Can we solve the problem of scheduled cases on the weekends?

I’ve been to a lot of hospitals, and listened to a lot of people talking.  What are they talking about?  Scheduled cases on the weekends.  The “Since-you-was-here” cases.  Can anything be done about it?  Do we want to do anything about it?

First, why is it happening?  For some reason, doctors want to do more cases; more difficult and involved cases, lasting longer and longer.  But the big thing is, they are doing more cases.  They are doing them in and around their office time.  In the past, they doctors had a day or two in the lab and a couple of days in the office.  Now?  They seem to be trying to do it all.  But I don’t think we can stop that trend.  Unless, of course, we can do something about Medicare and Insurance reimbursements.  (I don’t think so).

But what can we do?  We do need to have our lives outside the hospital.  We need a break.  It is as dangerous for us to work massive amounts of overtime as it is for any pilot or driver.  As a matter of fact, since our work is done in a radiation environment, the more hours we work, the more radiation exposure we receive.  That can be a problem in itself, since we work with all doctors, not just one.

So…is there an answer?

As a traveler, I was thinking about this.  I would not be averse to working 3 12-hour shifts; Friday, Saturday and Sunday.  Or even, Friday 1 – 7 pm; Saturday and Sunday 7 – 7 and Monday 7 – 1.  I would agree to a Thursday-Friday-Saturday-Sunday shift 10-hour shift.  Do you think the hospital managements would agree to add Saturday as a normal work day?  Of course, they would have to agree NOT to allow the call team to do scheduled cases on Saturday/Sunday.  If, of course, the doctor can work knowing there is another team “available”.

Times are changing, and we have to go outside the box to adapt.  Opinions?

As a traveler, I have worked with and for many managers in the past few years.  You could call it the good, the bad and the ugly.  There were some places where I couldn’t wait to leave.  Some of that could be attributed in part to the upper management, some to the doctors and some to the co-workers.  Well, it seems like it was the co-workers.  We all know that the management affects the attitudes of the line workers.  They can’t do much about the doctors…or can they?

However, I am seeing at my current position the power of a good manager.  This manager has built a great lab using travelers to fill in while they train new employees to accommodate their growth.  And many of the travelers are asking to stay as permanent employees…a testament to the good management.  A big part of the success of this lab is boundaries.  There are strict boundaries placed on the manager and employees.  However, within those boundaries, the management is allowed to work as they see best.  They can be flexible and laid-back, making the employees comfortable.  The boundaries keep them from playing favorites, so everyone trusts the managers.  If I wanted to stay in a place permanently, I would choose this place; or a place like this one.

So the answer to the question?  I would like to work for a manager who sets expectations and boundaries early, and sticks to them.  I would also like to work for a manager who is allowed by their managers to be flexible and lenient.  This doesn’t require a union contract; it only requires management that understands that the way to keep turnover low is to keep employees happy.  And that doesn’t require lax expectations; it only requires flexibility.

I’m currently working on an IR 101 course for new IR techs.  I’ve had to go back to look at a lot of things I haven’t thought about in a long time. But what is the most important part of performing a case?  Is it the knowledge?  The skills?  What is it?

Knowledge of the case is important.  The anatomy, the equipment, and the monitoring of the patient are all important.  The tech must know the disease process, and how the procedure will affect the patient and their diagnosis.  We must be able to watch the patient and ensure their safety.  We must know what the physician wants, and how to use each piece of equipment.  But knowledge is not the most important part of the procedure.

Skills are also important.  A tech must have “muscle memory” of the most common equipment, and be able to manipulate catheters and wires without thinking.  We must also know what the physician will use to treat the disease.  We must be an extension of their hands…and their minds.  In time, we should be able to anticipate the doctor’s needs, and perform the action before he asks for it.  But skills are not the most important part of the procedure.

Regardless of the procedure, whether you are in the cath lab, the EP lab or the IR lab, the most important thing to remember is to keep your head in the game.  Pay attention.  Don’t allow yourself to be distracted by things going on around you.  Paying close attention to each case you are in allows you to see the similarities between different modalities.  It allows you to move from cath to EP to IR seamlessly, even when you have little experience in those modalities.  It will also allow you to work with any physician anywhere…even the first time with a doctor who is extremely particular.  But most importantly, paying close attention will allow you to be ready to react to any situation that arises.  Even the most intense emergency situations.

So, while skills and knowledge are vital, the most important thing you can do during a case is to PAY ATTENTION!  Keep your head in the game.

As a traveler, I usually find there is a reason for travelers; there are situations where people just don’t want to be part of this lab or that lab.  The culprit is usually either the management, the doctors or a small number of staff members who make life miserable for everyone else.  My personal preference is a place where the staff is friendly and the management cares about them.  I can deal with not-so-nice doctors!

However, I am lucky enough to have landed this time in a place that works!  The staff work together well, everyone knows their role, and they help each other to get a large volume of work done.  This is a busy EP lab, with 3 labs and open 12 hours/day.  A lot of wisdom went into making this work. Even now, while they’ve added physicians and are adding and training staff, it works.  Part of it is that the labor is divided along definite lines.  There is the scrub tech, the recorder, and the nurse/circulator.  The scrub tech and recorder are usually interchangeable, although there are times they are not.  However, no one is asked to do anything with which they are uncomfortable.  They seem to have grasped the concept that within the Cath (or EP) lab, there is equality.  Nurses and techs (both RT and RCIS) work side-by-side, with no antipathy for each other.  Sometimes it is an RN recording and an RT/RCIS scrubbing; sometimes it is the RT/RCIS recording and the RN scrubbing.  Of course, due to the medication administration, only an RN is allowed to circulate.  Knowing your role is important to making a department work.

Chance for advancement is also important to employee satisfaction.  In the department where I am now, everyone is receiving training to record and to scrub.  The hospital has brought in travelers to fill in the slots so other employees are trained.  This is amazing.  There are few facilities that will provide this opportunity for their employees.  It satisfies each person’s need to improve themselves, and to advance their careers.  At the same time, it provides the hospital with a larger staff pool from which to draw, easing problems encountered when team members are absent due to vacation or illness.  Cross training creates a win-win situation for facilities.

Last, and probably most important, is the feeling that each person is appreciated.  In other facilities, breaks happen between cases and lunch is a “sometimes” occasion.  At two hospital groups, staff members clock out for lunch, ostensibly to protect the staff.  This keeps management from insisting on “short lunches” and ensures staff members are able to at least stop for 30 minutes.  Or at least, that they get paid for it.  At another hospital, clocking out includes the question “Did you take a 30 minute uninterrupted lunch break away from your workplace?”  These help, but do not really provide the appreciation necessary for employee satisfaction.  At my current position, each staff member is allowed a morning and afternoon break and a full lunch break.  These are rigidly enforced, probably due to a union contract.  However, a union contract shouldn’t be necessary for a facility that is truly interested in staff retention and employee satisfaction.

I worked at a hospital many years ago; a well-known hospital where roles were rigidly enforced, lunches and breaks were prompt, and continuing education was even provided monthly.  However, there was a restlessness among the staff.  I believe that restlessness was caused by the facility’s unwillingness to cross train them.  When people are held back or kept in a position, without the possibility of advancement, there is no satisfaction.  My thought is that the cross training at this hospital, along with fairness and appreciation, is what makes it a good place to work.  And the doctors are pretty good.  Of course, there is always one…

For New Nurses

When I first went into the cath lab, the nurses scrubbed, monitored and circulated cases.  Of course, techs also scrubbed, monitored and circulated cases.  There was very little difference between the roles and everyone worked as equals.  Over time, some separation was introduced, as nurses claimed the circulator role, as only they were allowed to administer medications.  This made sense, and the nurses continued to scrub and monitor as well.  That made things easy for the scheduler; just put a team into a room with their schedule and leave them alone for the day.  Everyone rotated through the roles, and it was great (until there was only one nurse, who circulated all day).  This worked, as it is easier to perform your role when you know what is happening in the other roles.

As a traveler, I have seen many new nurses come into the lab, trained only as circulators.  That is good, but I sometimes I wish their training included many more things.

Here are the things I wish new cath lab nurses knew:

1. This is a procedure area. The patient comes to the cath lab for the procedure. The nursing care is part of that procedure, but it is not the top priority.  The procedure is the top priority.
2. All cath lab employees are equal. Because it is a procedure area, everyone pulls an equal amount of weight.  If (and it’s a BIG if) anyone is in charge, it is the scrub.  The scrub determines when the procedure is ready to start; when to call the physician; when the procedure ends.  Everyone is equal, but the scrub is the team lead.
3. Understand that everyone in the lab is a professional. The techs are knowledgeable about all aspects of the procedure.  Many nurses have looked at me in amazement when I mention something they didn’t expect me to know, such as a change in the EKG or some other physiologic response.  Cardiac cath lab techs know a great deal about cardiology, and peripheral vascular disease.  Give them the respect they deserve and remember that you might be able to learn from them!  Understand that everyone in the cath lab is an educated professional.
4. Learn how to scrub and monitor. It always amazes me how a new person will try to direct traffic in the lab without knowing what is actually happening.  Learning to scrub and monitor, even if you don’t normally perform those roles, gives you an understanding of the procedure itself; the reason you are here.  Come into the lab and learn to scrub and monitor first.  You can function as a circulator only, but without understanding the procedure, you can’t really be a part of it.  Learn to scrub and monitor.
5. Learn the equipment. There are a lot of sheaths, catheters, and wires, and even more other little things (torquers, tuohys, indeflators to name a few) that we need during a case.  The more you know, the more valuable you are.
6. This is a team effort. While there are a few things that only nurses are allowed to do (administer medications), there is a lot to do.  Please jump in and help get the patient connected to the monitors.  Help us with draping and connecting the manifold to the pressure transducer.  Be a part of the team!
7. Learn cardiology. Learn the anatomy and physiology we are working with.  Learn about the EKG (we never have a “real” EKG in the cath lab).  Learn the difference between PVCs and V-tach…and why we don’t jump when we see either.  Coming into the cath lab is not like going anywhere else.  It isn’t enough to know how to medicate and monitor your patient.  You need to know what we’re doing and why we’re doing it.  Learn cardiology.

It’s a lot.  You will learn these things over time.  That’s how I learned it, but I was surrounded by others who knew…and I was eager to learn.  Any onboarding for new Cath Lab Nurses should include this.  And, it should be included in an annual competency for all cath lab personnel…in my opinion, of course.

I heard something troubling today.  Two physicians were talking about 3-D imaging (rotational angiograpny), and one said to the other, “You can get subtraction on 3-D without doing two runs.  The software subtracts it for you.”  My first thought was, “How wrong can he be?”  Then I thought about it.  While it is technically incorrect, that is the effect.  When you perform a 3-D spin, the software automatically enhances the contrast material in the vessels while adjusting the window and level settings (contrast and brightness) so that the vessels appear free of bone and other structures.  It looks like a 3 dimensional subtracted image.  However, if the window and level settings are adjusted, the other structures show up, proving that it is not a true subtraction.  I choose to call this “pseudo-subtraction”.

True subtraction only occurs when two images are acquired:  a positive, with contrast, and a negative, without contrast.  The two are overlaid so that only the difference between the two shows:  the contrast-filled vessels.  A subtracted 3-D image must include two runs; a mask run without contrast and an image run, with contrast.  Each 3-D run consists of multiple images and each image is overlaid over its corresponding image in the other run to create the subtracted image.  In a true subtraction, adjusting the window and level will not show any new bony structures.  They are removed, or “subtracted out” of the image.

If you choose to think of the 3-D reconstruction as a subtracted image, please remember that it is only “pseudo-subtracted”. A true subtraction MUST include 2 separate runs…even a 3-D spin!

Why do we do what we do?

We’ve all been there.  You’re on call and come in at 2 am or so.  Then, you get up to be back at work at 7 am.  You work a busy day with barely a chance to stop for a bladder break, much less lunch.  And you go home after 8…10…12 hours to finally rest.  Why do we do it to ourselves?

Because of the patients.  We’ve all been there, too, or at least I hope you have.  It happened to me again yesterday.  The patient came into the room in obvious pain.   A little Versed and Fentanyl later, we got the first guide in and saw the totaled right.  The wire went down easily and a stent soon followed.  We took a look at the left and the ventricle and we were done.  As we were transferring him to the stretcher for the trip to his room, he asked, “Anybody got any soda?”

This is why we do it!  We do it to take people from pain to relief.  We do it to take people from illness to normality.  We do it to take people from a bad place to a happy place.  But it’s even more than that.  We do it so a father can walk his daughter down the aisle.  Or so a grandmother can love on her new grandbaby.  We do it so the golfer can go back and make the shot he was in the middle of when the MI hit.  We do it to keep families together.  We do it so people can have a life again.

And that makes it all worth it.

Hello all! Not another rant today. For the last few weeks, I have had the privilege of working with some newbies (don’tcha love ‘em!) So today, we’re looking at some tricks of the trade. After 30 years (or so), I think I’ve gathered a few. Here we go…
Scrub:
1. All sharps are on the table to stick you. Develop good habits in sharps management. There is no reason to suffer an exposure by needle or scalpel.

2. It’s easier to squirt flush out of a syringe than to add more. For venous access, 2 – 4 ml. For flush, 7 – 8.

3. For every access needle, there must be a wire.

4. For every sheath, there must be a flush.

5. Pull up 5 – 7 ml of contrast while you clear the manifold. Use that contrast for your inflator. 5 ml contrast + 15 ml flush for peripheral; 7 & 7 for cardiac.

6. Run the flush from the pressure bag through the manifold, clearing as much air and as many bubbles as possible. Then, turn the handle to run the flush through the pressure transducer. Tap the manifold connection first. This will push bubbles forward. Tap the transducer to move the bubbles out.

7. When clearing lines, spend the most time on the connections. That’s where the bubbles will hide.

8. Make a habit of wet-to-wet connections; flush forward on the syringe and bleed back on the catheter. Wet-to-wet connections will decrease the possibility of bubbles.

9. Always hold the back end of a catheter or long sheath. Controlling the back end means no incidental contamination of a catheter, wire, sheath, balloon or sheath. I usually place the end between my 4th and 5th fingers.

These are just a few I can think of right now. Leave any of your favorite tricks in the comments section. I’d love to hear them!

What does it mean to be a professional? According to Merriam-Webster, Professional means:

a: of, relating to, or characteristic of a profession. b: engaged in one of the learned professions. c (1) : characterized by or conforming to the technical or ethical standards of a profession (2) : exhibiting a courteous, conscientious, and generally businesslike manner in the workplace.
And to follow, Professionalism: the skill, good judgment, and polite behavior that is expected from a person who is trained to do a job well (Mirriam-Webster, 2015)

So…are we professionals? Are Radiologic Technologists professionals? We have gone to school; we have passed a test to obtain our license. We conform to the standards of the profession. Do we exhibit a courteous, conscientious and businesslike manner in the workplace? What does that even mean?
Let’s start with courtesy. Webster defines courtesy as:

a: behavior marked by polished manners or respect for others: courteous behavior b: a courteous and respectful act or expression (Mirriam-Webster, 2015)
Who should we show courtesy to? We usually think of patients first, but there are two other groups: doctors and co-workers. Let’s focus on co-workers. How can we be courteous to co-workers?
We can be on time. Yes, it’s that simple. Here’s the deal. I’ve worked in the lab for many years. There is a lot to do before bringing a patient in for a procedure. A late arrival means your team members must perform these tasks without you. That shows neither courtesy nor respect for your co-workers. Yes, everyone is late from time to time; that’s not what I mean. I’m talking about people who are late every day; the ones we’re surprised to see arrive on time. At its most basic level, this is unprofessionalism. BE ON TIME.
You can jump in and help. There are always things to be done when the patient arrives. Someone who always has a phone call, or extra paperwork, or needs to step out at that time certainly isn’t showing respect or courtesy for their co-workers. If you have that much to do for the lab, ask for time to get it done. If it’s personal, well, do it on your personal time. A professional knows that the patient comes first; before the doctor, before the lab, and especially before your personal business. JUMP IN AND HELP!
What else is there? Oh yes…watch your language. That includes profanity as well as off-color stories and jokes. You never know who will be listening and offended by it. Especially now. Remember…you’re not working in a bar. You’re not working in a restaurant. You’re working in a hospital. People have a higher standard. Profanity doesn’t meet that standard. Frankly, profanity shows a lack of respect as well as a lack of imagination. It just doesn’t belong in a hospital! So the last work on being professional? WATCH YOUR LANGUAGE!
So how to be professional? Three things:
1. Be on time
2. Jump in and help
3. Watch your language
I’m sure there are many more, but this is enough to get most of us started. Have fun…?

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!