go make that phone call to your primary care provider.  In the meanwhile, you can take a baby aspirin every day until you complete your work-up, that will help your platelets to not stick to each other.”
“Thanks for the info, Sharon.  I’ll start the aspirin today and go call my primary care provider.”
“Let me know what happens, Kate, good luck.”
“Sure thing.”

Peripheral vascular disease, is a disease of the lower limbs where they have atheroslerotic plaques within the blood vessels.  Peripheral vascular disease is very similar to coronary artery disease, where there is plaque formations in the coronary arteries.  As just like in the coronary arteries, which have plaque formations with patient’s having angina (chest pain) due to not enough blood flow being presented to the heart muscle, the same thing happens in the legs.  The plaque formations prevent an adequate amount of blood flow from getting to the legs/muscles.  When this happens patients end up with leg pain.
The risk factors for peripheral vascular disease include: 1) hypertension, 2) hypercholesterolemia (high levels of blood lipids or fats), 3) history of smoking, 4) diabetes.
 
Most patients also have a family history of cardiac disease, which Kate’s family had. 
Patients can present to their clinician with symptoms (as in Kate’s case) or be asymptomatic.  20-50% of patients will be asymptomatic, 40-50% of patients will have atypical leg pain, 10-35% will have classic claudication symptoms, and 1-2% will have critical limb ischemia (totally impaired lack of blood flow).    

I didn’t follow-up with Kate for several weeks, due to a busy clinic seeing patients.  One day in clinic I was sitting at my clinic nurse’s desk, signing some prescriptions for patients that needed to be faxed off.  Kate just happened to walk by my clinic nurse’s desk and I called out her name. 
“Kate, hey what happened about your leg pain?”
Kate turned around and seeing that there wasn’t anyone else in my clinic nurse’s office, she walked in and sat down. 
“Sharon, I saw my primary care physician a few days after we talked about a month ago.  He ordered my lipid panel and it came back with high levels, so I’m on 40 mgs of lipitor.  He also listened to what I had told you and immediately sent me off to the cardiologist over at the University who specializes in peripheral vascular disease.”
Kate continued, “I saw the University cardiologist, and he ordered an arteriogram of my lower legs.  They found quite a bit of atherosclerotic plaque in both legs.  So, as you probably know I was gone on Friday, that’s when the interventional cardiologist went in and did a balloon angioplasty on one of the lesions and put in a long stent into another lesion in my leg.  Both of the lesions were up in my femoral arteries.  I’m still a little sore from the procedure site today.  I’ve been referred to the cardiac rehab program and I’m supposed to start it later this week.  But the one good thing is that I’ve been walking my dog and my leg pain is gone.  So now every day I’m having to take two medications, the lipitor and cilostazol, which is supposed to help with my intermittent claudication.”
“Oh, Kate I’m so glad you got everything worked up.  Is your cardiologist going to order any additional testing on your heart, like looking at your coronory vessels to assess for plaque there?”
“Yes, I’m scheduled for that in about 3 weeks.  The cardiologist told me that he can only give me so much dye in one sitting, so that’s why he did my legs first, seeing that I was symptomatic from my legs.  He told me that I could have some plaque that needs to be taken care of in my coronary arteries, so I’m scheduled for a coronary CT calcium scan in about 3 weeks.  He told me that based on my test result, he may have to go in and do a coronary angioplasty on any plaque found there.”
“Well, I’m glad that you are getting everything taken care of.”
“Well, I owe you a big thank you, had you not told me what it was I would have just continued to ignore it.  It was a wake up call for me.  I knew my brother and dad had coronary heart disease, I just never thought I would have it.  I thought I was taking care of everything by quitting my cigarette smoking and keeping my blood pressure under control by keeping weight off and walking my dog every day.  So thanks.”
“You’re welcome.  Talk to you later, I have to get going, I’ve got some work to do back in my office.”

Prevalence of peripheral vascular disease increases with age.  For those over age 50 the prevalence is 2.5% in the general population, for those over age 60 the prevalence is 4.7%, and for those over age 70 the prevalence is 14.5%. 

A quick and easy way to determine whether a person has peripheral vascular disease is to do take a blood pressure reading of the patient’s ankle vs. their brachial artery.  The two systolic pressures are compared.  If the pressures are the same, i.e. comparison is 1 to 1, then this is considered a normal test.  If the pressures are different, i.e. less than 1 to 1, ankle systolic pressure less than the brachial pressure, <.9 then this is considered a positive test and the patient most likely has peripheral vascular disease.

Patients are treated for peripheral vascular disease based on how extensive the plaque formations are.  Type A formations usually show only a single formation.  Type B is multiple plaques.  Type C is multiple, long lesions.  Finally, Type D is lesions which are 20 cms or longer.  Based on the type of lesions patients have they receive either medical intervention (balloon angioplasty, stent placements) or surgical intervention (arterial bypass, i.e. some type Cs and all type Ds).  

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