How long before a case can a table be set up and still considered sterile?

Should a table be covered?

Should you wear a mask and gown just to set up a table?

These are questions we hear a lot. I had been taught that a dry table could be covered and was considered sterile for 24 hours. A wet table would be considered sterile for 2 hours. I have heard many other things. I have even done many other things. As a traveler, I worked in a lot of hospitals, who all had their own way of doing things. At one place, we set up a tray and covered it so the call team had a tray set up in case of call-back. If there were no call-ins, we used it for the first case in the morning. Another place set a tray out (closed) with all the equipment in a bag. If we were called in, the ED RN would open and throw the tray (not set it up) to save time for us. Every hospital is different…and that is a problem. There is no consensus for the sterile tray in the cath lab.

I have been researching this subject, and have gone to ACC/SCAI for their consensus document. It is a thorough document, and covers a lot of subjects, but does not address the sterile tray setup. TJC has no clear consensus on the back table. The only groups that really address the tray issue are the AST (Association of Surgical Technologists), Infection Control professionals, AORN, and Interventional Radiologists. The conclusions I drew from this research follow.

Personnel

• All personnel must change into scrub attire upon arrival
• Hair coverings are to be worn at all times
• Masks are to be worn when an open tray is present
• Sterile gowns and gloves are to be worn when participating in the sterile field (scrubbing the case)

Tray preparation

• The back table should be prepared less than one (1) hour prior to the procedure; preferably immediately before the procedure begins
• A table cover is not recommended. If the table must be covered, the drape should not extend over any edge of the table.
• The tech preparing the table should wear a gown and gloves in order to maintain integrity of the sterile field
• The table should be prepared inside the suite in which it is intended to be used. It should be monitored continuously to ensure there are no breaks in sterility
• No patient other than the one for which the field is prepared should enter the suite with the sterile field, whether it is covered or not
• A new table meant for a different procedure or patient cannot be prepared in a room that is currently being used for a procedure or patient

I agree with all these for several reasons. First, changing at the hospital. I don’t know how many places I’ve worked where I watched people in scrubs with scrub hats on (you KNOW they were in surgery) walk into the hospital after riding in their car or on a bus or train. Changing into scrubs at the hospital ensures that you don’t bring outside germs with you. Seriously. How often do you get your car seats cleaned? And how do you know what’s on the seats of that bus or train? (I worked in Boston and changed clothes immediately after arriving at home following a train ride!) Changing into hospital-laundered scrubs helps to ensure patient safety.

Hats and masks? Yes, you really should. We’ve learned a lot from COVID-19, and one thing is, when we breathe, we breathe out lots of germs. And hair really does have a tendency to fall out, even when you’re not balding.  It doesn’t hurt to wear a mask during a case, and it doesn’t hurt to wear a hat (or two…I worked in the 80’s and had 80’s hair). It really will protect the patient.

Sterile gown and gloves when you’re scrubbed in. Need I say more?

Now, about that table.

According to the Society of Interventional Radiology (SIR), the table should be set up no longer than 1 hour prior to the start of the procedure, and preferably immediately prior to the start. It is possible to do that; I worked at a facility who mandated that the tray was not opened until the patient was in the room. Now, come on, guys. Most of us can set up a tray in 5 minutes or less. This shouldn’t be a problem. SIR also recommends that the table not be covered. And if it is covered, the cover should not extend over the edges of the table. The Association of Surgical Technologists (AST) agrees with this part. Having said that, I have seen table covers that are designed to break in the center and pull off (takes two people) in a way that never leaves unsterile over sterile. I’m not recommending products…it’s easy to find on the internet.

SIR and AST also recommend that the team member setting up the tray wears a gown along with gloves, hat and mask. I must say I agree with this for everyone. I’ve done that for years personally, because I’m short and round and tend to bump the table when I’m setting up. If you’re short and round like me, PLEASE wear a gown! But even if you’re tall, and can reach across the table safely when setting up, remember that when you reach across the table your unsterile arm is over your sterile field. That’s a no-no. And that’s the reason I recommend wearing a gown for setup. I also understand that this may not happen for COVID-19 reasons, but please make that the only reason it doesn’t happen!

The table should be set up inside the lab where it will be used. I’ve seen places that set up tables and moved them from room to room (covered, of course). This should not be done, although I understand the concept of emergency and changes within the cath lab. One thing that certainly should never happen is for a patient to be in a room with a table that will be used, or even meant, for someone else. Not even if it is 2 COVID-19 patients. Again, AORN, SIR and AST agree on this one. And don’t set up tray 2 while patient 1 is still in the room. Just, don’t.

Okay. I’ve given my opinion on this subject, along with explanations of why I believe what I’m saying. And this is my opinion. And my opinion plus $5 will buy you a cup of coffee. But it’s not just my opinion. It’s also the opinion of people who know.

References

Association of Surgical Technologists. (2019, November 4). Guidelines for Best Practices for Establishing the Sterile Field in the Operating Room. Retrieved from ast.org: https://www.ast.org/uploadedFiles/Main_Site/Content/About_Us/Guidelines%20Establishing%20the%20Sterile%20Field.pdf

Chan, D., Downing, D., & Keough, C. et al. (2012, July 17). Joint Practice Guideline for Sterile Technique during Vascular and Interventional Radiology Procedures. Retrieved from Journal of Vascular and Interventional Radiology: https://www.jvir.org/article/S1051-0443(12)00742-7/fulltext

Recommended Practices Committee, ICT. (2005, March 25). AORNs Recommended Practices for Maintaining a Sterile Field. Retrieved from Infection Control Today: https://www.infectioncontroltoday.com/view/aorns-recommended-practices-maintaining-sterile-field-review-and-public-comment-through

Happy New Year!  I hope your 2019 got off to a great start!  Mine did.  Except that while I was doing CPR during a procedure, the doctor decided he wanted an RAO view.  I caught the c-arm in the leg.  OUCH!  But it wasn’t that bad…and I guess I deserved it.  I’ve done that to a couple of doctors over the last 30 or so years.  But anyway, other than that, 2019 has been absolutely great!

But it’s time for resolutions.  Lose weight, exercise more, take less call…  Here’s one.

TAKE CARE OF YOURSELF!

You know, I’ve done this job for a long time.  It’s a very physical job, as we all know.  It takes its toll on the back and knees and all the rest.  And I’ve played pretty hard for a long time.  Including beginning to ride horses at age 30.  You don’t bounce back as easily at 30 as you did at 10!  So I learned the value of Chiropractic several years ago.  And I learned the value of massages.  Most people think of massage as a luxury.  But for those of us who have endured this long, massage is a lifesaver. My massage this morning was a 1½ hour session.  I like this length because the therapist has time to work each section of my body.  I came away feeling more relaxed and ready to face the week.

But it’s not just the physical therapy, it’s the idea that I deserve to be taken care of.  Not only do I get a massage once a month (at least!), I also get a manicure and pedicure twice a month.  OK…we can’t wear fingernail polish, etc., but a it’s more than polishing your nails. It’s the warm bath for your feet, and the leg massage during the pedicure.  And seeing your red toes peeking up at you really says, “THE DAY IS OVER!”  It’s having someone else take care of your hands…those hands that are abused every day with washing, scrubbing, gloves, and all the other things we do each day.

And it’s not just for women.  Guys, you won’t lose your man-card because you got a manicure and pedicure.  In fact, your significant other might be happy you did.  And there is such a thing as a couples massage.  Maybe for Valentine’s day…

So this year, take care of you!  You spend your time taking care of other people, take 5 – 6 hours each month to take care of yourself.  YOU DESERVE IT!

Lately, I’ve been observing cath and EP labs who have questions about staffing. They’re good labs, but they’re not living up to their potential. The biggest question to ask is, “Do you see the lab as a nursing unit where nurses perform procedures assisted by non-nurses, or do you see the lab as a multi-disciplinary procedure area where nurses and non-nursing professionals assist physicians to perform procedures? These issues seem to arise in labs where nurses have moved from the floor or an intensive care unit to manage the cath lab without ever working or observing in the lab. With no one to ask, they do their best, and they create good labs…where there could and should be great labs.
The biggest problem with seeing the cath lab as a nursing unit is that it turns all other lab staff into sub-professionals. It is vital that a cath lab manager understand who is qualified to work in the lab. Here they are:
• RN (Registered Nurse)
RNs bring general patient care knowledge into the lab. They are the ones who are trained in pharmacology, physiology of the entire body, and medication administration. RNs can be BS or ADN trained. There is a Cardiac Vascular Nursing Certification (RN-BC) for RNs, but it is not specific to the cath lab. Many RNs come from the ICU and have a CCRN certification. However, the RNs I have spoken with have told me that ICU and CCRN certification do not adequately prepare a nurse for the cath lab. Many RNs choose to earn their RCIS certification, as it is cath lab specific.
NOTE: LPNs are welcome in the lab, but usually function as techs due to their inability to administer narcotics.
• RT (Registered Technologist – Radiography)
RTs bring strong anatomy knowledge, as well as experience working with radiation and radiation-producing equipment. They tend to be more “techie” than most nurses. Cath and IR Lab is included in the RT training. RTs can be BS or Associates degrees. There is an advanced certification for RTs in the cath lab: The Cardiovascular interventional (CI) credential. This is an exam taken by RTs after working in the lab for some time.
See https://www.arrt.org/docs/default-source/discipline-documents/cardiovascular-interventional-radiography/ci-clinical-experience-requirements.pdf?sfvrsn=fadb01fc_24 for details
NOTE: The CI and VI were combined into the CV credential until the early 2000s, when they divided into the CI and VI.
• RCIS (Registered Cardiovascular Interventional Specialist)
The RCIS brings cardiac-specific knowledge to the lab. The requirements to challenge the RCIS exam are found on the CCI website,
http://www.cci-online.org/CCI/Certifications/RCIS.aspx
• Other professionals are also welcomed into the lab:
 EMT
 LPN (functions as tech)
 Respiratory Therapist
A fourth professional is found in the EP lab. This is the RCES (Registered Cardiac Electrophysiology Specialist). The requirements are found on the CCI website:
http://cci-online.org/CCI/Certifications/RCES.aspx?WebsiteKey=2f9db85d-c27a-48f7-bcac-db6a6c42de51
And so, it is important for a cath lab manager to understand who is available to work in the lab and what their strengths and weaknesses are.
Then what’s the solution? First, ask some questions.
1. Do you staff according to credentials?
Do you put the nurses into the cases and then look to see what holes are there to be filled?
2. Do you staff according to roles?
Have you defined the roles and what is required for each?
If you are staffing according to credentials; if you put the nurses into the case and “fill in” to assist them, how do you decide what your nurses can and can’t do? Are your nurses expected to scrub? Are they expected to monitor? Have they been trained to do these things? Do the nurses sedate the patients? Do they do anything else while they are sedating the patients? Are your other lab staff BLS certified? ACLS certified? What do they do in emergencies? How many staff are in each procedure? How many are nurses? How many are not nurses?
And the big question:
DOES YOUR CATH LAB FUNCTION AS A TEAM OR AS INDIVIDUALS PERFORMING THEIR TASKS INDEPENDENTLY OF EACH OTHER?
If you are staffing according to roles, what are the roles? Do you have only nurses filling some of the roles and only techs filling some? As you have seen from the definitions above, there are some roles that can be filled with either nurse or tech. So…let’s define the roles and who should fill them.
But before we can define the roles, we should probably define the tasks to be performed.
In the cath lab:
• Write/Scribe/Document
• Sedate and monitor patient
• Gather equipment for procedure
• Scrub
• Pan/Drive table
• Set up extraneous equipment (Impella, IABP, Atherectomy (Rotational, Directional), Thermodilution CO, Thrombolysis, Thrombectomy, Laser)
Can any of these be combined? According to new guidelines, the sedater should not do anything other than sedate the patient. Therefore, they should not gather or set up equipment. The scrub will be busy at the procedure table. They can pan or drive the table. So, we can call it scrub/pan. That makes the roles in the Cath Lab:
• Sedater
• Write/scribe/documenter
• Scrub/Pan
• Circulator
So what credential is necessary for these roles?
The Sedater, with a few exceptions, can only be an RN, as moderate/conscious sedation involves administration of narcotics. I’ve been in facilities where they called it “Sedation Nurse”.
The Writer/Scribe/Documenter (we call it “Monitor”) needs to be educated and informed, but could be either an RN, an RT or an RCIS.
The Scrub/Pan, with a few exceptions, can be any of the above. In a few states, only an RT can pan the table. They become the driver, with anyone else scrubbing. The RT can pull equipment if they are available to pan for the case. In that instance, the RT pan would be called the “Circulator”.
The Circulator pulls and sets up equipment. In rare cases, they may be called upon to assist the sedater in case of emergency. Therefore, the circulator should probably be an RN, although it could be any of the above.
The conclusion? In the cath lab, in order to have the roles filled, there should be, at the least, 2 RNs, 1 RT, 1 RT or RCIS. 4-man teams. I have worked with 3-man teams where the sedation nurse is also the circulator. A good cath nurse can do this.
The 2 RN/2Tech model works well in most labs simply because it provides expertise from all three professionals.
In the EP lab:
• Write/Scribe/Document
• Sedate and monitor patient
• Gather and open equipment for procedure
• Connect cables to pin blocks/PIU
• Set up irrigation lines to catheters
• Scrub
• Pan/Drive Table
• Run ablator (Cryo or RF)
• Run Stimulator/pacing/mapping
The EP Lab is a little different.
• The sedater should watch the patient exclusively. However, in the EP lab, anesthesia is usually present for ablation cases. This frees up a nurse for another role. If there is no anesthesia, the sedating nurse must be free to do nothing other than watch and sedate. With a few exceptions, this must be an RN.
• The Writer/Scribe/Documenter (Monitor) can pull equipment, set up irrigation lines and pin cables. This team member can be RN, RT or RCIS/RCES (EP specialist)
• The scrub will break when the catheters are in place; they are then available to run the ablator. There is very little panning done during an EP procedure, and it is typically done by the physician. This team member can be RN, RT or RCIS/RCES
• The person running the stimulator/pacing/mapping should not leave their position. It can be either RN, RT or RCIS/RCES.
Therefore, the mix in the EP Lab is:
1 RN for sedation if anesthesia is not present.
3 RN/RT/RCIS/RCES for the other roles if anesthesia is present. As always, it is good to have a mix of credentials, in order to have all knowledge bases represented. A 3-man team is all that is necessary. For implants, a 4th may or may not be present, again, if there is no anesthesia for sedation management.
This should be a 1 RN, 1 Tech, one either RN or Tech.
The conclusion, then, is to ask the big question: Are you running a nursing unit that does procedures with nurses and their assistants or are you running a procedure unit with a multi-disciplinary team?
The best labs are a procedure unit first, utilizing a multi-disciplinary team (with the emphasis on “TEAM”). Everyone should be equal. Except where necessary (narcotics, radiation), credentials should be left at the door. This approach creates an atmosphere, where everyone feels like a valuable member of the team. It creates an atmosphere where everyone has incentive to earn an extra credential and become even more valuable to the facility.
If you run a nursing unit, you will have nurses and assistants. If you run a procedure unit, you will have a team. Which do you want?

Everyone knows the issue…physicians bring the call team in on Saturday or Sunday for a routine case. Or even for a non-STEMI that a couple of years ago, they would have held until Monday. Then there’s the inevitable, “While we’re here…” and what should be a short day turns into 10 or 20 hours over the weekend. Before and after 40-plus hour weeks. We are pretty sure the doctors aren’t going to stop, and management isn’t going to even ask them. So something else needs to be done to keep us from being burned out to the point of quitting something we all love. You know, I used to (and still do) tell Fellows, “If you want your staff to like you, have a life outside the hospital. No one has an issue with coming in for a legitimate emergency. We live for saving lives…it’s why we do what we do. But no one wants to come and work another 12-hour day because you don’t want to be at home.” I guess they didn’t really listen.
So…we need another solution. Here’s my suggestion (for what it’s worth): Change the shifts to 12-hour days. The weekend call team works Friday, along with the other daily teams and…
A WEEKEND TEAM.
A team that works only Friday, Saturday, and Sunday, 12 hours per day. They are paid for 40 hours at a premium that compensates them for the loss of their weekends. They take no call; they only do emergencies while they are in house. There will be a call team for emergencies only, both during the day Saturday and Sunday while another case is going on and weekend nights. In other words, the call team goes back to what it originally was: a team for night and weekend EMERGENCY cases.
Who would do this? A quick FaceBook poll says that there are many people who would do this shift. Of course, they want the old fashioned weekend: work 24 and get paid for 40. I don’t think that will fly in this financial climate. The Friday weekend day allows the hospital to hire fewer employees to cover the shifts. For the weekday staff, this cuts down on overtime. Yes, you are working 12 hours while you are working, but you are only working 3 days per week. And you know what time you are getting off each day. A good manager will work with her people to let people have days off when they need to go to a function in the evenings, and you will be able to plan other functions for when you are off. A good manager will schedule call for when you are at work so when you’re off, you’re off.
Of course, this depends on a good manager.
Anyway, it will also require hiring 2 – 3 new teams plus the weekend team, depending on the number of labs you have. The big question is, will the extended hours pay for the extra people? Maybe some part-timers, who only work 1 or 2 days would help. But there is also the question of turnover. If the current hours are causing too much turnover, it would be worth it. It is very expensive to onboard someone every 2-3 months, not to mention how long it takes for them to be ready for call. And travelers can help immensely!
The biggest hurdle would be keeping the physicians in line. Upper management needs to be on board to ensure that:
1. Physicians don’t take advantage of 2 teams on the weekend. They must be reminded that the call team is only for emergencies (STEMI), and not for “emergencies of convenience”. Even a non-STEMI can be delayed for 24 hours and not violate length of stay rules.
2. Physicians must obey rules about loading times during the week. For example, a known CTO or peripheral cannot be started after 4:30 pm (if leaving at 7:30). These cases should not be scheduled after 3:00 p.m. Add-ons cannot be started after 5:00 p.m.
Remember: we are giving them 4 more hours each day; they need to respect that compromise.
I would love to hear responses on this, from staff, management and physicians. Who would do the weekend shift; who would hate the thought of going to 12-hour shifts; do managers think this could work? How much work would it be to set up? From physicians; would this help you manage your work-life balance? Because it would certainly help ours!
In short, I believe that the only way to cover the onslaught of new patients is to extend the work week, using more staff. This is one way to create jobs…and isn’t that a good thing?

US News and World Report has labeled Cardiovascular Technician/Technologist as one of the most stressful jobs in the country.

Overview

Welcome to the Cardiac Cath Lab!  This is arguably the most fun place in the hospital.  It is a high-stress, high-volume procedural area, where an interdisciplinary team saves lives on a daily basis.  The high-stress schedule is balanced by the support from each team member.  In this course, we will look at the makeup of the team and each member’s strength, the role each colleague plays, the procedures performed, the equipment used, and the diseases we treat in the Lab.  This course is intended to prepare you to begin your journey in the Cardiac Cath Lab.  The course will begin with a short description of the procedures and roles in the lab.  More in-depth descriptions of each will follow.  By the end of this course, you will know what each procedure is, and what are the expectations for each staff member.

The Cardiac Cath Lab is the area of the hospital where Catheters and wires are used to place therapeutic equipment to open blocked blood vessels and save hearts and legs.  We also work on the electrical side of the heart, to treat arrhythmias and to insert devices to keep a heart beating or to restart it when necessary.

The Cath Team

The Cath team is composed of three distinct professionals:  The Registered Nurse (RN), The Registered Radiologic Technologist (RT), and the Registered Cardiovascular Invasive Specialist (RCIS).  Each profession brings to the Lab expertise in a different segment of the procedures.  Each is an equal member of the team and should be treated as such.

The RN brings expertise in patient care and pharmacology.  While the RCIS and RT both receive training in these areas, the RN is the “resident expert”.  We depend on the RN to administer conscious sedation, to ensure the patient’s safety while sedated, and to move quickly to treat any adverse reactions the patient may experience.  Nurses should remember that the patient is in the Cath Lab for the procedure; patient care is an important component of the procedure, but not the reason the patient is here.  If the patient only needed nursing care, he wouldn’t come to the Lab!

Many labs include EMTs, Respiratory Therapists and other professionals as part of their Cath Lab teams.  These colleagues add extra knowledge that is useful during procedures.  In short, anyone who is willing to train and learn the Cath Lab, should be welcomed to the team!

The RCIS is the expert in all things Cardiac.  Their in-depth training includes the diseases of the heart, pressures, calculations, and each of the different tools in the cardiologist’s arsenal.  Their training includes someradiation safety, radiology, patient care and pharmacology, but their true expertise is in the Cardiac Catheterization itself.The RT is the expert in the x-ray equipment.  Radiologic technologists spend two years training with radiation.  During that time, they develop a deep respect for radiation as well as an understanding of the angles and projections necessary to provide the physician with the best views of the coronary arteries in which to work.  The RTs also understand the equipment and how best to keep it running, whether to reboot or to call in the field service techs.  RTs also study vascular anatomy in great detail during training, and can be considered experts in peripheral and carotid studies as well.  These subjects are covered as part of Vascular and Interventional Radiology units.

It is the opinion of this author that the RCIS has received adequate training to safely pan the table during the procedure.  However, due to the training mentioned above, I believe that each Cath Lab should be staffed, at a minimum, with one RT for each x-ray system.  Further, there should be sufficient RNs in the department to add an extra RN if needed during a procedure.  Call teams should be 2 RN, 2 tech (either RT or RCIS).

Each member of the team is valuable because of what they bring to the team. A functional Cath Lab consists of either all RNs, all RTs or all RCIS.  A good Cath Lab team contains RN and either RT or RCIS.  A complete and great team consists of all three:  RN, RT and RCIS.  Most Cath Lab teams have three members; with the changes in regulations, many are going to 4-man teams.  The extra person may be a second RN, as one RN will be administering sedation and monitoring the patient without distraction.  The extra person may be another tech, as many states require an RT to operate the x-ray equipment.  Whomever is added, it is always nice to have an extra pair of hands during an emergency!

Description of Roles

There are three major roles in the Cath Lab:  The scrub, the monitor and the circulator.

Scrub

The scrub is responsible for setting up the table and pulling equipment to begin the case.  The scrub drapes the patient and assists the physician.  In some labs, the scrub preps and cleans the patient; in other labs another team member performs that function.  The scrub then assists the physician during the procedure.  In the lab, the scrub should be the unofficial team leader, determining when to call the physician to scrub in and begin.  The scrub is usually a tech, but can be a nurse.

Monitor

The monitor is the “scribe”, or “writer” for the procedure.  They are responsible for recording everything that occurs from the start of the procedure to the end.  This team member ensures that all patient information is entered into the record, including identifying numbers, allergies, and lab results, and that the patient information is entered into the x-ray system.  The monitor provides the consent, H&P, and other paperwork for the physician to sign.  In many facilities, the monitor is responsible for initiating the “Time Out” prior to the procedure.  Following the procedure, the monitor enters the radiation dose into the appropriate place, gathers the reports, ensures the physician and circulating nurse sign the medication sheet, and enters charges according to facility protocol.  The monitor may be either an RN or a tech.  If the monitor is a tech, it is a good idea to check with the RN to ensure all medication has been entered into the record.

Circulator

The circulator is responsible for patient care, safety and comfort during the procedure.  They ensure the patient is connected to the proper monitors, and administers the conscious sedation along with any other IV medication ordered by the physician.  The circulator communicates with the monitor to ensure all medications are entered into the record.  In some facilities, the circulator is responsible for gathering additional diagnostic catheters and wires, as well as interventional equipment.  New regulations require that the conscious sedation nurse does nothing except monitor the patient during the procedure, necessitating another team member to pull equipment.  The circulator should be an RN, due to the narcotic/medication administration.  However, in some states, non-nurses are allowed to administer medications; in that case, the circulator may be either an RN or a tech.

Extra

Some facilities are adding an extra team member because of the state requirements regarding radiation and/or medication administration.  The extra member is usually an RT.  The RT is typically stationed at the end of the table and pans for the procedure, then moves to pull other equipment as needed for the diagnostic or interventional segment.  If the extra member is an RT, they are usually responsible for entering patient information into the x-ray system and recording radiation dose at the close of the procedure.

 

This is the beginning of a complete Cath Lab 101 course.  Stay tuned…

If you’ve never been to the Cath Lab, you should visit. It’s really a fun place! However, if you’ve never been, there are probably a few things you haven’t learned. Here’s what we wish you knew:

Please give the patient their meds!  It doesn’t do them or us any good at all for them to arrive in the lab with a frighteningly high blood pressure!  Coumadin and Xarelto are the only two exceptions.  A few sips of water to get the meds down is ok, but please…no cup of coffee, no full breakfast, etc.

Please have them remove all clothing, even if we are going to perform a radial (wrist) access.  We will usually prep both groins, because as I tell the patients, we only need to access the groin if it isn’t prepped!  Also, if we are inserting a pacemaker or ICD, we need the legs for the grounding pads.

If you are at a facility who preps for us, or if you have a lot of spare time (right…I know), please shave an area about 7” in diameter.  This is the size of the tape on the fenestration in the drape and if they’re not shaved that large, they will get waxed.  The hair is coming off one way or another, and it’s a lot more pleasant for the patient if it’s clipped!

If the patient is coming for a PICC line, please let us know if it is single, double or triple lumen.  Let us know what it is for, and if there are any contraindications to one arm or the other.  A pacemaker in the left is a contraindication for the left arm.

The consent is also important.  Your facility should have the specific wording for the consent.  It should be signed by the patient or their representative and a witness, according to your facility protocol.  The physician will sign it when they arrive in the department.  There will be several places on the consent the patient will need to initial.  The cath lab will be happy to send a sample to guide you with the consent.  The patient will also need an anesthesia consent for conscious/moderate sedation.  For a routine cath with intervention, the RN manages the anesthesia, so the anesthesiologist will not visit the patient prior to the procedure.  There are exceptions, such as EP procedures and implants.  Again, the cath lab will be happy to guide you.

Following the procedure, simply watch the patient.  The groin site should stay soft and flat (relative to patient’s body prior to the procedure), with no pain.  If the site begins to bleed, or if it swells, the best thing to do is to remember basic first aid:  pressure for bleeding.  Call the physician, then apply pressure proximal to the access site for arterial access and distal to the site for venous.  Just remember which direction the blood is flowing, and stop it before it gets to the hole.

The patient may eat and drink, but should not do anything that resembles a sit-up.  Their head should stay on the pillow, and their leg should remain straight.  The head of the bed may be raised to 30^o but no farther (depending on facility protocol).  Following a pacemaker, the patient should not move the affected arm too far:  they may raise the arm enough to feed themselves, but not enough to comb their hair.  A sling should be placed to remind them not to move very much.

Please remember that when we ask for a bed, or try to bring a patient to you, it’s not to ruin your day.  It’s usually because we have another patient to go onto the table and need to keep things moving.  We run from 7 am until we’re done, 8 or 10 or 12 hours later.  It isn’t unusual for us to work 12 hours on an 8-hour shift, and get up and do it again 5 days in a week.  The weekends are even worse.  We are a single team, on a call-back basis for each procedure we perform.  We have usually already worked 40+ hours in the week, and are trying to work as quickly as possible.   All we ask is to get one patient off so the next can get on, especially if a STEMI has just arrived and we are on the clock for a 90-minute door-to-balloon time.

Cath lab is physically demanding work but we do it because we love it, even though it is very wearing on us.

We appreciate all you do, and hopefully this will help you know where we are coming from, so we can be a better team.

We work hard. Really hard. And long hours. Really long hours. What makes a place we want to work hard for long hours?
Teamwork, for one. We need people who will do what needs to be done when it needs to be done for no reason other than because it needs to be done. We need nurses who will come in to the other lab and connect the patient to get that case started sooner. We need techs who will cross over and start the monitor to get the case started. We need anyone who will, to come in and clean after the case. And we need the people who got help to do the same thing when it’s their turn. Because…it will come back to you. Maybe today, you will be the one who does more than anyone else. But over the course of a week or a month, it will all balance out. We all get tired of Dez Bryant complaining about not getting the ball thrown his way enough. But over the course of the season, he made a lot of TDs, right? He got it when it counted. And you will, too. Nurses, please be more than just med-pushers. Please understand that you can pull wires, and you can open catheters, and you can keep up with contrast amounts, and you can watch radiation doses just as anyone else can. And techs? You can watch the monitor and be the first to call out “V-FIB!” at the right time. You can scratch the patient’s nose. You can (yes, you can!) put a bedpan in and take it out. (To be honest, that’s one reason I DIDN’T go to nursing school: I didn’t want to do bedpans!) But when it needs to be done, I need to do it. I like it here, because while I don’t like legs, I do enjoy a good IR case from time to time. So my coworker does the legs and I do the TIPS and Kyphoplasty and whatever else comes along.
Competence is next. Come in and learn your job. Know when to call out “V-FIB!”. Know that an RCA injection may cause arrhythmias. Know that a wire in the ventricle may cause arrhythmias. Know what’s coming next in the workflow. Know the difference between compliant and non-compliant; and monorail and OTW. Know the difference between drug-eluting and bare metal. Be able to differentiate between .014, .018 and .035 wires. Please don’t open a 300 cm wire when we’re using monorail, and don’t open a 180 cm when we’re using OTW. Learn how big to shave the groin. Learn where to put the EKG patches so they’re not in the picture. These are small things, but they make such a difference in how the day goes!
And that’s one thing I like about the hospital where I am now. It’s a small place; 2 labs, 3 techs, 4 nurses (2 in training) and 2 nurses in the recovery area. But everyone steps in to help; the nurses in training are learning fast. Even the doctors step in to make sure they don’t schedule too much for one day (wish we could clone them!). Being a fairly new department, there is no call, so we all stay late to finish cases, but we only get 2-4 hours OT per week. That’s not too bad. The manager (RCIS) lets us do our job with a minimum of supervision but is ready to step in when needed. The director (RT) stays out and makes sure we have what we need. It’s a good setup, and looks to grow at a good pace. It’ll be fun to check in with them in a couple of years to see what’s happened. Hopefully, the upper management won’t get too caught up in credentials and will allow the cath lab management to continue, since they are running the lab efficiently and keeping the employees, doctors and patients happy. And that’s what makes a good lab!

I always find it amusing to speak to other techs and nurses in the lab. It amazes me the number of lab staff who believe that the more equipment you pull, the better doctor you are. Or, the longer you take to perform a procedure, the better you are. I’ve always seen the opposite: use less hardware and less time, and the patient is better off for it. Of course, that could come from a horse riding perspective where the less hardware makes the better rider.

But seriously. How can it make a better doctor when he routinely uses 2-3 guide catheters for an intervention? (Of course, there are those times, but I’m talking about doctors who have been doing this for years and still call for multiple guides for a left system or right system.) And don’t start with, “But they’re just out of school!” I’ve worked in enough training hospitals to know how many procedures these guys do. They should know what works best for them. And just today, 3 12mm stents placed when one 30mm would have worked better. (And it wasn’t a great result, either.) The less hardware, the better.

I started in the lab in the old days, when Rotablator had just come out; IVUS was fairly new, FFR wasn’t used much where I was, and laser was big…but only one of our doctors used it. And we got GREAT results. The reason? Our doctors were good. They did what was necessary, not what was “fun” or “new and improved” or anything else. They tried Rotablator, and found it didn’t make the results any better; it just cost them time and extra contrast and radiation doses. Of course, they can charge more for using it…

There will be times for the “toys”. A time for the Impella…but not every unprotected LMCA (I did an unprotected LMCA last month without Impella, and it went beautifully). A time for the CSI, a time for the Rotablator, a time for the laser. BUT NOT EVERY CASE.
Remember, especially the RTs: TIME is an important factor in radiation protection. The less fluoro time, the less exposure to the patient. And the less exposure to the patient, the less exposure to you. And everyone should remember the cost to the patient in contrast. Contrast Induced Nephropathy is on the rise. And long cases with 250+ ml of contrast is a big reason. Those are things to think about, too.

And now for the techs and nurses who believe you know better than the doctor: YOU DON’T. Well, not most of the time, anyway. The doctor is thinking about dozens of things that never entered your mind. You see the image, he sees the image + lab work+ radiation time + patient history + the last image that looked like this + a dozen other things that you don’t know about. He’s the one making the decisions, not you. He’s the one in charge, not you. He’s the one losing his license if something goes wrong…and you don’t want to join him because you went outside your area of expertise. You see, doctors are like referees: No matter how wrong they are, they are right. There will be a doctor here and there who will take suggestions from you, and you are right to offer them. (And sometimes it works best to phrase them in the form of a question.) But they are only suggestions from someone who isn’t seeing the entire picture. The doctor is in charge. It is his job to place the stent. It is his job to decide what equipment to use. It is his job to decide when you’re done. Focus on your job and let him do his.
OK. Rant over. Carry on!

One of the things I had issues with when I started in the Cath Lab was monitoring. We all know that during a case, it can be difficult to call out what we’re doing. It helps when the monitor can look at the image and know what’s happening. And especially, during a Right Heart, to know what the waveforms are, knowing what normal pressures and saturations are; and knowing how to calculate FICK output (even though we usually let the computer do it).
To assist the “newbies” (and even a few veterans), CVIR Education has created a pocket sized reference book that includes everything above, plus images and diagrams of coronary anatomy and cardiac anatomy, and tables showing normal sats and pressures. The books are in limited production now, and will be available for order beginning July 19. They may be ordered on our website, www.cvireducation.com, and will cost $25 each.
We really hope this reference will help you as you begin (or advance) your career in the Cath Lab!