Meddling with Medusa

Peripheral angiography can have a bleak reputation. There are people, myself included, who trudge towards the peripheral rooms with leaden steps. I step into these rooms with determination, doggedness and duty, but anticipation? Rarely. Cheerfulness? Right. A group of people who work seamlessly through five heart caths spend the same amount of time stuttering through two peripheral cases. Solid working teams evaporate in the face of a two-hour PICC line placement. My effort here is to identify the barriers. I believe that in listing our frustrations, we begin to get a handle on this Medusa.¹ I want to find a way to approach peripheral work with the same energy I lend to cardiac cases. Run through in your mind the response to an acute myocardial infarction (MI) from the ER. Lights and sirens on the way in, pain, ST elevation, arrhythmias. This often complicates and lengthens the day, but there is a sense of excitement. The potential of heroic accomplishment. We might just save someone's life. We might save myocardium. This is what we do; we intervene to bring someone out of harm's way. We feel good about this kind of work. Now: a call comes into your room from the unit coordinator. There is a "cold leg" in the ER. A universal groan resounds from the room. No excitement or anticipation. The heroic aspect (however imagined) is gone. If you're lucky you might retrieve a pulse in the foot, but generally the results are less palpable. If it is Friday evening and you are the call team, your goose is cooked. Remember when we used to open a thread of a pathway down the leg, start a urokinase infusion and recheck the progress every four hours for two days? Now there, my friends, is a scenario that the folks at Fear Factor never dreamed of. A peripheral room is very much like the mythological figure of Medusa. One head with many hissing snakes; the most troublesome snake being complexity. Dozens of procedures spring from one table. In a coronary room we do one thing hearts. There are many vessels in a heart, as well as chambers and valves, but it's still just the heart. Medusa, however, challenges us with a plethora of locations, puzzles and hurdles. We set our sights on the cerebral, carotid, subclavian, brachial, renal, aorta, illiac, femoral and popleteal arteries. PICC lines, dialysis catheters, Port-a-Caths, stents, IVC filters and drains are all placed in the body. We also remove devices from the body such as venous lines, tubes and drains; not to mention retrieving the occasional severed PICC line. We embolize as well as de-clot. We not only diagnose cerebrovascular accidents (CVAs) but attempt to stop them in their tracks. We treat nose bleeds, uterine fibroids, esophageal varices and visceral bleeding. We visualize any and all vascular dysfunction as well as lymphograms, ductograms and bulging spinal disks. If something needs draining, we can do that. If something needs opening, we can do that too. The sheer variety of procedures and mammoth equipment required is probably the crux of our difficulties. It would seem that with such a spectrum our interest level would be maintained, yet it is the following hurdle that prevents many of us from enjoying peripheral work the twin serpents of frustration and hopelessness. Where is the satisfaction in de-clotting the same fistula over and over? Frustration because we cannot keep the above fistula running and hopelessness because we don't make substantial headway. Our problem-solving instincts are thwarted again and again. Headway is made, but too often it is one step forward and two steps back. We feel we are not solving the problem. One dark and stormy night, I was calling any and all cath labs in the area looking for a 32-cm ureteral stent. Needless to say, we did not find one and returned our patient to their room without placing the stent they needed. In three hours, with everyone's experience and efforts extended to the max, we could not resolve this problem. No satisfaction, no sense of completion. You don't feel like you're fighting the good fight; you are just fighting. And there you have it. Don't you just love a straightforward runoff or cerebral angiogram? Take some pictures, make a diagnosis, maybe place a stent, maybe call a surgeon, and you're done. This used to be the standard. Venous work was minimal. Now it is just the opposite. Most peripheral schedules are choked with some kind of indwelling venous catheter.ii The procedure itself is not particularly challenging, but our frustration level is high. These patients are often suffering from a terminal disease and therefore, over time, we witness the patient's physical decline. We may replace catheters many times in the same patient; each visit seemingly as hopeless as the last. People who come to an interventional radiology room are generally sicker than the average coronary patient. When was the last time you transfused blood in a coronary room? Respiratory function may exclude the level of sedation needed for comfort. These patients' illnesses are chronic and debilitating. In short, they are suffering and it is hard to watch someone suffer. It hurts my motor to go so slow. Assuming that your peripheral rooms are anything like the ones I've had experience in, you know exactly which Medusa snake James Taylor is referring to. If the above difficulties of peripheral work don't wear you down, the pace surely will. Increased complexity results in decreased speed. There is just no way around this. Often there are several medical conditions in play at once and therefore, multiple physicians. Renal, internal, surgical, respiratory and cardiology are just a few that may be involved. The patient's chart is thick with orders, progress notes and lab values that must be waded through before they even get to the room. Frequently you or the radiologist must consult with these physicians before or during a case. OK, I need to know just where this ties in. If you're lucky, you are scrubbed in when this statement is uttered and someone else has to wade through the many surgical reports or find the surgeon who last revised the fistula you are trying to unravel. Another element of the complexity is the variety in which many of these procedures are approached. Sometimes we are innovating every step of the way. When one avenue has been exhausted, you may find the peripheral team digging through cupboards in CT, endoscopy or coronary rooms. That scuttling sound so often heard yet rarely identified is a cath lab tech secreting some treasure from a neighbor's inventory. Much of interventional radiology is new and exciting, but breaking ground is hard work and it is not delicate or refined. Every day someone, somewhere finds a piece of the puzzle. They share this information, we add it to our arsenal and continue on. There is a special place in heaven for those people who live and breath peripheral work. They may not know this, but they are the spine of the whole team. Their strengths and attitudes allow them to side-step each snake Medusa, apparently, having little effect on them. I have watched these people closely and learned two things. First, I've finally come to the understanding that peripheral work moves slowly because it has to. It is a course of perseverance. It is complex and frustrating yet it does move forward. Secondly, I noticed that the people who do well in peripheral rooms are generally positive or downright cheerful. How they manage this is often a mystery, but if I can fall into their slipstream everyone benefits. The team that earlier fell apart, begins to reconvene. Naming the serpents of this Medusa was a starting point for me in dealing with my less than ideal approach to peripheral work. Identifying the difficulties gave me an appreciation for the efforts involved and the barriers in place. Yet there was a factor missing that kept myself and others from coagulating, if you will, into a single force. My final realization came from, of all places, a staff meeting where we were discussing the many issues regarding peripheral work. Our manager remarked that cardiology and peripheral work are equally important. As can happen, I was only half listening and then he said, These people need our help too. And it was just that simple. He had struck right to the heart of our professional nature. We are highly trained technical people, but at our core we offer our knowledge and time for the benefit of others. This is what we do and it feels good. After having read my opinions and accepted or discarded them, please add your own. Prove me wrong with stories of your own peripheral labs. List the things that make these rooms work. Rumor has it that there is hope even for Medusa.iii 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.

[Medusa] was once a beautiful maiden whose hair was her chief glory but as she dared to vie in beauty with Minerva, the goddess deprived her of her charms and changed her beautiful ringlets into hissing serpents. She became a cruel monster of so frightful an aspect that no living thing could behold her without being turned into stone. From Bulfinch, T. Bulfinch’s Mythology. New York, New York: Modern Library;1993.ii I live and work in the Pacific Northwest and this is my experience. I might be wrong regarding peripheral demographics elsewhere, though I hear much the same stories via techs, physicians and vendors. iii While Medusa is usually considered to be ugly, one myth states that it was her great beauty that paralyzed observers, according to deTraci Regula, author of The Mysteries of Isis.* Try as I might, I could not dig up this particular myth, but it suggests that perceptions can change for the better.*from Llewellyn Publications; 1st ed edition [September 1, 2002]. ISBN No.: 1567185606.