Does your cath lab do acute myocardial infarction patients via the radial approach, and does it interfere with the door-to-balloon time?

  Excellent question. At our facility, we prefer to do all ST-elevation myocardial infarctions (STEMIs) via the transradial approach. As you know, STEMIs represent a subset of patients in which revascularization is very time-sensitive issue and these patients often require potent adjunctive anticoagulation therapy. Therefore, they are at increased risk for bleeding complications, particularly of the access site. Data from clinical trials has demonstrated that the radial approach is associated with lower bleeding complications in all subsets of patients (Figure 1). In addition, bleeding increases mortality, which is why the transradial approach is the default method for the majority of our STEMIs.

  I am an invasive cardiovascular technology student enrolled at Spokane Community College in Spokane, WA, currently finishing my final twelve-week clinical rotation. I am nearing the end of the invasive cardiovascular technology program directed by Darren Powell, RCIS, FSICP, and felt compelled to write this article as I mulled over the experiences I have had as a student.

  While cardiologists have recently been spared a substantial pay cut from Medicare, all is not well with the reimbursement and regulatory system. Hospitals are currently being penalized when physicians do not follow a set of rules that does not exist, coronary procedures are substantially under-valued, and physicians have systematically been intimidated into under-billing their most common services since the early 90’s.
  Many of the Medicare regulations and payment rates are illogical and impossible to fully understand. When confronted with speculation regarding the way we bill for services, it is alluring to respond in a conservative manner. For example, when Medicare notifies doctors that they are reporting substantially more level four follow-up office visits (99214) than the average cardiologist, many tend to report less of these in the future. This shift in coding could easily cost the physician $30,000 - $40,000 per year.

  If your facility already offers, or is in the process of implementing, percutaneous coronary intervention (PCI) for the emergent nature of acute myocardial infarction (AMI), then you have likely come across the topic of on-call compensation for the interventional cardiologists who cover this 24/7 service. Regardless of your facility’s culture and opinion related to on-call compensation, all healthcare professionals must know the reasons why this topic remains a “hot button” at all types of hospitals in all areas across the country. National and regional benchmarks, and the need for a fair market valuation of payment amounts, are necessary in order to competently address this issue.

Reasons for On-Call Compensation

  Neil Holtz, BS, RCSA, RCIS, EMT-P, has worked on fire department rescue teams in the New York City Bronx and on the emergency room teams at Grady Memorial Medical Center in Atlanta, Georgia. He currently functions as cardiovascular professional with the support teams in the Cardiovascular Laboratory at Emory University Hospital in Atlanta, Georgia.
  When Neil served on the emergency department (ED) teams at Grady Memorial Medical Center, he performed ECGs on patients and developed a keen interest in the art of interpretation of 12-lead ECGs. His mentor was Tomas B. Garcia, MD, medical director of the ED. Together, they have reviewed thousands of ECGs. Neil became known as Mr. ECG because he would be observed running through the ED with a patient’s ECG, trying to find a physician to interpret the 12-lead ECG of a patient.

  You finish the coronary angiograms on the 78-year-old grandfather who reported 6 months of chest pressure and shortness of breath with activity. His high blood pressure was well treated, as was his cholesterol. He did not have diabetes. He had a positive stress perfusion imaging study 1 week ago. His coronary angiograms show 3-vessel (3V) coronary artery disease (CAD) with a proximal 70% narrowed calcified left anterior descending artery (LAD), 90% mid-circumflex and two lesions (60%, 80%) in the mid and distal right coronary artery (RCA), proximal to the posterior descending artery (PDA). The left ventriculogram (LV) gram was normal. How do we decide whether his CAD is too much for percutaneous coronary intervention (PCI)? Which revascularization approach [PCI vs. coronary artery bypass graft surgery (CABG)] should be recommended?

When you only have two leads to look at and one is an axial lead (1, 2, 3, R, L, F) and the other is a precordial lead (V1-6), how can you differentiate between right bundle branch block (RBBB) and left bundle branch block (LBBB)?

  The answer is relatively simple. Look to the V leads, specifically V1.
  What are we looking for to be present in V1?

Tell us about the cath labs at Akron General Medical Center.
  Susan: We have 3 cath labs. We are a certified chest pain center with percutaneous coronary intervention capability. We perform approximately 2,500 caths and 1,000 interventions each year. We have 20 cardiologists who use our labs, and we have 22 staff members staffing our cath labs and an 18-bed prep and holding area.

What led you to the structured reporting offered by ProVation Medical?

  Patients presenting in cardiogenic shock have poor in-hospital outcomes despite emergent revascularization, inotropic support and intra-aortic balloon pump implantation.1 We report the case of a patient with acute myocardial infarction who presented in cardiogenic shock and underwent emergent left main (LM) percutaneous coronary intervention (PCI) supported by the Impella 2.5 left ventricular assist device (Abiomed, Danvers, MA).

Can you share some of your research interests and how the individual risk consent software came about?