October 6th, 2022

Given the uncertain circumstances surrounding our elective placements brought about by the Covid-19 pandemic, writes Thomas Fisher, I thought that there would be no better opportunity to arrange to spend time at Barts Heart Centre.

While I have been a student at Barts and The London School of Medicine and Dentistry for six years and have intermittently held jobs at the hospital helping in administration and as a healthcare assistant during the pandemic, I have always felt that spending time in a specialised cardiac department would give me a rare insight into what world-leading specialist care is provided by the NHS.

For these reasons, I arranged to join the Barts echocardiography department for a six-week attachment. Echocardiography (meaning ultrasound scans of the heart) stands out among different types of medical imaging in that it is typically organised by cardiologists rather than radiologists. Part of this is due to the fact that, with echocardiography, you are watching the heart pump in real-time and therefore can assess its movement (and therefore its function) in great detail, in contrast to many other imaging types which just give you an un-moving snapshot of an organ’s structure.

Echocardiography can give you information about whether certain parts of the muscle are not functioning properly, whether any parts of the heart are unusually thickened or stretched, and about the flow of blood through the heart, from which it is possible to calculate more information such as the levels of pressure within different chambers.

Barts has a large echocardiography department staffed primarily by specialised cardiologists and cardiac physiologists. Many from this team work both at Barts and at other hospitals within the area, enabling the expertise derived from Barts Heart Centre to benefit patients across London, including within some of the country’s most deprived areas in East London.

Echocardiography is something I have only been tangentially exposed to as a medical student and spending time in the department I was impressed at how useful a tool it can be. I spent a lot of time in outpatient clinics where patients come from home to have their heart scanned for various reasons. Some have known heart disease and are being routinely followed up, some have recently been discharged from hospital for a heart issue and others have been referred by other doctors in order to investigate whether there could be a cardiac cause of chest pain, breathlessness or feeling like one’s heart is racing.

Barts also has a specialised cardio-oncology department which addresses heart issues pertaining to cancer and cancer treatment. In some patients, specialised techniques including 3D ultrasound imaging and computerised interpretation of images can provide detail about subtle abnormalities which would be difficult for the naked eye to pick up. In patients undergoing chemotherapy for cancer treatment, computerised analysis of how much the wall stretches during heart contraction can give clues as to whether treatment is affecting the heart which in some patients may suggest need to adjust their treatment or scan their heart more frequently in future.

I also spent time seeing inpatients who required scans. Some of these were routine post-operative after, for instance, a valve operation, while others were more urgent scans prompted by new symptoms. In a patient who has new breathlessness, an echo could help determine whether poor heart function is causing blood to backup into the lungs. In a patient with fevers and a new abnormal heart rhythm, an echocardiogram could help determine whether there is a ball of bacteria attached to the heart causing these issues. In these cases, I learnt more about the difference between a formal echocardiogram and a more focused scan.

Point-of-care ultrasound continues to rise in popularity amongst doctors, particularly in the intensive care and emergency department settings. This generally means that scanning is performed by the treating doctor with a specific clinical question and the findings can be immediately integrated into a patient’s care.

This contrasts somewhat with a formal echocardiogram which is a more detailed study that systematically assesses a patient’s heart and characterises more precisely the nature of issues. I feel that in future, training of point-of-care ultrasound will become more prevalent as it becomes a routinely used adjunct to a physical examination.

Understanding the limitations of this and the differences between what questions you can answer on a quick focused scan versus a formal echocardiogram is important to ensure certain conditions are not prematurely ruled in or out.

Transoesophageal echocardiography, where the probe is inserted into the oesophagus rather than simply resting on the chest, was something fairly new for me to see. This is clearly a more lengthy and more invasive e procedure than other forms of echocardiography. As the oesophagus sits just behind the heart, the ribs and lungs can no longer make it difficult to get high-quality images of the heart. While this type of scan is not routinely needed for most patients, I was impressed that selection for who needed this type of scan was clearly quite judicious. Each patient I saw undergoing this more unpleasant procedure had their management influenced by it in some way which should be the goal of any medical investigation.

Throughout my time in the department, I had opportunities to practise basic scanning myself. There is something quite impressive about holding a probe and watching it provide a real-time moving image of what is beneath the skin. I certainly found it to be harder than I expected to navigate around ribs and lungs and occasionally even to acquire an image of the heart. Certainly, when physiologists went on to do the full scan of patients afterwards, they were much quicker in finding the correct position to place the probe and acquired images orders of magnitude better than mine.

Nonetheless I am sure that spending time in such a specialist centre has provided me with a solid foundation upon which to develop echocardiography skills in future, and I am extremely grateful to Barts Guild for supporting me with my costs during the elective period.