6 CLINICAL EDITOR’S CORNER

What Should a New Team Member correct lab data are present. Premedication
is given after the time out.

Do on Day 1 in the Cath Lab?

6. Vascular access is obtained according to
the patient’s procedural need. Radial artery
access is now routine in most labs. Venous
access can also be obtained in the same arm
Morton J. Kern, MD as arterial access.
7. Coronary angiography usually follows,

E very July, we welcome our new cardiovascular

trainees (aka, fellows). The fellows on the cath
rotation become the newest additions to our cath
As time goes by, the team will see value in your
work in the lab. (4) Be prepared (know the patient
info, indications, etc.). The attending physician is
as it is the most common procedure per-
formed in the lab, but of course, there will
be many other procedures to be done as
lab team, most with no prior experience in this depending on your input to help teach and care for well. Right-sided heart catheterization may
area. For many years, I have had the honor (and the patient. (5) Learn the lab routine, watch, and be performed as indicated.
sometimes the pain) of teaching these beginning try to understand why things are done in a certain 8. Percutaneous coronary intervention (PCI)
cardiologists how to do a cardiac cath. The new way. The lab experience is an apprenticeship and may proceed ad hoc if consent was obtained in
fellows are always anxious and curious at the is one of the pillars of cardiology. advance. A second time out is recommended.
same time. In thinking about their upcoming 9. At the conclusion of the procedure(s), the
experience and expectations, I asked one of the What Happens in a Cath Lab? catheters are removed, followed by hemosta-
fellows, “What were you thinking about on Day 1 Here’s a quick overview of the “routine” in the lab: sis. For radial artery hemostasis, a pressure
as you came into the cath lab?” His answer: “Where 1. In the pre-procedure area, the patient is band, usually with an inflatable balloon, is
do I start? What am I supposed to do? (And what seen by a team member (often a fellow, but used. For femoral access procedures, manual
will Kern think of me?)” Before answering these could be a nurse or other team member) compression or a vascular closure device
questions, I want to remind us that over the year, who explains to the patient what is going to (VCD) is used. Two to four hours of bed
the cath lab often gets other new team members happen. This team member often reviews rest with observation before discharge is
including nurses, technologists, and students, as the indications for the planned procedure. usually sufficient.
well as additional physicians in training, or new The method, risks, and anticipated results 10. Before discharge, the patient is checked
physicians to the hospital. What is a good starting are described. with attention to the access site(s). It is
place for someone coming into the lab and how 2. Informed consent is obtained, preferably in good practice to provide the patient and
does that person become an integral part of an the presence of a family member. Depending the family with the procedural findings and
already well-functioning team? on the procedures, special preparations may inform the referring physician of the same
Although described In the first chapter of the be needed (Table 1 lists procedures that results. Scheduling for further treatment
Cardiac Catheterization Handbook,1 I thought it may accompany coronary angiography). is made after review by the attending and
would be good to review the starting point for a 3. Orders and chart notes are written. The referring physicians.
new fellow (or anyone), what they should do, and patient is then moved to the cath lab.
what they will need to know. 4. When the patient arrives in the laboratory, What’s My Role? Who Comprises the
he/she is greeted by the nurses, moved from Catheterization Team?
The Starting Point a holding area into the angiographic suite, New team members may not know all the play-
The 5 keys for a new fellow on DAY 1 (Figure) are: and is prepared and draped. On the cath ers. The composition of a catheterization team
(1) Show up early and suit up. The day generally lab table, the patient is made comfortable, varies among laboratories. The smallest func-
starts early in the cath lab. (2) Keep your mind and intravenous (IV) lines and electrocar- tioning unit consists of a physician, an assisting
open, listen more, speak less (i.e., mouth closed), diograms (ECGs) are secured. physician (fellow) or nurse, a nurse circulator or
and your questions will be answered. (3) Introduce 5. A “time out” is performed to ensure the recording technologist, and a nurse outside the
yourself to the team and be helpful when possible. right patient, right site, right procedure, and laboratory able to assist. For more specialized
procedures, the team is increased appropriately.
Each member of the team assumes an important
role during the procedure.
1. A circulating nurse or technologist acts to
address all aspects of care of the patient
during routine cath procedures and delivers
emergency care when required.
2. A scrub nurse or technologist assists the
operating physician at the cath table with
all equipment, supplies, and medications
used during catheterization. This person
assists in the exchanging of catheters and
other specialized maneuvers.
3. A radiologic technologist is trained in x-ray
principles related to cardiovascular proce-
dures, cineangiography, fluoroscopy, and the
use of power contrast injectors and digital
cineangiographic imaging systems. He/she
Figure. Advice for new fellows that may also be useful for new team members in the cath lab. is also at the table.

August 2022 • Cath Lab Digest www.cathlabdigest.com

8 CLINICAL EDITOR’S CORNER

Everyone in the lab should be “in the game,”

Table. Procedures That May Accompany Coronary Angiography.* watching and listening, and be ready to act without
undue delay. At the same time, communication
Procedure Comment
from the “room” back to the “table” improves
1. Central venous access Used as IV access for emergency medications (fem- efficiency by clearly acknowledging requests from
oral, internal jugular, subclavian) or fluids, temporary the operating table, reducing redundant and un-
pacemaker (pacemaker not mandatory for coronary necessary repetition of orders. Clear and open
angiography)
two-way communication, especially under critical
2. Hemodynamic assessment portions of procedures, improves safety through
a. Left heart pressures Routine for nearly all studies (aorta, left ventricle) error reduction and timely performance of the
catheterization.
b. Right heart pressures Not routine for coronary artery disease procedures.
Clarity, Brevity, and Wit Are the 3 Pillars of
Combined left and right heart pressures are commonly Good Communication
obtained for valvular heart disease; right ventricular
1. The physician, as well as the staff, sets the
dysfunction, pericardial diseases, cardiomyopathy,
tone of communication in the laboratory,
intracardiac shunts, congenital abnormalities
like a pilot with the “right stuff”: cool, clear,
3. Left ventriculography Routine for many studies; may be excluded with high- and confident.
risk patients, left main coronary or aortic stenosis,
2. Orders from the “table” should be acknowl-
severe CHF, renal failure
edged clearly. Just as military efficiency
4. Internal mammary artery Not routine unless used as coronary bypass conduit is built on this dictum, so should that of
selective angiography the well-run laboratory. It is disturbing to
5. Femoral angiography Routine for femoral arterial access assessments before request medications and supplies and not
closure device know if someone has heard the request and
a. IC/IV/sublingual NTG Useful during coronary angiography and intracoronary is attending to it.
device manipulations 3. Repeat orders back to reduce errors.
4. Operators should speak to individuals by
6. Aortography Routine for aortic insufficiency, aortic dissection, aortic
name, e.g., “Bob, please give 5000 units
aneurysm, with or without aortic stenosis; routine to
locate bypass grafts not visualized by selective angi- heparin IV.” Then everyone knows who is
ography, anomalous coronary origin supposed to act.
7. Cardiac electrophysiologic Usually performed a separate setting to assess arrhyth-
Laboratory Atmosphere and the Patient’s
studies mias or perform catheter-based ablation procedures
Confidence Builder
8. Coronary or structural heart Coronary stents, rotoblator, etc., with FFR/CFR/IVUS/ 1. In the laboratory, a confident, professional
interventions OCT for lesion assessment attitude should be always adopted by all
personnel. Straightforward routine commu-
Usually performed at a separate setting, TAVR, balloon
nication should occur quietly and without
valvuloplasty
alarming tones. Patients should be addressed
9. Special procedures Myocardial biopsy directly, by name, to let them know what
their instructions are, as opposed to requests
Transseptal or left ventricular puncture
or communications to co-workers.
9. Vascular closure devices Routine for femoral access hemostasis 2. The circulating team members should be
CFR, coronary flow reserve; CHF, congestive heart failure; FFR, fractional flow reserve; IC, intracoronary; IV, in- confident, reassuring, and professional in
travenous; IVUS, intravascular ultrasound imaging; NTG, nitroglycerin; OCT, optical coherence tomography; TAVR, every respect. The patient feels helpless and
transaortic valve replacement.
is tuned in to all types of stimuli (especially
From Kern’s Cardiac Catheterization Handbook, 7th Edition, 2019. verbal). Extraneous conversation is distract-
ing for the patient and the operators. This
4. A monitoring technologist is responsible for his/her procedure will enhance his/her ability to is especially true when the patient is draped
observing and recording the hemodynamic manage time and minimize delays in operations. in a manner that does not allow him or her
or electrophysiology data, and keeping the Likewise, communication from the physician to to see his or her surroundings. In the labo-
physician apprised of changes in cardiac the staff will assist their ability to move patients ratory, all “players” should be in the game;
pressures and rhythms. The technologist into and out of the laboratory to satisfy the needs of that is, focused on the patient’s needs and
interprets pressure and ECG waveforms, and the numerous operators and types of procedures, as safety, which become paramount goals.
operates all physiologic recording equipment. well as ensure the availability of special equipment. 3. Background music is soothing but should
Communication at the “table” during the pro- never distract the team or operators from
Communication in the Catheterization cedure will also improve lab efficiency. The in- the procedure.
Laboratory: The Key to Success formed team can anticipate equipment, catheter 4. Communication with the patient (and family)
New team members may not immediately ap- and pharmacologic needs. It will shorten the setup before, during, and after the procedure ensures
preciate that clear communication in the lab is and lab time. By letting the team know where the a satisfied and well cared-for individual.
critical. Sharing patient information and scheduling operator is in the procedure, the next steps can be 5. Patients overhear hallway conversations. Fac-
at the beginning of the day will improve efficiency. anticipated. The recording technologists appreciate tory worker attitudes of “another coronary”
Keeping the physician informed as to the status of these announcements for documentation. or “another ST-segment elevation myocardial

August 2022 • Cath Lab Digest www.cathlabdigest.com

 CLINICAL EDITOR’S CORNER 9

infarction (STEMI)” should be avoided. Each include vascular injury, allergic reaction, bleeding,
procedure is potentially life-threatening and hematoma, and infection. If PCI is anticipated, con-
should be undertaken seriously and with con- sent for this should be obtained as well as discussing
cern, as if each patient were a family member. options for medical therapy, stenting, or coronary
bypass surgery in advance of the procedure.
Explaining the Procedure and Obtaining Explain any portions of the study used for re-
Consent search and the associated risks (e.g., electrophys-
Consent should be obtained by the operator or iologic study — perforation, arrhythmia [<1:500];
his or her assistant, but is usually obtained by a pharmacologic study — varies depending on drug
physician. The new fellow is tasked with explaining and study duration; intracoronary imaging or
the procedure and obtaining consent. Since his/her sensor-pressure wire study — spasm, myocardial
experience is limited in the beginning, this role should infarction, embolus, dissection [<1:500]).
be demonstrated with a more seasoned person initially. Provide the necessary information and explana-
Here’s the short version. After introducing your- tion, but try to not overwhelm the patient. It is good
self, it’s helpful to establish rapport and begin practice to include the family when explaining what
building the patient’s confidence in the team. I will happen and the possible outcomes you expect.
often ask about the patient’s understanding of After explaining all aspects of cardiac cath-
why we are going to do the cath. Listening to the eterization, the patient can sign the informed
patient is just as important as explaining what will consent document. Informed consent entails a
happen. The procedure should be discussed with shared decision-making process, in which there
the patient in terms that he or she can understand. is a two-way exchange of pertinent information.
I recommend using simple language, and lay terms This information allows the patient (and family)
at a 4th-grade English level, no matter the patient’s to make a fully informed decision based on his or
presumed educational level or background. Pa- her expectations, risks of the procedure, and choice
tients are nervous and do not always receive the of alternatives. If the patient is reluctant to have
information you are providing. the catheterization, the procedure can be deferred
Clearly explain the purpose of the procedure until the referring physician speaks to the patient to
—“to look at the arteries in the heart (coronary clarify why the procedure is necessary. A reluctant
arteries)” and “to examine the heart muscle (ven- patient should never sign the consent form. When
tricular function).” Simple terms are best so that possible, the family should be present when the
the patient can grasp the concepts. The clinician procedure is discussed. This approach encourages
should explain what small catheters are (plastic a cooperative and sympathetic appreciation of the
tubes similar in size to spaghetti) and that they procedure, the risks, and the expected outcome. HOPEFUL HEALER.
will be used to put x-ray contrast solution (“dye”) ACTIVE VTE CONQUEROR.
into the arteries supplying blood to the heart. Post-Procedure Review
Explain that the procedure is not painful because A new fellow or team member should review
the arteries are not sensitive to the passage of the every procedure until he/she becomes well in- The truth is, VTE
small catheters. The heart muscle may be weakened formed and comfortable with how things work affects more than just
(infarcted) in certain areas, and the way to identify and what their role is. For routine procedures, the patient.
this weakness is to take x-ray pictures of the “main the entire team can continue to run through the
pumping chamber” (i.e., the left ventricle). A sim- day’s work, moving forward with each new case. To discover the
ple, forthright explanation facilitates the operator For complicated procedures, the team should device that will change
team–patient relationship and confidence that the pause and discuss what will be needed for both your practice:
patient will have a safe and comfortable procedure. the routine part and what might be needed for
www.thrombolex.com
Explain the risks of routine cardiac catheterization. anticipated problems or potential complications
Major risks include stroke, myocardial infarction, (e.g., “we might need a left ventricular assist device
and death, usually less than 1 in 10000. Minor risks for this complex PCI”). For any procedure having
a complication, the entire team should gather for
a case review to understand what happened and if
anything could have been done better to prevent
Morton J. Kern, MD, MSCAI, delay or bad outcomes.
FACC, FAHA
Clinical Editor; Chief of
Cardiology, Long Beach VA
The Bottom Line
Medical Center, Long Beach, For the new team member, Day 1 can be daunting.
California; Professor of Medicine, For our best results, best working environment,
University of California, Irvine and best patient care, we should all remember
Medical Center, Orange, California what our first day was like and reach out to help
teach and support our newbies. n
Disclosures: Dr. Morton Kern reports he is a consultant for Abiomed,
Abbott Vascular, Philips Volcano, ACIST Medical, and Opsens Inc.
Reference
Dr. Kern can be contacted at [email protected] 1. Sorajja P, Lim MJ, Kern MJ. Kern’s Cardiac Catheterization
On Twitter @drmortkern Handbook, 7th ed. Philadephia, PA: Elsevier; 2019.

www.cathlabdigest.com Cath Lab Digest • August 2022