So team dynamics is something that we utilize an interventional radiology. My background is I've been a nurse for 25
My background was the neur was stroke coordinator all at the University of Maryland Medical Center. And it was too much desk oriented. It was very exciting very fun but a lot but of
data-driven work and I found that I'm not someone who sits well as you can see with me walking up here. So then I went into interventional radiology because we do both neuro and vascular and I love neuro so I've been in interventional
radiology for now for the last I think 10 or 11 years. So one of the things that I find that is so important in an interventional radiology department is Team Dynamics. It's a skill set and a model set that I learned in the ICU
because of the way that you have to treat patients and what's going on. In the ICU a model that works in most ICUs is very team dynamic oriented with your nursing staff your critical care attendings your surgeons as well as your
social workers multiple interdisciplinary people with physical therapy speech therapy as well as people who are working to make sure that the families are communicated with and understanding what is going on. And that's a
very dynamic important environment. Patients are critically ill but you need that kind of team dynamics in order to make sure both the patients and the families have the best communications and understand what's going on with
their patients. In interventional radiology we want to model that same kind of atmosphere. But it's a little different. In interventional radiology are your patients there for long periods of time? It's a very quick environment.
You still have patients and families that have lots of questions... Can't go any further than that... you have lots of questions and you need to try and answer those questions and utilize all of your team components to make sure
that your families and patients who come in for both outpatient and inpatient procedures get the information they need so that they can continue to improve and improve their function continue to heal or continue to manage the disease
process that they're dealing with. As well as dealing with the inpatient families who rarely get to see our department because the patients come down without their family members but making sure that we're communicating
adequately to the staff and the unit that the patient is going back to so that if the family has questions hopefully the nurse and the staff on the unit will have answers for that family. And if they don't have answers they know who to
relay the information to. They know who to contact to get the information. So we're going to talk about the dynamic team environment in interventional radiology.
how many of you work in interventional radiology right now? Excellent. Ok and those of you who don't you probably see different areas you've learned a lot about interventional radiology today and you're going to continue to
learn more tomorrow. It is procedurally based treatment of patients who are both critically ill and stable both inpatients and outpatients. And the stable outpatients is kind of my little joke because if you work in
interventional radiology your patients are coming in for procedures and they are stable because they are at home really how many times you have patients that walk in the door who really are not necessarily stable. And we're preparing
to do a procedure on them that could be problematic or could lead that slight instability into a great increased instability. So again your team dynamics come into play with your assessing the appropriatenss of the patient for the
procedure or any safety precautions we need to take or educating or possibly having the patient admitted if you feel that they're that unstable. Which in many cases they do turn out to be when they come in the door.
Our department or in our interventional radiology department you'll see this in departments across the United States you have some that are both cath lab VIR and neuro IR. Ours is
just neuro IR and vascular IR. Our cath lab is completely separate entity. But we do both vascular procedures like a lot of the procedures you heard about today as far as you know chemo embos catheters drains we do TIPS procedures... so we do a
lot of vascular IR. We have five labs. Two of them are our biplane so they're more neuro. So we have neuro IR neurovascular IR. And in our neuro IR department we do things such as LPs aneurysm coiling we do tumor we
do gamma knife procedures preparatory to gamma knife assessments we also do of course brain attacks or our acute stroke treatments. So they're two very different departments. They are run completely separately. But we're housed in the same area.
Our technologists group is separate. So we have a vascular IR technologists group and we have a neuro IR technologists group. And that enables our technologists to specialize in the areas that they really have
strong interest in. Nursing wise we actually cover both areas. And the fun about covering both areas that you get to work in multiple different scopes of practice. You get to learn about the liver you get to learn about the lungs
you get to learn you do pudendal blocks you learn about UFEs you learn about you know women's issues and women's situations. So you're learning about multiple different parts of the body as well as doing neuro IR
which is also very exciting. And since that's my background of course that's my love but we get to train you nurses to cover both areas especially with call.
suite. This is the neuro IR and this is a vasospasm code. So one of the things that we try to continually do in our environment is continuing education. We find that continuing
education amongst the staff together actually helps improve satisfaction and team compatibility. The teamwork with working together. So this is one of the things that we do and I'll talk about it a
little later but we do continuing education with both the nurses and technologists the fellows the residents and the attendings together to be able to answer questions to be able to learn new technologies to be able to continue
to improve our practice in caring for the patients that we care for as a team.
We are in university settings so we have as far as physician side we have neuro IR attendings we have fellows and
residents and we even have medical students who come through because we're university hospital setting. So one of the things that we find as you do find as your physician practice practitioner goes through the levels of education you
can find it's very interesting to teach the residents and the fellows about the global aspects of the patient and the multiple different areas that you have to be concerned when you're taking a patient to IR. But then as they grow in
their practice and learn more than what you know necessarily my practice level is then they turn around and educate us as to the new devices the new treatment options the new research that that it's going to help better manage
and treat your patients in interventional radiology. So its very fun dynamic environment because when they first come in the door as residents they're in a very big learning mode and then as they advance into fellowship
they continue to learn and interact with the technologists and learn from the technologists and nurses. But then as they're required to continue their education and get involved in research then they turn around and start
educating us on new treatments and theories that are out in the environment that could benefit our IR patients and then helps our practice grow. And then as our attendings continue with their research and their specific treatment
modalities for maybe specific patient populations again come to SIR present their information learn from others and then bring it back to the unit and educate us. It enables us to do
cutting-edge and interesting research with our patients who don't have other options to improve their physical deficits or physical disease process and enables us to continue to grow in an area. One of the most exciting things
about interventional radiology... do you think it's a static field? Its a very dynamic field. Is much of we what we do off-label? A lot of what we do is off-label until eventually enough research is done it becomes on label. But
a lot of what we do especially with our our new procedures and technology is unique its new and its continuing to evolve at a very dramatic pace. I can tell you the things that I've seen in the last 11 years that have been that in
IR its just continually to amaze me that we're utilizing new devices that we're trying new drug treatments that we're treating patients that with a procedure that was initially only maybe going to be done for the kidney and now we're
doing the kidney and the liver. Now we're doing the kidney and the liver and the lung and maybe even eventually the breast. So we're trying we're learning how these procedures can benefit patients with multiple different
diagnoses at a very rapid rate. So it's a very exciting field. As far as the IR technologists and our IR nurses as well of course our IR technologists and nurses come from a background that has multiple very different levels. To get
into the field you can have an associate's degree for your technologists and nurses. And then usually the advantage of being in a university setting... one of the things we like... is they'll initially help you
continue with your education. You know they're not giving out tons of money but they are giving out some incentives and some financial help so that when you want to go on. I mean it is highly encouraged
especially the university setting to go on and get your bachelor's and even go on after that and get your masters so that you can continue to help the field grow and continue to improve your patient outcome with your knowledge base
that you have. Training and education is definitely highly regarded and this isn't just have to be in a university setting in any interventional radiology suite. I find that continued education is
definitely a big proponent of the growth of practice. And that's why technologists and nurses alike are encouraged to come to conferences like that to go to the national conferences to do webinars through ARIN and through AVIR. Because
the continuing education will only help your IR practice grow. Its going to help you better have....have better plans to offer your patients with multiple different diagnoses. We do have planned roles in the IR lab. But the cool thing
and one thing I like about IR is very much like the ICU those roles are fluid. So when you come into an IR suite what do you expect to see your technologist doing? And those of you too are technologists tell me what
you do. What do you do? I'm sorry can't hear. Okay circulate and scrub. You're not going to necessarily find that in all interventional radio on where you are. Sometimes one of the...
you know sometimes a little disadvantage can be when you're in a large university setting and you have residents and fellows that have to learn your technologist get a little frustrated because they don't get to scrub as much.
But then they are expected to be more involved in research. So you have to find where your aspect of what you like to do is which area that it's in which type of center that you're in. But yes they're expected to scrub they're
expected to you know manage and monitor and and utilize all the equipment in the room. What about the nursing roles... What are your nursing roles? Ok the timeout right. Does the nurse usually lead the time
out. What about your patient management? The patient sedation patient monitoring. Also as a person who's doing sedation with your patient. If you're in a situation where your technologist is scrubbed... and depending on
us... in our vascular IR we have two technologists and then one fellow and one attending and one nurse in the room with a patient. In our neuro IR we actually have one technologist but we usually have two fellows
or resident and a fellow and attending. So we have at least three practitioners on the table with the patient and then one nurse who's doing the sedation and monitoring the patient unless it's an anesthesia case. So in those two types of
settings if you are in a dynamic environment and you have a technologist who is scrubbed or technologist who's out of the room getting a wire or getting a catheter that the doctor needs and
would you as a nurse go get that equipment it's if it's in the room? Yes. It's a good thing to do. So again the same thing happens if I'm trying to sedate my patient or my patient is starting to wake up
or my patient is trying to take their oxygen off and the doctor asks for a syringe...a 10cc saline syringe...as a technologist would you be able to do that for me? Yes okay these are things that we work together to do. So yes we
have individual roles your attendings role your fellow and your residents role is going to be doing the procedure on the patient. But the roles should be fluid and dynamic in order to create a great team environment. And the reason behind
that is while I'm doing something with the patient you can be my eyes and ears for the position. While my technologist is busy in a brain attack writing down the times of what wire in wire out I can run
and get something I am in the room I can run and grab a wire and monitor my patient at the same time. We're in a room i can see what's going on. So I can grab it and I have all of my alarms set. So i can grab the wire I can grab the
catheter drop it on the table for the physician hop back over to my patient and still be seeing what's going on. Because the monitors are all over the room. I have my alarm set. I know what's going on with my patient I
can take the time to do that. Again these things may seem like little aspects but they make a big difference in a team environment because when I'm in trouble my resident my fellow my technologist can help me if one of them is needing
help i can lend a helping hand we are working together. Because ultimately everything we're doing is to help improve the patient's outcome as quickly as possible. Right. So these are just some fun
pictures you can see that this is our... Oops! Best fingers. This is our team room here with our one of our boards. These are one of our attendings and one of our attendings and one of our
fellows discussing the case we're actually in the lab and this is one of our chief technologist working with the other two technologist to look at the case board to see what's coming into the room now. While the docs playing that out
while the nurses bring the patient back. Here's the nurse bring the patient back. And this is one of our other technologists we have the patient we're getting ready to get them on the table. The plan has been discussed usually the
technologist is in with the attendings and the fellows and the residents to know the plan. And then the technologist when the nurses bringing the patient in will be relaying to us any pertinent information we need for
the procedure that's going to be done. Pertinent information might be what? How are you going to position the patient? You know I need to know are my leads going to be in the way? How can I make sure that my leads don't get in the
middle of the pictures? Oxygen? We have oxygen from multiple different areas of the room depending on if we're going to do spins or not. So if we're going to do a spin I know that I need to use the oxygen that's hooked up at the bottom of
the table so that as we're doing the spin my oxygen doesn't get yanked out of the patient's nose or you know get flying off the wall. Ok so again communication is the biggest key for the team environment. And one of
the things that we do is we continually try to build on communication. Are we perfect? Is anybody perfect in communication? Are you perfect in communication? Is anybody's
days and we have days that just at the
bottom of your shoe. Like gum on the bottom of your shoe. And it just didn't work out. But the thing that we try to do is when we have days like that sometimes we need to get a little insular and just gripe about it ourselves and then what
we try to come up with in a huddle because we have huddles every morning with the technologists and the nurses is try to figure out what went wrong and how we can improve it. Who do we need to talk to what do we
need to relay what did we miss. What wasn't relayed that would have made the situation better. We don't do it the day of because sometimes the feelings are a little too close to the surface and frustrations are a little
too close to the surface so it's always good to take a break back you know go home maybe have a glass of wine come in the next morning and then huddle. Ok so these you know these rooms these rooms these rooms worked really well we
kind of had a real big flow down in this room... what happened what was the situation was missing information was it something that could have come from the team side up...you know from the team upstairs...
from the physician that sent the patient over what we are we missing and where did we drop the ball and how could we improve it next time is the continual habit with this particular groups of physicians that send our patients over or
is it something that we're just noticing that we need to address and ask the ime the patient this gro I'm not clicking there you go and this is one of our technologist. This
is our CT room so this is our technologist that are our CT room. These are the nurses out in recovery prepping the patient. Everybody was really happy. We feel in our department that education is the key to our success.
It's really strongly motivated from our hospital side down. So our hospital pushes continuing education our nurse manager pushes continuing education our manager of the technologists you know as well as our physician champion
really recommends that we do continuing education. We do get some financial incentives to do continuing education. It does make a difference on your resume. It is a question that you have to produce and show your
continuing education. And I'm not just talking you know the 30 credits or however many credits that you need to have each year. I'm talking about additional work. What we've tried to do in our department for the continuing
education is we have a monthly education meeting. Ours was this morning 30 minutes I went and talked about subarachnoid hemorrhage for 30 minutes en I headed up here...or down here. We do it every month. Physicians nurses
and technologists are all invited. Yes we try to start cases early but on that Friday we work with the physician group and the scheduler to make sure that the group of patients that are coming in are coming in a half an hour
later. Everybody's agreed to that because it's important for us to continue to learn what we're doing. We'll have physicians come in and give a lecture the nurses will come and give a lecture
our technologists will come and give a lecture. Everybody's responsible with a senior person in the Department for producing a lecture. You don't have to give it yourself but you have to find someone to give it and usually it's topics we'll put
out a list of topics at the beginning of the year of things that we all think that we're interested in. So people get together a list of people who are interested. Ok so this is one of the other things
that we do we do this really awesome thing and this is created by one of our technologist it is the best thing in the world. It's called skills day. Everybody loves it. People coming from their day off to
do it. Skills day we have reps from all the different companies that bring products into our department and they set up a table. And they set up a table with their newest devices that we can touch and play and look at. They'll bring
in pig's livers that we can
treat. They'll bring in you know pig feet. They'll bring in cow stuff. They'll bring in eyeballs you know and stuff that we can then use these devices on to embolize to coil to do all sorts of
procedures. And it allows us all to get to know the devices. As a nurse I really don't get to be involved at all in the procedure side because I'm doing moderate sedation. I would love to embolize the liver.
I would love to cryo a liver. This is so cool. I see it but I'm usually trying to sedate the patient to keep them from feeling pain. So I don't get to look up close and really ask a lot of questions.
This is the day that we get to do that. We have it for two hours in the morning. We started six were done by eight so that we can start to get the first ts on the table. But we all g residents love it are attending are the
stuff and allow us show us how to do the procedures. It's the most fun thing that we've ever done and again are technologists loved
it so much that we do it every year we have nursing group and we have the technologist group working together because then we do get in some of the things that are required. Like chest compressions and like airway management.
Those are the things that we all have to defibrillation... every year w we get to do all the fun stations too. So it's completely awesome I highly recommend it. And honestly all of the
groups that come in and bring products to us are so excited they bring us massive amounts of food they bring in the products because they're teaching us they're teaching us all the newest things that we can be doing for our
patients. And it's completely awesome. So here's some pictures of us doing that. Continuing education is also highly is a highly recommended in our department that you join the groups that you belong...that
you can continue to get your education from. So from the nurses for ARIN for the technologists for AVIR and there's no reason you can't join both. I'm actually part of both groups because I find the education that I get from both groups
continues to allow me to grow. I learned a lot of technical information a lot of patient procedural information so that I can better manage my sedation from AVIR. And then I learn a lot of nursing standards and processes and
nursing management of conscious sedation from ARIN. So I like to belong to both groups. I think i get a wealth of information from both groups. I do enjoy it and so I highly recommend checking out both groups for the education. Formal
education is encouraged like I said continuing education is highly recommended and the most thing that we do with all of this is we have fun. We do eat we enjoy food. I think anybody enjoy food especially in interventional
radiology setting. Most recently I think we've been short-staffed in our department for quite some time and then we've had a change of management. And that's always interesting because there's new dynamics that are involved
new relationships that are being formed. Coming together as a team since we have been so short-staffed recently I'd say it's been about a year has one of the things that's really build a stronger as a team.
Because we all have the same concerns. We don't have enough hands we want to make sure we do adequate patient care. So we're working together not as a nurse and technologist and a resident and a fellow - we're working together as a team.
My fellows will bring my patients back for me well I'm running to get drugs while my technologist is cleaning the room. Because we've been having a really short staff with housekeeping as well so we've been cleaning our own rooms. And
boy you know we have downtime to what we can do we can flip a room it's amazing when we get housekeeping back it's going to be a shock to our system and I don't know if we're gonna be able to handle it because you're not gonna be quick enough
because we're so used to just flipping it ourselves. And we're doing an
keeps us going. So one of the things is we do is we have fun. We have a one room where we all sit
and eat. Everybody gets grouped together it depends on what time and what time frame when your lab is breaking. So you're going to be eating a lot of times with your own staff that you're working within the lab that day. But also from
recovery because we do our prep and recovery in our own department. We do prep recovery and the labs. So eating is something that we all do together. We do a lot of other things together outside of the hospital setting. We do get
together at a local watering hole on occasion... payday... to have some fun and hash things out. But we also go bowling because there's a really neat bowling rink in downtown Baltimore that also has the bar involved in the bowling rink.
And bars and bowling is really fun! But we do other things. We do mud runs together we actually we do mud runs together. We also do lots of baby showers we do birthday parties we have lots of fun. And honestly it helps us
differentiate not everybody goes together but usually everybody attends at least one or two or three events a year and I think that because it makes us more of a family. And the mud runs are great because we just we look ridiculous.
much fun. I have some really bad pictures of myself in a mud run with a couple of my technologist friends and nurses and a couple of the docs and yes they're
not allowed to be on facebook. Ok I had to like totally untag myself off of that but it was fun. It definitely was fun. We dress up for Halloween. We goof around. We weren't so happy because the Steelers lost.
So you have a diverse patient
population in IR. Because of that diverse patient population you need to work as a team. And that's what we're constantly doing. I think the greatest training process we have actively for working as
a team is when we're dealing with a brain attack. When we're dealing with the brain attack environment time is brain. We are comprehensive Stroke Center. We are actually landing our patients from the helipad right into IR. If they
have any concerns about the time element they will go to MRI first. But majority of the time if we have not enough information we want to see what's up there and the younger patient we're going to land them right into the IR lab.
That's a little bit confusing it's a little bit crazy because when we're doing that our brain attack team is actually doing a neuro assessment at the same time to find out what their NIH Stroke Scale is. At the same time my
physician is shaving the groin. At the same time the technologists that I'm working with is putting on my leads for me. I'm checking really quick to see if I have pulses down below. And then like I said the brain attack team is at the
top trying to do a neuro assessment. We are trying to get everything done so we can stick as quickly as possible. And we are actually doing times from groin stick to recanalization less than 60 minutes okay.
We're landing the patients and getting to a groin stick in 15 minutes. Ok but it's crazy but it's controlled chaos. There are roles. Our roles are blurred. The goal is to get the patient get up to the brain find the clot
see what we can do about it and resolve the issue. So everybody is on double-click mode. We are controlled but it is chaotic so we can get it done and get the patient off the table get them back to
the ICU and hopefully have resolved the clot to allow them to continue to heal. So same thing with our trauma patients. The goal is organized chaos. Again with the trauma patients its a little different because you have
multidisciplinary teams that are trying to come in and out room the whole time... like your surgeons and stuff like that... the hybrid room that he was talking about earlier is fabulous. We do not yet have it. When we get
something like that I think the controlled chaos will be a little more controlled but right now we are putting the patient on angio and then taking them back to trauma to the OR. So it is a little chaotic and you'll have
anesthesiologist there you'll have the trauma team and surgeons. So those cases it's trying to make sure that nobody comes into the lab that's not protected that if they are coming to the lab they have the proper gear on and that
everybody is making the safe choices for their own health. And expect the unexpected can I tell you equipment breakdowns call cases can we do a quick reboot can I have more hands. Call cases we have two
separate teams it's a nurse and a technologist and whatever attending is on for that service both neuro IR and vascular IR. We have to have two teams because if we have a brain attack and we have a trauma they both have to go. So we
have two separate teams. We have had instances where you do have. What are you going to do when you're you're doing biplane and your whole system shuts down. Have you ever had that happen? It freezes ok.
Ok. Ours is not a Siemens room so you're good. We have had that happen. I had it happen the middle of a brain attack. What do you do? They rebooted but time is brain. Still wasn't working. We
have to biplane rooms. Our other one is older we were in the favorite new room. We got the patient off the table we took them to the old room and we finished the procedure. Ok we try to maintain sterility as best
as we could. We re-scrubbed everything but that's what you have to do. So everybody has to be prepared to deal with whatever is going to happen when it happens. Sometimes you need more hands. Call cases you don't have a lot of
hands you only have those three people. So again things happen be prepared for them to happen again the goal is for the best management for the patient. Work together as a team come up with a plan do it
activate the plan and resolve the issue. And then allow your patient to continue to heal and go either back to the ICU back to the unit or back as an outpatient to their home with family. And then make sure you're
communicating to the off services and the family information that was given what was done any questions they have and give them a source for the answer. So give them a number or somebody to contact as a source person so that we
can get their questions answered. Communicate communicate communicate and work together as a team. You can do we do it all the time. We do it in sports we do it at life. Moms do it with their kids. Moms do it with their husbands. Husbands do it with
their kids. Husbands do it with their wives. We're always working together as a team. We do with our friends. So we just need to take it and make sure we're utilizing those skills that we all have and we all know in our environment and
interventional radiology. And be nice. I love you all. Thank you so much have a great day
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