Should Reps be in the lab during cases?

We’ve all seen it…the doctor is doing a case and wants the rep to be there to advise him on the equipment.  Sometimes, if it’s a new procedure, that’s necessary.  But should they be there during the plain old stent procedures they’ve been doing for years?

Back in the olden days when I started in the IR lab (late 1980’s), reps were non-existent in the IR lab.  Even when we were doing biliary stents using Gianturco Z-stents, and some of the first femoral artery stents using hand-crimping tools, the reps weren’t in the lab with us.  They visited us, sure.   They brought lunch, coffee, and the best Snickers® cake in Texas (Thanks, Laurie!).  But they didn’t come into the lab for every case, or even most of them.  And when I went into the Cardiac Cath lab in the early 90’s, the only reps in the cases were for implants or new technology such as distal protection and rotablator.  Even when we did the first DES in Dallas, the rep was outside the room.  So why, all of a sudden, are reps necessarily part of the procedures?

Recently, I worked in a lab where some of the doctors wouldn’t do a case without the rep present.  Mostly, it was peripheral cases; legs, below the knee, using various atherectomy devices.  I understand having them there the first couple of cases.  But in the three months I was at that hospital, one doctor needed the rep there for every case.  This rep, however, pulled only equipment needed for this particular procedure, using this particular modality.  Good for her!  But at that same hospital, a different doctor needed the rep for plain old reperfusion procedures…stents.  The doctor would ask what diameter and length he needed, and the rep would pull something out of stock.  His product, of course.   But the really bad part was when the doctor said he was finished and the rep suggested he stent one more lesion.  A lesion that I saw as 30-40%; certainly not enough to stent.  The doctor stented.  Is that appropriate?

Another hospital where I’ve worked has banished all reps from the labs.  Period.  Is that too severe?  Maybe.  Sometimes we need the reps in, especially when it’s a new procedure.  Or, when we’re new to the procedure.  But the doctor should never ask the rep how to do a simple procedure that has been around as many years as stenting has been!

My thought is that a doctor should have training on procedures, then maybe have the rep there for the first 2 or 3.  After that, if he’s not on his own, he shouldn’t be doing the procedure!  The rep’s job is to ensure the product is there, and support the physician’s use of it, not to tell the doctor how to practice medicine!

There have to be boundaries for the reps when they come into the lab.  The physicians must be aware of, and agreeable to those boundaries.  And those boundaries must be enforced by the lab managers.  Otherwise, we end up with reps practicing medicine using the physicians’ hands.  And those boundaries should extend to the techs and nurses.  But that’s a topic for another day!

Who belongs in the Cath and IR labs?

So…who belongs in the Cath and IR Lab anyway?


There are a lot of questions out there, from a lot of people, all of whom say they are the most important group in the Cath and IR labs.  The RNs say they are, because of their knowledge of patient care.  The RCIS say they are because of their knowledge of everything, and the RTs say they are because it started as a Radiology department, and they know Radiology.  In my opinion, they are all important to the proper operation of a Cardiac Cath or IR department.

Here’s why:  Each of the three professions address a vital part of the procedure.

The RN has a vast knowledge not only of the medications used in the lab, but of the medications the patient may be taking for other conditions.  An RN is trained in medication interactions, and should be able to treat and recognize symptoms of those interactions.  Further, an RN will be able to go beyond basic emergency medications to administration of IV therapies following a bad crash.  While crashes (thankfully) only happen a small percentage of the time, they do happen, and for that reason we need RNs in the lab!  Of course, in my (humble but most accurate) opinion, any RN coming to the cath/IR lab should at least have critical care experience, if not be certified CCRN.

The RCIS has an amazing depth of knowledge of the heart itself.  Included in the RCIS exam are cardiac diseases, intense work in right heart wave forms and pressure measurements, cath math (all those formulas…), coronary and cardiac anatomy and panning.  As part of their training, they discuss medications and patient care along with the basics of radiation protection and imaging.  However, they do not reach the level of instruction on medications and patient care that the RN reaches; nor do they reach the amount of knowledge that the RT has regarding radiation protection and imaging.  Therefore, the RCIS is and should be a vital part of the team, but needs the expertise of the other two groups to be complete.  My thought is that the RCIS should be accepted into the Interventional Radiology lab carefully as their education is incomplete regarding neuro and mesenteric angiography and intervention, and non-vascular interventions such as nephrostomy and biliary procedures and dialysis access treatment.

The RT has studied and is licensed in radiation biology and protection along with extensive training in anatomy.  The RT has as much training in anatomy as the RN has in physiology.  RTs spend 2 – 4 years earning a license and passes a test that includes complete human anatomy, some patient care and communication and hospital operations.  But the RT’s main area of expertise is the amount of time they spend with and around radiation, learning the importance of protecting themselves, their colleagues and their patients from deleterious effects.  Further, an RT with the CV, CI or VI credential (Cardiovascular, Cardiac Interventional and Vascular Interventional) has passed a test that includes the specific areas of expertise required in the Cardiac Cath and Interventional Radiology labs.  For this reason, the RT is a vital member of the Cardiac Cath and IR lab teams.

So…now that we have cleared up that all three professions:  the RN, RT and RCIS belong in the cath lab, who should be in charge?  There is a school of thought that says that only an RN should be in charge.  I have no issues with an RN being in charge, as long as they have experience (5 years or more) in the cath lab.  No one can manage a procedure area if they haven’t worked there (IMHO).  However, I don’t believe that it must be an RN.  I believe that any of the professions with appropriate experience (5 years or more) is capable of leading the team; the real question is, are they able to lead and manage people?  All the experience and knowledge in the world doesn’t make up for someone who can’t manage people.

So…who belongs in the cath/IR lab?  A balanced team of RNs, RTs and RCIS who are willing to work together to provide the best care possible for their patients.




Studying for any exam is difficult, and should never be rushed.  We at CVIR Education certainly want you to be successful in passing the Vascular or Cardiac Interventional exam.  Here are some tips to help:

  1. Set a definite date to take the exam. Giving yourself a deadline will ensure you study consistently.
  2. Study consistently. Experts have found that consistent study helps with your retention of the material and ensures that you will be able to recall it at the testing center.  Inconsistent study habits, procrastination, or sporadic studying will hinder rather than help.  Look at the material each day even if it is only a few minutes.  Even at the end of a long day on call, look at it for 5 minutes or so.  This will keep it fresh in your mind.
  3. Schedule your test for within 6 months of beginning to study. Experts say that you retain material for 3 weeks to 6 months.
  4. The original access is for 6 months. Our suggestion is to complete the guide in five months and then use the last month to review the weak areas and complete the practice exams.
  5. Don’t panic and don’t be afraid and don’t second-guess yourself. This is material you work with every day.  As my physics professor used to say, “Think long, think wrong.”  You can do this!

Please feel free to contact us with any questions or concerns.  We would love to hear your success stories!  Best of luck on your exam!


Welcome to CVIR Education!

CVIR Education began as a result of speaking to many techs wanting to take the VI or CI Registry and searching for a study guide.  I looked online and found a few study guides.  Many were outdated, and those that weren’t outdated used terminology specific to their area or even their facility.  That doesn’t work!

Using the outline found on the ARRT® website, we have written a comprehensive review covering everything mentioned in the outline.  We were so complete, we might have gone into too much detail!  What we didn’t do is ask people to give us specific questions found on the exam.  Besides being dishonest, it serves to decrease the integrity of the exam.  It also lowers the meaning of the VI or CI credential.

We are working with an 85% passing rate(!) currently, and are getting good reviews.  Here are a few:

  • “I PASSED the Board EXAM! I took the exam this morning and I finally PASSED it! I am so incredibly relieved! My position at work was on the line, basically if I didn’t pass, I would lose my position at work. I had so much riding on this.”
  • “…just wanted to let you know, I took my exam today and passed it! Thanks so much for your review course, it was a big help!”
  • “I am certain the CVIR review was a great help in accomplishing this difficult feat. When I was taking the CVIR practice exams on line, I felt all the subjects were thoroughly covered. They were tough, and I never did pass any of the CVIR practice exams. But I would go over the lessons/review tests and learn from them for the next time. The information on your review was most helpful!”
  • “…would not have passed without it.”
  • “There really is no other information out there available to prepare a technologist for the difficult board exam.”

It is our hope here at CVIR Education that everyone who uses our Registry Review can echo the above statements.

But there is more to CVIR Education than just reviews.  We have started creating CEU activities that will be uploaded to the site.  They will be completely online, and open to RT and RCIS.  Our credentialing is obtained through the AVIR® (Association of Vascular and Interventional Radiographers).  We are working with Advanced Health Education Center in Houston to do live review courses.  We’ll post the calendar on this site.  Not to mention that one of our staff is a traveling technologist (Cath, IR and EP!), and may be coming to an area near you.  We’ll post that, and if you’re interested in a live CEU presentation, we can provide that.

This blog will be written primarily by our traveler, and focus on issues in the hospitals and labs around the country.  We hope it will be a resource for you!