Precious Minutes

Gerard Lagasse, RCIS Borgess Medical Center Kalamazoo, Michigan
Gerard Lagasse, RCIS Borgess Medical Center Kalamazoo, Michigan

Introduction: Who is this article for? And why?
This article is directed toward new staff. I’m talking about the time the staff member has spent in the cath lab. Even for a person with years of cardiac patient care, critical care or emergency room care can find those first few months in the lab to be totally mindnumbing. The first real cardiac emergency can be a shock. Suddenly, you become all thumbs, and don’t know where to stand or what to do. Scheduled cases that are done on a daily basis are planned events. In an emergency there is no knowing. There is no knowing what to plan for ‘till you’ve hooked your patient to your monitoring devices and started to assess the patient now lying on your cath lab table.
This past year I went to the Cath Lab Basics Course in Chicago, presented by NACCME (North American Center for Continuing Medical Education). The main speaker was Dr. Morton Kern. His talk and slides were the same that he uses to teach cardiology fellows preparing to pass their boards. It was a wonderful conference. Interestingly, he started his talk by asking the same question asked at previous Society of Invasive Cardiovascular (SICP) conferences I had also attended in Chicago. He asked for members of the audience to stand who had one year or less in the cath lab. He then asked for those with two years. He stopped at three years, by which time over half of the attendees had stood up. In my own lab, we have four staff with two years or less in the cath lab. One new staff member has less than a month (she’s still in overload mode).
This article is directed toward you, the new staff member, and preparing yourself for your first emergency patient.
Education is a funny thing. Education for an experienced cath lab staff member may mean reading an article on the longterm effects and incidence of sudden closure of one drug-eluting stent versus another or against a bare-metal stent. For a new member of the cath lab, education is vastly different. Education is learning where the drugs are located and which ones to use. Education is learning where to get procedural supplies. Education is learning which catheters are for the right coronary artery (RCA) and which ones are used for the left coronary artery (LCA). Education is learning the angiographic views of the heart and which coronary artery is which. Education for a new staff member is learning to use a physiologic monitor, how to chart into the cath lab data system and how to charge the patient for the procedure. Education is doing these things over and over again, until the new staff member (and their proctor) feel comfortable that he or she can perform appropriately for normal scheduled procedures.
All too often, however, staff education is a rushed affair, with a back seat given to teaching the how, the why and what to expect when an emergency appears.
Scheduled cases are the meat of a cath lab. As a new staff member, you’re shown the schedule for the day, and you are assigned a lab. When the patient arrives, you look at the schedule and set up the lab for the assigned procedure. You look over the patient’s chart, read the H&P, look at the labs, check the consent form, introduce yourself to the patient and ask the patient if they understand the procedure along with questions of height, weight, allergies and any other relevant questions that may help in making the procedure a success. The physician arrives and goes over the plans for the procedure with the staff. Pertinent data about the patient is discussed among the team and any necessary changes are made before the procedure begins.

The Emergency Patient and the Cath Lab Team
An emergency patient is totally different from the scheduled patient and procedures described above. This patient is unscheduled and the cath lab usually is unable to plan. There may not be an H&P or labs available. The patient may arrive responsive or unresponsive. The patient may arrive with a rhythm, none or attached to an external pacemaker. The patient may arrive in pain or pain-free (and both may be an acute situation). The patient may arrive from an outlying hospital, home, an accident, your emergency department (ED), postsurgery or even from your own waiting room. The physician may arrive knowing all about the patient or as clueless as a new cath lab staff member.
Remember the first rule of patient care in the acute setting — door-toballoon time. I prefer to look at it as time = muscle. The longer the vessel is closed, the more muscle tissue is lost. With this in mind, the sooner a staff member prepares for the arrival of the emergency patient, the greater the likelihood of success. Once the cath lab has been notified of an incoming emergency, three steps of patient care come into action. These are pre-preparation, assessment and preparation of the emergency patient for a cath lab procedure.
Knowing what to do in those first few minutes of the patient’s arrival may save their life. How prepared the team is for the emergency is broken down into specific tasks that need to be done. These tasks are team-driven. Think of this as a race. When a racecar pulls into the pit at an Indy race, everyone has a specific task. One person fills the gas tank while others are changing tires and someone is cleaning the windshield. They work as a team. They each know their assigned task and winning the race may very well be determined by how well the Pit Team performs their job. An emergency patient arriving in the cath lab is similar to the racecar arriving in the pit. There are specific tasks that need to be done to get the patient from the transport cart to the cath lab table, and ready for the procedure. You can’t have three people on one side of the patient attempting to shave the groin at the same time. A welltrained team will know who is going to scrub, who will be on the monitor and who will circulate before the patient even arrives in the lab. A well-trained staff will understand what responsibilities or tasks automatically are assigned to that particular position, and upon the patient’s arrival, will start to perform those tasks just like a pit crew at the racetrack.

There are two possible scenarios when dealing with an emergency. One is during shift hours (on hours) and the other is off shift hours (off hours). If the emergency occurs during on hours, the room has already been checked. Doublechecking that all emergency devices are available and setting up a tray may be all that’s necessary. The secretary will be in contact with admitting, the cardiac physician and Path (your emergency HQ). She’ll get the paperwork made up and get the physician there on time. Start the process of getting a patient bed. If it’s in the middle of the night, then things are a little more complicated. The room you’re using for the emergency may not have been re-stocked by the staff that last used the room. I can’t count the number of times I’ve arrived in our predetermined emergency lab to find the room still set up for a pacemaker (from the left side), temporary wires or pacer missing or no balloon pump. When you arrive, don’t take it for granted that the lab is ‘good to go.’ Check it out, and replace or restock any necessary supplies. You have no secretary making up paperwork for the patient and some piece of equipment may not come on as expected, so check the room and get the paperwork ready. Once the room is ready, tray is set up and paperwork available, then it’s time to think about the patient.
Saving an emergency patient’s life begins before the patient arrives in the lab. An important thing you can do is check hospital records. If you have the patient’s name available, then check the cath lab records for possible previous cine films.
If something curious was seen on a previous cine, then looking up the old cath data report can give you information that the cath lab video can’t answer. The cath data report will have information on the patient’s height and weight (necessary for proper weight-base medical care), allergies, catheters used and medications given to the patient during the last visit. It will give you information the type, size, length and number of previous stents and also the pressure used at deployment time. This may be very useful to know if the patient arrives unresponsive, intubated or in such great pain that he is unable to respond to the simplest of questions.
We have saved many, many, many precious moments over the years by simply having this information available before the patient arrived in the lab. The physician is better prepared for the patient and it also means that the staff and physician can all start on the same page for the planned procedure — as a team. By being prepared as a team, we can deal with potential problems before they become a problem. In other words, we save time (time = muscle) by not trying to reinvent the wheel.

Patient Reports
“We have the ER nurse’s report, that’s all we need.” I can’t count the number of times I’ve heard that from less experienced staff. A report is only as good as the person giving it. A report is only good as the moment it was given. There are three kinds of reports: physician reports, nurse reports and the bedside report.
Physician reports. I’ve heard many ‘physician-to-physician’ reports over the years (during daytime working hours). Some of these reports are very extensive and detailed, and some are: ”Hi, this is Dr. So-and-so. Will you accept Mr. Smith? He arrived to us a short time ago and is in the process of having an inferior MI.”
Nurse’s report. The outlying nurse’s report can be so-so to excellent, depending on the reporting nurse’s experience. We have to accept and make use of what is given. At the very least you’ll get a name, birth date and possibly drugs administered, current drips and rate, blood pressure, heart rate and whether the patient is stable or unstable, and how long the acute event has been in progress. Very infrequently do we hear information about allergies, weight (which is important if you are planning weight-based drug therapy), information of previous procedures or that the patient has bypasses, stents or a pacemaker.
A nurse’s report is only accurate and applicable at the moment the patient is assessed and sent to the cath lab. There may be an hour to ten minutes (time from ED to your lab) between that report and your receipt of the patient. The report is time-limited.
I remember once being given a report from the ED. At that time, our lab was on the fifth floor and the ED was on the ground floor. The patient was being assisted in his breathing but otherwise resting comfortably and stable when he left the ED. We received the nurse’s report that the patient was stable and on his way to us. He expired on the way to the cath lab. The ED had been so busy pushing the cart and bagging the patient that no one paid attention to the EKG monitor. He arrived too late and we were unable to revive him.
A bedside report is the third and the most important report. This is a realtime report. An in-flight EMT/nurse report, ambulance EMT report, or an ED nurse arriving with the patient is much more relevant to immediate patient care. The bedside report allows you to make necessary changes in your treatment and know how to best prepare the patient for the procedure. For instance, from the report, you may decide to throw a temporary pacemaker wire on the cath table.
Remember reports are just that — reports. They may contain relevant information that may assist you in planning for or anticipating the patient needs, but the reality is that the patient becomes your responsibility the moment he enters your cath lab. You start assessing and observing that patient from moment one.
I remember a patient arriving from the ICU. The patient had arrived days earlier as a coronary emergency. At that time, she developed rhythm problems requiring temporary pacemaker assistance. We were called the middle of the night to take care of her as an emergency. The primary physician wanted the temporary pacemaker removed because the patient was stable and he worried about a possible groin infection. The patient arrived with two ICU nurses at about 5 am. The first thing I always do is look at the electrocardiogram (EKG) monitor. As I was watching the monitor, the patient went from sinus rhythm to asystole. I yelled at the ICU nurse to turn on the pacer, but she was paralyzed by shock. I jumped across the cath table and landed on the patient’s knees to turn on the temporary pacemaker. Her heart started beating, her eyelids fluttered open, the patient took a breath and saw me laying across her knees. Her first words were something about getting my sorry body off her feet.

Patient Arrival
A team mentality is the only successful method of getting the patient on the table and ready to go in five minutes or less.
The cath lab tasks are straightforward and are done on every patient coming into the lab; however, in an emergency, the speed has to be kicked up a notch. You know what has to be done and now it’s time to surround the patient and get it done like a pit crew at the Indy 500. One person will get on one side of the patient, one on the other and the third person will get busy listening to the bedside report, checking intravenous (IV) catheters and writing down patient information. Learn to work as a team. Pick your side and fulfill all the setups necessary to that side before stepping away from the patient and going into your assigned duties for the procedure.
There are three elements to consider at the patient’s arrival:
1. Assessing the patient.
2. Getting the patient hooked up to all pertinent sensing devices (also hooking up O2 if necessary and shaving the groin).
3. Planning for the procedure.

You’ve received two reports so far: one from the outlying ED and one from the EMT/RN/in-flight MD, nurse/EMT, or surgical nurse bringing you the patient. Armed with these two reports, it is now time to fill in the empty slots in the assessment, make the patient comfortable/ aware of his new surroundings and plan for the procedure. The patient has arrived in a diagnostic/interventional department and not transferred from one hospital bed to another. Your assessment must be couched in a different mindset and geared toward a possible intervention. Determine that patient’s sense of self and awareness of his surroundings. It’s possible this may be his first experience ever with a hospital or critical event. During the assessment, you may need to talk to the patient, explain what is going on and what to expect. Keep it professional and light. Attempt to help them to bond with those present. The other members of the team can help greatly in this part by also interacting with the patient on the table. Check out the peripheral pulses and the groin. Keep in mind that this may be an interventional procedure and you’ll need an excellent access site. If the patient has poor peripheral circulation or scars in the groin, this may be the only time to evaluate the degree of possible success in arterial access. (Optimally, you want one stick and access done in under a minute.) Also, you will be putting a cuff on one of those arms in the next few seconds. Problems have arisen because staff was responding to a pressure emergency, only to discover subclavian steele or poor circulation in the arm being monitored. Palpate both radial arteries if you have any suspicions. Feeling the radial pulse also means the patient has a B/P of at least 99mm/hg, which gives you a little breathing room till the cuff has had a chance to register static blood pressure.

Getting the Patient on the Table
Once the patient has arrived, it becomes imperative to transfer the patient and get him hooked up to the equipment as quickly as possible. Make sure you have the patient gown resting on their body and not around it (arms in sleeves and tied in the back) because you may need to get to their chest quickly. Make sure all personal clothing has been removed. Remember this is an emergency. You may start the procedure thinking this will be a simple through-the-groin procedure, only to end up with sheaths in the groins, the arms and a tube in the chest after a pericardial centesis procedure.

I remember an emergency where a patient arrived at the door to the ED slumped and unresponsive in the passenger seat. He arrived to the cath lab a few minutes later with CPR in progress. He had a closed left main trunk (LMT). He was intubated while the physician was performing arterial/ venous access in the right groin for the guiding catheter and temporary pacemaker, and I was accessing and inserting an IABP in the left and acquiring another vein for IV access site. We were successful in treating the patient. He went home two weeks later to continue enjoying his retirement with full mental function.
I remember another emergency in the middle of the night where the patient delivered her baby on the table while the physician was opening her acute infarct vessel.
In other words, expect the unexpected with emergencies, and keep access to the patient as open as possible, because you just don’t know what procedural course change will happen during the procedure.

Hooking the Patient to Monitoring Devices
Cuff pressure. Hook the cuff pressure opposite the preferred IV access. If, during the patient set up, you noticed your only IV access is questionable, then you have several options. If the IV is ‘iffy’ and the patient unstable, then throw another sheath on the table for a venous access (along with sterile IV supplies). If the IV is functional, but looks ‘iffy,’ leave it alone. Stabilize it as much as you can and keep on going.
If the IV is on the left side, then use the right arm for the cuff. If the IV is on the right, then use the opposite arm. You don’t want to affect IV access during a procedure with cuff inflation. If the patient is obese and you don’t have ready access to a larger cuff, then put the cuff around the wrist. If the patient has had a mastectomy, then use the opposite arm. If you can’t use the other arm because of the IV and the patient has good peripheral pulse, then use one of their legs. Finally (this has happened), if you can’t use the arms or legs for cuff pressure monitoring, then your only other course is to tell your monitoring system to not monitor the cuff pressure. Instead, you can set up your monitor to insert, into your records, an arterial pressure from your manifold system every five minutes. You may not get a pressure every five minutes because the moment the computer takes a snapshot of the pressure may also be the moment the transducer is turned off from pressure, the scrub person is injecting, you are making a catheter exchange or your ‘y-connector’ valve is open. Any pressure in the chart is better than no pressure being acquired.
O2 sensor. Our normal technique is to attach it to the left hand. It may become non-functional during left arm cuff inflation, but that’s much better than having the patient taking the sensor off their right hand during the procedure. With the sensor off the right hand, it becomes somewhat crowded on the right side. Suddenly, three people are trying to occupy the same space with the circulating person, all under the covers trying to find the sensor, the hand and trying to re-attach them to each other while the physician is trying to position his stent into a coronary. If the patient has poor peripheral circulation, low blood pressure, medication on board, is cold or has nail polish, then try the sensor on their toes or get an ear clip sensor for the ear.
Caring for an emergency patient requires the same monitoring devices as all cardiac cases coming into the lab. We monitor the patient’s oxygen saturation level, a static arterial pressure and EKG. Once the procedure has begun and arterial access has been achieved, real-time arterial pressure will also be monitored. Of the three systems attached to the patient when he arrives, two have shortcomings. The first is cuff pressure. It’s a static pressure from the patient. Its accuracy is relegated to the moment that the pressure was acquired. Inflation cycle time is set by your monitoring system. Ours is typically set to Joint Commission requirements of every five minutes. You may change the cycling of the cuff to shorter times, down to a minute, but still remember the system has a failing. The second that pressure number flashes onto your monitor, then that number will remain till the next cuff inflation. A millisecond after that number goes on your screen the patient condition can change and there will be no clue to correct arterial pressure until the next inflation. Five minutes can be an eternity. The other system with a failing is the O2 sensor. As mentioned earlier, the location of the sensor to acquire accurate information can be somewhat critical. The system also does not come with an audible alarm. The O2 level may start to drop so slowly that no one notices until someone is suddenly scrambling for a non-rebreather or a bag. The sensor is slow to react to rising levels of O2 levels and equally slow to respond when the level drops. As a result, once problems with this sensor start occurring, one team member’s attention may be taken off patient care and onto worrying about the proper operation of a device.
EKG & Einthoven’s Triangle. New staff need to understand how crucial it is to learn and appreciate the EKG as it is used in the cath lab (six or twelve leads are not the configurations used during a diagnostic/interventional procedure). The EKG is your most important patient monitoring device. It is the one device that will tell you immediately when something goes wrong with the patient. Furthermore, it is important to appreciate that the EKG we use is actually two important diagnostic devices in one. The first important function of the EKG is patient monitoring. The second function is as a self-testing device that allows you to immediately know when and where a lead came off the patient. There’s nothing worse than losing access to dynamic patient information in the middle of a procedure, and watching as the circulating person pulls up the drapes and destroys the sterile field while trying to figure out which leads came off and attempting to re-attach them. Immediate hookup of the EKG is imperative. However, if you understand the EKG system properly, its loss during a procedure will be simply a matter of walking up to the patient, reattaching the offending lead and being back at work in seconds without disturbing the patient, the sterility of the field or the physician.
First, let’s look at patient monitoring. The EKG system, as we use it in the cath lab, allows for immediate knowledge of the patient’s cardiac well-being. Seeing the first trace allows you to start planning for a procedure that might require interventional supplies, temporary pacing or a basic setup. The EKG monitor allows you to keep track of the patient’s well-being on a second-to-second basis, something no other attached device can accomplish. EKG is also the only monitoring device attached to the patient that will tell you when and where it’s not working correctly. Three leads of EKG, leads I, II and III, are the normal setup and work quite well for second-to-second patient monitoring. These three leads will give you what you need to monitor the patient and also to troubleshoot the system if something goes wrong.
Leads I, II and III were the first lead configurations, developed by William Einthoven, to monitor and diagnose human heart rhythm about one hundred years ago. Einthoven’s triangle configuration (Figure 1) is the setup for our three leads and how we monitor our cardiovascular lab patients. Einthoven’s triangle gives us three leads on our monitor while only having to attach four wires to the patient. The added advantage is that all four wires are limb leads, so nothing appears on the fluoroscopic field that will interfere with the procedure.
• Lead I is made up by attaching our white lead to the right shoulder and the black lead to the left shoulder.
• Lead II is created using the white lead, attached on the right shoulder, and the red lead, attached to the left hip.
• Lead III is created using the existing connections acquired from the black and the red lead.
• The green lead attached to the right hip is our reference electrode. Reference electrode means that we’re grounding the patient to the same electrical reference as the monitoring system. Without the green connection, you might see your EKG wandering up and down on your monitor.
Cardiovascular lab lead configurations show all the rhythm changes typically associated with ACLS rhythms. However, using the three lead configurations, you can go a step further. You can be more specific and can plan further ahead into the procedure.
For example, lead I can show you a bundle-branch block and even determine a right bundle-branch block from a left.
• A left bundle-branch block makes the QRS wave appear as a widened square wave in lead I.
• A right bundle-branch block makes the QRS wave look like a pair of reverse rabbit ears: a positive ‘R’ wave coupled to a negative ‘S’ wave.
• A right ventricular premature ventricular contraction (PVC) will appear similar to a left bundle- branch block.
• A left ventricular PVC will have the appearance of a right bundlebranch block. (Think of it this way. When you place a pacer wire in the right ventricle and pace the heart, you’re effectively energizing the right ventricle before the left ventricle. The resultant EKG beat in lead I is a widened QRS. The resultant QRS looks just like a left bundle-branch block.)
Anticipation, anticipation, anticipation is part of our job when receiving an acute patient. Observing ST elevation or depression in lead III can help in preparing for what may happen when the vessel finally does open. Seeing an elevated or depressed lead III also helps the staff in planning for an interventional procedure and getting the necessary supplies ready.
In the acute patient, lead III can give you a good idea as to whether the ischemic event is on the anterior or posterior walls of the heart. An elevated ST segment in lead III indicates obstruction of the RCA (in a dominant RCA, which is about 90% of the time in men and 85% of the time in women).
A depressed ST segment is a good indicator of an obstructed left anterior descending (LAD) artery. A depressed ST segment to the EKG suggests LAD involvement. With a closed LAD, the circulation to the septal wall, anterior and apical walls of the left ventricle are in jeopardy. The SA and AV nodes aren’t involved, so atrial or junctional rhythm problems should not be anticipated. Events surrounding ventricular arrhythmias, heart failure (maybe a balloon pump) and pressure drugs may be the areas of greatest interest once the intervention has begun.
If there is no lead III ST changes occurring and the patient is uncomfortable, then there are several possibilities:
1) The patient doesn’t have a heart problem. It may be something else such as a hiatal hernia, reflux, pancreatitis, gallstone or severe emotional anxiety (such as divorce, death in the family, job loss, etc., that is being experienced as chest pain).
2) A closed circumflex. Lead III does not show acute ischemic events of the heart well (unless it’s a dominant circumflex where the postero-lateral (PLA) branch is part of its anatomy). A nondominant circumflex just won’t be seen well in lead III.
3) A patient with equivocal ischemia. I have often scrubbed next to a physician that has looked over at me and told me we were wasting our time. That he was doing this to satisfy the ED physician’s request. That there was nothing wrong with the patient. That the twelvelead EKG was perfectly normal. Fifteen minutes later, the patient had a balloon pump and we were calling for open heart. This happens when a patient has triple vessel disease and suddenly develops ischemia in one artery. The ischemia causes other parts of the heart to try and compensate for the decrease in heart function, thereby exacerbating the ischemia in other parts of the heart to the point that the patient develops global ischemia. The global ischemia neutralizes or cancels out the EKG changes that would normally be seen from opposite parts of the heart. Thus you see what appears to be a normal EKG.

Now you may be wondering about lead II and why I didn’t mention anything in particular about this lead. I don’t think about lead II being an ischemic diagnostic lead, but look upon it as my reference base lead. I think of it as a base guitar in a musical band. It sets the rhythm for all the other devices and the patient. Whatever happens to any of the other monitoring devices attached to the patient can often be verified by what’s happening to lead II. If the 02 sensor drops below 90%, look at lead II for the rhythm changes in the patient. If the cuff reads zero, look at lead II for rhythm changes in the patient. During a procedure, I look at lead II to verify rhythm rate. I think of lead II as the most stable lead. It’s not as affected by ischemic events. It’s more stable in showing and determining cardiac rhythms, such as atrial fib or flutter, than the other two leads during an acute event. If a patient arrives with a small ‘R’-wave in lead I and your monitoring system is set to give you a digital readout off lead I, then in all likelihood you won’t have a digital readout. Check out lead II and I’ll bet there is an ‘R’-wave large enough to trigger your digital readout. Switch your monitor to trigger off lead II for an functioning digital readout. When you lose lead II and any other lead, 66.6% of the time, you’ll know which lead attached to the patient has become non-functional.
Now let’s look at using Einthoven’s triangle to troubleshoot your monitoring system. When you connect the EKG leads to a patient, you are, in effect, finishing the connections for several electronic circuits inside the physiologic monitor. You are using three wires attached to the patient to create three leads of EKG. Lead I monitors the patient’s EKG across the upper torso from right shoulder to left shoulder. Lead II monitors the cardiac rhythm from right shoulder to left hip. Lead III monitors from left hip to left shoulder.
Rather than needing six wires attached to three different EKG monitors, the physiologic monitor used in the cath lab electronically uses the three wires attached to the patient to create six reference points for our three limb leads. The right shoulder wire is used as a patient reference point in both leads I and II. The left shoulder wire is used as a reference point in leads I and III. Finally, the left hip wire is used as a reference point for leads II and III (see Figure 1).

Einthoven’s triangle gives us an excellent diagnostic tool for equipment malfunction. If you lose any one wire connection to the patient, you end up losing two leads of EKG and you know immediately which lead needs to be corrected.
• If you lose leads I and II, then the right shoulder wire has become disconnected from the patient, you have a bad electrode connector attached to the patient or your patient wire has become disconnected from the EKG cable. Check the patient connection first, as that is usually the primary source of the problem.
• If you lose leads I and III on the monitor, then the left shoulder lead is bad, it has become disconnected from the patient or you have a bad electrode connector on the patient.
• If you lose leads II and III then the left hip lead is bad, it has came off the patient or you have a bad electrode connector attached to the patient.
• Your right hip lead (green lead) is the ground reference for the connection of the patient to the physiological monitor. If you don’t have it attached, you may have a wandering EKG line on the monitor.
• If you connect the right hip lead (green lead) to the right shoulder and the white lead to the hip you’ll change your reference to the patient and you’ll wind up with a negative going ‘P’ wave on lead I. If you suddenly lose two leads on the patient, stop and take time to think of Einthoven’s triangle. You’ll be surprised how quickly you can correct the problem and be back up to speed. The Acute Patient Needs a Cath Lab Team As new staff in the cath lab, the most stressful case is the incoming emergency. You need to learn to meld with the rest of the staff and become a team player. Think of the patient as a racecar coming into the pit. You have only a few minutes to get the patient off the emergency cart and get them ready for the procedure. You need to learn the set-up protocol and synch yourself to your teammates. If the scrub person is busy on the right side of the patient, then you go to the other side and take care of connecting the patient to equipment, applying electrodes and whatever else needs to be done on the left side. If the two sides are being taken care of, then you can acquire needed information from the emergency staff and the patient, get a new gown, put the patient’s clothes into a bag, put warm blankets on the patient and get all pertinent information into your computer systems. Most labs operate with a three-person team. All three are responsible and are expected to be constantly assessing the patient upon his arrival.
Hillary Clinton once said that it takes a village to raise a child. In the cath lab and with an acute patient, it takes a cath lab team to save a patient. The team effort starts off with the emergency call crew that received the patient. Talking to the patient, getting a report from the emergency staff that brought the patient, reviewing all past relevant data in the hospital records, setting up the patient and attaching all monitoring devices (and looking at what they are telling you) gets the patient ready for the physician and the procedure. The team becomes a cath lab team when the cardiologist arrives, receives all the assessed information from his team and reviews all the pertinent data that his team has put together. Then and only then, as a team and with a plan in mind on to how to proceed, can we go forward and help the patient to the best of our ability.

Now what are my qualifications for being so brazen as to explain what you need to do? I have spent thirty-two years doing something I love, working in the cath lab. I’ve been assisting in interventional cardiology since the fall of 1978 (Borgess Hospital was the fifth hospital in the nation to start performing angioplasty procedures). I’ve been privileged to train staff and physicians over the years. I have also had the opportunity of working in a cath lab where emergencies are an everyday experience. Having two or more emergencies at once is not uncommon. For example, one recent Friday was extremely unusual. We had four emergencies at once. But what made it extremely unusual was that I happened to be one of those patients! I was having the BIG ONE, with severe chest pain and a tombstone EKG. So you could say that my qualifications are based both on 29 years of emergency interventional cardiology and personal experience as an emergency patient (twice).