On Teaching Cardiac Catheterization: ‘Seeing’ the Patient

It’s July again. I am reminded that it’s not easy to teach cardiac catheterization. This revelation is not new as I scrub in with a brand-new trainee for his first time. It’s now my 32nd year teaching fellows, residents, techs, nurses, and industry reps about cardiac catheterization. I never tire of this job; I love doing cardiac catheterizations and helping my colleagues and cath lab team ‘up their game’ about the cath lab. I had no idea that the Cardiac Catheterization Handbook, first released in 1991, would provide me such great satisfaction in knowing that what we do in the lab translates to better performance for future cardiologists and cath lab teams, and better outcomes for our patients.  

Performing a cardiac catheterization procedure for an experienced operator is easy, but teaching a novice how to do cath is not. A text message from Dr. Jimmy Diep, one of our recent graduate interventional fellows, now a new interventional faculty member at the University Nevada, Las Vegas said, “Thanks for the good teaching, but how did you have the patience to do it [teach the fellows]?” I was entertained and delighted to know now that he really got what I was telling him, and what it takes to be trained and to become a trainer.

Although I am now a Chief of Medicine, recently moving from Chief of Cardiology to a senior member of the cardiology division, I’m still doing caths at least one day a week. Changing responsibilities had the advantage of giving up ST-elevation myocardial infarction (STEMI) call, the benefits of which are a complete discussion unto itself. (As an aside, while it’s a relief not to carry the call beeper, I miss the action. But I’m sure I’ll get over it. I always knew this transition would come to me and eventually to all my contemporaries, but I wanted it to happen gracefully, before my eyes and hands begin to fail. As interventional cardiology procedures move toward fewer routine cases and more of those with higher complexity, especially those of structural heart disease, many of us [senior cath guys] will recognize that it’s always been young man’s game. It is hard to accept this fact, but in the end, it’s better to step aside on a high note.)

Starting cath lab teaching: seeing the patient

As our academic year is just starting, I thought I’d mention a few things that will help the new trainees or new techs in the cath lab get started. This week, when my first-year fellow showed up to the cath with an eager smile and bright look on his face, the first thing I asked him was, “Did you see the patient?” — a simple question. In fact, all of us in the lab should ‘see’ the patient, meaning not just say hello, but recognize that this person is going to have an minimally invasive, potentially dangerous procedure. We need to keep this fact in mind before and throughout the case. Seeing the patient means more than just getting a history and doing physical exam. It means appreciating his and his family’s psyche and giving them the security of professionalism. That said, don’t forget to check the labs, chest x-ray (CXR), electrocardiogram (ECG), and get consent.  

Obtaining consent without “doctor” talk

The next part of seeing the patient is explaining the procedure and getting consent. While considered an obvious skill, I think its importance is underestimated. I know my fellows, like all recent residents, speak “doctor” talk (excessive use of medical terms which often have no meaning to a lay person). At this point, I show the fellow (or a PA or NP) how to obtain consent from the patient in the language the patient can understand, simple and direct, no medical words (see “A Typical Script” on previous page). While not a universal practice, consent is usually obtained by the principal operator or his or her designee, but usually is a physician. In obtaining consent, one should explain in clear, easy terms what procedures will take place, what are the reasons for each step, and what is expected to be learned by the test.  

It is also a critical part of consent to explain the risks for both routine cardiac catheterization and, if a possibility, ad hoc percutaneous coronary intervention (PCI). Again, use simple, non-medical language. Major risks include stroke, myocardial infarction, and death occurring in 1 person in about 1000 (do not use 0.01%). Minor risks include allergic reaction, bleeding, hematoma, and rarely, infection. Some labs have very detailed, written consents enumerating every possible complication. Provide the form to the patient and family after your discussion and give them time to read before requesting a signature. For PCI, a detailed discussion is needed stating the options for medical therapy, stenting or coronary bypass surgery in advance of the procedure. 

Remember that when you give the patient the necessary information, do so in a way that will not overwhelm the patient. It is always good practice to include the family when explaining what will happen and what possible outcomes are expected. After explaining the procedure, you can ‘see’ the patient again in a new light. As always, the final decision to undergo any medical procedure is always the patient’s. If the patient is reluctant, anxious to the point of tears, or cannot cooperate with simple instructions, the procedure can be deferred until the referring physician speaks to the patient. A reluctant patient should never sign the consent. Thus, the company of the family for support becomes one of the reasons why the family should be present when the procedure is discussed. This approach encourages a cooperative and generally sympathetic appreciation of the procedure, the risks, and expected outcome.

Seeing the procedure

To learn a procedure, one must ‘see’ a procedure, meaning not only understanding the purposes of each step, but also how the steps flow together. This can only be done by observing the procedure in action. See what each team member does; see what the set up for the equipment is; see what steps of the procedure are routine and which are not. The new fellow or tech should scrub into the case, but only observe for at least 3 cases. (Another aside: Invariably, one of the fellows will be so energetic that he’ll scrub and gown before I get to the room. The nurse then reminds him that he did not put on a lead apron. We all have a good but kind-hearted laugh while he breaks scrub and starts over again. It happened again just this week. No harm, no foul).

Repetitive steps at the learner’s speed

Teaching the procedure continues as the attending takes the fellow through each step, explaining what and why we do what we are doing, initially with the fellow just watching. The repetitive steps of radial or femoral access, coronary catheter advancement, performance of angiography and ventriculography, and access hemostasis are discussed with increasing detail on each repetition. Like all new learners, some get it quickly, some don’t. The experienced teacher knows this and adjusts his style to the speed of the learner. I found that expecting the fellow to increase his learning rate does not work and produces frustration and bad results. It would be like teaching your 2-year-old daughter something brand new and expecting her to learn it at your speed. She’ll show you what learner speed really means and truly test your patience and teaching skills.  

Cath lab teaching continues after the patient is taken off the table. The attending physicians set the example of how the procedure should conclude. The fellow and I talk to the patient and his family about the results, provide them with a diagram of the angiography, and explain our recommendations. We return to the lab to complete the procedure note and orders. We review the angiograms again, naming each projection and artery, and discuss the left ventriculogram (LV gram) and left ventricular end diastolic (LVED) pressure. We do it all again for the next patient. After several procedures, the fellow is able to do a few more parts of the procedural technique each time. This repetitive process begins the learner’s routine and path to becoming an independent operator toward the end of his fellowship.    

In working with this new fellow, I was reminded of some technical details that I took for granted; some simple things that make a difference are shown in Table 1. I hope these thoughts will be helpful to your lab and your new trainees, as it has been for ours.