Clinical Editor's Corner

What do you mean, you don’t have a 2.25 stent? Managing frustration with supplies in tight times.

Your diagnostic catheterization procedure turns into a PCI. The left anterior descending artery (LAD) is accessed with the 6F JL4 guide catheter. Your circulating nurse is drawing up the heparin. The operator then requests his equipment: “Please get a 0.014 XYZ guidewire, a 2.0x15 ABC balloon and a 2.25x12 OMG (aka, “oh my gosh”) stent. The staff then scramble to collect the needed PCI items. After lesion predilatation, the operator is ready for his OMG stent. “Let’s have it,” he says. The circulating nurse then informs him, “Sorry, we do not have this stent in stock. Dr. Jones just used up our last one this morning.” A small tableside explosion signals the frustration that all labs experience at one time or another related to managing inventory in tight times. This common scenario is managed in different ways, depending on the systems, personalities and budgets involved. The key to the problem is, how do you manage the frustration and overcome the times when you run out of a piece of requested equipment? First, everyone must recognize this situation cannot be avoided. It is impossible for a busy lab to keep up with the endless equipment needs of many different physicians and procedures. It is unreasonable to expect to be able to stock every size of every brand of every guidewire, catheter and stent. Most labs carry a reasonable selection based on the most common types of procedures and the most frequently used equipment, and favor adding special items for specific physicians who have the procedure volume sufficient to justify the inventory addition. But even under the most diligent manager, the lab may run out of a particular item and then we all hear about it. What should you do when this happens in your lab? One of my cath lab technologists told me to recall the words of Theodore Roosevelt — “Do what you can, with what you have, where you are.” I would modify this to say “Do the best you can with what you have at the time,” and apply this wisdom to the cath lab. As an aside, this philosophy can readily apply to all aspects of both your work and personal life, but that’s a subject for different time. Let’s return to the cath lab and when you don’t have exactly what the doctor orders. Provide Equipment Options Different operators have specific preferences for equipment depending on their experience and training. Fortunately, the variations of equipment (sheaths, guidewires guide catheters, angioplasty balloons and stents, etc.) in today’s modern cath lab are relatively small. Coronary angiographic catheters are of similar construction, size, materials and general handling characteristics. Does it make a difference which brand of diagnostic catheter is used for the study with a competent operator? I doubt it. What may be more important is whether or not you have a JL4 or a JL3.5, which may make a difference, since seating the catheter in unusual anatomy can become extraordinarily difficult regardless of the brand used. Remember, you may not have a 6F JL3.5, but the lab might stock a 7F or 5F version of the JL3.5. These occasions also reinforce the need to review inventory and anticipate future needs based on current activity. Stent selection is a more personal choice for the operator in terms of his ability to place the stent. Depending on the type of lesion, the characteristics of the stent (e.g. flexibility and deliverability) may become critical. For most cases, it has been said that a skilled operator can generally place any type of stent in any location. The procedure can then be performed with any of several different stents. Thus, for stents, several options are usually available when one brand or specific stent is missing. The major stent selection issues are not so much the stent type, but rather the stent size (diameter and length). The same discussion applies to angioplasty guidewires. Most experienced operators can perform their procedure with any guidewire or catheter. Of course, there are special cases which require unique technique, equipment and judgment. For these particular circumstances, operators will make important decisions as to whether to proceed if their particular piece of equipment is not available, especially when the procedural aspect is complex and outcome likely critical. The less experienced or very early career interventionalists may rely exclusively on the equipment upon which he/she was trained. To this less experienced operator, lacking a particular device might represent a challenge associated with a high chance of technical failure. The operator might complain that the lab is inadequate in not stocking the particular equipment necessary and presents a thorny dilemma for the laboratory. However, the operator and the lab must think again of the words of Theodore Roosevelt. For complex procedures in which complicated devices are required [e.g. patent foramen ovale (PFO) or atrial septal defect (ASD) closure, alcohol ablation for hypertrophic obstructive cardiomyopathy, etc.], the exact equipment is mandatory and the procedure cannot proceed without assurance that the equipment is available. A review of the specific equipment in advance will avoid this problem. Even with all of the devices available for these complex procedures, circumstances will occur where you won’t have exactly what you need. At that moment, being creative, thinking on your feet, using ideas from cath lab staff and doing the best with what you have, where you are, can get you out of trouble. Making the Best of Who You Are The concept of doing the best with what you have also applies to management of personnel in the cardiac cath lab. Just as operators have different skill sets, so do they have different relationships with people in the lab. You also have different relationships with your co-workers. Not everyone who works in the cath lab has the same skills, knowledge or inclination to perform certain tasks. The cath team must organize itself so that the operators and patients will not suffer from expertise shortfalls. The cath team and physician leaders need to coordinate their efforts to achieve this endpoint and employ the best management traits of maturity, perseverance, creative thinking and dedication to the task. Although this team formulation is employed on an everyday basis, it is not always appreciated how well cardiac cath labs do make the best of what they have. While it’s easy to say, “perform this procedure with whatever you have on hand,” it’s always better to be prepared and well-stocked in advance. However, despite the best preparations, operators and staff must have the ability to identify options, maintain a positive attitude and have confidence in the operator and cath team experience. Overcoming Impediments The request for a piece of equipment often sends the team on a frantic search for the missing item. For the operator, time moves slowly. Finally, when this item is not found to be available, the next question is usually, “What else would you like to try?” I suggest instead that the cath team anticipate what is needed and available. For example: “The 3.5 x 15 mm stent you asked for is out of stock right now. Would you like a 3.5 x 18 or a 3.0 by 15 mm and consider over-expanding?” This approach helps the operator make the decision easily and quickly, with less frustration. Similarly, you could apply this method to other diagnostic and angioplasty equipment. Present the options whenever a specific piece of equipment is not available. This approach, however, does require the staff to be very familiar with the procedure and physician, and perhaps an experienced team member should be the one to break this news. Mick Jagger put it succinctly: “You can’t always get what you want, but you can get what you need.” Making the best with what you have, where you are, does not mean settling for mediocrity. Each laboratory should make an effort to have the state-of-the-art equipment in the appropriate sizes and numbers to permit operators to deliver the best care possible on a daily basis.