Welcome to the Ohio-ACC FIT Bootcamp, chaired by Dr. Bala Pushparaji and Dr. Bilal Hussain. Here’s what you can expect:
- Focused topics
- Concise, high-yield teaching points
- An exclusive video for in-depth learning
This isn’t a textbook, and it isn’t a lecture series -it’s a practical foundation from fellows who have been exactly where you are. Use it, refer back to it, and don’t hesitate to reach out to your FIT council with questions or feedback along the way.
EPISODE 1 – Things I Wish I Knew in the Beginning of Fellowship
Before the procedures, the boards, and the subspecialty decisions – there’s week one. This episode is where we start, because how you approach the early months of fellowship shapes everything that follows. Three senior fellows, each heading in different subspecialty directions, share an honest reflection on what helped them, what they’d do differently, and what they wish someone had told them on day one. The clinical knowledge will come. This episode is about the mindset and habits that let it stick.
Teaching Points:
– Embrace the learning curve. Be humble, ask questions early, and resist the urge to pretend you know more than you do – nobody expects you to.
– Build structure into your learning from the start. High-yield resources like ACC question banks, focused podcasts, and concise textbooks will serve you better than trying to read everything.
– Your best teacher is your patient. Every rotation, every consult, every call night is a learning opportunity if you’re paying attention.
– Find your mentors early and invest in those relationships. Your career path will evolve – stay open to where it takes you.
– Wellness is not optional. Fellowship is a marathon, not a sprint. Protect your time, your health, and your sense of self outside medicine.
EPISODE 2 – Basics of Coronary Angiography
The cath lab will be one of your earliest and most formative rotations. Before you can interpret hemodynamics, troubleshoot equipment, or discuss revascularization strategy with an attending, you need to know the language – the anatomy, the views, the nomenclature. This episode builds that foundation. It also covers cardiogenic shock and mechanical circulatory support, because STEMI and shock aren’t hypotheticals in the cath lab – they’re your first week on call.
Teaching Points:
– Start with the nomenclature. Knowing how to correctly name coronary vessels, segments, and lesions is your entry point to meaningful cath lab participation.
– Master the standard projections: RAO/LAO with cranial/caudal angulations form the backbone of coronary assessment. Learn when and why to deviate from standard views to better visualize a specific segment.
– Recognize shock early. Hypotension, low output, and signs of end-organ hypoperfusion are your triggers to escalate – don’t wait for the numbers to be perfect.
– Understand why mechanical support devices work, not just how to turn them on. IABP and Impella physiology, device positioning, and the ability to troubleshoot are skills that matter in the room, in real time.
EPISODE 3 – Basics of Echocardiography
Echo is the stethoscope of the modern cardiologist – and it’s one of the hardest skills to develop in fellowship. Image acquisition is a hands-on craft that takes time, repetition, and humility. This episode introduces the foundational concepts: probe mechanics, standard acoustic windows, and the structured approach to image interpretation. The ultimate goal is straightforward – when you’re on call at 2 AM and a patient decompensates, you should be able to wheel in an echo machine and answer the clinical question yourself.
Teaching Points:
– Learn from your sonographers. They are the most underutilized educational resource in the echo lab – watch them, ask them questions, and pay attention to how they move the probe.
– Understand the four core probe movements – angulation, rotation, tilting, and sliding -before worrying about advanced imaging.
– Know your windows cold: parasternal, apical, and subcostal. Small probe adjustments make the difference between a diagnostic study and a frustrating one.
– Emergent echo has a specific purpose – answering one question quickly. Common indications include tamponade, dissection, acute MR, PE, outflow tract obstruction, ventricular rupture, and hemodynamic instability.
– Ultrasound enhancing agents are a practical tool, not just an academic concept – know when to reach for them to better define the endocardium or evaluate for thrombus.
EPISODE 4 – Vascular Access and Related Complications
Every cardiac procedure starts with access – and how you obtain it, and what you do when things go wrong, defines outcomes as much as anything that happens next. This episode covers the principles of safe vascular access, how to choose between radial and femoral approaches, and the recognition and management of complications that can be life-threatening if missed or mishandled. These are skills you’ll use from your very first day in the lab.
Teaching Points:
– Radial-first is the default for a reason – improved clinical outcomes and significantly lower bleeding rates make it the preferred approach for most diagnostic and interventional cases.
– Micropuncture technique and ultrasound guidance are not optional extras – they are standard practice for reducing access-site complications, particularly with femoral access.
– Always perform an angiogram before proceeding with femoral-based intervention. Know what you’re working with before you commit.
– Recognize the common femoral complications: hematoma, pseudoaneurysm, retroperitoneal bleed, and AV fistula. Each has a distinct presentation and management pathway – know all four.
– Post-procedural hypotension demands a systematic approach: hold pressure, reverse anticoagulation, resuscitate. If the patient remains unstable, endovascular or surgical intervention may be necessary.
– Radial complications are rare but real – compartment syndrome is the one you cannot miss.
Tamponade kills quietly. It’s a clinical diagnosis – not an echocardiographic one – and the fellows who catch it early are the ones who thought about it before the patient was in extremis. This episode covers the pathophysiology of pericardial fluid accumulation, the cardinal clinical findings that should trigger your suspicion, and the echo features that confirm it. It also addresses the decision to drain – including the situations where pericardiocentesis is not the right answer.
Teaching Points:
– The rate of fluid accumulation matters as much as the volume. A slowly accumulating effusion can reach 1–2 liters without tamponade; a rapidly accumulating 200 mL can be fatal.
– Tamponade is a clinical diagnosis first. Tachycardia, hypotension, elevated JVP, and pulsus paradoxus are your bedside clues – don’t wait for echo to make the call.
– Know the echo findings cold: IVC plethora, RV diastolic collapse, RA systolic collapse, respiratory variation in mitral and tricuspid inflow, hepatic vein diastolic flow reversal, and left atrial collapse.
– Location matters when planning drainage. Not all effusions are amenable to subxiphoid pericardiocentesis – know when to involve surgery.
– Always consider the underlying cause before you drain. Concomitant pulmonary hypertension and aortic dissection are critical contraindications to pericardiocentesis that you cannot miss.
EPISODE 6 – On-Call Device Dilemmas
It’s midnight. The nurse calls you about a patient with a pacemaker who’s in “VT” on the telemetry strip – except it might be oversensing, or undersensing, or it might actually be VT. Devices on call are anxiety-provoking because there are a lot of moving parts, and the stakes are high. This episode gives you a systematic framework for approaching the most common device issues you’ll encounter, so that the next time your pager goes off about a device problem, you have a plan before you pick up the phone.
Teaching Points:
– Be able to identify pacemakers, ICDs, and CRT devices on chest X-ray, and know normal lead positioning for each. This is the starting point for every device troubleshooting conversation.
– The 12-lead ECG at the time of a potential malfunction is your most important diagnostic tool -get it before you call the device clinic.
– Understand why asynchronous pacing occurs and what it looks like on telemetry – it’s easy to misinterpret as a malfunction when it’s actually the device behaving correctly.
– When an ICD delivers therapy, your first question is always: was it appropriate? Identify the underlying rhythm, treat the cause, and work backward from there.
– After any ICD shock, confirm that the shock was effective. An ineffective shock changes your entire management approach.
EPISODE 7 – Arrhythmia Differentiation and Management
Arrhythmias don’t wait for convenient hours, and they punish delayed recognition. This episode builds the systematic framework you’ll use every time you’re handed a rhythm strip – starting with hemodynamics, then moving through the narrow-vs-wide, regular-vs-irregular decision tree that gets you to the right diagnosis and the right management, fast. Whether it’s AF on a new admission or wide-complex tachycardia on a crashing patient, the same disciplined approach applies.
Teaching Points:
– Three mechanisms generate arrhythmias: reentry, automaticity, and triggered activity. Understanding the mechanism guides both acute management and long-term treatment.
– Hemodynamics first, always. If the patient is unstable – cardiovert. Don’t lose time trying to characterize the rhythm in a decompensating patient.
– Narrow or wide? Regular or irregular? These two questions will get you most of the way to a diagnosis before you even look at the P waves.
– Narrow irregular → AF, MAT. Narrow regular → AVNRT, ORT, AT. Wide irregular → AF with BBB, pre-excited AF, PMVT/Torsades. Wide regular → antidromic tachycardia, SVT with BBB, ventricular pacing, MMVT.
– Pre-excited AF is the arrhythmia most likely to get a fellow in trouble. Adenosine, AV nodal blockers, and amiodarone are all contraindicated – procainamide or ibutilide if stable, immediate defibrillation if not.
– If you’re overdrive pacing a VT, have your hands on the defibrillator. VT can deteriorate to VF or PMVT without warning.
EPISODE 8 – My On-Call Nightmares
You’ve spent 7 weeks building the foundation. This episode puts it all together. Three real on-call scenarios walk you through the decision-making, the escalation, and the moments where the right call -or the wrong one -changed everything. Cardiogenic shock, hemopericardium, VT storm: these are the cases that will test everything you’ve learned, and the ones you’ll remember for the rest of your career. The goal isn’t to scare you. It’s to make sure that when it’s your night on call, you’ve already thought through what you’ll do.
Teaching Points:
– Triage is a skill. Learn early how to prioritize simultaneously sick patients and manage your time when the pager won’t stop.
– Cardiogenic shock demands early, aggressive action. Know your escalation pathway -pressors, MCS, ECMO – and don’t hesitate to activate it.
– Ask for help. Knowing when to call your senior or attending is not a weakness – it’s one of the most important clinical skills you’ll develop in fellowship.
– Hemopericardium means aortic dissection until proven otherwise. If the patient is too unstable for CT, perform a TEE immediately and call surgery. Do not proceed to pericardiocentesis before ruling out dissection.
– VT storm has many etiologies. Stabilize first -cardioversion/defibrillation, beta-blockade, antiarrhythmics, sedation, hemodynamic support – and pursue the underlying cause simultaneously.
