Cath Lab Digest talks with some of the many experienced, dedicated and passionate staff and physicians who have helped build the Nurse and Technologist Symposium at the Transcatheter Cardiovascular Therapeutics (TCT) meeting.
History: The First “Round Table”
Twenty years ago, Dr. Martin Leon visited the research nurses’ office at the Washington Hospital Center (WHC) and suggested they share their expertise at the Transcatheter Cardiovascular Therapeutics (TCT) meeting, then only in its fourth year. Regina Deible, RN, BSN, recalls, “[At the time,] I was one of the research nurses at the WHC and Marty Leon was putting together t
he TCT meeting. We would help him pull together data for his slides or pull films, and one day he strolled into the nurses’ office and said to us, ‘You know, why don’t you share your expertise? You are privy to technology that lots of local hospitals haven’t yet seen. Wouldn’t that be a great avenue for the nurses and techs to explore?’
“It was an extremely informal venue that first year. We had a side conference room with a round table. We brought Rotablators, Palmaz-Schatz stents, directional coronary atherectomy catheters, and lasers, and essentially sat in the room, networking. If 12 people came in, that was a big turnout. It was a fun, exploratory venture to see if it would work.”
“I have to give full credit to Marty Leon,” said Regina. “He was the vision behind everything. He nurtured the program to match the current needs and spotlight advances in our field. As things progressed, he picked new directors each year that he thought would send it into a new direction. Ultimately, when Tom Maloney and Chris Nelson came on board, the nurse-tech meeting concept was exploding and they were ready to take the reins and propel the meeting to yet another level.”
Sue Apple, PhD, RN, was a clinical nurse specialist at the WHC. She notes, “At that time (the early 90s), all the medical leaders of TCT were part of the Washington Cardiology Center (WCC) running the cath lab. TCT took place at the Hyatt in downtown DC. The first Nurse/Tech meeting was actually a lunchtime breakout session, consisting of maybe 10 people at a table! Probably all of them were from the WHC.
“After this start, Marty Leon and others envisioned a separate, all-day nurse/tech symposium within TCT, and I became a co-director along with other nurses from WCC and later from the cath lab. At this point, it was still largely a WHC endeavor, but now we had a whole day of lectures, as well as formal continuing education credits for the nurses and later the techs attending the meeting. From a small breakout room at the Hilton, we soon moved to the old DC convention center across the street. Nurse/Tech by this time was really expanding. We had morning sessions in a room to hold over 1,000, and breakout sessions of several hundred each during the afternoon. About this time, the Nurse/Tech Symposium started to include personnel from other cath labs, such as Baltimore, Maryland (Johns Hopkins) and San Diego, California (Scripps Clinic). By 2002, we celebrated the 10th anniversary of Nurse/Tech, and the meeting was held in the grand ballroom at the Hilton, in the same room where I attended my first TCT all those years ago! My opening PowerPoint held greetings in many languages to reflect the international scope of the current conference.”
Nancy Morris, RN, MSN, MBA, worked as a research coordinator at Scripps Clinic with Dr. Paul Teirstein. She recalls, “There were very few people working on stents then — there were 10 primary sites, and we were all friends and helped each other out. We were in an exploding world. Then the WHC said they wanted to do a nurse/tech meeting. Really, Regina Deible was the impetus for putting together the whole meeting. Many of us worked together, and we are still all friends.
“The Nurse/Tech Symposium started really small, with (seriously) just a room and a roundtable discussion, and it is amazing to see what it has now evolved into. We began our planning by saying, okay, what would nurses and techs want to know? When we started, there was a great deal to talk about in regard to care of the patient with a stent, a patient with only an angioplasty, with post care, etc. There were just a few of us at that time, including Ann Greenberg and Regina Deible, getting up and giving talks.”
After that first year, Regina said, “It was completely terrifying — being in a room with a podium up front and a big screen, and talking about what we did. You didn’t know how many people knew what you were talking about and if this was going to be boring to them, or really innovative. In retrospect, it really was cutting-edge, because nobody had the devices; they were all completely investigational. It was an exciting time then, and the meeting just kept growing and expanding, year after year.”
“The Nurse/Tech Symposium started out almost like a book club in someone’s living room,” said Nancy Morris. “And it has just grown and evolved to where it is now, which is pretty much a behemoth. I always get amazed when I look in that room and think of what it was in the beginning, with a couple of us standing there, and what it is now, which is absolutely packed.”
Gregg W. Stone, MD, who for the last 10 years has been overseeing the organization of the annual Nurse-Tech meeting at TCT, is proud of the growth of this session and its contributions to TCT, and to improving patient outcomes. "The annual TCT Nurse-Tech course provides an invaluable opportunity for catheterization laboratory nurses, technologists, physician assistants, hospital administrators and other allied healthcare personnel to be exposed to the most contemporary advances in the field, and to learn from each other. The Nurse-Tech course has been the perfect complement to physician education at TCT, which together have contributed to improved outcomes for patients with cardiovascular disease," Stone commented.
Dr. Gary Mintz has been involved with the TCT and Cardiovascular Research Foundation since 1991. He comments, “We think [the Nurse and Tech Symposium is] a very important component of TCT for lots of reasons. We’ve always believed that nurses and technologists are our partners in the cath lab and quite frankly, throughout the hospital. We can’t function without them. There are things in the general TCT sessions that are clearly applicable to the nurses and technologists, but they also have concerns of their own that are, if you will, beyond what physicians understand. This is why we created a nurse and technologist program at TCT, a program that is organized by their peers, that addresses their needs, and of course, has physicians as some of the faculty because of physicians’ expertise, but is not just for physicians talking to nurses and technologists.”
Tom Maloney, MHA, RCIS, has been a meeting co-chair with Marian Hawkey, RN, for the past several years. He said, “Everyone thinks that coordinating a meeting like the Nurse and Technologist Symposium is a glamorous thing to do, and maybe for one day out of the year, it might be. But let me tell you, you start planning that meeting about 51 weeks in advance. You get the week after TCT off, but the next week, the CRF staff, led by Colleen Whelan (towards whom I have the utmost gratitude), are gathering evaluations, and the directors get a debrief of how the meeting went. Each comment on every evaluation is personally read and weighed for the subsequent year. Then, we are almost simultaneously rolling into what will happen next year. In fact, during the meeting, I will be writing notes about what worked, what didn’t work, and what we can do for the following year. Really, it’s 51 weeks of planning. During those 51 weeks, there are numerous conference calls, emails, phone calls, and documents you are writing and trying to coordinate, as well as figuring out who is the right speaker for a particular topic. I couldn’t count the number of hours that are put into it. It’s a passion and it’s been what I feel is my baby for a long time. If you were to ask my wife, Angie, she would tell you the hours put into it are far too many, especially since all the effort is done for the better of the field and not for pay…it is all volunteer.”
“I think it’s really important to note how much time and energy people put into making this meeting special,” notes co-chair Marian Hawkey. “It is a ton of work, but everybody involved is really committed. From the very first year, it’s purely been the interest and energy of the involved parties that has helped to bring it forward. It’s been an unbroken chain.”
Chris Nelson was a co-director for 12 years. He notes, “I think probably the greatest development I have seen has been the strength of the team leading the initiative. The meeting started out with one or two people basically coordinating the event. We would make phone calls to different faculty members, put together a program, submit that to Marty Leon, he would say yay or nay, and it was up to us to physically contact everyone and make sure we had it. Over the years, we added to the team, and we have had program directors and co-directors. Today, this group remains very dynamic, puts together an amazing program, and reaches out to their colleagues. We have been able to target all levels of clinicians, so that we have programs that are directed toward the novice who is just entering the cath lab, whether a nurse or a technologist, up to those individuals who are working in advanced research centers. Additionally, we now have outreach to specialty groups like the managers and the nurse practitioners. That evolved year after year.”
Tom Maloney says, “The one moment I love the most is the morning of TCT. The course directors and the co-directors all get together in the faculty lounge to have breakfast. It’s never been planned, but we do come together. At that moment, we have been going 51 weeks to get this ready. Everything is done, and everyone is in their suits and dresses, and the feeling is, ‘It’s game time!’”
Oh, the Memories!
Sue Apple commented, “Those of us of a certain age will never forget the slides! The A/V room in the WCC offices turned into a nonstop slide development room for at least a week or two before the meeting. You always had to make sure the slides were lined up correctly in the carousel, with your name and lecture time in tape on the side. In 1998, I successfully defended my PhD dissertation on Tuesday, wrote my TCT lecture Tuesday night (this was still during the time of slide presentations) and gave my lecture on Thursday with simple black-and-white slides, due to a camera malfunction. PowerPoint sure changed everything.”
In 2001, TCT was scheduled to begin September 11th. Sue recalls, “That morning, no one knew what to do or expect. After talking with my co-directors, I went down to the convention center. At this point it was still thought we might have to put on some sort of conference for Nurse/Tech. DC was a ghost town. The convention center was truly strange — everything was set out for a meeting of several thousand — the food, the banners, the registration booths, but there were no people, and it was so quiet. After a stressful morning, the decision was made to cancel the entire meeting. I remember listening to some morning lectures with the sound of the expo hall being dismantled in the distance.”
Chris Nelson, RN, RCIS, FSICP, remembers some of the waves of change that have swept the entire TCT meeting. He shares memories of what “I would politely label the IIb/IIIa wars, between ReoPro and Aggrastat, and others,” as well as the time “when brachytherapy was introduced, appeared like it was going to be the next best thing, and we discovered that clearly it had a very focused group. There was also the launch of drug-eluting stents, and everything that has fallen out of that, up to today, with the discussions and decisions on drug-eluting versus bare metal. There really were some heavy-hitting milestones. What is probably most telling or amazing is just how much has been accomplished with respect to technology, innovation and patient care in just the past decade. When I started out, we were still dealing with a significant percentage of patients coming back to the cath lab after angioplasty, about 35-50% of the cases that we would treat. Today, we see door-to-balloon times that are going to be under an hour, and in the past, we were just happy to have people acknowledge that they have chest pain and make it to an emergency department in the same day. I am grateful I had the chance to appreciate and bear witness to the evolution of care. The Nurse and Technologist Symposium had some hand in that by bringing experts together, and sharing information so that people could take it back to their facilities and diagnostic testing centers, and make a difference.”
Marian Hawkey notes, “None of the new technologies that have emerged are purely physician-related; they are usually associated with a very particular patient population. The involvement of the whole allied health team is so important to moving these technologies forward and offering the best possible care for patients.”
CEU certification has only become more challenging over time, and remains an essential part of the Nurse and Technologist planning process. Colleen Whelan is the Director of CME Program Development at the Cardiovascular Research Foundation. She commented, “Our attendees are looking for credit to attend the entirety of TCT, not just the Nurse and Technologist Symposium. We have accredited the entire TCT for CEUs in the past, but last year (2010) was the first year that we were not able to do it, because the requirements were just too great, so we just accredited the nurse/tech program. We are looking to other accrediting bodies this year in order to go back to what we were able to do in the past, which is offer nurses and technologists credit to attend the entirety of TCT.”
The RCIS Review Course and Structural Heart Education
Tom Maloney said, “We have offered the Registered Cardiovascular Invasive Specialist (RCIS) Review mini-course for about 6 years. It began when we started receiving evaluations that said, ‘This has been great, but I’ve only been in the cath lab for less than a year. I need the basics.’ We heard that theme over and over again, so we brought the Society of Invasive Cardiovascular Professionals (SICP) RCIS Review Course to TCT. It presents people with the foundational knowledge they need while they are at TCT. We put the course on its own separate day, because we have learned to break the basics and the contemporary practice apart.
“For structural heart last year, we did a half-day of lectures that were very focused on mitral and aortic valvular disorders, and within that session were the basic fundamentals of hemodynamics of the mitral and aortic valves. We went over calculations and waveforms and then a physician presenter gave the contemporary view. For the aortic valve, there was a discussion on normal hemodynamics, abnormal hemodynamics if there was a stenosis, and actually calculating gradients, instead of just hitting a button. Dr. Jeff Moses then did a presentation on transcatheter aortic valve replacement (TAVR). Dr. Saibal Kar was our physician speaker for the mitral valve.
Didactic lectures included an audience response system, something we have used year after year. We have a complete audience response with sample questions from the exam matrix at the Review Course. We try to take each question and be very meticulous so people understand why certain answers are incorrect. The faculty put the questions together as a scenario and not just a ‘yes or no,’ so attendees have to put an entire patient scenario together in order to get the answer.
“Finally, this year we asked CVPath, with Dr. Renu Virmani and her pathologists, to bring in tables of aortic and mitral valvular disorder hearts. We broke after the lectures so people could get gloves on and actually touch a stenosed aortic valve or hold a heart with mitral regurgitation. Once attendees could understand the theory, and then hold an actual heart, it brought everything together. It was really an ‘aha!’ moment. I have never, in all the years of TCT, had this many people hand-write comments to me saying what a great experience that was. It allowed them to put it all together.
“My ‘aha!’ moment was when I held a stenosed aortic valve in my hand, and I tried to take my finger through the valve. You would think — it’s a small valve, it’s my finger, I’m a pretty strong guy — I can get it through there. But I couldn’t budge it. I just could not budge it. It made me appreciate how small that jet is — and the physician is trying to get a wire through that? Now I understand why an aortic stenosis case can take so long.”
Education for the Team
Nancy Morris emphasizes that the cath lab requires a higher level of education from its staff. “The cath lab involves a different type of collaboration with the physicians. Out on the floors, it is much more formal and not as relaxed. The expectation of the nurses and techs both in the cardiac cath lab and with research is that your education and knowledge will be brought up to a high level, and there is a great deal of responsibility put on you. If you don’t raise yourself to that level, you are culled out. The expectation is that you can act independently if there is a situation with a patient. If the physician is doing a case, and things are not going along smoothly, perhaps the guide catheter is just not going into the vessel as it should, the expectation in the cath lab is that someone will speak up and say, have you thought of trying this curve? It’s more being part of a team than receiving directives. It’s not passive; you are expected to be active — always with respect, always with the knowledge that we are not physicians. Yet there is a partnership and an expectation that you are going to operate on a certain level.”
Dr. Alexandra Lansky, actively involved with the Nurse/Tech meeting since the mid-1990s, comments, “Nurse/Tech has always been a very special part of TCT. The leadership of TCT/CRF has always wanted to emphasize this symposium and to identify the nurse and tech group as a key part of the team in the cath lab and in interventional cardiology. It was always a very special symposium, and was a unique, dedicated day from the very beginning. What was interesting is we have gone through many years since then and have seen nurse and tech symposia popping up all over the place. But I’m proud to say that CRF and TCT formed, I think, one of the very first venues for nurses and technologists.”
Dr. Mintz concludes, “We truly value our nurse and technologist partners. We believe that TCT is a great place for them to learn, and not only in the dedicated Nurse and Technologist Symposium. There are so many other things going on, such as live cases and challenging case presentations.
“The one thing that we are trying to do more and more is network with societies around the world and get them involved, even just as organizers of case presentation sessions. We see TCT as a global meeting. Last year, we introduced the idea of ‘TCT in Three.’ The central focus of the meeting, rather than being 5 days long, is being directed to people who can only come for 3 days, because it is harder and harder for people to spend a full week at a meeting.
“This year will continue TCT’s emphasis on science and the practical applicability of technology, with probably a greater interest in structural heart disease and valve therapies. It will be a great educational event for everybody, whether they are physicians, nurses, technologists, scientists, or engineers. I hope everybody can learn from attending TCT.”
Readers are cordially invited to attend the 20th Anniversary Nurse and Technologist Symposium at TCT, held November 7–8, 2011 in San Francisco, California (the entire TCT meeting will take place from November 7–11). The opening session will include roundtable discussions with some of the founders of the Nurse and Technologist Symposium. Learn more at:
Cath Lab Digest thanks the following cath lab professionals
and physicians who contributed to this article:
Sue Apple, PhD, RN
Regina Deible, RN, BSN
Marian Hawkey, RN
Alexandra J. Lansky, MD, FACC
Thomas Maloney, MHA, RCIS
Gary S. Mintz, MD
Nancy Morris, RN, MSN, MBA
Christopher M. Nelson, RN, RCIS, FSICP
Colleen Whelan, Director, CME and Program Development, Cardiovascular Research Foundation, New York, New York