HeartWare is a third generation left ventricular assist device (LVAD), widely used for the management of advanced heart failure patients. These devices are frequently associated with a significant risk of gastrointestinal (GI) bleeding. The data for the management of patients with LVAD presenting with GI bleeding is limited. We describe a 56-year-old lady, recipient of a HeartWare device, who experienced recurrent GI bleeding and was successfully managed with subcutaneous (SC) formulations of octreotide.

Lyme disease is caused by the spirochete Borrelia burgdorferi and is carried to human hosts by infected ticks. There are nearly 30,000 cases of Lyme disease reported to the CDC each year, with 3-4% of those cases reporting Lyme carditis. The most common manifestation of Lyme carditis is partial heart block following bacterial-induced inflammation of the conducting nodes. Here we report a 45-year-old gentleman that presented to the hospital with intense nonradiating chest pressure and tightness. Lab studies were remarkable for elevated troponins. EKG demonstrated normal sinus rhythm with mild ST elevations. Three weeks prior to hospital presentation, patient had gone hunting near Madison. One week prior to admission, he noticed an erythematous lesion on his right shoulder. Because of his constellation of history, arthralgias, and carditis, he was started on ceftriaxone to treat probable Lyme disease. This case illustrates the importance of thorough history taking and extensive physical examination when assessing a case of possible acute myocardial infarction. Because Lyme carditis is reversible, recognition of this syndrome in young patients, whether in the form of AV block, myocarditis, or acute myocardial ischemia, is critical to the initiation of appropriate antibiotics in order to prevent permanent heart block, or even death.

Inspired by the ABIM Foundation's Choosing Wisely ® campaign, the "Things We Do for No Reason" (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent "black and white" conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. CLINICAL SCENARIOA 28 year-old woman presents to the emergency department with acute onset bilateral chest pain and dyspnea. She has a respiratory rate of 28, a heart rate of 106, blood pressure of 110/65 mm Hg, and pulse oximetry of 92% saturation on room air. She has no history of cardiac or pulmonary disease and no personal history of venous thromboembolism. She takes an estrogen-containing oral contraceptive. On examination, she has no jugular venous distention, normal cardiac tones without murmur, and no lower extremity swelling. D-dimer is elevated at 3.4 mg/L (normal < 0.5 mg/L), and she undergoes computed tomography (CT) of the chest, which demonstrates acute segmental pulmonary emboli (PE) in the right upper and middle lobes as well as multiple bilateral subsegmental PEs. The CT suggests right ventricular dysfunction (RVD), and her troponin T is 0.06 ng/mL (normal < 0.01 ng/mL). Bilateral lower extremity venous Doppler ultrasonography demonstrates no acute thrombus.

Background: Bone marrow aspiration and biopsies (BMAB) are a relatively frequent procedure needed in the inpatient setting, especially in a tertiary care center.Objective: Procedure-focused hospitalists can provide an excellent option for doing inpatient BMAB. Here we present five years of experience with a hospitalist bedside procedure service (BPS) performing BMAB.

Background: In 2007, the American Board of Internal Medicine eliminated numeric procedure requirements for licensing. The level of exposure to procedures during residency, and subsequent competence of graduating residents, is variable. In 2015, our institution developed a bedside procedure service (BPS) with the intent to teach ultrasound guidance and procedural training to internal medicine residents with direct supervision of technique by Hospital Medicine faculty to optimize learning, increase con dence, and improve patient safety.Objective: In this study, we review the number and complication rates of resident procedures on a dedicated internal medicine bedside procedure service (BPS) as a resident elective.Methods: In this retrospective, observational, single-center study, we reviewed internally collected data from BPS procedures performed from 2015-2019. The BPS offers a variety of procedures done with ultrasound guidance at an adult tertiary care referral center. BPS services are available to all inpatient hospital services. A rotation with the BPS was offered as a stand-alone resident elective for the rst time in 2015.Results: 69 residents performed a total of 2700 ultrasound-guided/assisted procedures and 146 diagnostic ultrasound scans from 2015-2019. Residents performed an average of 40 procedures during their elective month. There were 5 resident performed procedural complications with an overall complication rate of 0.19%. Conclusions: Our BPS increased procedural opportunities for residents and allowed for real-time feedback by an experienced faculty member in a one-on-one setting. A dedicated rotation allows the time to focus on becoming pro cient in invasive procedures with expert supervision.