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Lessons in Life as Taught by the Cath Lab
The title of this editor’s page is the same as that of a brief viewpoint article that I recently read by Dr. Haider Javed Warraich, a cardiovascular fellow in training at Duke University. The article is published in Circulation1 this month and I recommend it to all those working in a cath lab to read and enjoy it as much as I did. It was among the very best expressions of how a new team member sees the beauty and potential dangers of the cath lab. It galvanized several of my own experiences in the cath lab that made this life’s work so pertinent and enjoyable. Dr. Warraich’s words succinctly condensed a few of the most important principles in cardiac catheterization teaching that I would like to pass on to my trainees, nurses and technologists, and my younger colleagues while we work together in our common goals.
To those who have focused their lives as invasive and interventional cardiologists, cath lab professional nurses, cardiovascular technologists, radiologic technologists, and other cath lab support team members, the cardiac cath lab is an all-encompassing experience. It can be overwhelming for many of our new team members, and at times, for even seasoned veterans. Participating in a procedure that has the potential to save or take a life is an awesome responsibility. After entering the lab as a new cardiology fellow, Dr. Warraich wrote about his experience of seeing and working in the cardiac cath lab, and how it provided several important life lessons.
Before writing this editor’s page, I called Dr. Warraich. He is an engaging, young cardiology fellow, soft spoken and helpful. Like all cardiology trainees, he was rotating through various cardiology services in the Duke University program. What I wanted to learn was how Dr. Warraich developed his gift for writing, clearly unique among his peers. For background, Dr. Warraich grew up and went to medical school in Pakistan, before starting medical residency at the Beth Israel Deaconess Medical Center in Boston, thereafter moving to North Carolina to complete a cardiology fellowship. As I learned, he has been a writer for many years with wide-ranging interests. He has contributed and published many letters and articles to several prestigious sources like the New York Times and other well-known periodicals. His most recent article on “Lessons in the Cath Lab” for Circulation has some of the most exquisite descriptions and “take-home” messages that I’ve encountered. After reading his article, I’m sure you’ll agree. I thought I would take a few excerpts and share them with you here.
The Cath Lab “…where life and death…are precariously balanced…”
Dr. Warraich has echoed many of my sentiments about how the cath lab operates, but in a way that I haven’t thought about for a very long time. Let me paraphrase a few of his words and thoughts. Dr. Warraich notes, “There is no greater teacher of life than the practice of medicine, but none greater than the place where life and death are often most precariously balanced.” To me this sums up the cardiac cath lab experience and mission in one sentence. The cardiac cath lab taught him (and us) that everything we do has consequences; lapses of concentration, fatigue, and unfocused activity may produce an error resulting in injury or even death. The fellows (and of course, the attending physicians) in the cardiac cath lab must be constantly vigilant to ensure that the patient’s procedure is safe while at the same time permitting the fellow to learn without harming our patients. The nurses and technologists in the lab stand in support of the patient and in support of the trainee. The cath lab and its team is a community directed toward excellent and superior medical care and assisting in the advancement of the field.
Zen and the Art of Cardiac Catheterization
The cardiac cath lab taught Dr. Warraich awareness. This awareness was captured in a teaching moment coming from one of his cath lab attending colleagues, Dr. Mitchell Krucoff, “…a cath lab is like a sea of adrenaline”. Dr. Krucoff went on to say that Dr. Warraich was to use “Zen principles and master the turbulent sea, transforming it into a ‘still and rippleless pond’ such that he can detect any aberrant or random wrinkle; how is the patient’s pressure? What is the O2 level? What is the heart rate? Are there ST segment elevations? Is the C-arm in the right position, will it hit the patient?” Learning and ‘seeing’ all of the ‘ripples’ on the cath lab’s sea, of course, is a function of exposure, focus, mentorship and time.
“Four hands, one mind”
I was particularly taken with the phrase that Dr. Krucoff and his colleagues had imparted to Dr. Warraich about how the lab should work. “Four hands, one mind.” Working together as one unit produces the best result. We can all recall the times when we became uncoordinated, asking for equipment or drugs or gear out of sequence to what really was needed, actions that occasionally delayed the best result, mistaking initiative for productivity when in reality we needed to be better organized for a logical, stepwise, successful technique.
“Slow is smooth and smooth is fast”
Dr. Warraich noted that the speed of everything during his training seems to have accelerated “under the guise of efficiency” to work faster and increase productivity. The need to perform procedures in a faster manner, writing notes and orders faster, rapidly scrolling through a diagnostic study, a process, or procedure was apparently a new standard. This rapid-fire approach, however, is really a deceptive practice in the long run. Dr. David Kong, one of Dr. Warraich’s cath lab attendings, taught him to slow down, and quoted Colonel John Dean Cooper, a soldier and prolific writer about how procedures should be conducted. “Slow is smooth and smooth is fast.” The extension of this philosophy to daily practice is invaluable.
Struggling and Forgiveness
As novices to any procedure or manual techniques, all cardiology fellows struggle at one time or another before achieving mastery. This is especially common in their initial exposure to the cath lab. Dr. Warraich was insightful about how it feels to be a first-year fellow. He identified the fact that failing certain portions of the procedure during one’s initial attempts is a new experience for these highly trained, highly tested individuals, who are unfamiliar with failure. Their mastery of all things academic had brought them to this unique position in their life. Cardiology fellows can conquer the technical aspects of the cath procedure with time and mentoring, and in similar learning situations, we must learn to forgive ourselves, our trainees, and our colleagues, who sometimes struggle and even fail. This discussion reminds me of how my teaching style changed dramatically from the uncompromising tone of my first few faculty years to one of understanding and forgiveness after my daughter was born. During her journey of growth and development, I learned that I had to teach things to her at her rate of learning, not mine. I learned patience and forgiveness, forgiving myself for being impatient and not having the self-awareness of what I needed to do to become a successful parent and teacher. Dr. Warraich would likely agree that only through such self-awareness for both the student and teacher can the mastery of a procedure occur.
My Bottom Line
Although this article was only 2 pages long, it contained a wonderful view on life lessons not only in the cath lab, but also ones to carry outside — lessons to pass on to our fellows, team members, and colleagues. Thanks, Dr. Warraich.
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