The Art of Endurance: Part II

How can a perfectly healthy woman wind up in a cath lab in the middle of the night? Case study: A 52-year-old woman with no cardiac history, non-smoker, non-diabetic, some family history, height and weight appropriate and physically active, arrives in the cath lab at 2:20 am to R/O an MI. Currently experiencing sinus tachycardia without ectopy. Skin is cold and dry; turgor suggests dehydration. Complains of persistent nausea. Mental acuity is subtly off. Denies specific pain other than generalized aches that occasionally shoot upwards from her feet. Sound familiar? No? Actually, she is not the one having an MI. She’s the one looking down at the ER patient infarcting on the table. She is a cath lab tech/nurse on call. Thirty minutes ago, she jumped up from a sound sleep, threw on whatever clothing was handy and rushed in to work, which explains the tachycardia. Adrenaline is running amuck in her body because of a fight-or-flight reaction. Throughout the drive to work, her body is saying, Hurry, hurry! while her mind is saying, Take it easy; don’t get a ticket. She looks dehydrated because she is and the nagging nausea is because her blood sugar is low. She has had a scant four hours of sleep from the previous day’s 17 hours of work, which accounts for the leg and foot pain. Either you are this woman or you know her. You have experienced all of these symptoms, and more, yet you must perform appropriately and skillfully. You must call upon whatever resources available to endure not only the current case, but any case that may follow. Your co-workers, the physician and the patient are all counting on you to be a competent professional. Sometimes that is a tall order, yet we fill this order time and time again. Maybe you will finish this case and start home only to be called back from the stairwell, or lobby or the freeway. What happens if you are in the driveway when your beeper goes off? Or worse, just dropping off to sleep? Unfortunately, and against every grain of common sense, you turn around and go back. Overriding your brain and body under these circumstances requires a strong work ethic, will power and sometimes not a little courage. The ability to jump up and run from a cold start is what Ulysses S. Grant called 4 o’clock in the morning courage. I commend everyone I have worked with, currently work with and will work with as having exactly this quality that President Grant described. Yet this thing we call call is greatly underrepresented in the medical publishing world. The subject of call will come up several times each day in our conversations at work. It is a constant in our lives as cath lab workers, but is rarely documented as having a significant effect on our lives. It is both a burden and a boon. You hate the hours, but love the extra money. As a friend of mine says, There’s no tea like OT. Anne-Marie Nicol and Jackie S. Botterill, in On-call work and health: a review,1 reviewed 16 studies, mostly from the 1990’s, outlining the negative effects of being on-call, such as our sleep being less beneficial, accelerated heart rate during sleep and less (REM) rapid eye movement and (SWS) slow-wave sleep. They note an increase of auto accidents due to fatigue. The specters of anxiety, depression and stress are more prevalent. We plan our lives around the call schedule and we limit social activities for the same reason. I know what you’re thinking. There is nothing a published paper on call shifts can tell you that you don’t already know. In fact, each of us could write our own work on this subject that would be all-inclusive and accurate. It was, however, satisfying to see some acknowledgement of our efforts. On-call workers are a relatively small group of people who share the burdens, benefits and strategies of carrying a beeper. As Nicol and Botterril say so clearly, These limitations and interferences present unique challenges for on-call workers that are not encountered by those working set schedules or even people with rotating shifts. No one else quite understands why you leave a meal mid-bite unless they have a beeper of their own waiting to go off. A friend of mine would always urge me to, At least finish your soup and could not grasp why I chose to eat a boiled egg on the drive into the lab instead. All of us know how vulnerable we become during flu season and that no holiday or life event is immune. We grimly watch freezing rain settle on every surface or race home hoping to catch at least part of the game. There are fewer stressful instances in life than the absolute unpredictability of being on call. Therefore everyone has a different bag of tricks to get them through their shift or the weekend. Clothing, food, coat and keys all in a specific place ready to grab and run. A full tank of gas. Beginning the weekend with a well-rested body. Provisions made for children or pets. The issue of sleep, or more accurately the lack of sleep, is the most challenging aspect of call. It’s real simple the less sleep you get, the worse it is. Sleep deprivation is also the trickiest hurdle. The longer I go without rest, the less effective my tools for endurance become. Only sleep and rest reverse the effects of call-back and all-nighters, but in the meantime, I rely on some of the following techniques that I’ve seen or used over the years. The good news is that these tricks are effective; the bad news is that they are stopgap measures not unlike CPR. Artificial and short-term. 1. Cat naps or power naps. The stolen moments of sleep that many experts strongly suggest. I’m not a fan of cat naps. I want sleep, not a nap, but I’ve seen this work for other people. I saw a guy fall asleep leaning against the scrub table waiting for a physician and apparently those 5 minutes did the trick. Rest, even without sleep, can make a difference and this is what I most often call upon. Just closing my eyes will at least rehydrate them. 2. I like to put my feet up and return some venous blood northward. I take my shoes off and massage aching feet. If time allows, I even soak my feet in water. 3. I have only been able to indulge in this on rare occasions, but a long hot shower is about as close to sleep as it gets. If you have access to a shower and the time do it. 4. Get hydrated and stay hydrated. Especially if caffeine is part of your solution. I’m a strong proponent of caffeine, but its benefits are finite and will eventually take its own toll. Power drinks, instant breakfast foods and Gator-Aid type drinks are all helpful. Balance the caffeine and sugar with good portions of water. 5. Rest and relaxation in the form of meditation is an ancient remedy. Along these lines is pure escapism in the form or books, magazines or music. 6. One of my co-workers purchased a shoulder massager that we keep readily available. In the spirit of her good deed, it is not uncommon to see one person massaging the neck and shoulders of another. Usually there is a line of people waiting for their own turn while we all mutter about the day’s work, chat amiably or crack jokes. 7. Then of course there is food: good food. Food you like. Food you have brought in for yourself or food that is to be shared. Humans have always gathered around food for sustenance and comfort, and this tradition is well-suited to a call weekend. When you share food you are collectively celebrating or bearing the burden. Lighter food is best, I suppose. Lean proteins, fruits and vegetables, but I gravitate towards the salty and greasy stuff. Treating myself to taboo food fills a need to indulge in an otherwise captive situation. Even when I know I’ll regret the Chinese takeout from across the street, I view it as a reward for my suffering. Maybe later on I’ll stray from the dark side and have an apple. They say misery loves company and sharing an often miserable on-call experience with your co-workers is a powerful way to endure. Bonding through difficulties combines your own strengths with your fellow workers. We tend to follow the example of those around us and a positive example can infuse everyone. Try to laugh. Laughter is infectious. The subject of humor is vast and includes the most benign to the most offensive, yet it is vital. Sometimes the humor or tenacity of one person will infect the whole crew. When asked the inevitable, How was the weekend?, my most satisfying answer is, We worked hard but we laughed a lot. The Flip Side of Endurance: Cath lab mojo This is another kind of endurance a horse of a different color. This is something that is in every one of us, though to varying degrees, I admit. Some of us, myself included, are just flat-out superstitious. If I’ve had bad luck wearing my scrub hat with the blue chickens on it, you are not going to see me in that hat very often. Some of us, seemingly, have no such obedience to cath lab mojo. Yet these same people will visibly flinch if someone says aloud, You know, its been a while since we had an emergent cold leg. We all know what it’s like when someone promises that the upcoming stent placement will be a slam-dunk. You just don’t tempt the fates like that. You just don’t say the ‘S’ word. I think cath lab mojo and superstitious behavior is our way of trying to control an environment that is unpredictable. I may not be able to influence how many emergencies we get during a weekend, but I at least can wear my lucky socks and believe they have some positive effect. Paul Foxman, PhD, director at the Center for Anxiety Disorders, Burlington, Vermont², says there is a positive placebo effect (to superstitions). If you think something will help you, it may do just that. There is a tremendous amount of power in belief, he notes. Wanting more control or certainty is the driving force behind most superstitions. We all have our own techniques that get us through each day. Maybe it’s coaxing an old car to start on a cold morning with, Come on, come on! Or urging a stent across a tight lesion by muttering, Just a little further, just a little more! What I am glibly labeling cath lab mojo is when we insert our curious human nature into the nuts and bolts of cardiac and peripheral angiography. It seems that however frivolous this tendency is, it is abundant. Probably the most universal mojo is what I call Rattling the Saber. That .035 J wire just won’t find its way up the femoral artery. It keeps curling beneath some obstruction that is invisible to fluoroscopy. You shoot some contrast and still cannot discern what the problem is. So someone will eventually call out, OK, grab an angled Glide. But don’t open it. Just wave it over the table. Every time I hear this, I can’t quite believe it. We are announcing to a room full of science-minded people that the intended use of a different device will make the current device perform like it is supposed to. We freely admit that our little bit of trickery will sneak up on the blind side of whatever force is causing this problem. However when this works, as it so often does, we indulge in a moment of self-satisfied victory: Gotcha! If someone has to leave the room to retrieve said device, the chances of the original device working increases tenfold. All the while you are hurrying down the hall in search of that elusive Wholey wire, you know you have just wasted 5 minutes of your time. And sure enough, when you burst into the room, trophy in hand, you hear, We got it. Other examples of cath lab mojo: 1. Never remove a Doppler needle from the table until the sheath has not only been placed, but successfully flushed. I cannot stress this enough. To dispose of the needle at the first passing of a wire into a seemingly straightforward pulse of arterial blood is simply asking for failure. This will cause the wire to travel mere centimeters beyond the tip of the needle. Once the sheath is seated happily into its new home and the room has finished with its audible sigh of relief; then and only then may you toss the Doppler needle. Hey, I don’t make the rules, I just follow them. 2. Lube up the d-fib paddles and you will not need them. 3. Place two sets of ECG patches on an emergent MI and the IABP will remain quietly in its corner. 4. Pour MD-76 in a cup on your table and the case will not convert to an intervention. 5. Set a temporary pacemaker on the counter and your patient will stay in sinus rhythm. 6. Bring in an extra sandwich and you’ll be sure to get a timely lunch break. 7. Prep the groin in a clockwise motion if you want a short diagnostic case. There is a whole array of cath lab mojo for being on call: Stand your beeper up on end and it will not go off. If you see the number 12 on the time or date of your beeper, it will not go off. Put a package of cupcakes in the passenger seat of your car on Thursday evening and you will not get any night calls for the upcoming weekend. Back your car into the driveway to ensure a night’s sleep. Don’t say, See you in the morning to a fellow call crew person. Do say, See you in the morning to a fellow call crew person. This stuff sounds like it’s from the Middle Ages, but it is simply human nature. Healthy minds coping with an often volatile environment. We are struggling to control an environment that is chaotic. Every element of working in a cath lab is unpredictable. We can never predict the outcome of a case. The most challenging left main stenting may go smooth as silk. Or the most humdrum pre-surgical diagnostic may go terribly wrong. In fact, we not only have no idea how any one case will proceed, each phone call is a potential maelstrom of activity. I can get a handle on an eight-hour day with the above going on, but a call shift is an altogether different animal an animal with teeth. We leave for work and truly have no idea, no idea, when we will return home. Maybe it’s eight hours, or nineteen, or thirty-two. Maybe you have been called back and forth so many times in one 24-hour period, you have lost track of night and day. I remember returning to work so many times in one weekend that I did not know if it was Saturday, Sunday or Monday. And, frankly, Scarlet… My awareness had, over the weekend, boiled down to a simple need for food and sleep. I ate when I could, slept when I was able and for the rest of the time was in the cath lab. I have the utmost respect for my fellow cath lab inmates who endure such physical and emotional suffering. We do it for our livelihood and families. We do it because it is a service to humankind. We do it because we are good at it and we do it because we like it. Every one of us could be doing something different. Something without beepers and sharp bloody objects. Yet this is where we are. Enduring in all manner of ways. I welcome the opportunity to hear your own strategies for endurance and equally, your cath lab mojo stories. The more tricks we have access to, the better our call shifts will be. The more connected we are to each other; the lighter is the weight we must bear. 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 (at) peacehealth. org.

1. Nicol AM, Botterill JS. On-call work and health: a review. Environmental Health: A Global Access Science Source 2004;3:15. Available at http://www.ehjournal.net/content/3/1/15. Accessed April 16, 2007.

2. Albert S. The Psychology of Superstition. Available at http://www.medicinenet.com/ script/main/art.asp?articlekey=46749. Accessed April 16, 2007.