Some time ago, a patient remarked after the completion of his exam that he had rarely seen such a smooth execution of duties. He had apparently been watching our activities closely and come to the conclusion that in spite of the variety of tasks and the complexity of the procedure, we had demonstrated the workings of a top-notch team. It was quite the compliment, since he was a retired naval commander, old enough to have seen decades of military service in the three wars in which he served. So how do we accomplish such feats? How is it that our most simple tasks are interpreted as mysterious and smooth? In the eyes of the uninitiated, an angiogram with an experienced crew does, indeed, seem graceful and fluid. It is because we have participated in thousands of setups and exams that much of what we do is automatic. Only when training a new employee on the workings of a manifold do I glimpse how seamlessly the hands, eyes and brain combine to flush a catheter this being a microcosm of an angiogram. Consider how varied cath lab personnel are likely to be. In my lab, our ages range from under 25 to over 60 with experience working in the cath lab ranging between six months and 27 years. We have been trained on the job or received licensing and degrees from vocational schools, community colleges, universities and graduate institutions. Some of us are straight from school while others have a medical, industry or military background. I need not list the countless skills needed for one angiogram to demonstrate the complexities we navigate every day. Thus, upon witnessing an angiogram and perceiving it to require a complex hierarchy, every once in a while a patient will ask, Who’s in charge here? Answering this question has never been a matter of pointing to someone in the room and our first response is usually something like, Well… you’re in charge. If you say stop, we stop. If you say go, we go. At this point, the patient smiles indulgently and asks, No, I mean who’s in charge of you guys in the room? Again, our answer is often vague. Well, no one actually. Everyone has their specific job and they…just… do it. If this still doesn’t satisfy the questioner, its a good idea to simply name a co-worker as the leader. Having heard the above exchange a number of times, I decided to clarify once and for all just who’s in charge.1 However like everything else in the cath lab, my findings were all over the map. In my unscientific queries of cath lab people, I learned there is a wide spectrum of assumed leadership. Some believe the physician is clearly in charge and some the nurse. Others stated that no one is in charge while several claimed that everyone is. On paper it may designate a specific person as Room Charge or Team Leader. Perhaps it is uniformly understood that the physician is in charge of the room. Maybe it is the supervisor or manager of the lab itself. Is it the person who steps on x-ray? Is it the person who gives the medications? Is it the person who takes the departmental calls? How about the RCIS in the room? Or the person with the most seniority or most complex skill set? The possibilities are nearly endless. As you all know, nothing in the cath lab is precise. Medications are titrated according to each patient and their effect. Balloons, stents, wires and catheters are chosen based on a whole range of minute physical characteristics. The patient line-up is determined not only by classic triage guidelines but by elements such as: When did they eat last? Are they having pain, and if so, how much? Do they need to be discharged by such-and-such a time to accommodate an extended trip home? Maybe they need to be dialyzed by noon. Is surgery waiting for their own procedure on this patient? And the sad truth is, all it takes is one unstable chest pain in the ER for all of the above to go out the window. Thus, every aspect of a day in the cath lab must be fluid. Spontaneity must be initiated in the blink of an eye. Given all of the flexibility we expect from others and ourselves, it seems logical that our interpretation of leadership during a procedure would be just as free-flowing. Logical that the direction during a procedure would pass easily and automatically from one person to another. Who’s in charge when the patient needs an IV? Answer: The person starting the IV and ultimately, the IV, is in charge because the case does not proceed without one in place. Who’s in charge during an injection? Answer: The person injecting the contrast. Who is in charge during a decision between a 2.75 mm and a 3.0 mm stent diameter? Answer: The physician and the myriad of opinions he or she receives from the rest of the room. Who’s in charge when fluoro suddenly goes down? Answer: The person running downstairs to the generator room for a hard boot. There is a storm in New York that has grounded all air traffic and the oil-cooled tube that blew the day before is still in Germany. This means your cases are re-routed to other rooms which may or may not meet the technical expectations to visualize stents in a barrel chest. Holidays, Super Bowl Sunday and county fairs all have control potential for cardiac events or simply indigestion, which can mimic a myocardial infarction. Once, while scrubbed in during an emergency, a lens from my lead glasses popped onto the sterile field. Everything came to a stop as I fished it off the table, covered the area with a sterile towel, broke scrub to find another pair of glasses, then re-scrubbed in. So tell me, who was in charge during that fiasco? Or… A vector is spotted and announced to the room. Unless the timing is critical, all the lights are turned off and a door opened. We either wait for the fly to exit the lab or proceed with the case in darkness. We have catheters and wires inside someone’s heart and yet relinquish temporary control of the exam to a creature that only lives for three weeks! 2 As hinted, it doesn’t even have to be a human in charge. Any circumstance, large or small, may determine the direction of a procedure. World events, natural disasters, local happenings, leaky ceilings or a fly in the room can halt progress. According to the Miriam-Webster dictionary, Murphy’s Law states that Anything that can go wrong will go wrong. So it could be Mr. Murphy who trumps all bidders for control. Several people voiced that the patient is in charge and I agree completely. The patient is the only reason the exam even exists. It proceeds according to that patient’s physical and emotional state at any given moment. It is never more clear to me who is in charge than when the patient gets off the table and walks away. My personal favorite for the in-control factor is the work itself. It’s the job that is in charge. This is the common denominator. The tasks, practices and people are so varied that chaos would reign if not for the focusing point of the angiogram. The job is the focus and thus congeals the many ingredients into a single product. Every single person involved in the case is in charge at one point or another. It is a process whose choreography highlights any number of people, depending on the skill needed at the moment. We all come center stage to perform our task, then step back for a co-worker's performance; only to be called on again later. No one is more important than another. We are collectively in charge. Notes 1. I asked the people I work with if we should identify someone each day in each room to be the team leader. Much to my surprise, I learned that we had tried this at one time. Apparently this approach evaporated in the space of (depending on who I asked) either a few hours or a few days. The team leader was variously ignored, overruled, deemed unnecessary or simply forgotten. Of the 30 or so people I asked, only a handful even remembered the experiment. When given the information that the team leader approach had been implemented, the most common response was: We did? Myself included. 2. It goes without saying that you never say, There’s a fly in the room. Our use of the word ˜vector’ is clearly understood by whomever needs to know; and the patient is clearly not in that loop. If the patient hears ˜vector,’ they may very well guess our meaning, but their all-powerful denial process allows them the comfort of believing we are discussing a mathematical matrix. 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.