A patient in the room is a given. Patience among the staff is not, and here is why. Constant interruptions, complete unpredictability and countless details. If you add these three things together, you come up with the wrenching and all-consuming frustration of even the most straightforward task. All any of us want to do is solve the problem at hand and complete the task with which we are presented. It is our job and our nature to finish what we start. However, with the above tortuous trio, the simplest task can bring you to your knees. Not even 24 hours prior to this writing, I was transporting a patient from our lab directly to the OR suite. Because of the multiple devices (the usual suspects) required to keep the patient alive, the four of us on call were not enough hands for the move. We incorporated help from down the hall as well as Respiratory Therapy, and began our trek. It took all six pairs of feet and hands to maneuver one desperately ill patient and 20 wheels down the hall. We lurched forward like some epileptic leviathan towards the elevator, all the while listening to the Lasix pump alarming. The message on the pump said there was air in the line, but an inspection revealed no reason for the alarm. We decided that it was: Only Lasix, let’s keep going. Then the balloon pump began to alarm, its message inadequate augmentation. We stopped to inspect all settings and connections, but could detect no problems. Unable to solve this problem, we deduced that the augmented pressure was sufficient to sustain life: Let’s keep going, and collectively decided that unless we saw v-fib, we were not going to stop. Finally after a maze of corners and hallways, we reached the elevator, which you already know to be the most difficult portion of any in-house transport. I could say we negotiated all of those wheels into the elevator, but there was no negotiation involved. We bullied and coerced every single wheel. The Lasix continued to beep, the balloon pump was sounding and then the elevator began to alarm. For some reason, the hold button was not working and there began a loud, buzzing honk that drowned all other alarms and voices. As if we needed more stress during the struggle to get that last wheel out of the space between elevator and floor. Somehow, we were able to maintain enough slack in all the lines so we didn’t extubate or pull out the balloon pump and multiple arterial lines. After several jarring attempts at closing, the elevator door finally succeeded and we ascended. We arrived on the fifth floor, the elevator door opened and all of our noise and glory flooded into the hallway. I glanced towards the front desk to see a wide-eyed attendant. When next I looked, she was gone. We eventually delivered our patient to fresh hands and made a hasty retreat to the relative calm of the cath lab. And there we did a good thing. We did a team thing. We sat down, stared blankly at each other for a moment, then burst out laughing. Our tension and frustration was released by the absurdity of the situation. We speculated that the front desk attendant was probably still running and visited a long list of hopeful disasters for the elevator. We shared good wishes for the patient who was, unknowingly, at the center of the whole ordeal. In doing these things, we downloaded the positive and off-loaded the negative. Just as all our actions were automatic in solving every difficulty throughout the case, we instinctively took time to recharge after the case. Yet right in the middle of this peaceful moment, the phone rang. Doesn’t it always! It was the physician of our next case asking why we had not begun his procedure. He was informed rather brusquely that we were taking 15 minutes for ourselves. He paused for a moment, then contributed his effort to our team by saying graciously, Call me when you’re ready. In that 15 minutes, we solidified ourselves as a caring and nurturing team. We revamped our energies, bonded as friends, then got up to do it all over again. The physician also played his part in not trying to hurry a frazzled group of people. We trusted him to be patient and he trusted us to take only the time we needed. It doesn’t always work out this way, but when it does, it is worth noting and remembering for future reference. I did some basic research on work flow interruptions and found data to support how frustrating constant interruptions can be, but as usual in my searches, I found nothing that addresses cath lab issues. We are simply too small a group to qualify for serious study. Other work forces had any number of studies from which to choose and I came across two which chronicled the unproductive results of being interrupted every 15 minutes!1 I’m not trying to invalidate the difficulties of other job fields, but if I could count on 15 minutes without an interruption, 80% of my workplace frustration would evaporate. Equally unhelpful was the advice I found to decrease interruptions. These being vague suggestions such as delegating tasks, micromanaging and time management skills, but the one I found truly comedic was to inform your co-workers that you are busy. I don’t care who you are; that’s just funny. No doubt, these solutions will work in many fields of employment, but not in a cath lab. The only research that approached cath lab-specific difficulties involved the ER or ICU and another that described a parent’s chaotic attempt to fix dinner with small children in the house. These studies laid out the minute-by-minute decisions and changes of course made during every task. When every step you take is determined by the outcome of the previous step, the most simple job can reach catastrophic proportions, with each element a potential domino ready to fell its neighbor. Consider the following examples: Every 5 minutes of flouro time, an alarm sounds that must be reset. All it takes is a moment to reach over or turn around to do so. However, in the moment required, many things may need attending to, such as the physician asking to change the angle of the tube, answering the phone, hanging an additional bottle of contrast, getting a wire, catheter, balloon or stent. Perhaps another alarm has sounded and the micro switches must be manipulated in order for the C-arm to move. Has the pulse-ox come off the patient’s finger? Did someone drop a syringe off the table that needs replacing? If any travel is required to reset the flouro alarm, most of these other things will be attended to first. All the while, the timer is beep, beep, beeping. As I said, this diabolic little scenario will appear again and again throughout the case. Or: You need to look up the patient’s creatinine to determine which contrast to hang next. Okay, where is the chart? Where are the labs in the chart? Are they current? You could look online, but I have not found a paperless system to be any more straightforward than a good old-fashioned chart. You reach the page with labs on it and the phone rings, or the physician’s beeper goes off. By the time you deal with that call, the chart has snapped shut and you have to find the lab sheet again. As your finger scrolls down the page, searching through a smeared fax copy, the IV pump alarms. Or the patient tries to reach over the drape. You settle the pump or patient back into silence and begin the task again. The tech across the room is still asking what the creatinine is. Now the physician chimes in, wondering why you have not supplied this simple information. By the time you find what you’re looking for, your frustration level has climbed several notches. Or: Your patient is on the table and all you have to do is hook up the ECG. You reach for the ECG patches and find the drawer or box empty, so you have to cross the room or even leave to get them. Oh yeah, the V2 patch needs to be radiolucent. May as well grab a bag of those as well. Back at the patient’s side, you unsnap the sleeves of the gown and tuck them out of the way so flying saucers don't skim across the pictures. Upon doing this small task, you give a tug to the neck tie, expecting it to come free in your hands. Instead it pulls into a knot. You reach further for visualization, which may require rolling the patient on their side or even sitting them up. If you’re lucky and working on a full night’s sleep or have not been momentarily interrupted by the phone or a question, you will remember to untie the gown at the waist. If not, it is only a matter of minutes before you have to roll the patient on their side or sit them up again to untangle the second knot. How tight is the knot? Can you pick it apart or do you reach for a pair of scissors? Don’t try to deny this; you know you’ve done it. By the way, the scissors may or may not be anywhere near you, in which case you rip the tether from the gown. The gown has been vanquished. You see that you now need a razor and open the drawer behind you. Empty! Eventually five little circles are shaved and the patches are placed. You reach for the leads to find them, of course, ridiculously tangled. Every single case of every single day you will find them braided together. Yet again the victim of (as we call them here) the Macrama Pixies. Once combed out and attached, they cannot not be too taut or too slack. They must be secured somewhere so as not to get caught on fingers, tubing, rotating C-arms, BP cuffs or oximetry. You may have to isolate them in a towel to increase your success of a legible tracing. Finally, finally you look up at the monitor and what do you see? Richter scale tracings. Chaos. Utter and complete chaos. Nothing resembling a QRS. At this point, you begin to identify with the prehistoric squirrel from the film Ice Age, but no matter what, you must have a diagnostic tracing. It is key. You cannot leave the patient’s side until this problem is solved. Something that is specific to our type of work is that each of these scenarios happens every day, sometimes on every patient. There is nothing rare about any of them. Circumstances change constantly and quickly. No one stays at one work station all day. There are at least four work stations in each room and multiple rooms. Dozens of people rotate through each room and work station every day.2 So how do we keep our cool with such interruptions? How do we keep the frustration from wearing us down? I didn’t find anything specific to grab onto, but spun a collection of ideas and came up with the following. Know your enemy that worthy foe being expectations. Gather all your expectations together and jettison them into deep space. Go into the task without assuming it will proceed smoothly. It might do just that, but probably will not. Make your goal the completion of the task, not its speed or ease. Multitasking may not be the timesaver many have believed it to be. A researcher at the University of Michigan notes, Performing two or more tasks in rapid succession requires an individual to reorient to each new task, which itself takes time and other attentional resources. 3 Similarly, To do two things at once is to do neither, according to Roman philosopher Publilius Syrus in 100 A.D. If humankind has been questioning the effectiveness of multitasking for 2000 years, I personally have to re-evaluate my own practices. So when possible, I do one thing at a time, finish it and move on. Identify the points of frustration and put reasonable strategies in place. Keep supplies stocked and your lead apron handy, but understand that this will not always happen. By all means plan ahead, but don’t be surprised when your plans shred like tissue paper. This is the medical field. Nothing is predictable. Sometimes there is nothing you can do to ease the situation. It’s just going to be awful until it’s over. At least you’re not the one having the myocardial infarction. There is always a turning point with mounting frustration in which you can choose to defy adversity. Laugh when you can. I know it’s hard to laugh when you really want to snarl, but is any of this easy? We in the cath lab are good at doing what is not easy. Lastly, depend upon and respect your co-workers. They are in their own cloud of biting gnats. If someone is not responding to your request, it is probably because they are overwhelmed with their own interruptions. They know their jobs as well as you do and will get to that correction or omission when they can. No matter the issues between you, every single person you work with will be at your side in a second during an emergency. We work in an extraordinarily complicated environment. Instead of feeling hamstrung by these difficulties, we should celebrate the efficiency we do achieve in spite of it all. Endnotes 1. I started to footnote the articles and solutions I came across on the web, but kept getting interrupted. It didn’t take long to become frustrated in my efforts to relocate the data, so in the end, I noted only a few. But if you feel inspired, just do a basic web search with phrases such as work flow interruptions, work place stressors, or working with interruptions. 2. Ironically, when we tried keeping one person in the same position for a full day, we got bored. 3. From David E. Meyer, Dept. of Psychology, 4048 East Hall, 530 Church Street, Ann Arbor, MI 48109-1043. The Brain, Cognition, and Action Laboratory. Multitasking and Task Switching, available at http://www.umich.edu/~bcalab/multitasking.html. Accessed November 27, 2007. Shirly was in ICU and Surgical LPN nursing from 1978 to 1986, and has been a CVT from 1986 to the present. She can be reached at SCoffey@peacehealth.org.